Prevent Dropouts & Dropped Revenues
Once you understand the problem, the remedy is simple: 30 seconds of your time.
DR. MARSDEN: Dropouts happen to all of us, and they affect our practices in very concrete ways. Still, I think that some of our colleagues aren’t focused on preventing dropouts, to their detriment. Let’s start framing our discussion of dropouts in terms of how they happen — the slide from dropoff to dropout — and then we’ll talk about how to prevent it.
DR. DUROCHER: Dropoff is when patients’ wear habits start to fade. They wear their lenses fewer hours per day, and they don’t necessarily wear them every day. When they need to have superior vision, they may rely on their spectacles. Their contact lenses just don’t perform at the level they used to and they’re less comfortable, so patients use them less.
DR. MARSDEN: So, they go from full time to part time to no time?
DR. DUROCHER: Yes. It’s a continuum from dropoff to dropout, or “no time.” I don’t think that there’s a moment when patients decide to stop wearing their lenses. They just wear them less and less and finally say, “Enough already.”
DR. MARSDEN: How can we get over the psychology of the contact lens wearer life cycle? Patients start out, robust 18-year-olds wearing contact lenses all day, every day, for every waking hour. As they get a little older, it’s a little more of a hassle. The lenses aren’t as comfortable. Eventually, often around middle age, they convince themselves that they don’t want to wear contact lenses anymore.
DR. RUMPAKIS: I see the same progression, but I look at the psychology a little bit differently. I think patients who wear contact lenses for decades often perceive themselves as experts in contact lenses, their wearing habits and their eyes. They tend to follow our recommendations less and less as time goes on.
As a result, I don’t think that dropouts rise at age 40 primarily because of presbyopia; I think patients who have been wearing contact lenses for 25 years say, “I know my eyes and contact lenses better than my doctor does. I know exactly how my eyes feel and react to different products. I know what to buy at this point. I don’t need advice about new contact lenses or solutions.” And they aren’t proactive about telling us their symptoms because they think they have the answers. They’re certain they’ve “heard it all before,” and they don’t expect new innovations to address the problems they’ve been dealing with for years. This is why it’s so important for us to be proactive and engage in that conversation with patients.
Identifying Potential Dropouts
DR. MARSDEN: Ideally, we’d like to identify potential dropouts earlier in the continuum, when they’re starting to drop off or even before they notice a problem. That way, we have the opportunity to intervene and prevent dropout. How can we do that?
DR. DUROCHER: The only way to do it is through smart communication with our patients. We have to ask specific questions. If we ask, “How are you doing with your contact lenses?” they say, “I’m doing great.” That’s not enough. It doesn’t tell us anything.
DR. MARSDEN: So, do you use a questionnaire or consumer survey? Do you ask how many hours they wear lenses or how their shopping habits compare to 2 years ago? Do you add maximum wear time to your case histories?
DR. DUROCHER: I think it needs to come from us, not from a questionnaire. It doesn’t have to be a long conversation. It’s a brief exchange. And it has more value because patients want one-on-one communication with us. We all have our technicians get a history and a workup, and then patients tell us something completely different during the visit. They want to talk to us, and that’s a good thing.
DR. GEFFEN: That conversation gives us more information than any questionnaire. For example, you mentioned average hours of wear time, which I don’t consider very informative. We have that on our intake form, and patients put down 14 hours. But I have no idea if they really wear their contacts for 14 hours or if they’re comfortable.
In the chair, I like to ask, “When do you usually take off your contacts?” If they tell me, “As soon as I get home from work,” I say, “Why? Are your lenses uncomfortable at that point?” That elicits a whole new discussion. They might say, “I just like to get in my PJs and fall asleep on the couch,” which is fine. But if they say, “I take them off because my eyes feel like sandpaper,” then I have the chance to fix a problem and maybe give that patient a happier lifestyle. I can prevent a dropout.
DR. GIEDD: We can’t ask patients directly where they fall on the dropoff continuum, but we can open up the discussion. Asking a question like, “Can you wear your contacts as often or as long as you want to wear them?” tells me something about not only their duration of wear, but also their comfort and satisfaction. It’s OK if patients like to wear glasses sometimes, but I need to know if they’re getting everything they want out of their contact lenses. Their answers help me ascertain their status and identify where there’s room for improvement.
Questions to Ask
DR. MARSDEN: We’ve established that we, not questionnaires or surveys, are the keys to detecting dissatisfaction and dropoff and turning them around. Dr. Giedd, how do you have that conversation with your patients? What questions do you ask to prevent dropout in your patient population?
DR. GIEDD: As part of the contact lens exam, I tell every wearer, “I always feel it’s part of my job to tell you what’s new or different in the world of contacts since we last got together.” I give them a little synopsis of what new products they might be candidates for, and sometimes that comes with a recommendation to change. Even if I don’t recommend a change, I think the conversation opens up a dialog. They need to know that there’s always something new and different, and I offer it. Sometimes the conversation brings out issues the patient would not have raised on his own. Some patients think contact lenses naturally get dry after 6 hours, so there’s no need to mention that.
To find out how they’re doing in their current lenses, I ask a question such as, “What do you wish was better about your lenses?” because, of course, that implies that there’s room for improvement. If I asked, “How are your lenses?” I’d get, “They’re fine,” and never know that some problem was slipping through the cracks. I set the stage for them to give me a specific response. Tell me what could be better.
