Cataract surgeons struggle with blurred boundaries of expanding practices

Cataract surgery is the most commonly performed eye procedure in the United States, with about 3 million surgeries performed in 2009, according to some estimates. Demand for cataract surgery, and eye care in general, is expected to surge in the coming years, as more baby boomers reach 65 years of age.

The impending spike in demand for cataract surgery is multifactorial. Aside from a sharp increase in the number of aging patients with cataracts, evolving surgical techniques and improving outcomes promise to boost demand among relatively young, active patients who desire cataract surgery or refractive lens exchange.

In addition, seniors today are more physically and socially active than any previous group of seniors. In short, Americans are living longer and living well for a longer period of time.

Apart from being a large age cohort, baby boomers — people born between 1946 and 1964 — have higher expectations than previous generations. Ophthalmologists need to fully exploit breakthrough technologies and develop innovative practice models to meet increasing demand and rising expectations.

Anthony P. Johnson, MD, supports an equal practice model involving ophthalmologists and optometrists. Image courtesy of Johnson AP

“Seventy is the new 50,” John A. Hovanesian, MD, FACS, OSN Cornea/External Disease Board Member, said. “The baby boomers who are just beginning to have cataracts are seeking lens replacement surgery for relief of presbyopia and for their own visual disabilities that bother them because they, too, are active.”

Impending challenges will force clinicians and practice administrators to adopt an integrated practice template that revolves around increased collaboration with optometrists, nurses, physician assistants and technicians, David W. Parke II, MD, CEO and executive vice president of the American Academy of Ophthalmology, said.

“It behooves all ophthalmologists to prepare for these changes by fine-tuning their model of practice to meet the challenges of quality, service and efficiency,” Dr. Parke said. “For many practices, this has meant or will come to mean an integrated model of eye care led by ophthalmologists but certainly incorporating optometrists, nurses, technicians and others who are important to meet the overall spectrum of eye care delivery.”

A practice’s ability to handle increased patient volume hinges on efficiency, which in turn depends on the appropriate use of technology, more highly skilled staff and increased collaboration with optometrists, according to Robert Cherewich, MPS, CMPE, COE, president-elect of the American Society of Ophthalmic Administrators, sister organization to the American Society of Cataract and Refractive Surgery.

Uday Devgan

“It gets back to the holy grail of becoming more efficient or as efficient as you can be so that the doctor or the practice in general can see more volume. It’s a never-ending process,” Mr. Cherewich said.

Uday Devgan, MD, FACS, FRCS, OSN SuperSite Section Editor, echoed Mr. Cherewich’s comments.

“Ultimately, it’s going to boil down to increased efficiency in the way we do the procedure,” Dr. Devgan said. “It’s going to be maybe a rearrangement of our eye health delivery team using different players or more players, with the ophthalmologist being captain of that team.”

Increasing demand

According to U.S. Census Bureau projections, the number of U.S. citizens age 65 years and older is expected to rise from 38.7 million in 2008 to 88.5 million in 2050, according to a news release.

The bureau also expects the dependency ratio, or the number of people age 65 years and older to every 100 people of traditional working age, to rise from 22 in 2010 to 35 in 2030, when all baby boomers will be older than 65 years. The projection was based on adjusted 2000 Census figures.

Currently, combining patients covered by Medicare and those with private health insurance, about 3 million cataract procedures are performed annually on about 40 million seniors over age 65 years, or 75 procedures per 1,000 seniors, John B. Pinto, OSN Practice Management Section Editor, said. Fifteen years in the future, about 5 million procedures will be performed annually on about 60 million seniors, or about 90 cases per 1,000 seniors, Mr. Pinto said.

All told, the volume of cataract procedures for the typical surgeon will increase by about 75% in the next 15 years. A total of about 16,000 surgeons will average about 350 procedures per year, Mr. Pinto said.

“Are we going to be able to handle the cases in the future? Could the average ophthalmologist in America today perform 75% more cataract surgeries? I think the answer is clearly yes,” he said. “The average general ophthalmologist in America is doing about one-third optometric work, so he or she could readily shift his or her time more toward surgery, which is more economically productive and intellectually satisfying, and delegate more direct patient care, whether it’s post- or preoperative care of all the other domains of eye care, to primary eye care providers.”

David W. Parke II

Dr. Parke cited final 2009 and preliminary 2010 Medicare statistics showing that the number of cataract surgeries in the Medicare age group flatlined at about 1.8 million those years.

“Others with access to some industry numbers, etc., believe that the total number of cataract procedures in the United States, Medicare and non-Medicare, in 2009 was about 3.1 million,” Dr. Parke said. “That’s a somewhat squishy number, but it’s probably not a bad number to work with. I do think that the number is going to be going up, just looking at the demographic projection for the United States.”

Retirements and residencies

Anthony P. Johnson, MD, said that many ophthalmologists have delayed retirement amid the economic downturn of the last 3 years.

“But as the economy improves and as the retirement plans of these doctors that have been in practice for 30-plus years get back on track, I think we’re going to see the resuming of the retirement of a significant number of ophthalmologists, especially cataract surgeons,” Dr. Johnson said.

