ECPs may need to adapt to growing demand for eye care services

With the impending implementation of the Affordable Care Act, optometric pundits are revisiting the question of whether the eye care workforce will be able to effectively manage demand in the coming years. There are differences of opinion across the board, but most agree that existing eye care providers will have to adapt how they operate their practices to increase the number of patients they are capable of serving.

Demand

While the consensus is that demand will undoubtedly grow, exactly how much demand will increase in relation to the current workforce’s accommodative capability is being debated.

Richard Edlow, OD, former chair of the American Optometric Association’s Information and Data Committee, believes that the current and projected optometric workforce will be seriously tested by the coming demand for eye care services, and it may come up short.

“According to the American Optometric Association/Abt Manpower Study published in 2000 (White et al.), we will have an oversupply of optometrists until 2017, and then it will shrink,” Edlow said during a presentation at the IOMED program of the American Society of Cataract and Refractive Surgery meeting. “The American Academy of Ophthalmology said there were too many eye doctors, but those studies were flawed because they did not take into account the aging population, the Affordable Care Act (ACA), the changing ethnicity of the U.S. nor new treatment modalities. Oversupply, if it exists in your specific region, will disappear rapidly.”

Edlow said in an interview with Primary Care Optometry News: “If we take a look at the commercial population of the Baby Boomer generation 64 years of age and younger, the utilization rate for medical and surgical services in eye care is about 1.5% a year,” he said. “Right now, the utilization rate for the 65 years of age and older population is 12% to 15%, a factor of 10 higher.”

As the Baby Boomers become the new 65-and-older population, the growth curve and demand for services is going to rapidly outstrip any supply side, Edlow said in the interview.

“We’re coming off a 20-year period where we could be complacent because the 65-and-older population was flat,” Edlow said during the IOMED presentation. “It’s about to take off. Fasten your seat belts.”

Another factor that will increase demand, according to Edlow, is the fact that the ethnicity of the U.S. is changing. The Caucasian population is declining, the African-American population is increasing and the Hispanic-American population is growing twice as fast as any other ethnicity.

“Open-angle glaucoma and diabetic retinopathy occur in a much higher prevalence in the Hispanic and African-American populations than in the Caucasian population,” he said.

“We will need to provide about 100 million eye exams in 2020,” Edlow said during the IOMED presentation. “And the ACA may add another 40 million currently uninsured people into the mix.”

Private practitioner Kenneth H. Elder, OD, believes that demand in coming years will be less of an issue than people think.

“Obviously, the prevalence of eye disease and refractive error is a major factor,” Elder told PCON in an interview. “People who don’t see well generally seek out care. Insurance coverage is also a major component for some segments of the population. But eye care provided by optometrists is generally affordable and accessible even to many of those who in the past lacked traditional health coverage.

“When you consider that 30, 40, 50 million people have no health insurance now, before the ACA has gone into effect, in a country of 320 million people, that means that 270 million do have insurance,” he continued. “Health care reform and/or ObamaCare may increase demand, but it will be a relatively small amount.”

Regarding the aging population, while Elder does anticipate an increase in demand from this factor, he believes the supply of optometrists will still far outpace it.

“Schools and the ‘powers that be’ in our profession seem to operate based on a theoretical demand for eye care when they talk about their perceived shortage of ODs and how new schools and/or larger classes are needed,” he said. “Yes: in theory, if every single citizen of this country got an eye exam every single year from an optometrist, then maybe you could say that there is a potential undersupply of doctors. But, of course, not every citizen gets an exam every year and, of those that do, not everyone gets one from an optometrist.”

New York State case study

A recently published case study of optometric manpower in New York determined that the State University of New York’s College of Optometry has contributed to an overall increase of optometric practitioners in the state over the past 40 years (Soroka et al.). However, the net increase in providers has – as of the study’s publication in 2012 – slowed to approximately 1% a year. And during the same period, the number of ophthalmologists has not kept pace with practitioner attrition nor population growth.

“The supply data suggest that the cumulative number of eye care providers in New York State would remain constant for optometry while declining slowly for ophthalmology,” the study authors said.

In conclusion, the study predicted a shortage in eye care providers in the state of New York by 2030, as well as an apparent maldistribution of providers across the state.

Workforce hours

In the past decade, the percentage of women enrolled in optometry schools has risen. Ten years ago, women made up 55% of the student body; in 2010, they made up 64% of the student body, according to the New York State report.

Studies have shown that, on average, female physicians work as much as 7 fewer hours per week than male physicians, thereby reducing the effective supply of doctors in terms of full-time equivalency, the study authors said.

“Every study indicates that women work about 85% of a full-time employee,” Edlow said in the interview. “Taking this into account, if we need 51,000 full-time eye doctors, we’re going to need 65,000 actual doctors to fill the same hours. If the workforce is only increasing at 0.5%, as it is in ophthalmology, but 40% of the new entrants are women working at 85% of a full-time equivalent, then you actually have a declining workforce in ophthalmology.”

In optometry, Edlow said that between now and 2020, the workforce will be increasing about 5% a year, and the demand for comprehensive eye exams due to population growth will be increasing at the same rate.

“So you’ve got a flat supply-demand equilibrium there, but then 64% of those entering optometry nowadays are women who are going to work at 85% full-time equivalent,” he said.

“The Millennial Generation isn’t made up of the ambitious doctors the older generations are,” Edlow continued. “Doctors in their 50s and 60s worked 50 to 60 hours a week without thinking twice about it. The newer generation coming up has different priorities, and they’re working 35- to 40-hour weeks. So you’ve got doctors exiting the workforce that are accustomed to working 50- to 60-hour weeks being replaced by doctors working much less than that. That will be a crunch on the workforce supply as well.

