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2010: An Optometric Odyssey, Episode XLASIK in 2010: Will You Be There?Don’t let commodity health care tear you out of the picture.Jeffrey S. Eisenberg Senior Editor Sidebar: Taking the Lead with the Laser Optometrist Ronald Norlund tells of a patient who came for her pre-op LASIK evaluation at his Fort Wayne, Ind., laser center. He did his exam, educated her about the procedure, and told her the total cost for both eyes would be “twenty-three eighty.” Much to his surprise, she told him she would pay the entire amount right then. He was even more surprised when she handed him a check—for $23.80. Another patient also offered to pay for his LASIK up front and in cash. He then asked to borrow a nickel from one of Dr. Norlund’s employees, explaining that he only had $23.75 with him. Is something wrong with this picture? And, is it a picture you’ll even be part of by the end of the decade? Dr. Norlund shared these anecdotes at the Optometric Refractive Surgery Society’s fifth annual symposium and, between chuckles, audience members realized that there’s reason for concern. Although most patients don’t want to take risks with their eyesight, many have come to see LASIK as a commodity—something to buy and sell at the lowest possible price. It’s no wonder, given the plethora of billboard, radio and TV ads telling patients they can throw away their glasses for as little as $999. Nor is it any wonder when shoppers at some local malls can watch patients undergoing LASIK through a storefront window, or when at least one web site even allows patients to bid for the lowest cost surgeon online. As you consider where you’ll fit into this picture, others are painting their own picture of optometric comanagement. Some mainstream media reports describe comanagement as a “finder’s fee” that the optometrist gets for referring a patient to a particular surgeon. And, organized ophthalmology continues to urge its membership that surgical comanagement should be an exception, not the rule. In this 10th episode of our yearlong series, “2010: An Optometric Odyssey,” we’ll look at what the changing landscape of the refractive surgery business means for you and explain how you can remain in the picture. Also, you’ll meet some colleagues who will tell you about steps they’ve taken to keep refractive surgery as a major patient service and practice builder. On the Upswing Last year, Dr. Norlund and his partners realized they had only half the LASIK patients they had the year before. They knew they wanted to continue comanaging, but first they had to figure out what was driving their refractive surgery practice downward. It’s certainly not because the demand wasn’t there. According to reports from the AOA and Jobson Optical Group Data Base, U.S. surgeons performed nearly 1 million refractive surgery procedures last year, most of them LASIK. That’s more than double the procedures done in 1998. Refractive surgery revenues hit $2.2 billion in 1999—again, double that of the year before. And, you can expect demand for laser vision correction to continue rising, at least for the near term. In a recent Gallup poll, some 4 out of 10 Americans who wear glasses or contact lenses said they would consider having laser vision correction in the future; about 1 in 10 said they would consider it within the next year or two. The AOA predicts that eye surgeons will do 1.3 million refractive procedures by the end of the year, with numbers increasing to 1.6 million in 2001 and 1.9 million in 2002. Traditionally, people have avoided refractive surgery for two reasons: fear and cost. “These two factors are eroding very rapidly,” says optometrist Robert C. Bevington, CEO of Clear Choice Laser Eye Centers in Hudson, Ohio. As LASIK volume increases, so does the likelihood that your patients know someone who has had the procedure. What’s more, there is greater public acceptance of the safety and efficacy of LASIK. For that, you can thank refractive surgery centers and individual practitioners, who spent an average $200 in direct marketing expenses per procedure, according to the newsletter Refractive Market Perspectives. Meanwhile, golfer Tiger Woods, Dallas Cowboys’ quarterback Troy Aikman and other well-known athletes have had LASIK. They’ve talked up their experiences in USA Today and Sports Illustrated and on ESPN, further raising public awareness. An Evolutionary Cycle Cost, the second reason people traditionally avoided LASIK, also continues to decline, making LASIK accessible to patients who once could not have afforded it. Plus, when prices fall as low as $1,000 an eye, patients with as little as -1.00D of myopia are willing to consider the procedure. Optometrist Larry Alexander of Prospect, Ky., says: “When special