Issue: July 10, 2021
Source: Healio Interviews
Disclosures: Beckman reports no relevant financial disclosures. Lindstrom reports he is founder and partner at Minnesota Eye Associates and serves on the board of directors at Unifeye Vision Partners. Pinto and Teymoorian report no relevant financial disclosures.
July 09, 2021
10 min read
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Supply and demand: Navigating the future of ophthalmology

Issue: July 10, 2021
Source: Healio Interviews
Disclosures: Beckman reports no relevant financial disclosures. Lindstrom reports he is founder and partner at Minnesota Eye Associates and serves on the board of directors at Unifeye Vision Partners. Pinto and Teymoorian report no relevant financial disclosures.
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Individuals older than age 65 years consume 10 times the amount of eye care compared with those younger than 65 years.

With more baby boomers crossing that threshold every day, ophthalmologists can expect to see even more patients and take on more responsibilities. This influx of patients is coinciding with another factor that will likely increase caseload for eye care professionals but also provide some new opportunities.

Savak “Sev” Teymoorian, MD, MBA
Savak “Sev” Teymoorian, MD, MBA, said there is a shortage of physicians in all specialties, not just ophthalmology.

Source: Savak “Sev” Teymoorian, MD, MBA

OSN Practice Management Section Editor John B. Pinto, president of the ophthalmic consulting firm J. Pinto and Associates, was recently working with a client in a smaller community in the Midwest that went from five ophthalmologists to three. For a community of 300,000 people, the difference in ophthalmology care is significant.

“That community now has five times as many people per provider compared with the average community in the country,” Pinto said. “We’re going to be seeing more and more situations like this where the baby boomer surgeons are slowing down and retiring.”

From 1995 to 2017, the national density of ophthalmologists decreased from 6.3 per 100,000 individuals to 5.68 per 100,000. Over that same time period, the ratio of ophthalmologists older than 55 years to younger ophthalmologists increased from 0.37 to 0.82.

In 2016, the Health Resources and Services Administration estimated that there will be demand for approximately 22,000 ophthalmic surgeons by 2025. However, it also estimated that the number of available ophthalmologists would fall short of that demand by more than 6,000 physicians.

According to Healio/OSN Board Member Kenneth A. Beckman, MD, FACS, the pause in practice due to the COVID-19 pandemic has made everyone busier. This unexpected speed bump has pushed procedure scheduling back and created a significant backlog that physicians are still working to catch up to. It is unclear whether an ophthalmologist shortage is contributing to this increased workload.

“It’s hard to tell right now because there was a lull last year because of COVID,” Beckman said. “People’s numbers were down, and now, people are getting busier. It’s hard to tell how much of that is catch up vs. if it’s because of a shortage. We have to see if it levels out over the course of the next year.”

Kenneth A. Beckman, MD, FACS
Kenneth A. Beckman

With eye care demand skyrocketing and the number of practitioners not keeping pace, ophthalmologists and their practices can expect to see responsibilities start to shift while experiencing new challenges. However, for some, especially younger physicians, this change might bring new opportunities.

Integrated eye care

Ophthalmology is not necessarily unique in its shortage of physicians.

“There’s just an overall shortage of doctors, regardless of which subspecialty we’re talking about,” OSN Glaucoma Board Member Savak “Sev” Teymoorian, MD, MBA, said. “In ophthalmology, it follows the same pattern as everywhere else. We simply don’t have enough eye care providers, which means we need to recruit help outside of just the ophthalmologist to be able to manage some of the ocular care for our patients.”

A limited number of residency positions and an aging number of practicing ophthalmologists mean that more ophthalmologists retire than enter the workforce every year.

“If you take all the residency programs, they turn out about 450 new ophthalmologists every year,” OSN Chief Medical Editor Richard L. Lindstrom, MD, said. “And every year, about 500 to 550 ophthalmologists retire. So, every year there’s about 100 less ophthalmologists.”

As ophthalmology has been declining, the number of optometrists has been rising. From 1990 to 2017, the density of optometrists has increased from 11.06 per 100,000 individuals to 16.16 per 100,000. Integrated eye care practices are using this influx of optometrists, as well as other professionals, to manage increased demand for care.

Richard L. Lindstrom, MD
Richard L. Lindstrom

How care is delegated between ophthalmologists and optometrists depends a lot on geographic location.

