Growing demand for eye care services may highlight shortage of ophthalmologists

Population-based surveys predict a dramatic rise in the number of older individuals, leaving many experts to wonder whether the field of ophthalmology will be adequately equipped to meet an expected rise in demand for services.

A report released in 2009 by the National Institute on Aging (NIA), a component of the National Institutes of Health, projected significant changes in U.S. demographics in the coming decades, noting that Americans will live longer, healthier lives and that tomorrow’s seniors will most likely be more affluent and better educated.

While many studies have found a direct correlation between higher income and education status and better overall health — a finding echoed in epidemiologic studies in ophthalmology — advanced age has also been associated with an increased risk of a number of medical maladies. As it pertains to ophthalmology, older age may portend cataract development, glaucoma, age-related changes to the back of the eye including macular degeneration, and increased risk of diabetes, which may lead to diabetic macular edema or retinopathy.

According to the NIA report, by 2030 one out of every five Americans — approximately 72 million people — will be 65 years or older. The growth of that age bracket, however, is trumped by growth among seniors older than 85 years, the fastest-growing segment of the U.S. population. The report also suggested that more minorities will constitute the ranks of senior citizens and that growth rates among men will outpace women.

Larry P. Frohman, MD, suggests that consultative fields, such as neuro-ophthalmology, are undervalued, driving residents toward more lucrative specialties. Image: Sliva R

What impact the demographic shift in the U.S. population will have on future disease patterns is uncertain, but most experts agree that the total number of patients requiring ophthalmic services will rise, especially if proposed health care reforms add 30 million more patients to already-crowded physician rosters. At the same time, the number of new ophthalmologists has stagnated, and looming retirements among older physicians could leave practices in short supply.

Furthermore, while the demands on ophthalmologists may be driven by the increasing graying of American society, there is also an expected increase in demand for care of younger patients.

According to data from the U.S. Census Bureau, based on the 2000 census, the population of Americans age 65 years and older is expected to increase by 36% by 2020, 79% by 2030 and 120% by 2050. Projected growth among individuals 85 years and older is expected to jump almost 15%, 52% and 231% during that same time.

What may cause a shortage

According to William L. Rich III, MD, FACS, of the American Academy of Ophthalmology’s Governmental Affairs Division, there is little doubt that ophthalmology could face a shortage of practitioners in the near future.

“It’s because of two things: There is a fixed pipeline of ophthalmologists, and we have an ever-growing demand for our services,” Dr. Rich said. “If you look at the absolute numbers in ophthalmology, the number of residents declined 22% between 1993 and 2000, and now it is steady.”

William L. Rich

Between 1990 and 2005, Dr. Rich said, the total number of ophthalmologists rose 16%. But that growth pales in comparison to the 45% growth in the number of physicians other than ophthalmologists.

The number of new ophthalmologists entering the field out of residency has also slowed to a trickle, with about 400 residents graduating each year and less than 50% choosing to enter general ophthalmology practice after residency. However, Dr. Rich added, the number of residents per year is fixed and will remain fixed unless other medical specialties surrender residency training slots, an outcome he does not see as likely, especially given the dearth of internal medicine practitioners.

Moreover, due largely to the expected rate of older ophthalmologists leaving the field in the next decade as the first baby boomers reach retirement age, simply adding to the number of residents in training would likely not have a significant impact on increasing the workforce.

“If you look at medicine as a whole, ophthalmology — if you look at the age intervals of 45 to 54 — we have far more people, like 5% more than the rest of medicine. If you look at 55 to 64, about 10% more of us are in that age group. Those folks are going to be [retiring soon],” Dr. Rich said.

These various forces have already helped to shrink the number of ophthalmologists per 100,000 people to about 55.

“We’re not keeping pace with an aging population, and of all the medical specialties, ophthalmology gets the greatest percentage of its revenue in visits from those over the age of 65,” Dr. Rich said.

Shift in how to practice

To Dr. Rich, these numbers should be a call to practice differently, to convert the ophthalmic practice model to one that promotes efficiency and delegation. That means fewer solo practitioners, greater reliance on ophthalmic technicians and ancillary office support staff, and streamlined procedures, such as increased collaboration with optometrists.

