PART ONE
Bringing LASIK into Your Office
If you're merely waiting for co-management situations to improve, you may be missing out on the most important LASIK trend to date.
By Neil B. Gailmard, O.D., M.B.A., F.A.A.O.

There's a revolutionary trend developing in optometry, and it could change the types of vision care services we offer -- and the way we derive income. Optometrists are beginning to provide laser refractive surgery as part of their practices.

I'm not talking about laser consulting services, co-management or even co-ownership of a nearby laser center. I'm talking about building a laser surgery suite within the office, leasing or buying an excimer laser and bringing in a surgeon and specialized team to provide the whole service on-site -- in your practice.

Give it a try

A big difference exists between providing total laser vision correction therapy and operating within the referral-based models we're used to. My partner and wife, Susan, and I opened our own laser vision practice last April. Our first day of in-office surgery was June 2. Since then, we've noted several significant trends in our practice, including the following:

• Increased patient volume. Not surprisingly, we've seen a major increase in patient volume in our practice since we added our new specialty.
• Greater need for all of our services. Offering laser vision correction has garnered new interest from the entire community. Of course, not all patients are ideal candidates for refractive surgery; many are better suited for contact lenses or spectacles. But we were surprised to see that many of the family members of new laser-assisted in situ keratomileusis (LASIK) patients have visited us for traditional optometric services.
• An increase in new patients. It's also interesting to note that about half of the patients who've undergone LASIK at our office have been new to our practice. We have a large patient base, but it's too small of a pool of people to attract large numbers of laser vision patients. Once we made the commitment to offer the procedure, the people who were interested called us.

As you can see, our practice has undergone a very exciting and rewarding transition -- one that could add a whole new dimension, or even change the course of your practice, as well.

This month, in part one of a three-part series, I'd like to give you more information about this exciting new trend and explain how it could change the way we traditionally practice optometry. In part two, which we'll publish in February, I'll discuss step by step what to do to set up this refractive option in your practice. Then, in March, I'll wrap up the series with advice on how to market this new option to your patients.

Will optometrists do the procedure?

Eventually, I think O.D.s will have the legal option to become trained and licensed to actually perform a laser surgical procedure. But I'm not sure how long it will take for this to happen, and I'm not going to idly sit by and wait while LASIK prices continue to drop, cutting many O.D.s out of co-management by default. Market share and practice reputations are being built right now.

I commend Oklahoma and Wisconsin for their legislative efforts to allow optometrists to use lasers, and I encourage the schools of optometry to push the envelope in training our students for the future. However, I need to position our practice as a leading laser vision specialist now. Providing the service in my office with our own laser and our own surgeon on staff is a great way to start. This has poised us for greater participation in laser vision correction as laser technology develops and as optometric training increases.

In the beginning

When I first graduated from optometry school in 1976 and started my practice from scratch, I evaluated the competition among optometrists, ophthalmologists and opticians. I understood the strong points of optometrists and ophthalmologists, but I remember thinking that the independent optician was at an extreme disadvantage to me because he or she couldn't refract or prescribe glasses.

When I looked closer at the opticians who were most successful, I realized that in many cases they'd simply bought a lane of exam equipment, designed an exam and contact lens area and hired an optometrist. Many of them did very well, earning excellent reputations in the vision care market and growing into strong, profitable operations. I hope my venture into laser refractive surgery will take the same path.

Why do it in-office?

When I refer a patient to a laser vision center, I'm not concerned that I won't see that patient back for follow-up care. It's common practice for centers and surgeons to return patients to the referring doctor. I'm concerned about the future word-of-mouth referrals from that patient. And, you'll have a lot of them. Some studies estimate at least 10 new patient referrals come from each happy LASIK patient. I'm convinced that I'd have missed most, if not all, of these referrals if I'd continued working within the present co-management models.

My not receiving referrals may even be quite innocent on the part of the laser center or surgeon. They may not be trying to actually "steal" patients, but referrals just naturally flow there. My practice received very few referrals for LASIK when we were in the co-management model, but we're receiving many in the full-service model. If we look at the process of the word-of-mouth referral, we can break it down into two critical points.

