Cataract surgery is the most commonly performed eye procedure in the
United States, with about 3 million surgeries performed in 2009, according to
some estimates. Demand for cataract surgery, and eye care in general, is
expected to surge in the coming years, as more baby boomers reach 65 years of
The impending spike in demand for cataract surgery is multifactorial.
Aside from a sharp increase in the number of aging patients with cataracts,
evolving surgical techniques and improving outcomes promise to boost demand
among relatively young, active patients who desire cataract surgery or
refractive lens exchange.
In addition, seniors today are more physically and socially active than
any previous group of seniors. In short, Americans are living longer and living
well for a longer period of time.
Apart from being a large age cohort, baby boomers — people born
between 1946 and 1964 — have higher expectations than previous
generations. Ophthalmologists need to fully exploit breakthrough technologies
and develop innovative practice models to meet increasing demand and rising
|Anthony P. Johnson,
MD, supports an equal practice model involving ophthalmologists and
Image courtesy of Johnson AP
“Seventy is the new 50,” John A. Hovanesian, MD, FACS, OSN
Cornea/External Disease Board Member, said. “The baby boomers who are just
beginning to have cataracts are seeking lens replacement surgery for relief of
presbyopia and for their own visual disabilities that bother them because they,
too, are active.”
Impending challenges will force clinicians and practice administrators
to adopt an integrated practice template that revolves around increased
collaboration with optometrists, nurses, physician assistants and technicians,
David W. Parke II, MD, CEO and executive vice president of the American Academy
of Ophthalmology, said.
“It behooves all ophthalmologists to prepare for these changes by
fine-tuning their model of practice to meet the challenges of quality, service
and efficiency,” Dr. Parke said. “For many practices, this has meant
or will come to mean an integrated model of eye care led by ophthalmologists
but certainly incorporating optometrists, nurses, technicians and others who
are important to meet the overall spectrum of eye care delivery.”
A practice’s ability to handle increased patient volume hinges on
efficiency, which in turn depends on the appropriate use of technology, more
highly skilled staff and increased collaboration with optometrists, according
to Robert Cherewich, MPS, CMPE, COE, president-elect of the American Society of
Ophthalmic Administrators, sister organization to the American Society of
Cataract and Refractive Surgery.
“It gets back to the holy grail of becoming more efficient or as
efficient as you can be so that the doctor or the practice in general can see
more volume. It’s a never-ending process,” Mr. Cherewich said.
Uday Devgan, MD, FACS, FRCS, OSN SuperSite Section Editor, echoed Mr.
“Ultimately, it’s going to boil down to increased efficiency
in the way we do the procedure,” Dr. Devgan said. “It’s going to
be maybe a rearrangement of our eye health delivery team using different
players or more players, with the ophthalmologist being captain of that
According to U.S. Census Bureau projections, the number of U.S. citizens
age 65 years and older is expected to rise from 38.7 million in 2008 to 88.5
million in 2050, according to a news release.
The bureau also expects the dependency ratio, or the number of people
age 65 years and older to every 100 people of traditional working age, to rise
from 22 in 2010 to 35 in 2030, when all baby boomers will be older than 65
years. The projection was based on adjusted 2000 Census figures.
Currently, combining patients covered by Medicare and those with private
health insurance, about 3 million cataract procedures are performed annually on
about 40 million seniors over age 65 years, or 75 procedures per 1,000 seniors,
John B. Pinto, OSN Practice Management Section Editor, said. Fifteen years in
the future, about 5 million procedures will be performed annually on about 60
million seniors, or about 90 cases per 1,000 seniors, Mr. Pinto said.
All told, the volume of cataract procedures for the typical surgeon will
increase by about 75% in the next 15 years. A total of about 16,000 surgeons
will average about 350 procedures per year, Mr. Pinto said.
“Are we going to be able to handle the cases in the future? Could
the average ophthalmologist in America today perform 75% more cataract
surgeries? I think the answer is clearly yes,” he said. “The average
general ophthalmologist in America is doing about one-third optometric work, so
he or she could readily shift his or her time more toward surgery, which is
more economically productive and intellectually satisfying, and delegate more
direct patient care, whether it’s post- or preoperative care of all the
other domains of eye care, to primary eye care providers.”
David W. Parke II
Dr. Parke cited final 2009 and preliminary 2010 Medicare statistics
showing that the number of cataract surgeries in the Medicare age group
flatlined at about 1.8 million those years.
“Others with access to some industry numbers, etc., believe that
the total number of cataract procedures in the United States, Medicare and
non-Medicare, in 2009 was about 3.1 million,” Dr. Parke said.
“That’s a somewhat squishy number, but it’s probably not a bad
number to work with. I do think that the number is going to be going up, just
looking at the demographic projection for the United States.”
Retirements and residencies
Anthony P. Johnson, MD, said that many ophthalmologists have delayed
retirement amid the economic downturn of the last 3 years.
“But as the economy improves and as the retirement plans of these
doctors that have been in practice for 30-plus years get back on track, I think
we’re going to see the resuming of the retirement of a significant number
of ophthalmologists, especially cataract surgeons,” Dr. Johnson said.