Regulatory burdens created by the Patient Protection and Affordable Care Act of 2010 and the difficulty of adopting electronic medical records will compel some physicians to retire sooner than they may have otherwise, Dr. Johnson said.

Dr. Parke said there are no indications that the retirement rate among ophthalmologists is on the rise.

“There is no evidence to suggest that ophthalmologists are retiring at a higher rate,” Dr. Parke said. “In fact, the data suggest the reverse.”

An internal review of the AAO membership database showed that in 2010, the retirement rate among AAO members sank to an all-time low, Dr. Parke said.

“In fact, what we’re seeing is that the rate of retirement is slowing,” he said. “It’s not simply an argument. It’s actually proven by the numbers.”

The slowed retirement rate can be attributed to increasing life expectancy and many clinicians choosing to continue practicing beyond the traditional retirement age, Dr. Parke said.

“So, we actually expect that to not be a factor that is exacerbating an access issue but is actually helping the access issue,” he said.

Dr. Devgan estimated that while about 450 ophthalmic residency positions are available each year, about 500 or 600 ophthalmologists are retiring. SF Match, a residency and fellowship matching service that publishes total available residency slots on its website, is a resource that Dr. Devgan uses.

“Because of that, there are fewer and fewer ophthalmologists every year. Yet, the demand for patients to have surgery is higher and higher. If the models continue like they are today, you may have some sort of shortage,” Dr. Devgan said.

However, that trend is somewhat offset by technology enabling surgeons to handle more cases in a shorter amount of time, he said.

“Previously, people would do five or six surgeries a day,” Dr. Devgan said. “Now, you can do those five or six surgeries in an hour. Per surgeon, the surgeon can do a lot more procedures than in the past. That makes a huge difference as well.”

Integrated practice model

An increasing number of eye care practices are incorporating optometrists into their practice structure, Dr. Parke said.

“This is a model that the Academy supports, so long as it’s a model that is ophthalmologist-led, takes into account all the appropriate evidence-based standards of care and results in outcomes that are best for the patients,” he said.

Dr. Johnson described how his practice, Jervey Eye Group, operates under an equal partnership model that includes ophthalmic subspecialties and optometrists.

“It’s a partnership in everything, in our real estate partnership, in our surgery center and our optical wholesale lab,” Dr. Johnson said. “We’ve got all the subspecialties here, so it’s a great model because I don’t care what kind of problem I face with a patient, we have easy access and instant help from one of our partners. I think it’s actually a complementary relationship. It’s not a competitive relationship at all.”

Dr. Johnson said he supports an equal practice model involving ophthalmologists and optometrists, while the prevailing attitude in eye care tends not to support such a model.

“Everything they mention is all about ‘the optometrists work under me’ or ‘they work for me.’ They’re just employed, and they’re never an owner,” he said. “You’re not going to have training equivalency, but if you can have ownership equivalency, you’re going to have people being happier in their practice with what they’re doing and not feeling like they’re being held back.”

Co-management with optometrists is hardly a novel concept and is becoming the norm, Mr. Pinto said.

“The most vanguard surgeons in this country, administratively, business-wise and in some ways clinically, too, have been working with optometrists and co-managing for more than 20 years,” he said. “This is nothing new. It’s increasingly being adopted, no longer by the vanguard practices but now by rank-and-file practices that just realize that the average revenue yielded by a primary eye care visit, before you count in contact lens dispensing, is in the range of about $80 to $100.”

John A. Hovanesian

Dr. Hovanesian said there is intrinsic value of close collaboration between ophthalmologists and optometrists.

“Trust is a fundamental of the relationship between ophthalmologists and optometrists that we have to create,” Dr. Hovanesian said. “The old paradigm of conflict between these two professions is going away in many places and needs to go away in all places. Our societies need to work together toward establishing standards for taking care of patients cooperatively, rather than fighting over turf as to who gets to do surgery and who gets to prescribe medicine.”

A widespread push in optometry to support legislation to increase scope of practice is founded on false assumptions of a decrease in the availability of ophthalmologists, Dr. Johnson said.

“We just had a big scope of practice push in South Carolina just this year,” he said. “It stalled, but part of their rationale for legislators is to tell them there’s not availability of care by ophthalmologists. It’s just not true. It will take a lot of retirements of cataract surgeons before there’s really not the capacity for ophthalmology to take care of the cataract surgery needs.”

Dr. Hovanesian said that most optometrists do not covet the right to perform surgery.

“Most don’t want the right to do surgery,” he said. “They want to continue doing what they do now and get somewhat more involved in medical treatment. They also want to have the right to bill insurance companies — an appropriate request that’s going to have to happen anyway if we’re going to take care of this aging population.”

In addition, a trend toward staff members taking on more responsibility is beneficial to a practice’s workflow and bottom line, Mr. Pinto said.

“Twenty years ago, it was pretty vanguard to have a technician do the refraction,” he said. “Today, it’s the most commonly used model for using technicians. Twenty years ago, it was pretty vanguard to see a tech do a Goldmann tension. Today, it’s quite routine.”

