Article Date: 10/1/2008

Has Your Patient Gone Off Schedule?
COMPELLING PATIENTS TO COMPLY

Has Your Patient Gone Off Schedule?

Noncompliance with wear and replacement schedules can cause health and comfort problems. Here's how to detect problems and address them quickly.

Dr. Eiden: Of the more than 37 million Americans wearing contact lenses, about 7% to 8% will drop out.1 What's more, compliance with prescribed contact lens replacement schedules is poor, especially for certain contact lens replacement schedules.

Compliance, with regard to contact lens care regimens, has grabbed the headlines recently, but poor adherence to lens replacement schedules also can impact wearing comfort and vision quality and may increase the likelihood of infectious and inflammatory events. As practitioners, we're not only prescribing lenses, we're also prescribing the lenses' appropriate care systems and replacement schedules.

MEDICAL PROBLEMS AND DROPOUTS

Dr. Sclafani: My practice serves as a tertiary center, so we see many referral cases of contact lens-related ulcers and microbial keratitis. Quite often, the cause is abuse of the wearing schedule. In most cases, patients aren't ignoring direction in order to save money — they simply never had the proper education and follow-up care.

Dr. Curtis: I see many new patients who have a red eye, and the majority of them have infiltrative keratitis due to over-wear of their lenses. And like Dr. Sclafani, I've learned that education, not frugality, usually is the problem.

Dr. Eiden: Are patients who don't comply with replacement schedules more likely to discontinue contact lenses?

Dr. Feder: Absolutely. And they're more likely to be noncompliant in every way. When we see any type of noncompliance in new patients, we'll prescribe a daily-disposable modality right away. It's healthier for them, and we eliminate the solution issue. The replacement compliance rate is about 87% for Focus DAILIES.

DETECTING NONCOMPLIANCE

Dr. Eiden: In your practice, Dr. Keech, what are the indications that patients aren't complying with their replacement schedule? Is it biomicroscopy findings? Or is it more casual? For example, when you advise a patient you're going to order his next supply, and he replies, "I have plenty right now."

Dr. Keech: We ask the right questions, like "How old are the lenses you're wearing?" "How often do you replace your lenses?" and "What solution are you using?"

We also insist that patients wear their lenses to the examiation. When I do my initial biomicroscopy, I see the lens in vivo, determine the condition of the lens, evert the lids and perform fluorescein staining after lens removal. These are key elements in the exam, and this gives me the perfect opportunity to address compliance issues and review the solutions, wearing schedules and replacement requirements.

What to Ask …
• How often do you replace your lenses?
• How old is your current pair? How long have you had them in?
• What's your average/maximum wearing time?
• How do you rate your comfort/vision on a scale of 1 to 5?
• What solutions are you using?
• Do you sleep or swim in your lenses?

TREADING CAREFULLY

Dr. Eiden: One of the things I've learned over the years is to avoid being judgmental with noncompliant patients.

Dr. Keech: Absolutely. Instead of focusing on what they've done wrong, I want to educate them on why compliance is important. If they understand some of the physiology, the science and the history behind it, it makes a positive impression. A fact-based explanation about the importance of compliance will be more successful than a lengthy lecture on their noncompliance.

I might say, "We've found that contact lenses are like sponges, and they deteriorate over time." I also tell some patients, "You know, when soft lenses first hit the market, we tried to make them last as long as possible. It took us a while to learn that extending the life of the contact lens can lead to complications." Finally, I tell patients that by the time they feel the symptoms of a problem, it's too late.

Dr. Eiden: I tell patients that disposable lenses were developed to avoid the complications that they're experiencing, but for the lenses to function as intended, adherence to the replacement schedule is very important. CLS

REFERENCE

1. Barr JT. 2004 Annual Report. Contact Lens Spectrum. 2005;20:26-31.

Choosing a Modality

For patients who aren't following guidelines, a change of modality may be a step toward a healthy, successful outcome.

Dr. Eiden: Just as poor compliance can cause complications, proper compliance can result in healthier eyes, greater comfort and less temptation to end contact lens wear. All of this ultimately leads to greater patient satisfaction and practice profitability.

SCHEDULES FOR NONCOMPLIANT PATIENTS

Dr. Eiden: How do you select schedules for patients who aren't complying with their replacement schedules?

Dr. Sclafani: If the exam or history indicates they're over-wearers, I put them in an easy modality — daily or monthly. I switch them to a modality that will fit their lifestyle.

Dr. Eiden: When your patient has been noncompliant with a 2-week lens, stretching out the replacement schedule, do you typically suggest he switch to a daily disposable or a monthly? What goes into your decision-making process?

