Eyeball
Hardball
By Marc Borbely
Special to The Washington
Post
Tuesday, September 4, 2001; Page
HE01
As the Lasik vision-correction business has developed over
the past five years from an obscure ophthalmological specialty to a
highly competitive mainstream service, some laser surgery centers
have adopted more sophisticated sales techniques. Some advertise a
low price but encourage customers to pay more; some offer extended
coverage of follow-up services at additional cost. Some centers
reward office-wide sales performance with bonuses for all staff. One
center, Laser Vision Institute at Tysons Corner, pays its patient
counselors commissions and bonuses for each patient they sign up.
Counselors there have also used a sales technique taken directly
from the auto sales playbook: the faked consultation with a manager
to secure a lower price for the client.
Some Lasik centers still do business the "old fashioned"
way, with predictable prices and little sales effort beyond the
time-tested techniques of word-of-mouth and referral.
But with some Lasik customers facing higher pressure to
commit during consultation, it's more important than ever to know
how to find unbiased, complete information about the procedure's
risks and benefits. The process isn't easy or fast, but it's
necessary if you intend to approach the procedure with your eyes
wide open.
The key is to depend as little as possible on sources of
information provided by those who have a vested interest in your
decision. Following are some ideas to guide you.
1. Trust No One
Let's say a friend tells you great things about the surgery
he or she got at a certain laser eye center. Your friend may be
sincere and may have the best intentions. But your friend may also
benefit from your decision. One laser firm, LasikPlus, pays $50 to
patients who refer friends and family who end up having the surgery
done. Another firm, TLC, has offered discounts to former patients
who are willing to talk to other potential patients about their
experiences.
It's safe to assume that your friend would not knowingly
put your eyeballs in jeopardy for $50. But the money might determine
which friends with Lasik experiences you're hearing from, and how
enthusiastic those friends are. A friend's positive recommendation
is always valuable. A friend's positive recommendation for which he
or she may make $50 is slightly less so. Your job is to find the
best center for you, not for your friend.
2. Not Even Your Eye Doctor
Your optometrist or ophthalmologist might also have an
incentive to direct you to a particular laser center. Most centers
in the Washington area have engaged in "co-management" relationships
with optometrists that allow the eye doctors to provide patient care
before and after surgery for a certain fee.
These arrangement essentially make your optometrist an
agent for the laser center. The ethics and legality of such
arrangements are being debated across the country, the issue being
whether optometrists are being paid for referrals, which would be
illegal, or just for their work, which is legitimate. For patients,
the question is whether, absent this financial and professional
interest, your doctor would send you to the same center anyway. Your
goal is to find a center that will provide the best surgery, an
honest assessment about your likely outcomes and risks, quality
follow-up care and a fair price. Perhaps your doctor will send you
to that place. Perhaps not. The point is, again, that you need to
make the best decision for you, not for your doctor.
3. At Lower-Priced Centers, Expect to Be "Upsold"
Some laser centers advertise very low prices but try to get
patients to pay more. While the lowest advertised price may indeed
be available -- if it's not available at all, that's an illegal
"bait-and-switch" -- many companies have a "tiered pricing"
structure with a variety of prices and options.
The lowest price offered by Laser Vision Institute in
Tysons Corner is available only to those who need very little vision
correction or have no or very minor astigmatism -- characteristics
that apply to a small percentage of Lasik shoppers. At LasikPlus,
prices depend on which laser you choose for the procedure and how
long after the surgery follow-up surgeries are included. The lowest
price offered by TLC is available only if you have a special company
plan or are covered for the procedure by insurance, which is rarely
the case.
So if you decide to patronize a center that advertises low
prices, expect to be offered the opportunity -- or to be required --
to spend more. But even the highest prices charged at "discount"
centers are less than the lowest prices at a higher-priced company.
LasikPlus offers prices between $499 and $1,299 per eye; at TLC, the
range is $1,800 to $2,750 per eye. The average price nationally was
$1,628 per eye during the second quarter of this year, according to
market analyst David Harmon.
4. Seek Independent Information Sources on Risks
Statistically speaking, chances are very good that your
Lasik surgery will go well and you will suffer few if any lasting
negative side effects. Still, you want to go into this well aware of
the risks you face. Unfortunately, you may not get a balanced
depiction of risks and benefits if you stick to the most obvious
sources: advertisements, company or physician Web sites, or the free
consultations offered by many Lasik centers.
Advertisements paint such a rosy picture of Lasik that it's
hard for even a conscientious physician to persuade patients that
this is serious surgery that carries some risk and no guarantees of
excellent outcome, said Samuel Packer, ethics committee chairman of
the American Academy of Ophthalmology.
