Impact of ORA on Refractive Cataract Surgery and the Premium Channel Offering 8 Shareef Mahdavi • SM2 Strategic • Pleasanton, CA 7Intraoperative Aberrometry, a term receiving toric IOLs and/or present- Table 1: Surgeon Demographicsdescribing the use of a wavefront-sens- ing as post-refractive patients. Ining device during cataract surgery, has # Surgeons in Survey: 101 2010, the company changed its busi-been available in the US since 2008. ness model and now allows surgeons Cataract Cases per Month: First commercialized as the ORange® Average No. of Cases: 73 unlimited use of the device for aSystem, developer WaveTec Vision (Aliso Range: 8 to 350 fixed monthly fee of $3,000. (Note:Viejo, CA), has continued to develop the Orange/ORA Cumulative Experience in both models, the device was firsttechnology through a series of software Average No. of Cases: 365 acquired as a capital purchase orand hardware modifications to improve Range: 10 to 4,000 lease). This revised approach wid-utility of the device during cataract sur- ened the appeal to surgeons; surveygery. Its ORA System® was launched in respondents perform anywhere fromlate 2011; since that time, the company’s Table 2: Percent of Time ORA 8 to 350 cataract cases per monthinstalled base of sites and users has Affected IOL Power Selection and use ORA on a population ofexpanded nearly five-fold. n = 21 90-100% patients that include all patients hav- SM2 Strategic was asked to conduct ing refractive cataract surgery. Some n = 35 50-80%a survey of ORA users to better under- surgeons have opted to use the ORAstand the impact of the technology on n = 25 11-50% reading as a quality control check-the cataract practice. Given that ORA is n = 9 DK/NA point on IOL selection over a widea technology that surgeons are using to range of cases. n = 8 < 10%enhance their premium refractive cata- All surgeons continue to per-ract practices, most surgeons using the n = number of surgeons form pre-operative diagnostics anddevice are performing refractive cataract Average Among Surgeons= 59% Average Among Surgeons = 59% begin surgery with an IOL selection.surgery as part of the “premium channel” However, when they use ORA, theyoffering to patients in their practice. are then modifying the surgical plan based on the intra- This survey focused on how ORA is influencing surgeon operative ORA recommendation the majority of thebehavior in the operating suite and, consequently, how time (59% across the survey sample). Further segmenta-surgeons are using the device to make refractive cataract tion of the surgeon sample reveals that 1 in 5 surgeonsoptions more attractive to patients coming in for surgery. do this 90% of the time or more when using ORA.Of 215 surgeons invited to participate, 47% (101 of 215) According to Denise Visco, “I tell my patients, ‘I amprovided data in an online survey. 15% more accurate in selectingTwelve surgeons also took part in a Figure 1: Frequency of ORA your IOL when I use ORA versustelephone interview to further under- Saving Surgeons from when I do not.’ I tell other sur-stand surgeon motivation to acquire Refractive Surprises geons that you get better at it theand use ORA. Additional demographics more you use it.” The distributionof the survey sample can be seen in of usage of ORA over pre-op read-Table 1. The key findings can be sum- ings is shown in Table 2.marized into three main themes, each Similarly, the ability of ORAof which will be explored in the follow- Weekly At Least to prevent a refractive surprise 34% once/monthing sections: from taking place is occurring 36% with greater frequency. As shownFrom Niche to Mainstream in Figure 1, 14% of surgeons Initially offered as a “pay per Daily reported that ORA has kept them Rarelyuse” technology that would cost 14% from choosing the wrong lens “a 14%$150 per case, the first surgeon lot,” meaning every week andusers tended to be highly selective perhaps daily. Another 34% of sur-and used the technology on patients n = 93 Never 2% geons indicated this was occurring
“regularly,” meaning once per week. Only 2% of surgeons with other services. The remaining 9% of surgeons do notsaid that ORA has never prevented a refractive surprise. include a charge for ORA in refractive packages either “I strongly recommend ORA,” noted Michael because of limited access (e.g., ORA is only available at aWoodcock, who has used ORA in more than 3,600 cases. secondary surgery center) or have chosen to use it on all“It’s required for post-refractive patients without charging separatelypatients and I will not perform surgery Figure 2: Learning Curve for it.on them if they aren’t willing to have The average fee, weighted acrossORA.” 1 MO. all surgeons in the survey regardless of Mitch Jackson, with nearly half his < 30 TIME/NO. OF CASES whether or not they have a separate CASES TO REACH COMFORT LEVELcataract volume being post-refractive fee, was $337 per eye.patients, agrees: “ORA changes out- 35 Surgeon conversion of patient inter-comes. I am using it on all my post- est to a toric or presbyopic implant hasrefractive surgery cases so as not to 30 increased significantly, moving fromworry about what we used to think of 31% to 38% of all cases (see Figure 4). 25as ‘difficult’ cases. Fewer enhancements “ORA gives me a lot more confidence, 3 MOS.mean less chair time and less time spent 20 50-100 4-6 MOS. especially with the toric lens. I feelon ‘fixing the primary procedure with CASES 100-150 more comfortable treating post-refrac- CASES NOTeither an IOL exchange, piggyback 15 THERE tive eyes as I am better able to triangu-IOL, LRIs, and/or laser vision correc- YET late thoughts with other diagnostics,” 10 12 MOS.tion (PRK or LASIK), all of which lead > 150 said Richard Burns. “My results over-to additional patient dissatisfaction.” CASES all are better with ORA.” 5 Likewise, surgeon time spent man-The Learning Curve aging unhappy patients and performing This utility is achieved only with n = 84 surgeons associated enhancements has changedcommitment and focus by the surgeon significantly, decreasing from 10%to understand the technology and how to use it. Kevin to 5.3% of cases on average (see Figure 5). For some sur-Waltz contends “you will adjust surgical technique as you geons, the overall enhancement rate has not changed dra-learn how your technique impacts the refraction. This takes matically; while the tighter results have reduced the needtime, but it’s well worth it and you will find it impossible to for enhancement, the better outcomes have led to surgeonsgive up (ORA).” Surgeons were asked about their learning being more aggressive overall during primary as well ascurve; 38% of surgeons felt comfort- enhancement cases as a function ofable within the first month or 30 cases, Figure 3: Additional Surgeon greater confidence throughout the pro- Fees for ORAwhile 10% say they are still in their cess.learning curve. “It takes 2-3 months toget used to it; you have to have faith, Time Efficiency $337 average per eyeand you come to realize how heav- A concern of some surgeons hasily you have relied on IOLMaster and 30 been impact on patient flow and over- S U R G E O N S 29OPD,” remarked Jonathan Solomon. 