Pediatric ophthalmology facing economic crisis, workforce issues, disillusionment
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Pediatric ophthalmologists are facing economic challenges.
Reimbursement cuts, the aftermaths of the pandemic, workforce issues and general disillusionment among current practitioners are leading to a profound crisis within the subspecialty.
Source: Adobe Stock.
“Many states are already suffering from a shortage of pediatric ophthalmologists, and we are expecting to see an even greater decrease of workforce, leading to alarming limitations in the access to pediatric eye care,” Karen E. Lee, MD, said in an interview with Healio/OSN.
Lee and co-authors Jake A. Sussberg, Leonard B. Nelson, MD, and Tobin Thuma, DO, all from the department of pediatric ophthalmology and strabismus at Wills Eye Hospital, Philadelphia, recently published a series of papers on this topic in the Journal of Pediatric Ophthalmology & Strabismus.
“We gratefully acknowledge the invaluable contribution and support of Wills and JPOS in our effort to shed light and raise awareness on this issue, a matter of great concern for the future of eye care, which has not so far received the attention it deserves,” Nelson told Healio/OSN.
A significant decrease in revenue
Between January 2021 and July 2022, Lee and colleagues conducted a survey among 243 pediatric ophthalmologists to assess their economic viability and practice patterns. About 63% of respondents reported reduction in their surgical revenue by more than 10%, and 39.9% reported a decrease between 10% and 25% in clinical revenue.
“Close to 30% said they had to subsidize their income with other revenue-generating activities including general ophthalmology or elective procedures paid by patients out of pocket, such as LASIK, aesthetic treatments and plastic surgery,” Lee said.
An additional 11.1% of respondents reported they stopped pediatric eye surgery entirely.
“Reimbursement cuts for most of the major procedures, including strabismus surgery, have made surgery unsustainable for some practices,” Nelson said. “With fewer pediatric ophthalmologists available to keep their OR open, access to care will be heavily affected. There are states where patients may have to travel miles to be operated on.”
Early retirement among pediatric ophthalmologists is also increasing. A steady progression from 1.6% to 6.5% was reported since the start of the pandemic.
International medical graduates
“Because of all of these economic issues and workforce problems, we found that close to 38% of people would not recommend a resident to pursue a career in pediatric ophthalmology,” Lee said.
A declining interest in the field, with increasingly fewer trainees pursuing fellowship programs in pediatric ophthalmology, has been reported since 2007. More of those positions are currently being filled by international medical graduates (IMGs).
“Specifically, between 2010 and 2012, 31%, of fellowship positions were taken by IMGs, with a further rise to 38% between 2019 and 2021,” Lee said.
“This increase in IMGs, which is significantly higher than in other subspecialties, has serious consequences for our internal supply of pediatric ophthalmologists because many IMGs eventually return to their country of origin. Difficulties in obtaining the license to practice in the U.S. also discourage the few who want to stay,” Nelson said.
Insufficient workforce unequally distributed
According to 2020 data, there are currently fewer than 1,100 pediatric ophthalmologists in the country to meet the demands of 75 million children. Importantly, as per 2022 data, more than half of all children in the United States are covered by Medicaid.
“We showed in our second paper that 30% of providers have had to limit the number of Medicaid patients to maintain their economic viability because the reimbursements for Medicaid are substantially lower than for other insurances,” Lee said.
This, in addition to the uneven distribution of pediatric ophthalmologists across states and rural vs. urban areas within states, exacerbates inequities in access to eye care services.
The latest 2022 data from the American Association for Pediatric Ophthalmology and Strabismus showed great unbalances, with only one pediatric ophthalmologist in South Dakota, three in Arkansas, Montana and New Hampshire, four in Mississippi and Delaware, five in New Mexico, and 93 in California.
“In our third paper regarding access to eye care, we calculated the ratio of providers (namely AAPOS members) per population unit. What we found is that states with both high Medicaid coverage and below-average AAPOS members per million persons are the ones that are hardest hit by workforce issues,” Lee said.
Mississippi, Arkansas and Kentucky have high Medicaid coverage of 42.6%, 49.7% and 41.3%, respectively, and an AAPOS members per million persons ratio of 5.7, 10 and 8.9, respectively.
“Patients in these areas are forced to seek care outside of pediatric ophthalmology from optometrists or general ophthalmologists or travel to a different state entirely. And this is a big problem because eye conditions necessitate expertise, timely evaluation and early treatment to prevent visual impairment. Importantly, pediatricians should also be aware that they can be affected by the inability to provide referrals due to the shortages in pediatric ophthalmologists,” Lee said.
Suggested strategies
The fourth paper published by the Wills Eye group discussed potential economic strategies to reduce the need to pursue sources of income outside pediatric ophthalmology, thus mitigating workforce gaps and improving access to pediatric eye care.
“These include becoming a partner in an ambulatory surgery center, buying the property where you practice so that you pay rent to yourself, and having an optical shop in conjunction with your practice to supplement your income by enabling patients to order glasses in the same location. Also, increasing your marketing profile via website referrals or reaching out to pediatricians or other vision streaming outlets eventually pays out,” Nelson said.
Using OCT for the baseline evaluation and follow-up in patients with amblyopia is a useful adjunct that provides financial return.
“In a multispecialty ophthalmology group, the OCT is shared with retina, glaucoma and cataract specialists. But even if you have to buy it for yourself, it will pay for itself with the reimbursement fees,” Nelson said.
The same applies to the Spot Vision screener (Welch Allyn) to screen for uncorrected refractive error.
Negotiating a financial contract agreement for examining premature children in the neonatal intensive care unit may also be worthwhile, given the current high honoraria paid by most hospitals.
Last but not least, the AAPOS has recently hired a lobbyist to hopefully improve the economic workforce issues.
“Hopefully, these lobbyists will be effective in the many challenging and complex economic issues facing the pediatric ophthalmology subspecialty,” Lee said.
With her group, she has recently submitted for publication a paper examining the perceptions of third-year ophthalmology residents to further understand the factors that are influencing the choice to pursue pediatric ophthalmology. In addition, the group is presently working on a number of unanswered questions regarding the economic downturn of pediatric ophthalmology.
“We could potentially address those factors to really encourage more people to join us in the field,” Lee said.
References:
- Lee KE, et al. J Pediatr Ophthalmol Strabismus. 2022;doi:10.3928/01913913-20220817-01.
- Lee KE, et al. J Pediatr Ophthalmol Strabismus. 2022;doi:10.3928/01913913-20221025-03.
- Lee KE, et al. J Pediatr Ophthalmol Strabismus. 2022;doi:10.3928/01913913-20221108-01.
- Thuma TBT, et al. J Pediatr Ophthalmol Strabismus. 2022;doi:10.3928/01913913-20220623-01.
For more information:
Karen E. Lee, MD, can be reached at Department of Pediatric Ophthalmology and Strabismus, Wills Eye Hospital, 840 Walnut St., Suite 1210, Philadelphia, PA 19107; email: klee@willseye.org.
Leonard B. Nelson, MD, can be reached at Department of Pediatric Ophthalmology and Strabismus, Wills Eye Hospital, 840 Walnut St., Suite 1210, Philadelphia, PA 19107; email: nelson1090@aol.com.
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