Analyzing ophthalmology’s manpower issue
How the profession can meet patient demand despite potential shortages.
By Zack Tertel, Senior Associate Editor
Simply put, quality patient care is an issue of supply and demand — a sufficient supply of health care providers must be on hand to treat those patients in need. Applying this principle to ophthalmology, many in the profession fear there won’t be enough ophthalmologists to meet future patient demand.
Ophthalmic full-time equivalents are expected to decrease by about 1.2% from 2010 to 2020, while physician requirements engaged primarily in patient care are expected to increase by about 18.9% over the same period.1
“There’s going be an increase in demand for ophthalmology because of the demographic shift in our country toward an aged population, and our top four disorders, glaucoma, diabetes, AMD and cataracts, are all age related,” says Andrew Lee, MD, department of ophthalmology chair at the Methodist Hospital in Houston (See “Disease/condition estimates in the US,” page 30.)
Here, industry experts discuss the reasons for potential shortages and what must change to meet the demand.
By 2029, more than 20% of the total US population is expected to be over age 65. Also, projections show the 65-and-older population is expected to grow larger than the under 18-year-old population by 2056.2
With age comes more disease. The baby boomer generation enters its mid-60s this decade, and the 2015 diseases/conditions-per-ophthalmologist ratio is expected to rise to 914.3 to 1, a 17.3% increase from the 2008 ratio.3
David Harmon, MS, expects a continued rise in patient-to-ophthalmologist ratio, along with the number of patient visits. Mr. Harmon cites an increase in intravitreal injections as one reason.
“We have patients lined up who have to come in four to six times a year for injections, and every time they come in they have to have an OCT scan and a fundus photo to see how they’re progressing,” he says. “These technologies get more and more sophisticated, which is great for patient care but always take more time.”
Where are the replacements?
Along with the aging population is an aging group of physicians. In 2013, 47% of practicing ophthalmologists were age 55 or older, compared to 42% across all specialties.4 Despite looming retirements and demand for services, the number of ophthalmic residency slots that are offered remains low, says Mr. Harmon.
Ophthalmology-program graduates per year have consistently hovered around 420 students the last 20 years despite medical school expansions, says William L. Rich, III, MD, FACS, medical director of Health Policy for the American Academy of Ophthalmology (AAO). A majority of graduate medical education (GME) funding comes from Medicare support, which has been limited due to the Balanced Budget Act of 1997. Therefore, the number of ophthalmology residents remains frozen, Dr. Rich says he is pessimistic that this will change.
“There are no training slots in the specialties at the greatest need,” Dr. Rich says. “Even the federal data shows there are greater problems with some specialties, and we (ophthalmology) are one of them.”
The Association of American Medical Colleges (AAMC) leads the charge for change by continuing to lobby for government assistance, Dr. Rich says. For example, the AAMC supports legislation, such as the “Training Tomorrow’s Doctors Today Act” and the “Resident Physician Shortage Reduction Act of 2013,” to lift the cap on residency positions and help increase the number of Medicare-supported graduate medical education positions by 3,000 to 4,000 residents each year. Dr. Rich says the AAO backs the AAMC’s proposals to expand GME and help alleviate shortages, but he says an unwillingness to use federal dollars limits a major resource for financing.
“While there’s going to be a massive demand for surgical services and a huge increase in the number of people under Medicare, there is no sign of future hope that we are going to be able to increase the number of ophthalmology residents,” Dr. Rich says.
“If there’s no increase in the funding for residence slots at the graduate medical education level, there probably won’t be more residents trained in ophthalmology, adds Dr. Lee. “And, if that’s the case, it will exacerbate this shortage.”
If the supply of ophthalmologists remains unchanged, practices must look for ways to become more efficient to handle the patient demand, say those interviewed. Robert Wiggins, MD, MHA, AAO senior secretary for ophthalmic practice based in Ashville, N.C., uses a team-based approach in his practice, which he says can be a cost-effective model for many practices.
“In my own practice, we are utilizing all the members of the team, such as optometrists, technicians, and orthoptists to their fullest level so that we can take care of more patients efficiently,” he says.
In particular, ophthalmology’s relationship with optometry must continue to expand, Dr. Wiggins says.
“In our practice, we don’t have enough ophthalmologists to see all of the routine eye care visits patients are demanding, so we’ve hired optometrists to help take that load off ophthalmologists and let our practice see more patients then we could otherwise,” Dr. Wiggins says. “That team-based care model to more efficient eye care delivery allows practitioners to see more patients to do what they do best.”
As optometrists, technicians and other staff provide their services to the highest degree of their training, the ophthalmologists’ role will change, says Dr. Rich. “Ophthalmologists will need to develop the management expertise to act not only as providers of care but also the managers of care,” he says. “That’s going to be the seminal change that you see, and that’s not bad at all.”
Can physician assistants help?
Seymour R. Rosen, MD, of North Florida Eye Institute in Marianna, Fla., has partnered with PAs to assist with his practice’s patient demand. Dr. Rosen’s PAs perform history and physical examinations, freeing him to focus on surgery. Another advantage: PAs have provider numbers under Medicare and Medicaid and can bill for their services, proving to be a financial benefit to the practice, Dr. Rosen says.
However, only about a dozen PAs work in ophthalmology practices in Florida, a hub for the aging population, according to Dr. Rosen. This absence of PAs in ophthalmology exists throughout the US, he says.
