Workforce study results may indicate opportunities for optometry
Results of a workforce study commissioned by the American Optometric Association and the Association of Schools and Colleges of Optometry predict an adequate supply of eye care providers in the baseline market with excess demand. However, when alternative scenarios are analyzed, an excess supply may result. Some who have interpreted these results see opportunities for optometrists to fill in gaps left by a predicted reduction of general ophthalmologists.
The American Optometric Association (AOA) and the Association of Schools and Colleges of Optometry (ASCO) charged the Lewin Group with conducting a study to appraise the future of eye care in terms of supply and demand, and the results were officially released at Optometry’s Meeting in June. The Lewin Group considered both optometrists and ophthalmologists when collecting data and developing a computer model that could continue to analyze new data as necessary. The group’s evaluation estimated the state of the workforce through 2025, accounting for various factors including implementation of the Affordable Care Act (ACA).
The assessment projected that, while demand for eye care services will increase, optometrists who were surveyed desire and believe that they can increase their patient load without working extra hours.
Although some optometrists expressed optimism regarding the results, others shared concerns that questioned the group’s analysis in light of the realities of providing quality eye care to patients.
The Lewin Group employed various research techniques including databases, reports and surveys to project supply and demand. Researchers then defined their projections in terms of number of providers, visits and full-time equivalent (FTE) supply and compared them to possible influences on the demand of eye care.
In strictly analyzing the baseline supply of eye care providers, the group found a notable gap.
“In this baseline case, there will be excess demand for eye care providers throughout the projection period,” according to the report. “In fact, the excess demand grows continually over the period until, by 2025, a gap of approximately 4,300 FTE optometrist providers will emerge. Hence, under the baseline case, without considering additional factors, there is projected to be a shortage of eye care providers.”
However, after weighing those additional factors – including the added coverage of the ACA and the anticipated increased prevalence of diabetes – the gap widened even further.
“The estimated effect of the ACA on demand is to increase excess demand from 4,300 FTE in 2025 in the baseline to about 6,400 FTE by 2025. When the scenario of increased prevalence of diabetes is included, this gap grows to 9,000 FTE, or almost a 40% increase in the estimated gap from the effect of the ACA and baseline demand alone.”
One of the most-publicized aspects of the workforce study was the measurement of excess capacity, which AOA Board of Trustee member Steve Loomis, OD, and the AOA touted as a new quantitative metric.
Specifically, the study utilized the 2012 National Eye Care Survey of Optometrists, which asked practitioners about their patient numbers.
“Out of 3,919 optometrists who actually received the survey, 722 usable responses were returned for an 18.1% response rate,” AOA researcher Jennifer Spangler, MBA, MPH, said in a panel discussion regarding the study at Optometry’s Meeting. “These responses provided a 95% confidence interval and overall error rate of ±3.6.”
One of the questions that garnered the most attention was one in which optometrists were asked to report the possibility of additional patients.
“Considering the total visits provided in item 8d, if you were fully booked with zero no shows, how many additional (if any) visits could you have personally provided per week, that is what is your excess capacity for additional visits per week?” the survey asked.
In its report, the Lewin Group stated that if optometrists “were able to operate at their full capacity without increasing their current patient care hours, they could provide about 32% more patient visits per year than they were actually providing.”
During the panel, former AOA president and AOA-ASCO Workforce Project Team Chair Randolph Brooks, OD, FAAO, noted that this amounted to an additional 19.8 patients per week.
“If we take this excess capacity into account and compare supply including excess capacity to the baseline demand, there is no longer excess demand,” the Lewin Group said in its report. “In fact, our estimates indicate that there is significant excess supply when this excess capacity is included and, though it declines modestly over the forecast period, it remains substantial at about 9,100 FTE by 2025.
“Accounting for two of the factors that could increase demand, increased insurance coverage under ACA and increased prevalence of diabetes, excess supply is reduced substantially to 4,400 FTE by 2025,” they continued. “Hence, if these sources of demand are realized, then excess capacity in the workforce will be substantially reduced, but not eliminated.”
The realities of excess capacity
The Lewin Group acknowledged in its report that excess capacity, while helpful in concept, is only an approximation.
“The self-reported excess capacity reflected ideal scheduling of patients, which may be difficult to achieve or sustain,” the report said.
In an interview with PCON, David A. Heath, OD, EdM, FAAO, president of the State University of New York College of Optometry and immediate past-president of ASCO, addressed this issue.
“While the capacity may be there, the likelihood of every practice being fully booked 100% of the time and having every patient show up is probably negligible,” Heath said. “I can think of two scenarios when the 100% ideal might be nearly achieved. One is within some highly specialized disciplines – effectively a discipline shortage – and the other is in geographical areas for which there is a severe shortage of providers generally.”
Heath also shared his belief that optometry suffers from a poor distribution that leaves some communities with too many or too few eye care providers.
