Progressive myopia vertical may be a boon for eye care practices
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Those who read my Lindstrom’s Perspective regularly know that I have a special interest in demographics and medical economics. This time, I am going to share a few thoughts on the medical economics of managing the progressive myope.
Nearly all practicing ophthalmologists spend the majority of their time in office practice. Most of us practice only 4 days a week, 3 days in the office and 1 day in surgery. The typical comprehensive ophthalmologist sees about 4,000 patient office visits a year at about $200 per visit, resulting in $800,000 of revenue. During the 1 day per week in the operating room, 400 surgical procedures are performed at an average price near $1,000 per procedure (with the national average of 20% cash pay-supplemented refractive cataract surgery), yielding another $400,000. With a 65% overhead, that generates the Medscape-reported median U.S. ophthalmologist’s take-home pay of $420,000 per year. As an aside, most corneal, glaucoma and ophthalmic plastic surgery fellowship-trained ophthalmologists earn a similar income, while most pediatric ophthalmologists and neuro-ophthalmologists earn less and most vitreoretinal specialists more.
With the potential FDA approval of atropine eye drops for the treatment of progressive myopia in 2025 followed by a product launch in 2026, two interesting questions emerge: Who will care for the progressive myope? And will their care be economically viable?
Most children with clinically significant progressive myopia are between the ages of 3 to 14 years and have at least one parent with myopia between the ages of 20 and 50 years. While some progressive myopia patients will come from vision screening in schools and neighborhoods or pediatrician and primary care physician referral, I believe the primary source of new patients with progressive myopia is likely to be their myopic parents or family members. These myopic parents and family members are all familiar with and have seen an eye care professional. In America, about 70% of myopic patients are under the care of an optometrist. Refractive eye care is critically important to optometry. Including the associated eye examinations, refractions, and dispensing of glasses or contact lenses, optical eye care generates close to 90% of a typical optometry practice’s revenue. It is clear to me that our optometric colleagues will be highly motivated to care for and capture children with progressive myopia in their practices.
For ophthalmology, pediatric and comprehensive ophthalmologists, especially those who dispense glasses and contact lenses, along with integrated eye care practices in which ophthalmologists, optometrists, physician assistants, orthoptists and opticians work side by side will be most interested in treating the progressive myope. The cataract, cornea, glaucoma and retina specialist, not so much.
I believe the progressive myope will be worth capturing in an eye care practice. I expect these patients to be seen every 3 to 6 months depending on their rate of myopia progression and their parents’ anxiety level. The progressive myope will be treated with behavioral modification (outdoor play, the 20-20-20 rule and digital device time management), appropriate optical correction and topical atropine eye drop therapy. Clinical studies suggest that full correction of the myopic refractive error with glasses or contact lenses is beneficial. This fact will support a careful cash-pay refraction at every visit. The prudent practitioner will price this diagnostic and therapeutic refraction appropriately. Dispensing glasses and contact lenses is also a cash-pay business, with 65% to 70% gross margins. While standard eyeglass costs are about $250 each, specialty eyeglasses specifically designed to treat progressive myopia are being developed and are certain to be priced much higher, creating an important premium cash-pay eyeglass source of revenue. Two to four times yearly eye examination fees and point-of-service testing, which may include axial length measurement, choroidal thickness evaluation and corneal topographic screening for early keratoconus, will enhance the economics of caring for these patients. In addition, the practice that captures the adolescent progressive myope will likely also capture the myopic parents and relatives, and the myope develops cataract, glaucoma and myopic retinal disease more frequently and at an earlier age than the emmetrope or hyperope.
Every year in the U.S., there are about 1% fewer ophthalmologists in practice and 1% more optometrists, and the shortage of pediatric ophthalmologist is especially severe. I believe the ophthalmologist-led integrated eye care delivery model with ophthalmologists, optometrists, physician assistants, nurse practitioners, orthoptists and opticians working side by side in the same practice will be ideal for managing the new progressive myopia diagnostic and therapeutic vertical in eye care. Many practice models will evolve, including corporate eye care like we have experienced in refractive corneal surgery. This new eye care vertical managing the progressive myope will generate billions of dollars in revenue. Properly managed, it will be a win-win-win with patients, eye care professionals and industry all benefiting. The prudent practice will take note and plan for its preferred level of participation.
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