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Eyeball Hardball by Marc Borbely Tuesday, September 4, 2001 This article is wholly owned by the author and The Washington Post. 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. | |||||
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