“The extent of the maldistribution in optometry is not well understood and it wasn’t a goal of this particular study,” he said. “The potential for many practices to achieve what they define as 100% booking may simply be limited by a geographically competitive environment. That said, I personally think the data does indicate that there is a very real capacity for practices to see more patients, but probably not nearly the 19.8 as reported by respondents.”
PCON Editorial Board member Randall Thomas, OD, MPH, FAAO, disagreed.
In a survey conducted on PCON’s website, Healio.com/Optometry, of the 116 participants who participated, 20% said they could see more than 20 additional patients per week.
Several members of PCON’s Editorial Board considered their experiences in discussing the realities of patient volume in optometry.
“There is no way that we could see 20 more patients per week in the current delivery paradigm, especially with the advent of all the quality measures that electronic health records require,” Leo P. Semes, OD, FAAO, a member of PCON’s Editorial Board, said.
“Optometrists in general could see twice the volume of patients if they would begin to properly delegate many ancillary tasks to well-trained technicians,” he said. “Every person in an office should be performing at the highest levels of clinical competence. Many ophthalmologists see 40 to 50 patients daily. They perform at their highest levels of competence, while having numerous ancillary staff doing things they are competent to do including the refraction portion.
“While many naïve optometrists may view this as heresy, I have witnessed first-hand how well this works,” Thomas continued. “Also, it is a relative waste of human resources for surgeons to be performing any clinical duties that can be done by nonsurgeons. The entire health care delivery system needs to be revamped to provide a greatly enhanced utilization. There is no shortage of eye doctors, just a very inefficient utilization of the resources available.”
Loomis acknowledged that, should the excess capacity measurement not supply the amount of optometrists necessary to meet demand, the AOA does not have strategies in place to lessen the gap.
“We think that there is room for doctors to be more efficient with technology and additional staff,” he said. “So that’s our encouragement to our members: be efficient, and the opportunity for practice growth is in medical eye care.”
According to the study, excess capacity is not the only form of opportunity available for optometrists as demand increases. In projecting eye care supply, data forecast that the supply of ophthalmologists is not estimated to grow.
“New entrants into the workforce are determined by planned changes in class sizes for schools of optometry over the next several years, with class sizes assumed to be unchanged beyond 2019,” the researchers said. “For ophthalmologists, residency positions, which determine new entrants into the workforce, are assumed to remain unchanged from their 2012 level through 2025.”
Heath told PCON that this opportunity may be more significant than the workforce study alone suggests.
“An earlier study of medical residents by the University of Albany’s Center on Workforce Studies found that seven out of every eight ophthalmology residents in New York planned on subspecializing,” he said. “Thus, only one in eight planned on practicing general ophthalmology. So while the ophthalmology workforce may be relatively stable, the number of general ophthalmologists appears to be shrinking quickly. If you take this trend in combination with the projected increased need for medical eye care as highlighted in the AOA/ASCO study, it appears clear that optometry is well positioned to provide that care.
Panelist, former AOA and ASCO president, and Marshall B. Ketchum University president Kevin Alexander, OD, PhD, FAAO, echoed his colleague’s statements.
“This profession has really prepared for an entire generation – 30 years or more – to deliver comprehensive eye care and health care in terms of passing scope of practice laws, in terms of training our students years before the laws changed to provide these services,” he said. “The workforce study is simply that moment where we look at this explosion of medical eye care services that will be required in the years ahead. Now is our time, now is our moment. Our profession is ready.”
“The ongoing shift of responsibility from general ophthalmology to optometry for medical eye care and optometry’s commensurate ability to assume that responsibility from a workforce availability and educational perspective is the opportunity to grow,” Heath said. “Unfortunately, while the public health argument to maximize optometry’s ability to provide medical eye care is a powerful one, significant obstacles to optometry delivering that care remain in terms of both scope of practice legislation and limits on access to insurance panels.”
Continued analysis possible
The panel at Optometry’s Meeting acknowledged that the data collected is fluid.
“One of the elegant aspects of the study is that the assumptions are so clearly laid out,” Heath said. “You don’t necessarily have to reevaluate the entire study. You can take individual planning assumptions and find second data points and see whether the trend is correct or not correct. What we’ve got is a great starting point from one point in time, but in some ways, there’s no way you’re going to know whether our projections or trends are correct until you start measuring a second point and a third point.”
“While the study offers a snapshot of the workforce at this moment in time, one of the most important aspects of this project is that the Eye Care Workforce computer model will allow for continued analysis of the eye care market as external factors affecting both supply and demand change or are introduced,” Jennifer L. Coyle, OD, MS, FAAO ASCO president and dean of the Pacific University College of Optometry, said in a press release about the study results. “Workforce studies often generate as many new questions as they answer, and we can see some intriguing new avenues for investigation as we seek to advance optometry’s ability to meet the demand for services.” – by Chelsea Frajerman