“There’s been a buildup of retirement demand recently,” Edlow said during his IOMED presentation. “Retirement decisions were thrown off by the economic reality of the stock market in 2008, and a lot of eye doctors weren’t retiring for a number of years.”

In addition, the New York State report cited another study that showed that 87% of ophthalmology residents do not intend to practice general ophthalmology upon completion of their residency, but are instead planning to continue their training into subspecialty areas.

Role of optometric education

One way to address this increasing demand and stymied supply is to open new optometry schools and expand class sizes. However, some question the quality of optometrists being produced.

According to private practitioner and former assistant professor Mark R. Flora, OD, “The Accreditation Council on Optometric Education, which is supported by the American Optometric Association, needs to make requirements for starting a school stricter and more defined, including the local potential patient load required, clinical laboratory, research facilities, library, available and diverse medical clinics, medical laboratory, radiology and emergency facilities for clinical training.”

A plethora of new optometrists will be no better for a growing demand if many of those being added to the system are poorly trained, he told PCON in an interview.

“In today’s environment, we need to specify that any new school of optometry be associated with a medical school,” he said. “That in and of itself would remove any barriers to having adequate facilities available.”

Flora believes the market is oversaturated as it is and will continue to be oversaturated even after the addition of the aging population and the newly insured from the ACA. Therefore, bigger classes and more schools will only serve to exacerbate the problem, he said.

“You can ask any doctor, wherever they practice, if they need a new eye doctor in their town, and nine out of 10 will tell you absolutely not,” Flora said. “We’ve got two too many in my town already,” he said.

Elder agreed.

“I believe the effect will be more and more young doctors forced into less-than-desirable professional situations and a continuing stagnation of already-pathetic reimbursements from third-party payers,” Elder said.

Potential solutions

“The only feasible solution is for schools to close and/or to reduce class sizes,” Elder said. “I simply do not want to see the next generation forced into situations that they did not want because of the oversupply that has been predicted by at least two workforce studies commissioned in the past 10 to 15 years.

“Plus, the average number of patients seen by optometrists has remained at just over one per hour,” he added, “so optometry still has a massive amount of unused capacity to see patients.”

Edlow agreed on that point.

“The solution is technology to increase patient flow and integration of optometry and ophthalmology,” he said. “There are a lot of redundancies and inefficiencies when ophthalmologists and optometrists function independently.”

Utilizing non-doctor staff is another way to improve patient flow, according to Edlow.

“Things as simple as electronic medical records, automated refraction systems and patient kiosk registration can improve your capacity to see patients.

“We need to figure out how to provide care more efficiently and more productively,” he continued. “And there are solutions out there to do that.”

Flora added: “More importantly, our doctors need to be better trained and experienced in not only the plethora of outpatient eye medical, trauma and surgical cases we see today, but their attendant medical problems as well. When most of our doctors can recognize and take care of 90% of the patients we are presented with, efficiency will skyrocket.”

Schools adapt

Kevin L. Alexander, OD, PhD, agreed that there may be an oversupply of optometrists in certain areas, but says the profession will be faced with a different challenge.

“The health care system of tomorrow will be a team approach,” Alexander told PCON, “and the real question is: Are we preparing students to work in that environment?”

Alexander is president of Marshall B. Ketchum University, home of the Southern California College of Optometry (SCCO), Fullerton, Calif.; former dean of Ferris State University, Michigan College of Optometry, Big Rapids, Mich.; former president of the AOA and the Association of Schools and Colleges of Optometry; and a former private practitioner.

Three of the newest optometry schools – University of the Incarnate Word’s Rosenberg School of Optometry in San Antonio, Texas; Western University of Health Sciences College of Optometry in Pomona, Calif.; and Midwestern University’s Arizona College of Optometry in Glendale, Ariz. – all began with the concept of interprofessional education in mind, Alexander said.

Under a similar philosophy, on April 1, SCCO expanded into Ketchum.

“Our mission is to create an interprofessional health care campus that teaches students to function through interprofessional education,” Alexander said. “Optometry is the driver here; we are the principle program. We’ve added a physician assistant program, which has opened doors in the medical community, increasing our exposure for optometry.”

The Pennsylvania College of Optometry expanded into Salus University, which has programs for audiologists and physicians’ assistants.

Alexander said Ketchum plans to add a pharmacy program next.

“These are good environments for an optometry school,” he said, and noted that being affiliated with a medical school is not necessarily the best option.

These optometry-centric universities “see the future of optometry in the interprofessional delivery of care,” Alexander said.

He noted the substantial investment schools must make to purchase equipment that must be updated every 3 to 5 years.

“By the time you hire faculty, buy equipment and build a building, it is years before you get a return on investment,” he said. “It’s not about making money; nobody is getting rich on these programs.”

Moving forward

The American Optometric Association (AOA) and Association of Schools and Colleges of Optometry are currently working together on a new initiative to appraise the current climate of the eye care market in the U.S. and to develop a flexible model to predict changes in supply and demand, according to an AOA press release.

The initiative will result in the creation of an extensive database containing information on optometrists and ophthalmologists, providing an accurate picture of the number of eye care providers in the country, the release said.

“Ophthalmology residencies have not increased for 10 years at least,” added Alexander, “so we know from many sources that there’s a predicted shortage in ophthalmology. Those who think there’s an oversupply of optometrists should ask themselves if they’re practicing full-scope optometry. They can fill in that gap. If they would embrace the medical model, there’s plenty to do.” – by Daniel R. Morgan, with Nancy Hemphill, ELS

Disclosures: No products or companies are mentioned that would require financial disclosure.