Patient Education and the Three R's

By Stephen Cohen, O.D.
November 1999

Discover how to make the most of your educational opportunities.

Unfortunately, in the managed care arena, the only thing that's important regarding optometric services is whether or not they are "covered" by an insurance plan. Referrals are often a result of how close the doctor's office is to a patient's workplace, and patient loyalty may solely rely on what plan they're on. As eyecare providers, we can accept these issues as inevitabilities. Conversely, we can find ways to expand our services by encouraging referrals and earning patient loyalty by meeting and exceeding the expectations of our patients.

Stand Out From the Crowd

Perhaps the most effective way to distinguish ourselves from other practitioners lies in how we choose to educate our patients. I recently spoke with a colleague whose motto is to "make sure the patient leaves the office seeing better than when he came in." I modified this, offering that patients should also leave our offices knowing more than when they came in. Some direct benefits of patient education are that patients will recognize our expertise and will be more likely to follow our recommendations.

By taking every opportunity to educate our patients, we can increase our success in the "Three R's": Retention, Recall and Referrals. Education builds loyalty, reinforces recall recommendations and increases patient referrals, and should be treated as an integral part of the exam. Time constraints don't have to be seen as an obstacle. For example, in discussing contact lens modalities, you can say, "There are lenses available that can be replaced anywhere from 1 day to several months."

Ultra-violet (UV) blocking presents another tremendously underutilized educational opportunity. Some marketing studies have shown that over 90 percent of contact lens patients value having contact lenses with UV blocking. Surprisingly, only about 10 percent of these patients cited their eyecare practitioner as the source of learning about this option. Asking patients whether they are aware that there are UV blocking contact lenses available would provide a great opportunity for contact lens prescribing.

"R" is For Retention

Educating patients about UV lenses supports "Retention," the first of the "Three R's." A common reason why patients change doctors is because they think that another practitioner has something new to offer. If we consistently educate our patients about new opportunities and technological advances, they will consider us an up-to-date resource and perhaps, stray from our practices less often.

Vistakon revolutionized the contact lens industry 12 years ago with the introduction of the Acuvue lens. This company has now provided a promising opportunity to utilize and demonstrate our expertise and training with its newest product, the Acuvue Bifocal contact lens. When profit margins are eroded by managed care contracts, successfully fitting specialty lenses provides a chance to increase profits, patient loyalty and referrals. The Acuvue Bifocal, which can be prescribed as a disposable 1-week extended wear or a 2-week replacement daily wear modality, is a premium specialty lens, requires more sophisticated clinical decision-making and justifies premium fees for fitting and follow-up visits. Although the individual visit may be more labor intensive, the total number of follow-up visits are similar to that required with any other disposable contact lens. Vistakon provides diagnostic lenses to facilitate immediate prescription modifications, which may be indicated.

In contrast, consider the process involved with fitting other soft bifocal lenses. Typically, the initial examination is followed by ordering the initial lenses by calculation, followed by a dispensing visit and another visit about 1 week later. If a modification is indicated at the follow-up visit, yet another visit is required for dispensing the new lenses. The patient will then usually require another appointment after assessment in the real world. This process can be extremely time consuming. Further, consider the manufacturer's return process. Most companies allow a limited number of exchanges for credit within a limited period of time. Once surpassed, additional costs are incurred. If a patient tears a lens during the diagnostic period, you may have to absorb the replacement cost. You must also rely on a staff member to return exchanged lenses to the manufacturer for credit within that time frame. If any of these steps fail, the profits for that patient could disappear. The Acuvue Bifocal eliminates this issue entirely. Modifications indicated during the follow-up can be made immediately, negating the staff time for re-ordering and the subsequent dispensing visit. Torn lenses can be replaced and no returns are needed. Results can be achieved faster, which will help to maintain the enthusiasm of the patient, staff and doctor. The success rate, which is defined as the percentage of patients who actually purchase the lens and the number that have been diagnostically fit, has been between 50 and 75 percent for this lens. Maximizing this success can be achieved with three specific steps: a current refraction, positive, realistic product presentation and consistent fitting techniques.

"R" is For Recall

Another colleague discontinued his pre-appointment recall system. He stated that pre-appointments were easy, but getting the patient to show up for the exam was the challenge. It may have been that he was not giving his patients sufficient reasons to show up for that scheduled appointment. Let's say a patient comes in for an exam and finds out that there has been no prescription change, and no other problems have been found. Twelve months later, this patient receives a recall notice. Conceivably, he might determine that there is no reason to return for an examination until he notices a change in vision. By educating our patients at every opportunity, the recall notice will be seen as a reminder to them to return to our offices to learn what's new in technology and vision options. This approach reinforces "Recall," the second of the "Three R's."

"R" is for Referrals

Patient selection is not needed for the Acuvue Bifocal. The primary goal is to seek patient education opportunities. Therefore, the patient profile for presentation of this lens should be every presbyope. Even when a patient may not fit the profile (e.g., a prescription outside the available range of +6.00
to -9.00, or with a high degree of astigmatism), it alerts patients that we are keeping up-to-date on technological advances. Also, they may know someone who could be a good candidate for the lens, supporting "Referrals," the third of the "Three R's."

Approaching Emerging Presbyopes

Emerging presbyopes want alternatives to eyeglasses. Successful Acuvue Bifocal wearers are enthusiastic patients. Almost 90 percent of patients wearing the Acuvue Bifocal are likely to recommend it to others. Even apparently successful monovision patients shouldn't be excluded from this presentation process. In addition to the education and referral opportunities, it may be difficult to assess what "success" is with monovision. A patient may express satisfaction with monovision if they perceive their only alternative as being reading glasses over their contact lenses or bifocal glasses.