deals are out there, you’re seeing a different type of LASIK patient.” Laser vision correction is in the same evolutionary cycle as any other business. As more competitors enter the field, each tries to differentiate itself. “The way to do that is price,” says Jon Hayashida, O.D., vice president of clinical affairs, for Refractec Inc. And, there are more players. According to the AOA’s report, “Caring for the Eyes of America,” the number of laser centers went up from 476 in 1998 to 754 in 2000, a 58% increase. Look for that number to go up to 934 by 2002. Among these new players are corporations that have opened laser centers in different markets and are beginning to offer steep discounts. For example, ICON Laser Eye Centers Inc. announced plans in December to enter 100 U.S. markets and offer a “direct marketed value LASIK program” that would allow patients to undergo LASIK for as low as $499 per eye. Another player, LCA-Vision, now has 29 LASIKPlus Centers charging $2,995 for both eyes. On its web site, LASIK Vision Corporation, a Canadian provider, suggests that patients combine a vacation north of the border with the opportunity to undergo LASIK for $999 (U.S. dollars) an eye. These forces have set off a wave of discounts from independent surgeons. David Harmon, president of Market Scope, a market research firm, and editor of Refractive Market Perspectives newsletter (www.mktsc.com/news.html), surveyed 220 refractive surgeons. Some 27% said they charge less than $1,500 an eye. That’s especially significant when you realize that only 2% charged that amount when he conducted the survey a year earlier. And, only 13% said they charge $2,000 or more an eye, down from 37% last year. That may not be good news for your practice, at least during this phase of the cycle. As prices drop, so do comanagement fees. Some optometric practices are seeing LASIK referrals stagnate or, worse, decline. Worst case, it may force some of you out of the LASIK picture altogether. “Basically, there’s little room for a comanagement process in there,” Mr. Harmon says, especially when you consider the renewed backlash toward comanagement. At some point, you also might ask if comanagement is worthwhile to your practice. “As practice administrator, I know what my cost is to do a LASIK procedure,” Dr. Alexander says. “There’ll come a point where I have to say if we’re only making $50, we’ll either stop doing it or something has to give somewhere along the line.” Anticipated Shakeout It’s a question that some laser centers may also have to ask themselves. Azusa, Calif., optometrist Milton Hom, author of LASIK Clinical Co-management (Butterworth Heinemann, 2000) believes that discount laser centers will need to increase patient volume to turn a profit. He questions what impact that will have on service. If that occurs, will lower prices still be worthwhile to patients? Mr. Harmon predicts that a shakeout, of sorts, will occur, and that discount laser centers will eventually need to increase prices to make a profit. “The market is not big enough to handle more than two pricing levels,” he says. He believes that only higher prices will be found in smaller markets, but those high- and low-end centers will exist in major metropolitan areas. “A lot of it depends on the competition in that market, who’s in that market and what kind of marketing strategies they employ,” he says. A likely scenario: LASIK prices will ultimately fall into two strata: $750-$1,000 and $1,500-$1,800 an eye, predicts Chetan Mishra, M.D., editor of The Clasik Report.com (www.TheClasikReport.com), a biweekly newsletter about trends in the LASIK market. “I also think there will always be a handful of elite surgeons who will be able to ride their reputations to the $2,500-$2,750 per eye range for a while,” he adds. “But I don’t think that they will be pushing significant volumes in terms of overall patients and won’t be much of a factor overall. They will probably continue to exist only in major metropolitan areas.” The Crystal Ball Long-term, the outlook isn’t too glum, especially when you consider that prices should stabilize, allowing you to be able to compete against the discount centers. “As the price hits a level, which I project will stabilize at about $1,000 an eye, where everyone’s competitive, I think that optometry’s role will increase again,” Dr. Norlund says. In some ways, the refractive surgery marketplace is following much the same path that the contact lens and even spectacle markets did. Says Paul M. Dowd, O.D., of North Royalton, Ohio: “Those early years were really an aberration.” The main aberration right now is that two patient groups exist: your long-term patients whom you’ll refer for surgery and comanage afterwards, and those who do not have a private-practice