Regulatory burdens created by the Patient Protection and Affordable Care
Act of 2010 and the difficulty of adopting electronic medical records will
compel some physicians to retire sooner than they may have otherwise, Dr.
Dr. Parke said there are no indications that the retirement rate among
ophthalmologists is on the rise.
“There is no evidence to suggest that ophthalmologists are retiring
at a higher rate,” Dr. Parke said. “In fact, the data suggest the
An internal review of the AAO membership database showed that in 2010,
the retirement rate among AAO members sank to an all-time low, Dr. Parke
“In fact, what we’re seeing is that the rate of retirement is
slowing,” he said. “It’s not simply an argument. It’s
actually proven by the numbers.”
The slowed retirement rate can be attributed to increasing life
expectancy and many clinicians choosing to continue practicing beyond the
traditional retirement age, Dr. Parke said.
“So, we actually expect that to not be a factor that is
exacerbating an access issue but is actually helping the access issue,” he
Dr. Devgan estimated that while about 450 ophthalmic residency positions
are available each year, about 500 or 600 ophthalmologists are retiring. SF
Match, a residency and fellowship matching service that publishes total
available residency slots on its website, is a resource that Dr. Devgan
“Because of that, there are fewer and fewer ophthalmologists every
year. Yet, the demand for patients to have surgery is higher and higher. If the
models continue like they are today, you may have some sort of shortage,”
Dr. Devgan said.
However, that trend is somewhat offset by technology enabling surgeons
to handle more cases in a shorter amount of time, he said.
“Previously, people would do five or six surgeries a day,” Dr.
Devgan said. “Now, you can do those five or six surgeries in an hour. Per
surgeon, the surgeon can do a lot more procedures than in the past. That makes
a huge difference as well.”
Integrated practice model
An increasing number of eye care practices are incorporating
optometrists into their practice structure, Dr. Parke said.
“This is a model that the Academy supports, so long as it’s a
model that is ophthalmologist-led, takes into account all the appropriate
evidence-based standards of care and results in outcomes that are best for the
patients,” he said.
Dr. Johnson described how his practice, Jervey Eye Group, operates under
an equal partnership model that includes ophthalmic subspecialties and
“It’s a partnership in everything, in our real estate
partnership, in our surgery center and our optical wholesale lab,” Dr.
Johnson said. “We’ve got all the subspecialties here, so it’s a
great model because I don’t care what kind of problem I face with a
patient, we have easy access and instant help from one of our partners. I think
it’s actually a complementary relationship. It’s not a competitive
relationship at all.”
Dr. Johnson said he supports an equal practice model involving
ophthalmologists and optometrists, while the prevailing attitude in eye care
tends not to support such a model.
“Everything they mention is all about ‘the optometrists work
under me’ or ‘they work for me.’ They’re just employed, and
they’re never an owner,” he said. “You’re not going to have
training equivalency, but if you can have ownership equivalency, you’re
going to have people being happier in their practice with what they’re
doing and not feeling like they’re being held back.”
Co-management with optometrists is hardly a novel concept and is
becoming the norm, Mr. Pinto said.
“The most vanguard surgeons in this country, administratively,
business-wise and in some ways clinically, too, have been working with
optometrists and co-managing for more than 20 years,” he said. “This
is nothing new. It’s increasingly being adopted, no longer by the vanguard
practices but now by rank-and-file practices that just realize that the average
revenue yielded by a primary eye care visit, before you count in contact lens
dispensing, is in the range of about $80 to $100.”
John A. Hovanesian
Dr. Hovanesian said there is intrinsic value of close collaboration
between ophthalmologists and optometrists.
“Trust is a fundamental of the relationship between
ophthalmologists and optometrists that we have to create,” Dr. Hovanesian
said. “The old paradigm of conflict between these two professions is going
away in many places and needs to go away in all places. Our societies need to
work together toward establishing standards for taking care of patients
cooperatively, rather than fighting over turf as to who gets to do surgery and
who gets to prescribe medicine.”
A widespread push in optometry to support legislation to increase scope
of practice is founded on false assumptions of a decrease in the availability
of ophthalmologists, Dr. Johnson said.
“We just had a big scope of practice push in South Carolina just
this year,” he said. “It stalled, but part of their rationale for
legislators is to tell them there’s not availability of care by
ophthalmologists. It’s just not true. It will take a lot of retirements of
cataract surgeons before there’s really not the capacity for ophthalmology
to take care of the cataract surgery needs.”
Dr. Hovanesian said that most optometrists do not covet the right to
“Most don’t want the right to do surgery,” he said.
“They want to continue doing what they do now and get somewhat more
involved in medical treatment. They also want to have the right to bill
insurance companies — an appropriate request that’s going to have to
happen anyway if we’re going to take care of this aging
In addition, a trend toward staff members taking on more responsibility
is beneficial to a practice’s workflow and bottom line, Mr. Pinto
“Twenty years ago, it was pretty vanguard to have a technician do
the refraction,” he said. “Today, it’s the most commonly used
model for using technicians. Twenty years ago, it was pretty vanguard to see a
tech do a Goldmann tension. Today, it’s quite routine.”