25 all time spent in the operating room.“Having this tool available during sur- 25 There is a wide variety of surgeons’ 20gery has allowed me to be much more reports of how much time is added.aggressive in treatment.” The range of 15 17 Some say it adds only 15-30 seconds, O Fresponses is shown in Figure 2. 10 while others say it doubles the time to N U M B E R 5 perform a 5-6 minute case. “It takesThe Numbers Make Sense me five extra minutes per case, which 0 Given the elective nature of the $50-250 $300-499 $500 + means the outcomes have to be muchpatient’s decision to have ORA as part n = 101 surgeons; 71 have a separate line item on their fee schedule better, which they are,” remarkedof their cataract surgery, surgeons need Kevin Waltz.to determine the value of intraoperative aberrometry and Maria Scott, who routinely does 40 cataracts in a ses-how much to charge for this added component of premium sion, initially saw efficiency drop with ORA from 5.5 casescataract surgery. to 4.5 cases per hour. A software upgrade in August 2012 70% of surgeons offer ORA as a separate line-item; made a big improvement in capture and processing time ,21% do not break out the fee and choose to include it and case flow is now back up to between 5 and 5.5 cases
per hour. “My partner and I struggled with the original time in the OR to get it right the first time is worth everyhardware (ORange); I didn’t like it very much. The ORA second.”System and the upgrade have been a complete turnaround. According to Rob Weinstock, who was one of the veryI’m much more confident and now first users of the ORange System andoffer LRI (for a fee) along with ORA; Figure 4: Change in works closely with WaveTec’s engineersthe results are that good.” Conversion Rate to improve the platform, indicated “ORA is now much more bulletproof.Expanding the Category by Surgical outcomes are better and the barCreating Value 35 38% is being raised. This can be leveraged in In refractive cataract surgery, the exam room and in the community, 30ORA is not being used by itself but 31% which creates a very high value proposi-typically in combination with one 25 tion for surgeons.”or more elements that together com-prise the premium channel category 20 Discussionof cataract surgery. Along with other 20% There is little question that the addi-advanced diagnostics and the femto- 15 tion of ORA has meaningfully impacted increasesecond laser, surgeons are using ORA the surgeon’s ability to communicate the 10to make better decisions around IOL benefits of refractive cataract surgery.power and placement. These tools 5 Surgeon confidence from improved out-work synergistically to improve out- comes is translating to what is discussedcomes, the core premise of refractive % during pre-operative education andcataract surgery. Before ORA With ORA counseling. As a result, patients better Surgeons in this survey reflect a n = 101 surgeons: 49 reported no change in conversion rate understand the value of refractive cata-sense of optimism about the contri- ract surgery and accepting that they willbution of ORA to their field. Nicolas share in some of the cost directly in orderBatra, whose practice has doubled “taking the extra time in the to achieve the results associated with pre-in size in recent years, says the addi- OR to get it right the first mium cataract surgery.tion of ORA has made a meaningful The survey data are very clear incontribution to the premium segment: time is worth every second.” showing how this “product promise,”“Patient acceptance of our premium and ORA’s role in helping achieve it, isoffering has grown tremendously and increasing acceptance for the premiumgave me the resources to buy the FS Figure 5: Change in segment within cataract surgery. Enhancement Ratelaser on my own. I believe that ORA Like all new technology, there is ais the new ‘gateway’ for refractive learning curve associated with ORA.cataract surgeons.” 10% The path to successful integration by cat- aract surgeons needs to avoid the “plugIs ORA Worth It? 8 and play” mind-set enabled by some of Analysis of the data from the today’s medical devices. ORA is a pow-open-ended comments added by sur- erful tool that provides something sur- 6geons and from the interviews make geons have never before had: refractiveclear that the investment of time and 5.3% data to make decisions during surgerymoney into ORA is well worth it and 4 47% that differ from pre-operative planning decreasejustified by the improvement in out- and can meaningfully impact patientcomes. Surgeons have come to trust outcomes. “Surgeons must pay attention 2the readings taken during surgery, when first starting,” noted John Berdahl.and the resulting outcomes have led “They need to respect the art that comesto increased “confidence”, “comfort” % along with this technology.” There isand “trust,” words which appeared in Before ORA With ORA also a cost associated with integratingresponses from 41 of the 72 surgeons n = 69 surgeons: 22 of 69 reported no change in enhancement rate the device, in terms of time and money,who wrote them in on the survey. The but the overwhelming sentiment of userspositive comments span a wide range, including that ORA is that it is well worth the investment and requirement tois an “essential surgical step” and that “taking the extra adjust surgical thinking as part of the process.