American Academy of Ophthalmology Web Site: www.aao.org
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May 2007

 
Feature
The Boomers Are Coming! Prepare To Provide Their Care
By Miriam Karmel, Contributing Writer
 
 

The Baby Boom generation is aging, and, by dint of its sheer size, this cohort of nearly 80 million has never treaded lightly. Now it is expected to surge, tsunami-style, into the health care system. Ophthalmologists can prepare by optimizing their efficiency and anticipating the needs of patients of well-advanced age.

The storied demographic bulge in U.S. history known as the Baby Boom was launched by an exuberant America nurturing large families in the relative prosperity that followed World War II. Now the Baby Boomers, the kids born between 1946 and 1964, the kids who flouted convention and flaunted their youth, those kids, well, are not kids any longer.

Consider the numbers: By 2030, the over-65 population is expected to reach 69.4 million, having doubled in just three decades. Older Americans will outnumber teenagers by more than two to one.1 Ophthalmology, which treats so many diseases of aging—including glaucoma, macular degeneration, cataract and even diabetic retinopathy—will be especially hard hit. “Next to geriatrics, ophthalmologists have the highest percentage of patients in the Medicare age group,” said David W. Parke II, MD, professor of ophthalmology at the University of Oklahoma in Oklahoma City. “What happens to the Medicare population disproportionately affects ophthalmology relative to other specialties.”

Aging Is Just the Beginning

The graying of the Boomers would be daunting enough, but other factors will compound their health care consumption:

  • Many Boomers are living longer, more active lives than their parents did, and they will expect good vision to help them accomplish that.
  • Unfortunately, many Americans are also fatter than ever. Thirty-three percent are obese, spawning an epidemic of diabetes mellitus, and its spin-off, diabetic retinopathy.
  • Older patients tend to underutilize eye care. Some 30 percent of Medicare beneficiaries have no eye examination documented in claims data by either an ophthalmologist or optometrist.2 As previously underserved Boomers eventually seek eye care, their needs will strain the system’s ability to keep up.

“How does ophthalmology take care of all these new patients? That’s the question,” said Michael R. Redmond, MD, a member of the Academy’s Task Force on Eye Care Delivery, which has been grappling with this problem. “How do you handle that surge with the number of ophthalmologists not really growing?”

No remedy in physician supply? The projected number of ophthalmologists appears to be on a relatively level trajectory, and may even decline relative to the general population. After all, physicians who are also Boomers will be retiring along with the rest of their generation, leaving proportionately fewer doctors for proportionately more patients. And there is no change on the horizon, said Charlene Hsu-Winges, MD, associate clinical professor of ophthalmology at the University of California in San Francisco. “For the past five years, the number of first-year residency positions in the matching program nationally has only increased by 12 [to 450],” she said. “This is hardly enough to keep up with demand.”

“All signs,” said Dr. Parke, “point to a significant shortage of ophthalmic capacity.” The result, said Michael X. Repka, MD, professor of ophthalmology and pediatrics at Johns Hopkins University, is that “Physicians are likely to feel swamped, and patients might feel that they’re getting short shrift. That leaves us with developing ways to make sure a clinical practice is efficient.”

We Need a Plan for Surge in Demand

The surge of aging patients will indeed be both a challenge and an opportunity for the profession, said Paul P. Lee, MD, JD, professor of ophthalmology at Duke University, who announced in January’s Ophthalmology that the Academy plans to provide tools for streamlining clinical practice. While still under refinement, those tools are intended to help ophthalmologists maximize their efficiency, in part by adopting time-honored business models.

Be efficient. Be very efficient. If it isn’t already, “efficiency” is about to become the watchword of the ophthalmologist. Simply put, ophthalmologists are going to have to find ways to see more patients per day. Maintaining the status quo will not be an option.

Most doctors believe they already run efficient practices, but Dr. Repka said there is room for improvement. An Institute of Medicine study, for example, found chronic disease care in the outpatient setting delivers, on average, only 54 percent of what would be considered essential care in the United States.2

Plugging gaps and broadening services. “How can you do what you do better?” That’s the challenge, according to Ann M. Hulett, CMPE, COE, immediate past chairwoman of the American Academy of Ophthalmic Executives (AAOE). She offered a number of suggestions, ranging from smarter use of staff to elimination of scheduling gaps. Ms. Hulett, who is administrator for Rocky Mountain Eye Center, an eight-physician, four-optometrist practice in Pueblo, Colo., said that a few years ago, her office created a business plan to add retina, glaucoma and oculoplastic subspecialists to the historically general ophthalmology practice. They wanted to make subspecialty care available within its organization and community.

Rocky Mountain Eye Center also relies on 45 technicians to assist with the time-consuming part of workups. Technicians take patient histories, obtain refractions and get patients dilated. Ms. Hulett believes that for certain practices, adding another technician or training a staff person for that role will more than pay for itself and dramatically increase throughput.

