‘Inadequate to meet demand’: Report spotlights declining ophthalmology workforce as America’s eye health needs grow

December 14, 2023
Ophthalmology’s report paints a stark contrast between the two eye care physician workforces as the surgical specialty’s workforce adequacy plummets to second worst in coming decade.
Workforce image of people and puzzle pieces

Ophthalmology’s workforce inadequacy could climb as high as 36% relative to increasing demand for eye care services over the coming decade-plus, according to a new report that may conversely show opportunities for optometry.

Published in the journal Ophthalmology, the new workforce study anticipates a 12% decline in full-time equivalent (FTE) ophthalmologists by 2035 while demand is projected to increase by 24%, equating to the second-worst rate of workforce adequacy among all surgical specialties. These findings become far more pronounced as rurality comes into play with ophthalmology workforce supply adequacy falling to 70-77% for metropolitan areas versus 26-29% for rural areas by 2035. Despite ophthalmology’s limitations, the study finds optometry in a far better position to meet demand—similarly established in the AOA’s own workforce study.

“Optometry’s essential and expanding role in health care has become well-recognized by the provider community, policymakers, the health care media and the public,” says Ronald L.  Benner, O.D., AOA president, in response to the study findings. “Now, with every indication of an accelerating decline in the ophthalmology workforce outlook, our profession is poised for historic, new opportunities that will allow for the full use of our education, training and skills in caring for our patients.”

Increasing demand for medical eye care underscores optometry’s role in primary eye health care.

Ophthalmology’s workforce report uses two forecasting models

In ophthalmology’s recent workforce analysis, authors built supply and demand projections using the Health Workforce Simulation Model (HWSM), a “micro-simulation model” from the National Center for Health Workforce Analysis under the Health Resources and Services Administration (HRSA). The analysis leveraged a pair of models, one to estimate supply/demand based on a status quo national pattern of care and utilization (2015-2019) and another to estimate supply/demand based on a reduction in barriers to care for populations historically facing access issues.

Specifically, authors estimated 21,250 FTE ophthalmologists in the workforce as of 2020.

  • Under the status quo model, workforce supply was assumed to meet national demand as of 2020, yet FTEs steadily decreased by 2,650 FTE ophthalmologists by 2035 while projected total demand increased by 24% or 5,150 FTEs.
  • Under the reduced barriers model, workforce supply was shown already inadequate to meet national demand in 2020, short by 1,920 FTEs (authors note a surplus of 330 FTEs in metro areas and a deficit of 2,250 FTEs in nonmetro areas). Assuming a steady decrease by 2,650 FTE ophthalmologists by 2035, projected total demand increases by 25% or 5,840 FTEs.

“The present analysis of the HRSA HWSM shows that the ophthalmology physician workforce is inadequate to meet the demand for ophthalmologic services, and this inadequacy is expected to increase by the year 2035,” authors noted in the American Academy of Ophthalmology’s journal.

Similarly, authors found the current optometry supply is adequate for demand while the reduced barriers model indicates this will decline to 89% adequacy by 2035 in keeping with a slight growth in optometry. What’s more, the ophthalmology report notes that “given the increased anecdotal demand for ophthalmic technicians, eye care staff may represent one factor exacerbating the inadequate supply of the ophthalmology physician workforce.”

Authors continue: “Future studies should focus on the degree to which allied health professionals, such as ophthalmic technicians, expand the individual physician’s ability to meet patient volume demand within workforce forecast models.”

Optometry scrutinizes workforce report

In reviewing the ophthalmology workforce report, the AOA casts scrutiny over the numbers reported using HRSA data, especially concerning the size of the current ophthalmology workforce. The AOA’s own modeling estimates only 16,778 FTE ophthalmologists as of 2023, based on data from the American Medical Association (AMA) and residency data. The AMA itself reports approximately 18,200 ophthalmologists as of 2023, so the Ophthalmology study’s estimate of 21,250 FTE ophthalmologists as of 2020 appears inflated.

