Refractive Surgery | Nov/Dec 2012

The Demographic Tide

Advanced Ocular Care's Co-Chief Medical Editor discusses the challenges of treating an increasing number of senior citizens.

Many trends and developments have had a significant impact on the ophthalmic world in 2012. The most obvious example is the proliferation of femtosecond lasers for cataract surgery, which represents the first fundamental change in many years in the most commonly performed ophthalmic surgical procedure in the world. However, several other significant developments in 2012 also affect ophthalmic practitioners. First, the rise of microinvasive glaucoma surgery is poised to alter our thinking on the management of this condition. Second, an array of improved diagnostic devices has bolstered our ability to image the cornea and retina. Third, corneal collagen crosslinking has enhanced our ability to manage keratectasia. Fourth, the rise of resistant bacteria coupled with a virtual halt in new antibiotic development is a cause for major concern. Fifth, the increased use of electronic health records is changing the way we manage our practices.

All these topics have been the subject of a variety of articles published in Advanced Ocular Care this year. But, in my opinion, they pale in comparison with the looming effects of the largest single force facing worldwide eye care in the coming decades: demographics.

ACCOMMODATING THE INCREASE IN PATIENTS

No other factor can compare with the importance of the demographic shifts that will shape and define the way we practice ophthalmology in the future. In the simplest terms, the major disease states that we treat disproportionately affect the elderly—and there are about to be a lot more elderly. Frankly, in the United States, and likely elsewhere, we are vastly underprepared to handle this avalanche of patients with current care delivery models, and integrated eye care models that involve ophthalmologists, optometrists, and opticians working together are controversial in some circles.

In my opinion, these controversies are completely irrelevant. Demographic imperatives will make integrated eye care the only viable option for treating the huge increase in patient volumes we will face. This highly efficient form of practice will be the best situation available to many practitioners, regardless of their support for or opposition to this inevitable phenomenon.

Consider some of the numbers. The US Census Bureau projects that, over the next 20 years, the number of citizens over age 65 will nearly double (Figure 1).1 Europe’s populace is currently the most aged in the world, and it, too, is getting older. The International Monetary Fund recently warned of the economic consequences of an aging European population, noting that, by 2050, the ratio of retirees to workingaged people will double from 2006 levels.2

But this phenomenon is not limited to the United States and Europe. According to the World Health Organization, by 2025, population increases up to 300% in those over age 65 are expected in many developing countries, especially in Latin America and Asia.3 Globally, the US Census Bureau projects that the population over age 65 will triple by 2050.1

UNWILLING TO ACCEPT SENESCENCE

The numbers above tell only part of the story. Explosion in the growth of the elderly will have an even greater impact on the way ophthalmologists practice in the future. Our current octogenarians are less likely than previous generations to waste away in retirement homes. They are healthier, more active, and more likely to present with visual complaints warranting treatment than the very elderly we saw decades ago. Perhaps there has been a shift in the mindset of the elderly as well. As practitioners, we notice that the elderly are increasingly unwilling to accept senescence. They want high-quality vision, and when the technology exists to achieve this, they demand it. All this translates into large increases in the procedures commonly performed by ophthalmologists.

Each country will face difficult challenges in managing the elderly. These patients will place strains on every component of society; however, health care issues loom particularly large. Are US surgeons ready to handle what translates into a 3% to 5% annual increase in the number of seniors? At that rate, in 10 short years, the US demand for many forms of surgery could potentially be 30% to 50% above current levels. These numbers are similar elsewhere in the world as well. Some surgeons might answer that they would love a 30% increase in surgical cases, but that is not how things work. There will be a 30% increase in all forms of clinical eye care encounters with seniors, both surgical and nonsurgical. Are ophthalmologists truly prepared to absorb that volume, including the accompanying pre- and postoperative exams? Clearly, the answer is no.

In the United States, ophthalmic practices that adopt efficient models—those that utilize surgeons for surgery and optometrists for perioperative management— will ultimately thrive. Retina and glaucoma specialists will find themselves gravitating toward more severely affected cases that require their particular expertise. Optometrists who elect to work in a collaborative eye care delivery model with ophthalmologists will begin increasingly managing the screening of healthy or minimally affected patients. Inevitably, the heightened demand for surgical care will lead to further downward pressure on reimbursement for procedures such as cataract surgery, but economies of scale will work in our favor. This is not a statement of my personal perspective on the matter; it is a demographic inevitability.

FUTURE SUPPLY OF OPHTHALMOLOGISTS

Further compounding these issues is the fact that the future supply of ophthalmologists is highly unlikely to increase any time soon. Adding ophthalmology residency training slots is a complex and expensive proposition with major economic and political obstacles. Furthermore, we are losing more retiring ophthalmologists each year than we are gaining in new graduates. An additional factor is the demographic shift in the composition of ophthalmologists, who are increasingly female. According to a 2008 report from the US Department of Health and Human Services, female physicians work fewer hours per week than their male counterparts.5 The barriers to increasing the supply of optometrists are much lower. In 2011, two new US optometry schools were announced, with class sizes starting at 50 to 100 students.6

An abundance of patients is no great benefit to ophthalmic practitioners if the reimbursement for treating these patients is poor. The silver lining in this situation is our ability to provide services that are outside the reimbursement equation. Many patients in their 50s and 60s will elect to undergo refractive lens exchange prior to the development of visual impairment from cataract. We are also truly fortunate that, in the United States, noncovered refractive procedures performed in conjunction with covered cataract surgery can be billed to the patient at the discretion of the provider. This economic incentive has accelerated the development of technologies such as presbyopia-correcting and toric IOLs.

The elective surgical correction of astigmatism has also become an economic safe harbor in the United States, allowing laser cataract surgery to proliferate. Although third-party reimbursement for cataract surgery in the United States will inevitably decline, the economics of elective refractive procedures associated with cataract surgery will shift in a favorable direction for eye care providers. A relatively fixed supply of surgeons combined with an increasing pool of patients will result in pricing power for surgeons. The result will likely be increased fees for these noncovered procedures.

It is easy to swim with a tide, and for the next few decades the tide will be moving strongly in the direction of many new seniors headed our way.

Steven J. Dell, MD, is the Director of Refractive and Corneal Surgery for Texan Eye in Austin. Dr. Dell states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +1 512 327 7000.

  1. Aging Stats website. Population. http://www.agingstats.gov/Main_Site/Data/2008_Documents/Population. aspx. Accessed October 18, 2012.
  2. International Monetary Fund website. Can Europe afford to grow old? http://www.imf.org/external/pubs/ft/ fandd/2006/09/carone.htm. Accessed October 18, 2012.
  3. World Health Organization website. 50 Facts: Global health situation and trends 1955-2025. http://www.who. int/whr/1998/media_centre/50facts/en/. Accessed October 18, 2012
  4. US News and World Report website. Census Bureau: World’s 65 and older population will triple by 2050. http:// money.usnews.com/money/blogs/planning-to-retire/2009/06/24/census-bureau-worlds-65-and-olderpopulation- will-triple-by-2050. Accessed October 18, 2012.
  5. US Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions website. The physician workforce: Projections and research into current issues affecting supply and demand. http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Accessed October 18, 2012.
  6. Review of Optometry website. Two new optometry schools announced. http://www.revoptom.com/content/d/ news_review/i/1378/c/26554/. Accessed October 18, 2012.
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