Dr. Keech: I tend to look at things from the patient's perspective. I've been a monthly replacement advocate since the advent of disposable lenses, because I didn't experience good patient compliance with 2-week replacement schedules. But as materials have developed over the years, I've approached lens selection based on materials, rather than replacement schedules. I think we always need to go with the very best technology available for the patient, so I determine what's best for the health of the eye, and then fit each patient based on those precepts.

Dr. Sclafani: It's also important to avoid prescribing the same thing over and over again, and always emphasize that you're providing new technology. "Last year, we didn't have this…." Let patients know you're switching them to something better, not just different. Also, if you're stretching a 2-week replacement lens to a 1-month replacement schedule, you're medically and legally obligated to do a follow-up.

Suggested vs. Prescribed Schedules
Dr. Eiden: According to recent data from Health Products Research Inc. (HPR), there's a divide between the replacement schedules that manufacturers suggest for certain contact lenses and practitioners' prescription patterns. Specifically, practitioners are moving toward monthly and daily lenses, and away from 2-week schedules, sometimes even prescribing 2-week lenses to be worn for a month. Do you follow the manufacturers' suggested replacement schedules for a given lens type?
Dr. Sorrenson: When we average the numbers, people are wearing 2-week lenses for just 5 fewer days than they're wearing 1-month lenses. From a practice management and financial standpoint, that's just absurd. The profit is in selling a year's supply of monthly lenses to be worn monthly – not half a year's supply of 2-week lenses to be worn monthly.
Dr. Eiden: Dr. Feder, do you ever say, "Listen, I've worked with this lens. It works fine for a month, and I'm going to use it for a month?"
Dr. Feder: I think that's ludicrous, but I don't have a problem going the opposite way. I might have a patient wear a monthly lens for just 2 weeks under certain circumstances. As I said, I generally don't like the 2-week modality. I think it's suicide for a contact lens practice. But more importantly, what's healthy for the patient is healthy for the practice. We want patients to use the healthiest option, and that usually means adhering to the manufacturer's recommendations.

TRANSITION TO DAILY

Dr. Eiden: How do you position daily disposables in your practice, considering all of the reported advantages for both compliance and health?

Dr. Curtis: Daily disposables have evolved in my practice over the last 3 or 4 years as the largest-growth contact lens modality. Particularly, I was amazed how quickly parents adapted to daily replacement modalities for their teenagers. When we talked about replacement compliance with 2-week lenses, parents responded with, "I struggle with this at home. I'm really worried that my son isn't changing his lenses enough."

Dr. Feder: Seven years ago, when I first fit my daughter in contact lenses, she was 10 years old. It was automatic for me to choose daily disposables, because they were simply the best option. Then I thought, why would I treat any child or teenager in my practice differently? Eventually, I came to believe that daily disposables are right for all patients who can wear them.

COST VS. VALUE

Dr. Eiden: What advice would you give to practitioners who have been reluctant to prescribe daily disposables, based on what they perceive as cost issues for patients?

Dr. Feder: They're making a mistake. First, the cost for daily disposable lenses is very close to the 2-week modality when you factor in the solutions, lost lenses and the annual supply rebate. We as practitioners can't ignore our obligation to choose the best contact lens for every patient. We should educate them about all of the available lenses, rather than just assume they won't want to pay for daily disposables. Most people are willing to pay more for an increased value or benefit.

I tell patients they can have better comfort, convenience and health with a daily replacement contact lens. I suggest they try DAILIES for 1 to 2 weeks, then return to me for follow-up. When patients return, they usually understand the value of the lenses, so the cost is no longer an issue.

The "take-home" or diagnostic daily disposable contact lenses sell this modality, because patients love them, and that's how we've been successful. Patients often say, "Why didn't my previous doctor recommend these?" CLS

Education: Your Best Tool for Compliance
Teach patients the rules for their contact lenses – and the importance of following them.

Dr. Eiden: What's the importance of sticking to the replacement schedule? Patients who know the answer to this question are more likely to comply than those who don't. Who teaches patients about contact lens replacement in your practice?
Dr. Sclafani: I do it myself, and I take a very friendly approach. I say that I'm a contact lens wearer, and "I used to do that, but then…." When I admit weakness and empathize, they open up. And my view under the slit lamp is the truth test. I look and ask, "When did you really change that lens last?" They'll admit that they're stretching the schedule a little — which usually means a lot!
Dr. Curtis: The exam gives me an understanding of what patients are doing. I applaud compliance or address noncompliance myself.
Dr. Eiden: Patients sometimes want to avoid disappointing the doctor. I tell them, "If you're expecting a guilt trip, I'll give you my mother's phone number, but you won't get one from me!"