O.D. Dr. Dowd believes this latter group will seek laser vision correction, including pre- and post-op care, elsewhere. He’ll approach competition for refractive surgery patients the same way he took on competitors in contact lenses: quality service at fees that are reasonable for both the patient and practitioner. So, you’ll have to let patients know that you’re the eye-care expert now, before the laser center’s marketing pitch lures them away. That way, as the number of patients increases over the next years, you will continue to be involved in refractive surgery, says Jim Colgain, O.D., clinical director of TLC Laser Eye Centers in Fairfax, Va. For you and your colleagues to stay involved, you’ll need to find a center or surgeon you can work with, confront the issue of cost, and then educate you patients about why your recommendation is the best one. “In that way, [optometrists] gain credibility and maintain control of the patient,” Dr. Bevington says. Refractive surgeon Robert Wiley, M.D., of northeastern Ohio, believes optometrists do have a place in comanaging LASIK. “Optometrists know their patients’ eyes better than anyone else,” he says. “I believe they should start a refractive surgery evaluation with the confidence that they have something legitimate, something real, something important to bring to the table.” What they bring, he says, is their long-term interactions with patients, their ability to do “absolutely great refractions,” their under- standing of reading distances and computer vision, and a long-term commitment to that patient’s eye care. Of course, that means O.D.s must step up to the plate in offering refractive procedures as an option for vision correction. Houston optometrist Maurice J. Wilson of International EyeCare Laser Center says: “We see patients in our clinic on a daily basis who come in for surgery and have just seen their optometrist, and it was never mentioned to them that this was a possibility for their visual correction.” Dr. Wilson believes that fewer optometrists will comanage refractive surgery, but those who do will continue to grow their practices. You might get a read on how you’ll do with refractive surgery in 2010 by doing an audit of sorts. Are there brochures or signage in your office to let patients know you’re involved in refractive surgery? Is your staff educated? Do you do any other internal marketing? “Optometry 3 or 4 years ago was seen as the window into refractive surgery,” says Dr. Colgain. “And now people have begun to walk through a different door. If we’re going to reclaim that refractive surgery leadership as a profession, then we need to educate patients—our patients—on the importance of the history they have with us, the importance of our work both pre- and postoperatively, and why that will make a difference in their outcomes.” Leadership Now You must be ready to lead if you want to be part of the refractive surgery picture in 10 years. “If optometry doesn’t become the gatekeeper, the provider of all eye care now, they’ll lose that segment,” says optometrist Paul M. Karpecki, clinical director of refractive surgery for Hunkeler Eye Centers in Kansas City, Mo. Some O.D.s have taken this role to a new level, buying or leasing their own lasers and hiring ophthalmologists to do the surgery (see “Taking the Lead with the Laser,” page 56). Even if this is not ideal for you, there are still other steps you can take: • Push your education level. Learn all you can about all the refractive surgery options, evolving procedures, and what’s involved in pre-op selection and post-op care. “Become educated in preoperative selection such as knowing the LASIK side effect triad that usually lasts for the first month, or the three things that will get a practitioner in trouble if they don’t look out for them prior to surgery: P.K.P.—pupils, keratometry and pachymetry,” Dr. Karpecki says. Prepare yourself to confidently answer patient’s questions and offer recommendations. For example, Dr. Karpecki explains to patients the importance of addressing distance, intermediate and near vision needs. “A lot of what we have to do is present all options to the patient—present what works, what doesn’t, what they’re good for, and really be the gatekeeper,” he says. San Diego optometrist and industry consultant Jerry Legerton adds that O.D.s are especially valuable because of their expertise in refraction, but that you must also prepare to defend your refraction to the surgeon. If O.D.s are part of the surgical planning, their role in refrac- tive surgery will last, he says. It’s also possible that by 2010 procedures will continue to become simpler and less invasive. It will be up to you to let your patients know about them. • Involve your staff. When patients call to schedule exams, your