Staff and doctors may tell you that if a procedure doesn't
get you to your desired prescription the first time, you can simply
have another go at it. This is often true. But follow-up Lasik
surgeries are not always possible, for one thing because each
surgery reduces the thickness of your cornea. Ultimately it may
become too thin to withstand more surgeries. Also, follow-up
surgeries carry their own risks. The U.S. Food and Drug
Administration (FDA) says no laser company has presented enough
evidence for the agency to make conclusions about the safety or
effectiveness of enhancement surgery.
To emphasize that there can be serious consequences to
laser vision correction, Packer sends all his patients interested in
Lasik surgery to the Web sites of the FDA and to the site for Surgical
Eyes, a group representing people who have has unsuccessful
laser eye surgery.
5. It's Not a Consent Form, It's An Informed Consent
Form
The law does not dictate how doctors inform patients of
surgical risk, but all medical ethics codes require that patients
understand and accept the risks involved before undergoing surgery.
This is normally addressed via an informed consent form, which
patients must sign before surgery.
In practice, says Barbara Koenig, executive director of the
Stanford University Center for Biomedical Ethics, doctors too often
treat the informed consent process as a way to protect themselves
from lawsuits rather than as an opportunity to help patients
understand risks.
Any reputable center will permit you to see and take home
the informed consent papers before committing to the surgery.
Some patients have been informed right before surgery of
reasons their eyes are at increased risk of complications. Often the
meeting in which the surgeon relays this information marks the first
time the surgeon has met the patient in person. If this happens to
you, thank the surgeon for his or her honesty, cancel surgery for
the day and go home to reconsider your decision. No one should be
asked to make non-emergency medical decisions under pressure.
6. Educate yourself about personal risk
Ron Link, director of the Surgical Eyes Web site, whose
bulletin board is frequented mainly by people with bad Lasik
outcomes, says many serious problems occur when people who should be
medically disqualified are given the surgery anyway. "I would say
the majority of people at Surgical Eyes were told they were
excellent candidates, when in fact they were not," he says.
But the problem is, you are not qualified to assess whether
you are a good candidate for the surgery -- a medical evaluation is
required. Some background can help you ask useful questions if you
are told, in terms that make you uneasy, that you are a "good
candidate."
Candidacy is based largely on four numbers: your degree of
nearsightedness or farsightedness (measured in diopters, not in
"20/80" terms); your degree of astigmatism; your pupil size (in
millimeters); and your corneal thickness (in microns). Since you'll
need measurements for both eyes, you'll need a total of eight
numbers.
You can gather much of this data by accepting the free
consultations many centers offer -- ideally, more than one. You may
be surprised, or alarmed, to find that some of the measurements come
out differently at different centers. If this happens, and you have
genuine concerns about how well suited you are for the procedure,
you may want to pay for an examination from an ophthalmologist who
has no connection to any surgical center.
Insist that the surgeon who would operate on you review
your medical chart and discuss your personal risk levels. If a
center says you need to put down a deposit in order to do that,
you'll need to decide whether to proceed or seek another center.
Some centers offer a free consultation but charge a fee for the
required complete eye exam.
As you and your doctor discuss the numbers, there are some
things to keep in mind. The higher the degree of vision correction
you need, the more risk is posed by large pupils or thin corneas.
Make sure the physician talking to you has measured your pupil size
in the dark, when pupils are largest, to most closely approximate
night conditions.
If in the dark your pupils get especially large (bigger
than 6 millimeters, the FDA has told patients using one laser,
though this number may be laser-specific and no one is sure how big
is too big), you are at increased risk of experiencing post-surgical
glare and haloes, which may keep you from being able to drive at
night. For some people, night vision is more important than for
others, and that's a risk that needs to be carefully thought
through.
Dry eyes are another emerging risk factor for bad outcomes.
If you have chronically dry eyes, discuss this matter with your
doctor. Lasik surgery can dry your eyes even more, and the FDA says
this post-surgical condition may be permanent for some. You may wish
to reconsider having the surgery, despite an exam that otherwise
suggests you're a good candidate.
7. Know Thy Surgeon
First, find out whether your surgeon is board-certified in
ophthalmology. (To be certified, doctors must complete at least five
years of post-medical school training, pay about $2,000 in fees and
pass written and oral exams.) This is a minimum credential. Beyond
this, ask if he or she has completed a fellowship as a "corneal
specialist," which involves post-residency study and training.
Doctors who know the cornea intimately are more likely to manage
surgical complications well, which is precisely what you want if
your procedure goes anything but routinely.
And of course, when seeking a surgeon there are plenty of
things to consider, like where he or she went to school and where he
or she has published, but these things don't say much about surgical
ability. There's always the time-tested trick of asking people you
know and trust for recommendations.
Just be sure to read Numbers 1 and 2 above before you make
an appointment.
© 2001 The Washington Post
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