1) Refractive surgery practices have retreatment rates of around 10% on average, meaning one in ten patients needs additional procedures due to delayed visual recovery or other issues. 2) These retreatment patients experience disappointment that the initial procedure did not meet their expectations, and they often negatively influence other potential patients through word-of-mouth at a higher rate than satisfied patients positively influence others. 3) The negative impact of a single unhappy patient who received a retreatment can outweigh the positive impact of nine satisfied patients, slowing the growth of individual practices and the industry overall. Practices should focus on reducing retreatment rates to improve growth and referrals.

1. TODAY’S PRACTICE
The Whoops! Factor
Why refractive surgeons need to take a much closer look at their enhancement rates.
BY SHAREEF MAHDAVI
Consumers who undergo the process of be guaranteed. The frustration your customer experiences
deciding to have refractive surgery over- is the same as what you experience when a purchase
come a great deal of innate fear before doesn’t go as planned. It is no different from what you
choosing in favor of it. Having weighed the would feel if that expensive European car you bought last
potential benefits and risks, they go for- year had to go back to the dealership to correct manufac-
ward with the hope and expectation of turing defects. Actually, your patient’s disappointment is
experiencing daily life without glasses. For worse, because he can’t trade in his eyes the way you ulti-
nine of every 10 patients, the procedure goes as planned, mately can trade in the car.
the outcome is great, and everybody’s happy. The Wow! fac-
tor is alive and well. But what about the other 10%? I’m talk- THE COST OF RETREATMENTS TO YOU
ing about those patients who experience delayed visual Lost Time and Revenue
recovery and need a retreatment, which the profession has You probably know that retreatments can be expensive
neatly termed an enhancement. to your practice. I want to break them down into two areas
of cost. The first is internal to your practice and is a meas-
THE TOLL RETREATMENTS ure of the surgeon’s and staff’s
TAKE ON PATIENTS time, laser usage and fees, and
Those of us who work in the any disposables required to
realm of refractive surgery perform a secondary treat-
know that, over time, virtually ment. Daniel Durrie, MD, of
all complications disappear and Overland Park, Kansas , and
the patient will likely see very Richard Lindstrom, MD, of
well. From the customer’s per- Minneapolis, have each calcu-
spective, however, the product lated and published that a
has failed to meet his expecta- retreatment costs between
tions. Once he overcomes his $800 and $1,000 to perform.
concerns (rational or irrational) Expensive indeed, when you
about long-term problems, his also consider the cost of the
reaction is one of disappoint- lost time that you and your
ment. This scenario reminds staff could have spent treating
me of how Phillip Crosby, the new patients.
quality guru, describes poor
quality: “They didn’t get it right Reduced Referrals
the first time.” A colleague of There’s another cost of re-
mine noted that his LASIK treatments that might even be
patients who need retreat- more expensive. It is external to
ments give him a look that your practice and impossible
says, “You must have pushed to control. I’m referring to the
the wrong button on the laser.” rate of referrals from patients,
These sentiments are real, also known as word-of-mouth
and I cannot stress enough Figure 1. On average, nine of every 10 patients is marketing. Traditionally, cus-
how important it is to face happy with their refractive outcome, and each tells tomers who are happy with
them rather than ignore them. three people. The word-of-mouth impact of one their experience tell at least
No surgical outcome can ever unhappy patient, however, is much greater. three people. Studies have also
JUNE 2005 I CATARACT & REFRACTIVE SURGERY TODAY I 83

2. TODAY’S PRACTICE
shown that upset customers tell an average of 10 people
DO RETREATMENTS HURT FUTURE
about their negative experiences.1
BUSINESS REVENUE?