• Starting at 1-day post-op and continuing for the next several weeks, the LASIK patient is generally ecstatic. He's seeing great without glasses or contacts, and the recovery is very easy. He's quite proud for going through with the procedure, and he wants to tell everyone he sees about his experience.
  You can't get a much better practice building tool than this. Unfortunately, when everyone asks him where he underwent the procedure, he'll tell his friends and family the name of the laser center. He may even say the name of the town where the laser center is located and give the name of the eye surgeon who performed the procedure.
  However, I think you'll find that more often than not the patient won't mention his O.D.'s role in the process at all. Or, if he does, he'll position it as secondary in the process. This seems unfair because the referring patient may have been in the optometrist's practice for many years, and the O.D. also provided valuable counseling and pre- and post-op care.
• How does the laser center handle the call if a potential LASIK patient does bypass the co-managing O.D. and make a direct referral? Keep in mind that the caller I'm referring to isn't the O.D.'s patient -- just a friend of the O.D.'s patient, so there's no real loyalty. The response depends on the center's philosophy, and that may depend on who owns the center. But problems can develop in any case. Does the center accept patients directly? Does it ever provide primary care and pre-op and post-op services?
  If so, the original optometrist has lost the referral. Centers that have policies not to see a patient who calls without a referral may feel forced to change that philosophy as the laser market changes. Even if the center doesn't provide primary care at all, the center staff will generally give prospective patients a list of local O.D.s who participate with them. So, unless the new patient specifically asks for you, he may end up going to one of your colleagues.
  In addition to capturing the referral network, offering laser vision correction in your practice delivers important advantages to your reputation as an expert and leader in the fast developing field of laser vision correction.

What business are you in?

Successful firms of all types have learned not to define their businesses too narrowly. Companies that haven't changed with the times have suffered, or perished. Examples include:

• typewriter companies that thought they were in the machine business, rather than word processing and printing
• encyclopedia publishers that thought they were in the book business, rather than the information business
• railroad firms that thought they were in the train business, not the transportation field.

As optometrists, we're in the vision correction business. Refraction is our mainstay, and as technology brings new forms of refractive therapy, we must embrace them and become leaders in providing them. We're not just in the exam, eyeglass, contact lens and eye drop business.

Now, that's not to say that we can't survive if we don't participate in laser vision correction, but do you want to? Do you see laser vision correction as an opportunity or threat? I think it can be either, and it depends on how you position it in your practice.

If you seem to be seeing a lack of interest in LASIK among your patients, it may be because they're already perceiving that you don't do it. And those who are interested in the procedure will quietly go elsewhere. Some aren't interested now, but they may be someday. In my view, we must embrace change.

The future of laser vision correction

The trends we're seeing now tell us what's likely for the near future. We'll continue to see erosion of LASIK fees in the competitive marketplace. We'll see corresponding reductions of co-management fees, and some laser centers may eliminate them. The range of patients who are ideal LASIK candidates will expand, while excimer lasers will become smaller, more portable and less expensive to buy or lease.

The newer laser designs are contained in a machine that's the size of a large photocopier. Lasers are already available on what's termed a roll-on/roll-off basis. This allows many users to share the cost of the laser, and it makes the per-eye use of the machine affordable.

Also, lasers are more portable than ever. Special trucks with custom suspensions and power lift machines on wheels transport the laser from one location to another. A laser technician calibrates the device at each site. Many laser centers, M.D. offices and some O.D. offices acquire lasers this way.

Routine procedure?

Technological advancements and surgical experience will also make laser vision correction more accurate, less risky and more accepted. Couple that with low fees, and who knows where it will lead in 10 or 20 years? A laser vision procedure may become as common and simple as having a tooth filled.

In part two of this article, I'll focus on how we set up our laser vision practice, including the amount of space we allotted, the amount of money we spent, and more. Our experience may help you avoid any pitfalls of adding this valuable service to your practice.

Dr. Gailmard is in practice at Gailmard Eye & Laser Center in Munster, Indiana, and he serves as Chairman of the AOA's Practice Management University.