DR. DUROCHER: I always ask two questions. Number one is “What do you like about your contact lenses?” As they’re talking, I throw in the same question you’re asking: “If there was one thing we could change about your contact lenses, what would that be?” The most common answer is “how they feel at the end of the day.” They can’t wait to get home and take out their contact lenses. And I always ask, “What’s the best part of your typical day? Do you look forward to leaving work and getting home to your family? That’s the last time you want your contact lenses to be bothering you. What if we can make that better?”
The same goes for patients who have problems with visual performance at the end of the day. They might take out their lenses to drive home to avoid glare and halos. It’s inconvenient. We can improve that, too.
The Complacency Gap
DR. MARSDEN: We can prevent dropouts with a conversation that takes under a minute. So, why are dropout rates so high? Why are doctors disconnected from the problem?
DR. GIEDD: When you look at patient feedback, independent surveys show that as many as two-thirds of patients really don’t talk to their doctors about their problems — discomfort, dryness, visual complaints or otherwise. When the doctor doesn’t actively open the door to that conversation, the conversation doesn’t happen. Patients drop off and drop out.
DR. GEFFEN: It’s complacency. We don’t ask the right questions. We assume that patients are doing well because we’re busy and we don’t want to upset the schedule. And then we fool ourselves into thinking we’ll see these patients again. We need to spend those extra few moments asking those critical questions. If they return in 3 years wearing glasses and they haven’t worn their contacts in a year, then we’ve done them a disservice.
We send newsletters and emails to our patients announcing new technologies. We invite them to come in and try a new lens, material or product, just to keep them aware of what’s happening. It’s so important for us to work preemptively, inside and outside the office because it’s very difficult to find what unmet needs keep a patient from returning.
—David I. Geffen OD, FAAO
DR. DUROCHER: You may not even see the patient for spectacles again. When patients drop out of contact lenses, they may well go to another practice to avoid having the ‘where are your contacts’ discussion. They just want to start over.
DR. MARSDEN: And that’s why doctors are unaware of this dropout issue.
DR. RUMPAKIS: Our profession doesn’t take communication seriously enough. We often rush through things to check the boxes, to make sure that we ask the questions. We habitually prescribe the same things, not thinking about innovation and change and what we can do to improve the quality of patients’ lives. If patients aren’t complaining too badly, we send them back out the door. It’s the “if it ain’t broke, don’t fix it” attitude. It only takes a short conversation with a patient to change all of that. We can focus on the qualitative aspects of a patient’s status, really understand the situation, and keep the patient happy and part of the practice.
Inform Every Patient
DR. MARSDEN: On our intake form, we ask patients, “Do you want to know what's new?” I always find the phrasing a little odd because inevitably most of them write, “No. I’m happy with what I have.” The fact that they’re happy is the reason they’ve come back to see me — if they weren’t happy, they probably would have gone elsewhere. I need to talk to patients before they write, “Yes. I need to know what’s available because I’m not satisfied with my current lenses.”
Whether patients tell us they want to learn what’s new or not, we need to communicate that there are new developments, and those developments may help them see and feel better. How can we do this?
DR. GEFFEN: We send newsletters and emails to our patients announcing new technologies. We invite them to come in and try a new lens, material or product, just to keep them aware of what’s happening. It’s so important for us to work preemptively, inside and outside the office because it’s very difficult to find what unmet needs keep a patient from returning.
DR. GIEDD: I think patients find it impressive when you talk about new technology. It really builds loyalty to your practice. And in an era of online reviews and ways for patients to publish feedback about your office, impressions are more important than ever. It’s hard to measure these indirect and less tangible influences on our profitability, but I think they’re very real. That extra 30 to 60 seconds of chair time and dialog comes back to us in the relationships and loyalty we build. It’s a better way to spend our time than spinning our wheels trying to get new patients.
DR. RUMPAKIS: Yes. As a rule of thumb, one generally expends five times more effort on new patients than one would expend to provide the same services for an existing patient and make the same revenue. It definitely pays to market to your internal patient base.
Staff Must Help
DR. MARSDEN: We’re not the only ones talking to our patients. As we try to change the old paradigms of sticking with the same lenses for years and using the recommended solution, not just the one that’s on sale, what is the role of our staff? How do they help promote our choices to our patients?
DR. GEFFEN: My staff is critical because they participate in patient education as much, or more, than I do. They’re the first and last people patients see. We try to train our staff to educate patients and talk about what’s new in materials, and we make sure they understand solutions as well.
DR. MARSDEN: I think that the staff has to be well versed in your prescribing habits, whether it’s the care system or the lens modality. They have to understand the value proposition of what you’re prescribing, and recognize that you’re making a specific prescription for this patient. If the patient says, “Wow, that’s really costly,” and the staff member answers, “Well, we can put you in something cheaper,” this completely undermines the conversation you just had with your patient.
DR. DUROCHER: I’d add that I think the staff needs to experience these contact lenses and solutions, whenever possible. When they can give a true testimonial, it really makes a difference.
DR. RUMPAKIS: The staff really has more face-to-face time with the patient than the doctor does, and many patients look to the staff for validation of what the doctor recommended. A patient may say, “The doctor said this. What do you think?” And the staff needs to answer in a way that’s consistent with your practice’s view every time.■