Further, the Eyeconomist author Richard Edlow, O.D., former AOA Information & Data Committee chair of 15 years, notes while the analysis was well-intentioned nonetheless it contains flaws. Chiefly, HRSA’s HWSM itself is “archaic” in its understanding of the eye care delivery system, considering doctors of optometry in the same allied health category as pharmacy aides and community health workers. Dr. Edlow also questions the way demand is defined in a “convoluted method” determined by supply of providers versus actual demand for services.

For example, Dr. Edlow calls attention to a particular passage in the study: “Specifically, the work of ophthalmologists is not fungible with other allied health professionals, and ophthalmology requires specialized medical and surgical training.” This statement grossly fails to recognize optometry’s role in providing medically necessary eye care, Dr. Edlow says, with optometry already providing at least a third of all medically necessary eye exams for Medicare fee-for-service patients in 2021—about 8.5 million exams.

“There is no question that the U.S. has a serious issue with the eye care workforce, but it won’t be solved by looking at ophthalmology as a stand-alone profession without recognizing optometry’s role in the solution,” Dr. Edlow says.

Modernizing and expanding optometric scope of practice commensurate to the level of optometric services already provided in over a dozen states is a common-sense solution for the remainder of states to address this workforce crisis, says Rich Castillo, O.D., D.O., co-chair of the AOA’s Contemporary Practice Task Force.

Dr. Castillo says it’s vital to recognize optometry as the valuable resource already available to meet projected increases in demand for eye health services. Likewise, optometry’s scope expansion is already addressing geographic disparities noted in ophthalmology workforce inadequacy, he says.

“Optometrists are the primary—and often the only—providers in these underserved areas,” Dr. Castillo says.

“Optimizing optometric resources and specialization will allow the now-acknowledged undersupply of ophthalmologists to focus on complex cases, utilizing optometric physicians for routine and preventive care, such as office-based laser and minor surgical procedures. Communities benefit by promoting interdisciplinary collaboration between all eye care providers, encouraging a team-based approach to eye care and leveraging optometric physicians’ expertise in primary eye care.”

Dr. Castillo argues the near-term results of full optometric utilization would be improved patient outcomes, economic benefits for an already-stressed health care system, strengthening of educational and training standards, and alignment of standards of practice with a changing health care landscape.

He adds: “Unleashing the full potential of the ‘trained and ready’ optometric workforce, including optometric physicians, paraoptometrics and their professional staff, provides a strategic solution to the projected ophthalmology workforce inadequacy and ensures access to quality eye care services in the present and future.”

Further speaking directly to the ophthalmology workforce report’s point about demand for ophthalmic technicians, a 2023 AOA survey of member doctors and paraoptometric staff found that trained, certified practice staff helped optometrists see more patients. In fact, doctors say they recapture an average of 11 hours per week by delegating tasks not required of physicians, helping them see nearly 12 additional patients per week.

Optometry’s opportunity for medical eye care services

Earlier this year, Dr. Edlow’s annual industry report forecast optometry’s prime opportunity for meeting Americans’ medical eye care needs in the years ahead. His report similarly concluded that ophthalmology’s workforce through 2030 could not keep up with the spike in demand for age-related medical eye care.

“There’s a huge gap in being available to meet that increasing demand [for age-related medical eye care],” Dr. Edlow noted. “So, who are you going to call? Optometry.”

Dr. Edlow calls particular attention to demand for cataract surgeries commensurate to trends in the aging population. While about 4.2 million cataract surgeries were provided in 2020 with an estimated 16,042 FTE ophthalmologists available, by 2030 those figures increased to 5.6 million procedures and 16,518 FTE ophthalmologists. With an average ophthalmologist performing 400 cataract surgeries each year, Dr. Edlow suggests another 3,500 additional ophthalmologists would be necessary by 2030 just to meet demand for cataracts alone and not accounting for other age-related conditions, such as glaucoma, diabetic retinopathy or age-related macular degeneration.

But the rub? Only 500 additional ophthalmologists per year by 2030 can be expected by Dr. Edlow’s estimates.

“Ophthalmologists will be spending more and more time in their surgical facilities and less and less time providing all that medical, chronic eye care,” he said.

Such is the case, Dr. Edlow urged optometry to lean in to their ability to provide medical eye care services and argued now is the time for optometry practices to start preparing—e.g., equipment, staffing and facilities—for the future.

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