July 2008




Untapped provider pool for ophthalmology

by Kevin J. Corcoran, COE, CPC, FNAO


Most planning revolves around near term events that can be readily identified and understood. Yet, these near term challenges and opportunities may not be the most significant for the survival and success of the practice. Instead, large long term changes may pose the greatest threat and require creative strategic planning that contemplates much more than incremental improvements in operations. Beginning in 2011, medicine faces a perfect storm consisting of a triple threat: 1) a rising number of Medicare beneficiaries due to retirement of baby boomers, 2) a decreasing supply of physicians to serve them, and 3) growing economic constraints on the Medicare budget to pay for services. At present, there are 44 million Medicare beneficiaries, but there are 75 million baby boomers on the way!1 In 2010, 13% of the population of the US will be at least 65 years old; by 2030, that figure jumps to 20%. Every year, 23,000 physicians retire or die at the same time as 16,500 students enter medical school.2 Many new graduates prefer specialties with a better balance between work and time off, fewer work hours or seek part-time employment. Female physicians work 18% fewer hours than their male counterparts. Finally, the Trustees of the Social Security and Medicare trust funds issued a Medicare funding warning for the first time in 2007, and then again in 2008. The latest report3 of the trustees states, “Medicare’s financial difficulties come sooner—and are much more severe—than those confronting Social Security. While both programs face demographic challenges, rapidly growing health care costs also affect Medicare. Underlying health care costs per enrollee are projected to rise faster than the wages per worker on which payroll taxes and Social Security benefits are based. As a result, while Medicare’s annual costs were 3.2 percent of Gross Domestic Product in 2007, or nearly three quarters of Social Security’s, they are projected to surpass Social Security expenditures in 2028 and reach 10.8 percent of GDP in 2082.” Despite inaugurating physician payment reform in 1992 and initiating the resource based relative value system (RB-RVS) for setting professional reimbursement, there remains a considerable need for maintaining and improving physician compensation—a perfect storm on the horizon. More help is needed. Where is the untapped supply of health care providers for eye care? Physician assistants and nurse practitioners make significant contributions in primary care, emergency medicine, dermatology and orthopedics, yet they are virtually unknown in ophthalmology. There are 130 training programs for physician assistants throughout the country and 5,000 new graduates every year. More than 90% of these graduates have a college degree or graduate degree; 87% work full time; 75% work in primary care; 40% are employed by physicians; and 60% are salaried at an average of $85,000 per year.4 But, none of the training programs provide specialized instruction in eye care. A survey of ophthalmologists by the author found that nearly all believe that a physician assistant could learn enough to be very useful during on-the-job training which typically lasts 6-12 months. Unlike medical assistants and optometrists, a physician assistant has valuable potential capabilities in ophthalmology as the scope of practice of a physician assistant is ultimately determined by the physicians and surgeons who supervise him or her.5 With proper training, a physician assistant could perform history and physicals prior to surgery, assist at surgery, administer intravenous dyes such as fluorescein, manage chronic disease such as diabetes, take weekend call, triage emergencies, manage an ambulatory surgery center or provide screening services for glaucoma and other diseases Medicare reimbursement for physician assistants is equal to the physician’s fee schedule whenever the services are “incident to” the supervising physician. The “incident to” provision requires that the supervising physician be on site when physician assistant sees Medicare patients. Other limitations of “incident to” billing include a requirement that physicians, rather than physician assistants see all new Medicare patients, as well as established patients with new conditions. Since 1998, Medicare loosened its supervision requirements for physician assistants and permits billing under the physician assistant’s NPI number instead of the physician’s number where services are not directly supervised, however reimbursement is reduced to 85% of the physician fee schedule.6 Medicaid, Tricare and other third party payers have slightly different rules and payment rates but generally cover the services of physician assistants. While many progressive group practices have added optometry to their provider mix, primarily to address vision care for younger patients, the perfect storm facing ophthalmology will not be averted by seeking more help in that quarter. In 2006, the most recent year for which there is published data, optometrists performed about 6 million eye exams on Medicare beneficiaries while ophthalmologists performed 22 million eye exams7; this in spite of the fact that there are 30,000 optometrists in the US and only 20,000 ophthalmologists. Far sighted practice administrators must consider where they will find help for overworked ophthalmologists in the not too distant future.

So, what’s the next step? Like any other human resource issue, you must first find some likely candidates; a training program in your vicinity is a good place to start. Then, you will have to consider their lengthy training needs; the classic textbook, The Ophthalmic Assistant8, is a good foundation. Probably, you will have to pay a high salary to recruit a raw, ophthalmology-illiterate physician assistant but it won’t be long before he or she will be useful. If my survey is right, the second year of employment should see a dramatic increase in revenue from an entirely new part of the practice, as well as hope that you can cope with the perfect storm. It’s not too soon to think about it.


1 United States Census Data, CMS enrollments 2 Williams, G. The Physician Shortage. NAS Insights, Physician Recruitment Report. Retrieved from www.nasrecruitment.com/MicroSites/Healthcare/Articles/featureH5b.html 3 A Summary of the 2008 Annual Reports, Social Security and Medicare Boards of Trustees. Retrieved from http://www.ssa.gov/OACT/TRSUM/trsummary.html 4 Nicholson, J. Trends in the Physician Assistant Profession. Retrieved February 10, 2005, from www.physicianassistant.wisc.edu. United States Census Bureau. (2005).

5 California Business and Professions Code §3535(2) for the author’s home state. Other states use similar concepts. 6 Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners 7 Centers for Medicare and Medicaid Services. Part B Extract Summary System. CY2006 8 Stein, HA, Stein, RM, Freeman, MI. The Ophthalmic Assistant: A Text for Allied and Associated Ophthalmic Personnel


Kevin J. Corcoran, COE, CPC, FNAO, is president of the Corcoran Consulting Group.

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