“If you work in rural areas, where there are not a lot of eye doctors to begin with, you’ll definitely see a shift in eye care moving toward the optometrist,” Teymoorian said. “It will depend on the geographical space and who is in that same environment, but it’s going to need to be pushed down to either the general comprehensive ophthalmologist or the optometrist.”

In 2017, rural counties in the United States had a lower mean density of ophthalmologists (0.58 per 100,000 individuals) compared with nonmetropolitan counties (2.19 per 100,000) and metropolitan counties (6.29 per 100,000). They also had the largest increase in older to younger ophthalmologists from 1995 (0.29) to 2017 (1.9).

“Obviously, the population is aging,” Beckman said. “It is going to be a shortage over time, and it already is in the rural places. In the big cities, there probably isn’t as much of a shortage as you would think.”

Pinto said he has been working with more practices that are realizing that to provide full service to their patients, they need to take advantage of this rising number of optometrists to keep up with demand.

“They are realizing that perhaps they should be moving toward having something like two, three or even four optometrists per ophthalmologist,” he said. “Most new optometry grads, especially those who have done residency training, are much better prepared than prior generations to provide significant portions of primary and secondary care that used to be provided only by ophthalmologists.”

At Lindstrom’s practice, there is a team of 18 ophthalmologists and 12 optometrists. Every year, more work is delegated to the optometrists.

“They do most of the optical care — glasses, contact lenses and the like,” he said. “We’ve also delegated a significant portion of our medical office space for them to handle office-based dry eye treatments, as well as medical therapy for mild well-controlled glaucoma. That has been a huge increase in responsibility for them, and they manage a significant number of those patients.”

Beckman said shifting responsibilities within an eye care practice might not be all due to physician shortages. Many practices and ophthalmologists see this kind of reorganization as the best way to produce more valuable work as reimbursement continues to change.

“A lot of surgeons are now designating more of the nonsurgical work to the optometrists so that they can get more surgeries on their plate,” he said. “It’s kind of a chicken and an egg situation. Are they getting more surgery because there’s a shortage and more patients are going to them, or are they getting more surgery because they’re weeding out the nonsurgical to partners who can handle it, giving more access to the patients?”

Between shifting care to optometrists and the addition of allied eye care professionals such as physician assistants, technicians and opticians, the typical workload for ophthalmologists has changed significantly in the last 2 decades. While Lindstrom may have spent 1 day per week in the operating room 20 years ago, ophthalmologists are likely committing two or even three times as much time to surgery now.

“We just don’t have time with the increasing number of pathology cases — cataract, glaucoma, corneal or retina surgery — to spend as much time with office-based care,” Lindstrom said. “We have to delegate that to our colleagues, either optometrists, medical ophthalmologists or physician assistants.”

This has also coincided with changes to reimbursement. While reimbursement for surgery has gone down, payments for office-based visits have gone up, Lindstrom said.

“The prudent ophthalmologist, either themselves or by hiring care extenders, wants to capture that office-based revenue as well because that’s what society has been rewarding — the internist or cognitive doctors, not the procedural doctors — for the last 20 years,” he said. “Meanwhile, they’ll be having increased demands on them as surgeons.”

Career opportunities and challenges

Enterprising ophthalmologists, particularly younger ones, have been presented with new opportunities to take advantage of the physician shortage. Whereas there might have been two or three physicians available for every job opening a generation ago, Pinto said now there might be as many as five job openings for each available physician.

John B. Pinto
John B. Pinto

“This trend is only going to increase,” he said. “If you’re a young doctor just finishing your training or someone who is more in their mid-career and wants to relocate, you’ve never had a better job market than you do today. This is particularly true for any of the subspecialties. For glaucoma or retina specialists, you can basically write your own ticket.”

Young and newly trained ophthalmologists are in a great position to capitalize and earn more money at the beginning of their careers. In many ways, these early career physicians are becoming more like professional athletes, Lindstrom said. Individuals with top training from strong residencies are in demand.

“A young ophthalmologist can lead a team and produce a lot of revenue for a practice,” he said. “Now, residents are in a much stronger position to negotiate both a salary and benefits starting out than they used to.”

There are even more opportunities if ophthalmologists look for positions outside of major cities.