Within our practices, there are several ways to present the bifocal contact lens option. To begin with, many of our insurance plans require a date of birth to verify benefits. Upon learning that a patient is well within the presbyopic years, the receptionist can mention the availability of a new disposable bifocal contact lens, suggesting that the patient ask the doctor about it during the examination. The office technician can also mention the availability, assess the patient's level of interest and note it on the exam form. This presents two opportunities to educate the patient before the doctor has even greeted the patient in the exam room.

Presentation and Expectations

Presentation can be critical in achieving success with the Acuvue Bifocal. It's important for patients to have realistic expectations, but the manner in which this is addressed can significantly contribute to the outcome. If we lack enthusiasm, how can we expect our patients to be enthusiastic? If we anticipate problems, won't our patients do the same?

There are several ways to positively present this option, while still creating realistic expectations. The key is to create enthusiasm, tempered with a small "dose of reality." I have found a high degree of success by doing an initial presentation prior to any diagnostic testing. I mention the following features of the Acuvue Bifocal to my patients:

• The lenses are made by Johnson & Johnson (mention Acuvue, if currently worn by the patient).
• The lenses have UV blocking built in, and a light tint to make them easier to find in the lens case.
• The contact lenses have a marking to tell whether they are inside out.
• (If no contact lens history) Almost 50 percent of the people successfully wearing the Acuvue Bifocal have never before worn contact lenses.

At this point, I stop the presentation, suggesting that we go through the exam to determine whether the patient might be a good candidate for this lens. In doing so, I have found that as soon as the exam ends, many patients ask whether they can try the new bifocal lens. I then offer a more detailed, yet simple description of the lens and expected results. Once, I heard a doctor describe the lens to patients as: "a concentric, simultaneous vision lens that has rings that alternate near and distance prescription." The description was completely accurate, but once he mentioned the phrase "concentric, simultaneous," the patient's eyes probably glossed over. Conversely, a simple explanation will ensure that the patient is nodding in understanding, rather than nodding off in confusion. I ask the patient to think about a "bull's-eye," with a central circle surrounded by rings. I tell them that the lens is designed like this, with a central circle of their distance prescription, surrounded by four rings, that alternate near, distance, near, distance. As a result, the lens does not need to be applied in a particular orientation; it doesn't have to rotate into a particular position; and it can spin around like an old phonograph record and still provide good vision. As a result of this design, near vision is not limited like it is with bifocal eyeglasses. Reading can also be satisfactory at eye level and above eye level. Near vision with this lens is typically outstanding, but it's possible we may have to make some modifications in distance vision. One of the benefits of this lens is that small changes are usually very effective, and diagnostic lenses are available to quickly make any prescription changes.

With this approach, I have presented the positive features of the lens, and the benefits to the patient. I have also touched upon the fact that distance vision may be an issue. I then continue by providing some realistic expectations, such as: "This lens should adequately take care of about 80 to 90 percent of your normal activities. For the other 10 to 20 percent, we have a number of options. Or, it is possible that you may not want to wear your lenses during certain times or activities. Those decisions will be based upon your feedback at the follow-up visit." Such other options, when indicated, present opportunities for "dual purchase," thereby increasing revenue and potential profits (it is noteworthy that a vast majority of patients wearing Acuvue Bifocal contact lenses also purchase back-up eyeglasses).

Whenever possible, the fitting process should commence immediately. While the patient is going through the 20-minute "settling down" period (which has proven to be critical in assessing the fit and increasing the likelihood of success), another patient can be seen. The "Acuvue Bifocal Contact Lenses Vision Checklist" covers specific vision needs, and will help to direct modification and decrease chair time. The flippers supplied by Vistakon (+/-0.25 and +/-0.50), effectively help to quantify modifications. When a change is clearly indicated, make the modification immediately. This will ensure that the patient remains motivated during the ensuing week leading up to the follow-up visit. I have also found that making such a modification decreases the overall number of follow-up visits.

Additionally, there has been a commensurate decrease in the number of "drop-outs" during the diagnostic period. I tell patients that I want them to be sure to return for the follow-up visit, because even a small change in the prescription could be helpful before ordering the initial supply of bifocal contact lenses.

There are approximately four million new presbyopes every year. A very small percentage of these people wear contact lenses. Rather than providing an alternative to other lenses currently available, the Acuvue Bifocal creates an entirely new marketing opportunity. It provides a tool to educate our patients, build loyalty, support recalls and create referral opportunities. The Acuvue Bifocal supports the "Three R's," offering a clear opportunity within the managed care arena.

Special Demonstration and Fitting Techniques

For prior monovision patients now wearing a bifocal in one eye and a distance contact lens in the other: If a patient is questioning the advantage of the "enhanced monovision" fitting technique (combination of a single vision distance lens on one eye and a bifocal lens on the other eye), versus the traditional monovision fitting technique, have the patient cover the eye with the distance contact lens. To simulate the difference between the bifocal lens and a near (monovision) lens, put a trial lens with the patient's ADD (e.g. +2.50D), in front of the eye wearing the bifocal lens. This should blur the patient's distance acuity and help him to assess the advantage of the bifocal lens versus the monovision near lens.

If a patient is being fit with enhanced monovision after unsuccessful attempts with bifocal lenses on both eyes: If distance acuity is unacceptable with binocular bifocals, the subsequent single vision distance lens is typically fit in the dominant eye. Rather than following this traditional approach, first determine whether there is a noticeable difference in near acuity between the two eyes. If so, keep the bifocal lens on the eye with the better near acuity, and fit the distance lens on the other eye (regardless of eye dominance or preference).