receptionist might ask if the exam is for glasses, contact lenses or refractive surgery. It’s also a plus when your staff can answer patients’ questions and talk on refractive surgery. Communicate with your employees, patients and surgeon regularly about refractive surgery. • Choose the right surgeons for each procedure. Monitor the outcomes to see that the procedures are serving your patients well. • Differentiate your practice. Ask your staff to tell you the top three reasons patients should see you instead of someone else. For example, are you a LASIK specialist? Can you meet the specific needs of your patient base? “If you’re run of the mill, patients will go to the cheapest place,” Dr. Hayashida says. • Emphasize your ongoing role in the patient’s care. Though your importance begins before surgery, it lasts long after the procedure. Let your patients know that. “Patients think they’ll have [the surgery] and they’re done,” Dr. Hayashida says. “Once you get that surgery, that’s only the beginning of where the care begins. We’re managing your vision, not just your surgery. It’s how you function, how you live your life.” The Good News Even though the refractive surgery landscape is changing, presently O.D.s are still very much a part of that picture. A 1999 AOA survey reports that almost 80% of optometrists comanage refractive surgery patients. And, optometrists still see two-thirds of primary eye-care patients, the AOA reports, so you remain a valuable referral source to surgical centers. And the AOA says that market research shows that patients don’t want to “commoditize” their eyes or discount their vision when it comes to surgical procedures. “People will opt for what they feel has good value—not the cheapest, not the most expensive, but something in between,” Dr. Hayashida adds. Looking ahead, there’s also the question of value that you provide to the surgeon, namely in the form of greater efficiency. “We, as O.D.s., free the ophthalmologist up to spend their time in the OR,” says optometrist Jeffrey Oberg of Clear Choice Laser Eye Centers in Brecksville, Ohio. “It’s not cost-effective for an ophthalmologist to see pre- and post-op patients, doing refractions and slit lamp work when I can do the exact same thing.” Dr. Legerton puts it in even stronger terms: “If refractive surgery grows to levels expected, the ophthalmologist who thinks [he or she] doesn’t need the optometrist will choke on pre- and post-op exams.” Granted, the picture of refractive surgery has changed, with patients having additional, lower-priced choices for their care. But as Dr. Bevington says: “View this as an opportunity, not a problem. Be proactive, not reactive.” There’s still a place for you in this picture, but whether you remain there in 10 years depends on whether you’re willing to assume a leadership role. Let surgeons know of the value you bring. Most important: Make sure that your patients see you as a vision expert—someone who knows everything there is to know about vision correction. Gradually, they’ll realize that value goes far beyond $23.80. u Thanks to Jeffrey M. Augustine, O.D., moderator of a roundtable on LASIK comanagement at the Optometric Refractive Surgery Society meeting in Akron, Ohio, last August. |
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| Taking the Lead with the Laser While many of you already comanage refractive surgery, some of your colleagues have taken this portion of their practices to the next level. They’ve purchased or leased an excimer laser, hired a surgeon and now provide LASIK in their practices. They have different reasons for doing it. Some had been comanaging LASIK with local M.D.s, but realized that patients were referring others to the surgeons or laser centers, not to them. In Baton Rouge, La., optometrist Roger Shaw brought in an excimer as insurance against price competition—and then started some price competition of his own. Now he offers LASIK for $900 an eye while the average fees in the Louisiana capital range from $1,250-$1,650 per eye. In Beaver Creek, Ohio, near Dayton, optometrists James D. Egbert, Steven C. Connett and their partners signed on to be a Clear Choice center when the center they had been working with placed restrictions on their comanagement. This approach takes careful planning. If you’ve thought of bringing an excimer into your practice, ask yourself these eight questions:
Of course, the more care you provide in your practice, the greater your liability, says Highland, Calif., optometrist and attorney Pamela J. Miller. Check with your malpractice carrier to make sure your have the right coverage.—J.S.E. |
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© Review of Optometry OnLine October 15, 2000 |
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