“A lot of people in the medical community are afraid to treat the eye — it’s a big mystery,” Dr. Rosen says. “They don’t have much exposure to it, they don’t have the feeling they can safely do it and I think that carries over to the PA students. It’s not such a terribly complicated jigsaw, but lack of familiarity breeds fear in a lot of people.”
Dr. Rosen points to PAs’ experiences with other medical specialties, including dermatology and orthopedics, to alleviate concerns that PAs would develop interest in practicing outside of ophthalmology’s supervision.
“The demand is there, and the need is there,” says. “It’s just a matter of getting the people trained and making the ophthalmologists aware of what a great benefit this could be in their practices.”
Few, if any, prognosticators foresaw the positive impact of technology, such as fundus photography and cataract surgery, when they arrived on the scene some years ago. Another missed prognostication: ophthalmic technology created a demand for more ophthalmologists. The next 20 years should be no different, either in adding technology that is progressive or that mitigates the human touch.
One technology that belies the others in terms of adding efficiencies is electronic health records (EHR). One recent study found mean total time per patient was 6.8 minutes longer with EHR than paper records.5 As practices familiarize themselves with EHR, the hope is that will change over time, says Dr. Wiggins.
“Physicians are just getting into EHR now and there has been slowing of efficiency in some practices, but we know things are going to get better,” he says. “The software is going to get better, and physicians are going to get more comfortable with it, which will help efficiency.”
Also, telemedicine could aid future patient care demands. Remote imaging allows ophthalmologists to follow and manage chronic diseases without the need for traditional face-to-face appointments, freeing physicians to operate on a more flexible schedule. While the technology exists, remote payment models lag behind for ophthalmology, says Dr. Rich, who is confident the profession could adapt to telemedicine rapidly.
“There have to be payment models that will reward ophthalmologists for taking care of chronic disease remotely and evaluation of diabetics and macular degeneration,” he says. “Certainly there is technology to do imaging and monitor patients remotely, but the technology will not be implemented until there’s a business plan allowed to happen.”
Disease/condition estimates in the US
• An estimated 7.32 million people are expected to have primary open-angle glaucoma in 2050, a 170% increase from 2011.6
• Diagnoses of people 40 years and older with diabetic retinopathy (DR) and vision-threatening DR are expected to more than triple from 2005 to 2050, from 6.7 million to 19.4 million.7
• Diabetes prevalence will likely increase from 14% in 2010 to 21% in 2050.8
• Those with AMD numbered 1.75 million in 2011; by 2020, an additional 2.95 million, a nearly 50% increase, will share that diagnosis.9
• The number of Americans with cataracts is estimated to rise to 30.1 million by 2020, a 46.8% increase from 2004.10
Concerns over the future of ophthalmology are nothing new, says Dr. Wiggins, who recalls his concerns after medical school when deciding on a career.
“I wanted to go into ophthalmology, but that was one of the specialties projected to be in oversupply by the time I was coming out,” he says. “Yet it never really seemed to materialize during my career.”
Many in the profession are confident that ophthalmology will continue to adapt to challenges such as potential shortages. Some inspiration comes from the retina community’s response to the explosion of millions with diabetic macular disease and macular degeneration injections, Dr. Rich says. “They figured out how to do it pretty quickly,” he says. “I think there’s the ability to innovate, as long as there are some payment models to support it.”
Looming patient demands from an aging population are no different, says Dr. Rich.
“Before these shortages have really gotten worse, the practice of ophthalmology has dramatically changed,” Dr. Rich says. “And that’s not bad thing — it’s a good thing.” OM
1. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions October 2006. “Physician Supply and Demand: Projections to 2020.” http://bhpr.hrsa.gov/healthworkforce/supplydemand/medicine/physician2020projections.pdf. Accessed December 19, 2014.
2. Colby SL, Ortman JM. The Baby Boom Cohort in the United States: 2012 to 2060. United States Census Bureau. Available at http://www.census.gov/prod/2014pubs/p25-1141.pdf (accessed December 19, 2014.
3. Harmon D, Merritt J. Market Scope, LLC. Demand for ophthalmic services and ophthalmologists––a resource assessment. Available at: http://www.meditec.zeiss.com/C1256CAC0038CEFF/EmbedTitelIntern/Market_Resource_White_Paper_04-2009/$File/Market_Resource_White_Paper_04-2009.pdf (accessed December 17, 2014).
4. Association of American Medical Colleges Center for Workforce Studies. 2012 Physician Specialty Data Book. https://members.aamc.org/eweb/upload/14-086%20Specialty%20Databook%202014_711.pdf (accessed December 20,2014).
5. Chiang MF, Read-Brown S, Tu DC, et al. Evaluation of electronic health record implementation in ophthalmology at an academic medical center (an American Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111:70-92.
6. Vajaranant TS, Wu S, Torres M, Varma R. The changing face of primary open-angle glaucoma in the United States: demographic and geographic changes from 2011 to 2050. Am J Ophthalmol. 2012;154:303-314.e3
7. Saaddine JB, Honeycutt AA, Narayan KM, et al. Projection of diabetic retinopathy and other major eye diseases among people with diabetes mellitus: United States, 2005-2050. Arch Ophthalmol. 2008;126:1740-1747.
8. Boyle JP, Thompson TJ, Gregg EW, et al. Projection of the year 2050 burden of diabetes in the US adult population: dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr. 2010;8:29.
9. Friedman DS, O’Colmain BJ, Muñoz B, et al. Prevalence of age-related macular degeneration in the United States. Arch Ophthalmol. 2004;122:564-572.
10. Congdon N, Vingerling JR, Klein BE, et al. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol. 2004;122:487-494.