Contact Lens Agreement
Dr. Eiden: How do you and your staff explain the importance of replacement compliance for new fits and your re-fits?
Dr. Sorrenson: We have an annual contact lens agreement for new patients, but we also have an annual contact lens agreement form that we review with each patient during their annual contact lens exam. Our staff reviews the information with patients, checking off instructions for their solutions, lens replacement, addressing issues like red eye, annual lens supply costs and so on. The last question is, "Did the doctor answer all of your questions?" Patients then ask more questions and check "Yes." Then they sign the agreement along with the technician. The form has worked for 15 years. Noncompliance is much less common, and I never hear my patients say, "Nobody told me."
Dr. Sclafani: We address lens replacement, too. Patients email my assistant or me, and we deliver. It's as easy as ordering lenses online. Our contract also lists "do's and don'ts" that are based on the AOA Contact Lens and Cornea Section guide "Do's and Don'ts of Contact Lens Wear."
Dr. Keech: When patients have a contract, they know they need to share responsibility for the success of their lens wear. They're signing a commitment to healthy vision and correct contact lens use.

Technology's Role
Dr. Eiden: Does anybody in this group use technology to emphasize the importance of compliance?
Dr. Sclafani: We use digital imaging. The slit lamp pictures are on a monitor, and I tell patients, "This is your eye, and it looks great. You're doing a good job. But see these blood vessels here, or this little spot there…." Sometimes, there's a scare factor, because I can show them an ulcer or other potential problem on the screen. That drives the message home.
Dr. Eiden: In our practice, we have in-office video information systems that continuously play short pieces about compliance. We're also thinking about emailing instruction sets to patients or automatically emailing patients when it's time to replace their contact lenses. Certainly, computers and other technologies are well-suited for systematizing compliance education and follow-up. A systematic approach is the best way to succeed.

Do Some Schedules Influence Compliance?
Dr. Eiden: Although we know there are compliance problems with contact lens replacement across all modalities of lens wear, studies suggest that certain replacement schedules are associated with higher compliance rates. Specifically, daily disposables have had the highest rate of replacement compliance — over 90%, compared to 66% for monthly schedules and 48% for 2-week replacement modalities.1 In your experience, have you found that patients comply with some replacement schedules better than others? And why do you think compliance rates with 2-week lenses are so poor?
Dr. Curtis: Not long ago, I believed strongly in a 2-week replacement modality. But patients began stretching their replacement interval from a little beyond 2 weeks, to 3 weeks, to 4 weeks. So I decided to emphasize a monthly-wear product, and in the last few years, I've been prescribing a 1-month lens for extended wear or a daily disposable for daily wear patients.

REFERENCE
1. Bailey GM, Shovlin JP. Compliance and contact lenses. RCCL; 2006; March:2-3.

Making a Profit

Use quality lenses and healthy wearing schedules to build a financially healthy practice.

Dr. Eiden: Patients' health and profitability are by no means competing goals. Making patients healthy and happy boosts the bottom line — with a little help. How do you ensure contact lens profitability?

SMART FEES

Dr. Keech: The best thing we did years ago to build profitability was enact an annual contact lens evaluation fee. Instead of including the fee in the cost of lenses, we priced our contact lenses very competitively. This appropriately raises the value of your services and emphasizes the importance of those services to patients. And I think it guarantees an increase in your bottom line.

Dr. Eiden: That relates again to perceived value. We're constantly looking at new contact lens technologies, and we make patients aware of this, so they know there's a reason to return. We may have something new and better for them. And I think the perceived value with that annual fee becomes self-evident.

Dr. Feder: That's an excellent point. The two most important strategies for contact lens profitability are fees and contact lens sales. Optometrists have been under-charging patients for many years, and now practitioners are realizing that they need to charge more appropriate fees for contact lens evaluations and re-fits.

Dr. Curtis: I agree. Carefully evaluate your fees and know what they should be. Understand the marketplace for contact lenses, and you'll have a very healthy contact lens practice.

Dr. Sclafani: Don't forget that patients in your exam room often have dry eye or blepharitis, so there's medical billing. That's a huge part of my billing at the hospital, where we charge for every visit based on coding guidelines, how many lenses I give them, my time commitment and how much work my staff does with the patient.

IN-OFFICE SALES

Dr. Eiden: Daily disposables may be the greatest commodity in contact lenses because we replace them so frequently. How do you address contact lens purchases with daily replacement wearers in your private practice?

Dr. Feder: For the health of the practice, we want patients to purchase lenses from us. We price competitively and offer services that mail-order companies don't offer. If there's any issue, patients can hand them back to us — there's nothing to mail. We make them understand that we have the convenience that they want, and that's why we're successful. Again, they respond to the perceived value.

Dr. Eiden: What does that discussion sound like?

