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EW FEATURE 37 of a second procedure, approxi- mately what that would be, and whether it's going to be covered or not, he said, adding that he believes these patients should be covered and the doctor should put enough money into the initial fee to take care of what is needed. It is neces- sary going in to know the cost to do the enhancement and what your rate of enhancement is, he said. Dr. Waltz said that there are other groups of patients with whom he will discuss refractive enhance- ment preoperatively. These include patients who are getting monovision and patients who have had prior laser vision correction surgery. Currently, he ends up having this conversation with about 60% of his patients. "You want to have a number of strategies available to cost effectively and clinically effec- tively do the enhancement," Dr. Waltz said. "You want to have a menu of options lined up and ready to go before you even do the first surgery." Extra costs The idea of extra costs associated with premium and enhancement procedures are often daunting to patients, but there are a number of ways physicians can deal with this. Dr. Trattler said that for his patients getting a presbyopic lens, the Crystalens (Bausch + Lomb, Bridgewater, N.Y.), Tecnis multifocal (Abbott Medical Optics, Santa Ana, Calif.), or TRULIGN (Bausch + Lomb), this cost is included with the procedure. For monofocal patients, Dr. Tipperman has these patients cover at least the facility fee costs. For advanced technology IOL patients, it is included in the service. Dr. Waltz's strategy is to amor- tize the cost over a large number of patients, so the extra cost would be very low. He said that he does not even present this to his patients as an extra expense, as it is inherent in the price. That way, if a patient needs the enhancement later on, it is already paid for. Patients realize that there is some cost associated with refractive enhancement because a physician would not be doing it for free, he said, adding that he gives patients his enhancement rate. If you plan to refer to a colleague, how is the cost determined? "I think you should emphasize the surgeon doesn't have to do these enhancements," Dr. Waltz said. "You can arrange for a refractive surgeon to help you." In Indianapolis, he does enhancement procedures for other doctors in the area. The ad- vantage is that surgeons can pre- arrange the relationship, whether they are receiving others' patients or referring to another doctor. "You cannot do multifocal lenses or toric lenses correctly without a backup plan," he said. Working on patients with two or more doctors can prove challeng- ing when the cost issue is brought in, but Dr. Waltz's practice has an internal system in place for when he performs enhancements on patients from his partner so that his partner will pay for the cost and Dr. Waltz would get some benefit as well. Externally, Dr. Waltz has a couple of options. Sometimes, other doctors will send patients for him to charge what he deems fair, and other times, the referring doctors will prearrange a particular patient and pay a certain fee. The bottom line, Dr. Waltz emphasized, is to treat the patients in the best way possible. Dr. Trattler said that if a patient is referred to him from another physician within his practice, then there is no charge for refractive enhancement. However, if a patient gets referred from outside the prac- tice, that patient would pay the usual customary rate for laser vision correction. What if a patient complains about the extra cost? Dr. Tipperman said that a preopera- tive discussion is helpful for patients who are dissatisfied or worried about the extra cost. Having that discus- sion ahead of time will help address concerns prior to surgery. The reason that Dr. Trattler's practice includes the cost of en- hancement in the price is to cover patients who have cataract surgery and pay extra for a premium tech- nology and then end up with vision that is unsatisfactory where they have to have more surgery, he said. "It's hard at that point to ask them to pay more money since they are already disappointed and frus- trated. It's much better to have it all included so if a patient is unhappy, the next step is already covered to make him happy," he said. EW Editors' note: Dr. Tipperman has financial interests with Alcon (Fort Worth, Texas). Dr. Waltz has financial interests with Abbott Medical Optics and WaveTec (Aliso Viejo, Calif.). Dr. Trattler has financial interests with Abbott Medical Optics, Bausch + Lomb (Bridgewater, N.J.), and LENSAR (Orlando, Fla.). Contact information Tipperman: rtipperman@mindspring.com Trattler: wtrattler@gmail.com Waltz: klwaltz@aol.com July 2014 Keratorefractive enhancement of pseudophakes Poll size: 214 EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put EW Pulse in the subject line—that's all it takes. Copyright EyeWorld 2014 30-37 Feature_EW July 2014-dl_Layout 1 6/30/14 8:42 AM Page 37

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