Physicians might also consider enlarging office space, employing certain business technologies to make it easier to communicate with referring physicians, altering patient flow patterns, or bringing optometrists on board if they are not already (see Appropriate Collaboration With Optometry).

Thoughts on Increased Efficiency

“Most of us aren’t yet feeling the surge,” said Ms. Hulett. But, she added, “The numbers show that in the future, most all of us are going to see more patients.” Ms. Hulett offered the following tips for building a more efficient practice.

  • Offer classes. Hold informational sessions to educate patients about common procedures, such as cataract surgery. You can cover the same material in groups of 12, as you previously did one-on-one.
  • Try block scheduling. You can save time by scheduling similar, time-consuming treatments for the same block of time. For example, set aside a block of time for AMD injections, and another for in-office laser treatments. With the increase in available treatments, you’re going to have to use blocks so you can move efficiently through patient visits.
  • Use technicians. The growing complexities of a practice require having talented, capable staff people in every position. Well-trained technicians can do as much of the time-consuming part of the workup as possible. Hire the best people you can, train them well, and then use them to their maximum capability.
  • Start the day early. You can see a few more patients each day simply by starting work a half hour early. An earlier starting time increases patient access, but won’t make a huge impact on your life style. “Instead of giving up your half day off, start a half hour earlier.”
  • Hire a surgery coordinator. A well-trained assistant who can show patients informational videos, explain the nuts and bolts of cataract lens choices, talk about financial ramifications and other patient concerns will leave you with time for more urgent medical matters. Let someone else handle these details, with proper physician backup and support.
The Numbers

By 2020, the number of blind people is expected to increase 70 percent, to 1.6 million, with a corresponding rise in low vision, according to the Eye Diseases Prevalence Research Group, which issued its predictions in April 2004, in Archives of Ophthalmology. The research group predicts that the prevalence of visual disabilities will increase markedly during the next 20 years, “owing largely to the aging U.S. population.”1 Diseases of aging are the most common causes of blindness and low vision. Here is what can be expected by the year 2020:

AMD. The overall prevalence of neovascular AMD and/or geographic atrophy in the U.S. population aged 40 and older is 1.47 percent, or 1.75 million people. Owing to the rapidly aging population, that number will increase by more than two-thirds to 2.95 million.

CATARACT. An estimated 20.5 million, or 17.2 percent, of Americans older than 40 have a cataract. Cataract prevalence will increase to 30.1 million.

DIABETIC RETINOPATHY. Approximately 4.1 million U.S. adults aged 40 and older have diabetic retinopathy. With the expected increase in diabetes, some 7.2 million persons will have diabetic retinopathy, and 1.6 million persons will develop a vision-threatening form of the disease.

GLAUCOMA. In the U.S. population aged 40 years and older, the overall prevalence of open-angle glaucoma is estimated to be 1.86 percent, affecting 2.22 million. That will increase by more than three-quarters to 3.36 million.
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1 Arch Ophthalmol 2004;122(4):477.

GRAPHS. Prevalence estimates drawn from "Vision Problems in the U.S.," an NEI-funded report compiled by Prevent Blindness America, 2002.

Caring for the Oldest Old

At the same time, ophthalmologists will have to move beyond the traditional medical model of eye disease and start thinking like geriatricians, as tomorrow’s elderly do something never widely done before—become very old. “We’re going to see a lot more octogenarians and nonagenarians than ever before,” said Andrew G. Lee, MD, professor of ophthalmology, neurology and neurosurgery at the University of Iowa in Iowa City and head of the Academy’s Committee on Aging. “With the over-65 cohort increasing, there will be a lot more people approaching 90 or 100.”

Ophthalmology has always been concerned with diseases of aging, and that hasn’t changed. “They’re still the same diseases,” said Dr. Parke. “But as people live longer, these diseases are becoming more significant.” AMD, for example, is more prevalent in 80-year-olds than 70-year-olds, and more people are living to 80. What’s more, the possibilities for treating AMD and other diseases are improving, thus expanding the opportunities for doctor-patient encounters.

In the next two decades, the very old, which represents the fastest-growing segment of the U.S. population, will be the driving force behind the expected rise in blindness and low vision in the United States, according to the Eye Diseases Prevalence Group. “Persons aged 80 years and older made up only 7.7 percent of the population in our study, but accounted for 69 percent of observed blindness.”3

Incorporating geriatrics into eye care. Though accustomed to caring for elderly patients, ophthalmologists may not be familiar with some of the issues associated with visual loss in the geriatric population, said Dr. Andrew Lee, whose Committee on Aging is developing materials to help ophthalmologists think like geriatricians. One effort has been to highlight the geriatric content in existing Academy materials, such as the Basic and Clinical Science Course (BCSC). “We’re not developing new knowledge,” Dr. Lee said. “We’re taking what other specialties already know about older people and bringing it to ophthalmology.”