Dr. Hovanesian echoed Mr. Pinto’s statement on the utility of expanding staff members’ skills and duties.

“Physician assistants and certified nurse practitioners serve important roles in other surgical specialties. There’s no reason ophthalmology should be different,” he said.

Broadening the scope of staff duties also frees surgeons to focus primarily on surgery, Dr. Hovanesian said.

“If we’re able to do cataract surgery efficiently and safely, it may be that our time is best spent just doing surgery. The idea of the old-world ophthalmologist who does everything for everybody will simply go away,” he said.

Regulatory concerns

The ongoing economic downturn, solvency of the Medicare system and health care policy may also impinge on the future availability of cataract surgery, Mr. Pinto said.

“The only fly in the ointment is going to be macroeconomic,” he said. “If we have a continuation of this economic malaise, which could well be expected to occur over the [next 15 years], then the federal dollars available for health care will be reduced and there are going to be some very difficult societal decisions to make about equity in terms of availability of care. … You’re going to see a great cleaving going on in this country between those private patients who can afford to jump the queue and get their cataract surgery from a private provider instead of having to wait in line for rationed care.”

Dr. Johnson said he was worried about the impact of accountable care organizations (ACOs) on access to eye care in general.

ACOs, collaborative entities comprising primary care physicians, hospitals and other professionals, would be eligible to participate in the Medicare Shared Savings Program starting Jan. 1, 2012. ACOs are a key component of the Patient Protection and Affordable Care Act, which was designed to increase access to care, improve public health and slow the rise of health care costs.

“Since ophthalmology is really one of the ancillary services, almost like dermatology, when you look at it compared to the primary care docs and those that, as we understand it, will be in charge of the accountable care organizations, I think that patient access is going to be very much tied to the economics of whether or not ophthalmologists are part of the accountable care organization,” Dr. Johnson said.

He said there is concern that patients may not be able to seek eye care from ophthalmologists outside their assigned ACOs.

In addition, an aging population and an “entitlement mentality” are likely to counteract any cost savings that occur as a result of ACOs or other initiatives, Dr. Johnson said.

Declining Medicare and private insurance payments and federally mandated use of electronic medical records may also discourage many physicians from specializing in ophthalmology, he said.

Impact of technology

Improved surgical procedures have made cataract surgery a more viable and attractive option for increasingly younger patients, Dr. Devgan said.

“In the old days it was extracapsular, and even before that there were no IOLs and patients had these thick aphakic glasses,” Dr. Devgan said. “So, they waited a tremendously long time until they had nothing to lose because their vision was so bad from the cataracts. The trend now is that people are having surgery much earlier. Not only are there a larger number of patients who get cataracts, but they’re not waiting until their vision is 20/200. They’re getting surgery when their vision is 20/40. They’re having it at a younger and younger age.”

On the other hand, technology can increase efficiency and productivity and enable surgeons to meet burgeoning demand, Dr. Hovanesian said. He urged practitioners to embrace new technology, particularly femtosecond lasers, as a way to improve outcomes and increase efficiency. Many surgeons believe femtosecond lasers decrease efficiency and do not significantly improve safety, he said.

“This is the very first generation of these lasers,” Dr. Hovanesian said. “Despite all those woes, the reason we’re excited about technology is because we know what it is capable of. We need to allow it to continue to evolve. We need to support it and use it. We should reward the innovation of those companies that bring these lasers to market so that they will make further developments that will benefit us and our patients. Let’s not be afraid of the future. Let’s shape it to be better for everyone and to move forward this great specialty that we’re all a part of.” – by Matt Hasson

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References:

• SF Match Residency and Fellowship Matching Services. http://www.sfmatch.org.
• U.S. Census Bureau. Aging boomers will increase dependency ratio, Census Bureau projects. http://www.census.gov/newsroom/releases/archives/aging_population/cb10-72.html. Published May 20, 2010.
• U.S. Census Bureau. An older and more diverse population by midcentury. http://www.census.gov/newsroom/releases/archives/population/cb08-123.html. Published Aug. 14, 2008.

• Robert Cherewich, MPS, CMPE, COE, can be reached at Ophthalmology Physicians & Surgeons, 331 N. York Road, Hatboro, PA 19040; 215-672-4300; fax: 215-672-9524; email: rpc10@aol.com.
• Uday Devgan, MD, FACS, FRCS, can be reached at Devgan Eye Surgery, 11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax: 310-388-3028; email: devgan@gmail.com.
• John A. Hovanesian, MD, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; email: drhovanesian@harvardeye.com.
• Anthony P. Johnson, MD, can be reached at Jervey Eye Group, 601 Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-3835; email: apj@jervey.com.
• David W. Parke II, MD, can be reached at American Academy of Ophthalmology, 655 Beach St., San Francisco, CA 94109; 415-561-8510; fax: 415-561-8526; email: dparke@aao.org.
• John B. Pinto can be reached at 619-223-2233; email: pintoinc@aol.com; website: www.pintoinc.com.
• Disclosures: No products or companies are mentioned that would require financial disclosure.