“Our approach, what we are advocating, is a team-based approach, where we can build in more efficiency and see more patients,” Dr. Rich said. “The problem we have is, because we are not going to get any more funded training slots, we have to change pretty dramatically the practice models that we currently have. And we’re frankly doing that now.”

A shift in practice patterns may also be driven by changing financial incentives to ophthalmologists. In 1995, most ophthalmologists were generating the lion’s share of revenue, as much as 65%, from surgical procedures performed in the operating room. More recently, the revenue streams have shifted the practice of ophthalmology to a diagnostic specialty more focused on office-based patient interactions.

“You have to look at how we get paid, and this is one area where I believe is not being addressed,” Dr. Rich said. “That ratio is exactly the opposite now. We make 65% of our revenue from seeing patients, talking to them and doing tests.”

If the economic shift stands pat, however, it may present a glimmer of hope for ophthalmology. According to Dr. Rich, older ophthalmologists, instead of choosing retirement, may decide to give up surgery and instead opt for office-based practices, which may, in turn, slow pending retirements among baby boomer ophthalmologists.

Shortage in neuro-ophthalmology

A shift in compensation to office-based practice would seem to benefit ophthalmic subspecialties that are already geared toward that dynamic. However, the field of neuro-ophthalmology, which is disproportionately consultative by virtue of its focus, still remains undervalued by the current compensation system.

According to Larry P. Frohman, MD, a neuro-ophthalmologist at the University of Medicine and Dentistry of New Jersey, simply increasing throughput in order to increase revenue from patient office visits may not be possible given the complex patient problems addressed by neuro-ophthalmologists. As a result, he said, a fundamental financial disincentive exists for those considering neuro-ophthalmology as a practice in the form of inequitable compensation relative to service delivered.

“The types of patients that a neuro-ophthalmologist sees are patients that are sent to neuro-ophthalmologists because they have very complex problems,” Dr. Frohman, a past president of the North American Neuro-Ophthalmology Society, said.

Revenue issues are not specific to financial compensation, either. According to Dr. Frohman, the subspecialty has seen a trend of neuro-ophthalmologists leaving the academic environment, where departments are often handcuffed by budgetary realities, for private practice. That shift has introduced the potential for inadequate staffing levels to ensure adequate neuro-ophthalmic training for residents and young physicians.

Dr. Frohman has written several editorials on the manpower shortage his subspecialty faces and has outlined several issues he believes need to be addressed. Most of these ideas revolve around the recognition that most academic ophthalmology departments are no longer capable of subsidizing their own neuro-ophthalmology component.

Arguing that neuro-ophthalmology practice can be cost-saving and help generate revenue, Dr. Frohman has suggested realigning distribution of inter- and intradepartmental revenue to support the work of neuro-ophthalmologists. Specifically, early consultation with a neuro-ophthalmologist could lead to earlier diagnoses of complex disorders while preventive measures could lessen downstream palliative care costs.

In addition, neuro-ophthalmic services could, for example, “improve the retina surgeon’s efficiency by managing their patients with fundus-negative vision loss, freeing the retina surgeon for more revenue-generating activities,” Dr. Frohman wrote in Ophthalmology in 2005.

Just as important would be to recognize and account for downstream revenue generation for the academic medical center by neuro-ophthalmologists in such cases as when a tumor is diagnosed that requires neurosurgery. Recognizing the extra-departmental contribution to institutional revenue might go a long way to justifying and improving salaries for academic neuro-ophthalmologists.

Neuro-ophthalmologists in academic departments also spend a great deal of time teaching, a task that is not always recognized in compensation. “If disproportionate responsibility for teaching is given because it is less expensive, in terms of lost revenue, to have the neuro-ophthalmologists teach, then this time must be appropriately valued,” Dr. Frohman wrote.

The issue of value, or more specifically relative value for services under the Resource-Based Relative Value Scale system, is a particular sticking point for neuro-ophthalmology. Although designed to control procedure-based costs in Medicare — and similar compensation schemes have been adopted by third-party payers — Dr. Frohman and others contend that the scale system has actually had the opposite effect in overemphasizing procedure-based compensation.

A survey of ophthalmology residents conducted by the North American Neuro-Ophthalmology Society found that while 31% of residents said they were not interested in neuro-ophthalmology because of the lack of surgery, a significant portion said they were concerned about the perceived lack of jobs, the difficulty of the specialty and the time required to practice the discipline.