Applying these averages to refractive surgery, nine of
every 10 of your patients will be happy with their experience SM2 Consulting is seeking a number of refractive prac-
and tell three people, while one of every 10 will be unhappy tices to participate in a survey that measures the impact
and tell 10 people. The quick math would show that happy of retreatments on referral rates. This will be a retrospec-
patients have told 27 people, whereas the single unhappy tive analysis that looks at the actual number of referrals
patient has told 10. But don’t breathe a sigh of relief just yet. generated from patients who have been re-treated and
The emotional charge of the experience has a long tail. If compares this to the number of referrals generated from
those 27 people each tell three more, then 81 people have patients who have had only a single treatment. To partici-
been positively influenced by the experience of those nine pate, you will need the following:
happy patients. Similarly, though, the 10 people who heard • computerized records for both practice management
about the bad experience also tell 10 more people about it, and outcomes;
and now you have 100 people who have been negatively • data entry that has accurately captured the name of
influenced about undergoing refractive surgery at your the former patient that has referred the new one; and
practice (Figure 1). • the ability to link outcomes (eg, retreatment required
The “influence score” is now 81 positive and 100 nega- for patient X) to practice management (eg, the new
tive—all from that one unhappy patient (out of 10) who patients referred by patient X).
needed to be re-treated. This effect is a form of homeostasis The results from this analysis will be a major benefit to
in the marketplace, where the negative word-of-mouth out- you and your refractive colleagues. With these data, we
weighs the positive. The net result is that referrals from will be able to quantify the financial impact of retreat-
patients decline, your practice’s growth is stunted (which, ments on referrals for the refractive practice.
consequently, puts pressure on the practice to spend more If you are able to help, please contact SM2 Consulting
money to attract patients), and the industry as a whole at (925) 425-9963 or shareef@sm2consulting.com.
doesn’t grow as fast.
centric solution, when what is needed is a customer-centric
REDUCING RETREATMENT R ATES alternative. Why are we further punishing the patient by
The math exercise above is meant to illustrate that cur- making him pay additional money when the product failed
rent retreatment rates in refractive surgery are likely having a to meet his expectations? You would not tolerate such
more negative impact on industry growth than any of us treatment at that luxury auto dealership, but you expect as
realize. The 10% (and that’s only an average) of patients who much from your customers. This doesn’t make sense in a
don’t achieve quality results (as defined by Crosby) equates customer-centered practice. For example, one surgeon I
to at least 70,000 people last year alone who don’t rate their know refuses to charge his patients for enhancements, using
experience high enough to enthusiastically recommend the event as an opportunity to strengthen the doctor-pa-
refractive surgery to their friends. That is, negative experi- tient relationship and fulfill one of his practice’s core values.
ences by even a small percentage of patients are significantly Always remember that what truly makes your practice
hurting growth in consumer demand for LASIK. grow is happy patients. Yes, it’s become increasingly harder
Solving this problem requires a multipronged approach. to please them, as their expectations continue to rise along
The first step is to improve your clinical outcomes by active- with improved results. But at the end of the day, you are in
ly measuring them and refining your surgical techniques. business to serve your customers, and you should strive to
The second is to invest in technology that helps reduce your serve them well. A focused effort on reducing retreatments
rate of retreatments. For a practice treating 100 eyes per will have a positive effect on your practice as well as on the
month, a 10% retreatment rate costs $8,000 to $10,000 entire industry. ■
every month. Reducing that rate by even a few points will
easily justify any monetary investment in outcomes analysis Shareef Mahdavi draws on 20 years of medical device mar-
and/or technology. keting experience to help companies and providers become
The secondary effect of retreatments is more difficult to more effective and creative in their marketing and sales efforts.
correct but, as stated earlier, even more critical. You should Mr. Mahdavi welcomes comments at (925) 425-9963 or
handle every retreatment patient with extra special care in shareef@sm2consulting.com. Archives of his monthly column
order to minimize the negative impact of their failed first may be found at www.crstoday.com.
experiences. Currently, most practices penalize the patient 1. Denton KR, Boyd C. Did You Know? Fascinating Facts and Fallacies About Business.
for retreatments by charging extra fees. This is a surgeon- Englewood Cliffs, New Jersey; Prentice-Hall: 1994.
84 I CATARACT & REFRACTIVE SURGERY TODAY I JUNE 2005