“Changing demographics mean that you’re going to have better job opportunities to choose from, especially if you’re gravitating toward the center of the country where it’s been profoundly difficult to recruit to today,” Pinto said.

“There certainly is an opportunity for people to do pretty much whatever subspecialty they want to do,” Teymoorian said. “It’s just a matter of trying to fulfill the need for patient care. We’re not oversaturated in any area. We need a lot of more in all areas.”

The downside of a supply shortage tends to hit physicians right at a point in their career when they are looking to build their value, Pinto said.

“The middle of your career is generally when you’re entrepreneurial and growth oriented,” he said. “You’re kind of whipsawed because on one hand you have the very good aspect of having more patients available per doctors, while on the other hand, there may not be enough doctors to care for them.”

Despite these early career opportunities, physicians joining the ranks today may have a smaller chance at ownership and equity than physicians in previous generations. Lindstrom said many may be looking at a career as an employee, whether that means within Veterans Affairs, a privately owned practice, or a university or health care system.

“The young doctor gets more to start but then less of an opportunity to build value through equity growth than they used to. That’s just the nature of the situation,” he said. “The classic model of buying into a practice and being a shareholder or equity owner is declining as the field consolidates.”

The other side of that coin is succession planning for older physicians with their own practice. The shortage has made recruiting difficult and expensive, which makes planning for the future harder.

“For practices that are needing to work on a succession plan or to even have more providers, they’re finding it more challenging and more expensive,” Pinto said. “You’re going to find the current environment, and certainly the environment out ahead of us, to be a challenge because it will be hard to find the young doctor who is able to buy into your practice. It’s generally easier in the coastal, urban settings and profoundly difficult in the flyover states.”

Beckman thinks that recruiting is the one area most affected by an ophthalmologist shortage.

“A lot of practices are having trouble as doctors are aging,” he said. “They’re having trouble getting younger ophthalmologists to come in and join, and that’s where people are feeling the shortage. We can handle the given volume, but as you start to do succession planning, many groups are having trouble replacing older doctors with younger ones.”

Meeting demand

At the current rate of training in the U.S., Lindstrom said it will be difficult to bring more people into the field to meet the surging demand. This is made even trickier with restrictive immigration policies that create barriers to bringing in trained ophthalmologists from overseas.

“If you immigrate here from another country, you basically have to start over,” he said. “You can’t just put up your shingle and say, ‘I’m an ophthalmologist.’ You actually have to train and do a residency, so that barrier is quite meaningful.”

Without increased training slots, which is unlikely short of new government incentives, ophthalmologists will have to learn to manage the influx of patients as best they can. That means handling more complex procedures while handing off less demanding cases to support staff and doing more cases in a shorter amount of time.

“We’re going to have to be very efficient, and if you’re motivated, you may want to work a few more hours a week as well,” Lindstrom said. “Today’s ophthalmologists are a little bit keener on a balanced lifestyle. Most doctors don’t necessarily want to work more, so it’s all about being efficient in your practice, and that’s how we’re going to manage it.”

Although the ophthalmologist shortage could create issues in the near future, Pinto said the push and pull of supply and demand is unlikely to reach “crisis proportions” simply because of population dynamics. About 10,000 baby boomers are turning age 65 years every day, but that will not go on forever.

“The over-65-year-old population is growing at about five times the pace of the country’s whole population,” Pinto said. “But eventually, the baby boomers are going to be passing, and after that there is a bit of a lull in the population. Just about the time when it could be destined to become a crisis, the senior population will be receding.”

Despite any kind of shortage, Beckman said it is important to remember the mission of providing top-notch care to patients.

“At the end of the day, you’re hoping that you can get quality care to the people wherever they are,” he said. “It’s not good enough to merely say there’s a shortage. That means you need to have more people who are trained to do the necessary work, and that could be at every level.”

To do this, Teymoorian said younger ophthalmologists must stay nimble and be ready for even more changes in the field.

“The way they envisioned themselves practicing 5 years ago before they started working is going to look very different 5, 10 and 20 years from now,” he said. “Some of my most senior partners, some who have been practicing for 40 years, never imagined we would be practicing the way we do now. Just be prepared for it to look different, and be nimble enough to fit into whatever environment you’re put into.”

Click here to read the Point/Counter to this Cover Story.