While those findings may reflect quality of life concerns among residents, to Dr. Frohman, these findings speak fundamentally to concerns over compensation for services.

“I think what it comes down to is, if you are going to work so hard, if you are going to deal with such complicated cases, you shouldn’t also have to be financially penalized for such,” Dr. Frohman said.

Shortage in pediatric ophthalmology

Compensation also appears to be a component of potential shortages in specialties such as pediatric ophthalmology, which, like neuro-ophthalmology, is already experiencing bloated patient rosters and long wait times for appointments.

“Very rarely do you hear a pediatric ophthalmologist anywhere talk about a wide-open schedule. Very rarely do you hear a pediatric ophthalmologist complain there are not enough patients to see. Usually it’s just the opposite. There’s more work than we can actually handle,” David K. Coats, MD, of the Baylor College of Medicine, said.

In a survey of ophthalmic residents, Dr. Coats and colleagues found that two-thirds held a positive outlook on job prospects in pediatric ophthalmology and another two-thirds found strabismus surgery interesting. But that favorable impression did not translate to a desire to pursue subspecialty fellowship training, with just 7% indicating that they were considering that career choice.

The discrepancy may be explained by the fact that half of residents said they perceived pediatric patients to be difficult to examine. In addition, 50% of residents also said that they believed income levels for pediatrics to be too low, and only 25% believed the field to be prestigious, a factor that has been identified as important to some medical school graduates.

In the survey, 43% of respondents had a rotation longer than 4 weeks and 32.8% spent no time on pediatric rotation during their first year of residency. Longer exposure to pediatric rotations in residency training may have the effect of easing some young physicians’ concerns about managing pediatric patients, according to Dr. Coats. However, he added, it will not change an average starting salary that is considerably lower than subspecialties such as glaucoma, retina or cornea — areas that residents can enter with an equal duration of additional training.

“I think people naturally tend to shy away from fields they perceive as not compensating them well, and they naturally are going to avoid going into a field in which the patients are difficult to deal with,” Dr. Coats said. – by Bryan Bechtel

How can ophthalmologists make their offices more efficient in anticipation of increased patient loads?

References:

• Age-Related Eye Disease Study Research Group. Risk factors associated with age-related nuclear and cortical cataract: a case-control study in the Age-Related Eye Disease Study, AREDS Report No. 5. Ophthalmology. 2001;108(8):1400-1408.
• Age-Related Eye Disease Study Research Group. Risk factors associated with age-related macular degeneration. A case-control study in the age-related eye disease study: Age-Related Eye Disease Study Report Number 3. Ophthalmology. 2000;107(12):2224-2232.
• Frohman LP. The human resource crisis in neuro-ophthalmology. J Neuroophthalmol. 2008;28(3):231-234.
• Frohman LP. How can we assure that neuro-ophthalmology will survive? Ophthalmology. 2005;112(5):741-743.
• Hasan SJ, Castanes MS, Coats DK. A survey of ophthalmology residents’ attitudes toward pediatric ophthalmology. J Pediatr Ophthalmol Strabismus. 2009;46(1):25-29.
• He W, Sengupta M, Velkoff VA, DeBarros KA. 65+ in the United States: 2005. http://www.census.gov/prod/2006pubs/p23-209.pdf. Accessed Feb. 1, 2010.
• US Census Data. http://www.census.gov. Accessed Feb. 1, 2010.

• David K. Coats, MD, can be reached at Texas Children’s Hospital, Clinical Care Center, 6701 Fannin St., 5th Floor, Suite 510, Houston, TX 77030; 832-822-3230; fax: 713-796-8110; e-mail: dcoats@bcm.tmc.edu.
• Larry P. Frohman, MD, can be reached at UMDNJ-New Jersey Medical School, Doctors Office Center, Suite 6100, P.O. Box 1709, Newark, NJ 07101-1709; 973-972-2065; fax: 973-972-2068; e-mail: frohman@umdnj.edu.
• William L. Rich III, MD, FACS, can be reached at American Academy of Ophthalmology, Governmental Affairs Division, 1101 Vermont Ave. NW, Suite 700, Washington, DC 20005; 202-737-6662; fax: 202-737-7061; e-mail: hyasxa@aol.com.