In the past, for example, a discussion of cataract focused exclusively on medical matters relating to diagnosis and removal of a cataract. The revised materials will include information on treating the older patient with cataract. “We used to think, ‘Take out the cataract and that’s that,’” Dr. Lee said. But the elderly require more.

Good vision is not necessarily good function. For example, traditional clinical measures of visual function—Snellen acuity and perimetry—probably are not adequate for determining the functional impact of visual impairment on older patients, noted Dr. Lee. Poor visual function affects other quality-of-life parameters, including disability, falls and fractures, activities of daily living, and independence. In fact, poor vision contributes to approximately 25 to 35 percent of older persons’ falls each year.4 Also, there is a correlation between depression and impaired vision.

The association between visual impairment and overall function means the elderly are more likely to need help grocery shopping or paying bills. They may experience difficulties with nighttime driving; reading traffic, street and store signs; reading small print; watching TV; seeing steps or curbs; cooking and doing fine handwork.

Make your office safe and friendly. The very old suffer from decreased contrast sensitivity, increased glare sensitivity, diminished color vision and impaired stereopsis. “Our ophthalmology waiting rooms and services will need to be more accommodating for these folks,” Dr. Lee said. “Those frail oldest old may need the extra railing in the bathroom or on the toilet to keep from falling.”

Appropriate Collaboration With Optometry

At Rocky Mountain Eye Center in Pueblo, Colo., eight ophthalmologists work with four optometrists. One OD has been with the practice for a number of years, but the other three were hired as part of an effort to attract primary eye care to the practice, said Ms. Hulett, the practice administrator.

While respectful of scope of practice boundaries, a lot of ophthalmologists are considering a similar move to bring optometrists on board. The rationale, said Ms. Hulett, is to avoid running the risk of losing healthy patients whose basic eye needs can’t be met in a timely manner because the practice is overwhelmed by more critical cases. With an optometrist on staff, you can offer patients prompt, routine, daily care. “You’re going to have a lot of routine care. Not everybody is going to need surgery,” Ms. Hulett said. “We do need to plan for that.”

“There is a role for optometry,” agreed Dr. Repka. “Optometry is not going away. Optometry is part of the solution.”

Academy president-elect Dr. Parke said data indicate that optometrists can dramatically improve efficiency in an appropriate ophthalmology-led care system. “More and more of our members practice with optometrists in a highly effective fashion,” he said. “Having a practice that consists of both ophthalmologists and optometrists can be a highly effective model.”

But, he said, the Eye M.D. should lead the team.

Caution: Challenge Ahead

Ready or not, the Baby Boomers are coming. “It’s impossible to argue with the fact that the Boomers are becoming Medicare-aged patients, they’re living longer, and we have to provide a way to care for their needs,” Dr. Parke said.

Care that will require change. “Doctors will have to accept the fact that they’re going to have to become more efficient,” said Ms. Hulett. “We cannot function with the same procedures and manage to accommodate the anticipated patient demand.” Plus, she added, given the pressures on reimbursement, doctors won’t be able to maintain their income, if they don’t become more efficient. But more than money is at stake. If ways are not found to meet patient demand, the health care system will be “stretched beyond the point of collapse,” Dr. Parke said. That will lead to untreated disease and unhappy patients, he warned, and could “create the opportunity for someone externally to impose change that’s not in the best interest of our patients and profession.”
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1 Population Reference Bureau, Washington, D.C.
2 Ophthalmology 2007;114(1):1–2.
3 Arch Ophthalmol 2004;122(4):477–485.
4 Lee, A. and A. L. Coleman. New Frontiers in Geriatrics Research: An Agenda for Surgical and Related Medical Specialties. Accessible online at www.frycomm.com/ags/rasp/chapter.asp?ch=7.
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MEET THE EXPERTS

Charlene Hsu-Winges, MD
Kaiser-Permanente staff physician, South San Francisco, associate clinical professor of ophthalmology at the University of California, San Francisco, and a member of the Academy’s Task Force on Eye Care Delivery.

Ann M. Hulett
Immediate past chairwoman, American Academy of Ophthalmic Executives and administrator, Rocky Mountain Eye Center, Pueblo, Colo.

Andrew G. Lee, MD
Professor of ophthalmology, neurology and neurosurgery, University of Iowa, Iowa City, and chairman of the Academy’s Committee on Aging.

Paul P. Lee, MD, JD
Professor of ophthalmology, Duke University, and chairman of the Academy’s Task Force on Eye Care Delivery.

David W. Parke II, MD
President-elect of the Academy, president and CEO, Dean McGee Eye Institute and professor of ophthalmology, University of Oklahoma, Oklahoma City, and a member of the Academy’s Task Force on Eye Care Delivery.

Michael R. Redmond, MD
Private practitioner, Pensacola, Fla., and a member of the Academy’s Task Force on Eye Care Delivery.

Michael X. Repka, MD
Professor of ophthalmology and pediatrics, Johns Hopkins University, and the Academy’s secretary for Federal Affairs and a member of the Academy’s Task Force on Eye Care Delivery.