Glaucoma ‘tsunami’ bearing down on how EyeMDs will practice medicine

A tsunami of glaucoma is sweeping toward the U.S. healthcare system, according to Cynthia Mattox, MD. “So let’s get ready and hold on to your surf board.”

For many ophthalmologists, coping with the increased demand will mean teaming up with other eye-care professionals, said Dr. Mattox, director of the Glaucoma and Cataract Service, New England Eye Center, Tufts University, Boston during the Glaucoma Symposium CME at the 2016 Glaucoma 360 meeting.

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There are more than 18,300 ophthalmologists practicing in the United States, a number that has not changed over the past five years, she said. That amounts to over 17,000 people per ophthalmologist. About 434 residents graduate per year, excluding those in the military, and that number has been holding steady.

Meanwhile, both ophthalmologists and the nation’s population are getting older on average. Almost half of ophthalmologists are 55 years old or older. “That has some implications for the workforce going forward,” Dr. Mattox said.

EyeMD shortage

She cited an estimate by the Lewin Group, a healthcare consultant, that there will be a shortage of about 7,000 full-time ophthalmologists by 2025.

On the other hand, there are about 40,000 optometrists in the United States, with around 1,600 to 1,800 graduating per year, Dr. Mattox said. Many of them are having trouble finding work.

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“Most optometrists when they are surveyed say they feel underutilized, underpaid, and interestingly two thirds of them are working two or more jobs in order to make a living,” Dr. Mattox said.

Such projections are not always reliable, she pointed out. “You always have to take this with a little grain of salt.”

Payment implications

But predictions about the aging of the U.S. population are on a solid foundation, Dr Mattox added. Notably, by 2025 the population over 65 is set to surge 46%. The number of glaucoma cases should increase proportionately, which translates to about 4.3 million new patients, said Dr. Mattox, citing Prevent Blindness America data.

The age group that will have the most glaucoma is ages 70-79, she said. “That continues to trend forward into the even more aged groups as we move further into the future.”

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The ethnic composition of the population with glaucoma is changing as well, with African Americans holding steady at 20%. Hispanic numbers are growing and expected to reach the same proportion by 2050, Dr. Mattox said.

Payment implications

These shifts have implications for payment policy, said Dr. Mattox. She cited a Medicare Trustees report in June 2015 that counted 53.8 million beneficiaries. Most of them are in the 65 years or older group.

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Of these, about 30% subscribe to the Medicare Advantage plans. “What’s really interesting to me is that of new enrollees, all those Baby Boomers, over two thirds of them are choosing to be in a Medicare Advantage plan,” Dr. Mattox said. “That has implications for payment and rules about how you get paid in the future.”

Medicare spent $613.3 billion in 2014, and what is concerning in this report is the projection by the Medicare Trustees that Part B physician services over the next five years will increase 6.7% year over year and Part D drug expenditures will increase almost 11% year over year.

Meanwhile, overall U.S. health expenditures are projected to increase an average of 5.8% annually over the next 10 years. “That’s after some historic lows over the past few years,” said Dr. Mattox. “Now, they’re expecting it to trend upward again.”

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By 2024, the United States will spend 19.6% of its gross domestic product (GDP) on healthcare, she said.

“Are we scared yet?” she asked. “So this is what we are facing, and a lot of work has to get done in order for us to manage how we’re going to take care of our patients.”

If you’re in the path of a tsunami, you can react two ways, she said. You can flee to high ground, or you can “grab your surf board and go surf the wave.”

Hard look

Hard look

While no one has the complete answer, ophthalmologists should look hard at what work they do themselves and what can be handled by other professionals.

“We need to revamp our practice teams–using technicians, physician assistants, optometrists, ophthalmologists, surgeons,” Dr. Mattox said. “How are we going to utilize our practice workflow, testing centers, reading centers, communication with patients?”

Researchers are beginning to produce helpful data in these areas. Dr. Mattox credited Joshua Stein, MD, associate professor of ophthalmology, University of Michigan, Ann Arbor, with important work on “predictive algorithms to figure out who is getting worse without even having to see the patient."

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She anticipates advances in home monitoring, telemedicine, and programs that educate patients on how to take care of themselves.

But ophthalmologists will have to think carefully about the cost effectiveness of diagnostics, medications, surgery, and other procedures, she added. They have to pay attention to how patients are affected by their copayments and out-of-pocket expenses, and when the ophthalmologists’ practices have to absorb the costs of supplies, drugs, lasers, and diagnostic technology.

“Really parse that out to make sure that we are providing the best possible care that we can to the people who really need it,” she advised

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