Dr. Feder: I take what I call an "assumptive sale" approach. I don't ask patients what tests they want — I educate them about the tests I'll be performing, and I tell them, "We're going to order you this year's supply today." It's successful. If they say, "Can I get them elsewhere?" I say, "Of course." But I explain the differences between buying from us and buying from another source, and typically they choose us. We carry a large inventory of daily disposable lenses and usually dispense them to the patient that day.

Dr. Curtis: I'd add that if you want less inventory, selling to patients via direct delivery is a very close second. Often, the contact lens manufacturer will deliver quickly and efficiently to the patient's home or workplace in 3 days.

Dr. Eiden: In terms of annual-supply costs, the price looks very different to patients up front. Two-week lenses cost roughly the same for lenses, solutions and so forth, but they don't buy all of those items at once. They buy an annual supply of daily disposable lenses, and that's a large sum up front. Do you address this difference?

Dr. Feder: We try to sell an annual supply up front at a discount. But if that's too much, we encourage patients to stick with the healthier, more comfortable modality and get a 6-month supply now, followed by another in 6 months. We give them the same discount. But most patients are willing to buy the annual supply up front. After all, parents don't blink when the dentist says their child needs braces. What's $300 a year for 730 contact lenses?

ALTERNATE DELIVERY

Dr. Eiden: Dr. Feder said that contact lens sales are half of the 2-part strategy for healthy profits. Do the rest of you feel the same way?

Dr. Keech: I'm very upfront about giving patients their prescriptions and saying, "If you want to buy them today, you can do that," but I don't want to pressure them at all. I point out the rebates, tell them that we'll replace defective lenses, and help them out if they need carryover lenses, and most patients do purchase their lenses from us.

Dr. Eiden: What about the Fairness to Contact Lens Consumers Act? How do you communicate with patients about alternate ordering and delivery modalities?

Dr. Sclafani: First of all, I want my patients to know that I'm not necessarily the only source for their lenses. They can choose to get them anywhere. Sometimes they feel guilty about asking to get contact lenses elsewhere. So I say, "You can get your lenses wherever you'd like." And we hand them their prescription as they leave. I would say that 90% of my patients purchase their lenses through us anyway, because they trust us. They know they're going to get the right lenses, and they know we're here for them when they need us.

Key Steps to Ensure Profitability
To increase contact lens profitability, you need to take some key steps:
Focus on efficiency. Consider technician scribing and empowering your staff to do more in your office.
Don't accept "Fine." Patients who say they're fine may still have problems, so be sure to ask a question such as, "If you could change one thing about your contact lenses, what would you change?"
Simplify. When patients are doing well, we don't need to see them two, three, four or five times like we did with conventional lenses.
Offer patients changes. Every 2 to 3 years, consider changing the modality, material or solution a patient is using.
Review your fees every year. Many doctors forget to do this, but it's important.
Learn how to bill for medically necessary contact lenses. Most doctors don't know how to do this appropriately.
Supply your patients' lenses. Make the assumption that they'll buy from you. Include the price of the annual supplies in the contact lens fee agreement.

— Laurie Sorrenson, O.D., F.A.A.O.

LOYAL PATIENTS

Dr. Eiden: When you educate your patients about the importance of compliance and emphasize all aspects of safety in contact lens wear, it increases profits directly in terms of lens sales. But does it enhance profitability in other ways?

Dr. Keech: Yes. I believe that a great deal of dedication and loyalty comes from giving patients a service that's unique. If you stay current and you're aware of the latest technologies, people will find you and stay with you. I think this is a wonderful profession, because there's so much opportunity to say, "I want to make myself competent in this area," and just do it. Right now, we have the best products, the most choices, and the healthiest lenses we've ever had, and it's a great opportunity for anyone who wants to expand.

LESSONS LEARNED

Dr. Eiden: Wikipedia defines medical compliance as "a patient agreeing to and undergoing a treatment program as prescribed by their doctor." Clearly, prescribing and compliance go hand in hand. We must take the responsibility of prescribing contact lens systems for our patients. These systems include prescribed contact lenses, required care systems and equally important — the recommended replacement frequency of the lenses.

Failure to comply with replacement guidelines for contact lenses affects our patients' wearing comfort, the quality of their vision, the likelihood of ocular infectious and inflammatory events, and increases the potential for discontinuation of contact lens wear. Additionally, poor contact lens replacement compliance impacts our practice's bottom line.

Our panel has presented the methods they've incorporated to maximize contact lens replacement compliance. Selecting lens modalities that result in higher replacement compliance rates, dedication to patient education, implementing effective practice management systems and emphasizing communication between our patients and the contact lens practitioner are elements that will result in a win-win situation for all involved. CLS



Contact Lens Spectrum, Issue: October 2008