Dr. Hovanesian echoed Mr. Pinto’s statement on the utility of
expanding staff members’ skills and duties.
“Physician assistants and certified nurse practitioners serve
important roles in other surgical specialties. There’s no reason
ophthalmology should be different,” he said.
Broadening the scope of staff duties also frees surgeons to focus
primarily on surgery, Dr. Hovanesian said.
“If we’re able to do cataract surgery efficiently and safely,
it may be that our time is best spent just doing surgery. The idea of the
old-world ophthalmologist who does everything for everybody will simply go
away,” he said.
The ongoing economic downturn, solvency of the Medicare system and
health care policy may also impinge on the future availability of cataract
surgery, Mr. Pinto said.
“The only fly in the ointment is going to be macroeconomic,”
he said. “If we have a continuation of this economic malaise, which could
well be expected to occur over the [next 15 years], then the federal dollars
available for health care will be reduced and there are going to be some very
difficult societal decisions to make about equity in terms of availability of
care. … You’re going to see a great cleaving going on in this country
between those private patients who can afford to jump the queue and get their
cataract surgery from a private provider instead of having to wait in line for
Dr. Johnson said he was worried about the impact of accountable care
organizations (ACOs) on access to eye care in general.
ACOs, collaborative entities comprising primary care physicians,
hospitals and other professionals, would be eligible to participate in the
Medicare Shared Savings Program starting Jan. 1, 2012. ACOs are a key component
of the Patient Protection and Affordable Care Act, which was designed to
increase access to care, improve public health and slow the rise of health care
“Since ophthalmology is really one of the ancillary services,
almost like dermatology, when you look at it compared to the primary care docs
and those that, as we understand it, will be in charge of the accountable care
organizations, I think that patient access is going to be very much tied to the
economics of whether or not ophthalmologists are part of the accountable care
organization,” Dr. Johnson said.
He said there is concern that patients may not be able to seek eye care
from ophthalmologists outside their assigned ACOs.
In addition, an aging population and an “entitlement
mentality” are likely to counteract any cost savings that occur as a
result of ACOs or other initiatives, Dr. Johnson said.
Declining Medicare and private insurance payments and federally mandated
use of electronic medical records may also discourage many physicians from
specializing in ophthalmology, he said.
Impact of technology
Improved surgical procedures have made cataract surgery a more viable
and attractive option for increasingly younger patients, Dr. Devgan said.
“In the old days it was extracapsular, and even before that there
were no IOLs and patients had these thick aphakic glasses,” Dr. Devgan
said. “So, they waited a tremendously long time until they had nothing to
lose because their vision was so bad from the cataracts. The trend now is that
people are having surgery much earlier. Not only are there a larger number of
patients who get cataracts, but they’re not waiting until their vision is
20/200. They’re getting surgery when their vision is 20/40. They’re
having it at a younger and younger age.”
On the other hand, technology can increase efficiency and productivity
and enable surgeons to meet burgeoning demand, Dr. Hovanesian said. He urged
practitioners to embrace new technology, particularly femtosecond lasers, as a
way to improve outcomes and increase efficiency. Many surgeons believe
femtosecond lasers decrease efficiency and do not significantly improve safety,
“This is the very first generation of these lasers,” Dr.
Hovanesian said. “Despite all those woes, the reason we’re excited
about technology is because we know what it is capable of. We need to allow it
to continue to evolve. We need to support it and use it. We should reward the
innovation of those companies that bring these lasers to market so that they
will make further developments that will benefit us and our patients.
Let’s not be afraid of the future. Let’s shape it to be better for
everyone and to move forward this great specialty that we’re all a part
of.” – by Matt Hasson
Is it better to use co-management with optometrists or hire ancillary personnel to reduce practice demands?
Eye care delivery model offers tools to prosper in coming years
- Robert Cherewich, MPS, CMPE, COE, can be reached at Ophthalmology
Physicians & Surgeons, 331 N. York Road, Hatboro, PA 19040; 215-672-4300;
fax: 215-672-9524; email: firstname.lastname@example.org.
- Uday Devgan, MD, FACS, FRCS, can be reached at Devgan Eye Surgery,
11600 Wilshire Blvd., Suite 200, Los Angeles, CA 90025; 800-337-1969; fax:
310-388-3028; email: email@example.com.
- John A. Hovanesian, MD, can be reached at Harvard Eye Associates,
24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax:
949-380-7856; email: firstname.lastname@example.org.
- Anthony P. Johnson, MD, can be reached at Jervey Eye Group, 601
Halton Road, Greenville, SC 29607; 864-458-7956; fax: 864-458-3835; email:
- David W. Parke II, MD, can be reached at American Academy of
Ophthalmology, 655 Beach St., San Francisco, CA 94109; 415-561-8510; fax:
415-561-8526; email: email@example.com.
- John B. Pinto can be reached at 619-223-2233; email:
- Disclosures: No products or companies are mentioned that would
require financial disclosure.