Guest Editorial

Optometric Surgical Expansion: The Real Costs

Lower reimbursements; less access to care.

By Nicholas H. Tosi

The politicization of scope-of-practice boundaries has recently taken a dangerous turn for the ophthalmology community.

While the optometry lobby has traditionally challenged the extent of treatable diseases, prescription powers and reimbursement, a movement toward the establishment of optometric surgical rights has now taken precedence. This legislative momentum has created state fragmentation regarding optometrists' surgical rights and is showing no signs of waning.

Why should every ophthalmologist care? Of course there is the realistic concern of patient safety that has been voiced by opponents of optometric expansion, such as the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery. However, the significance of legislation that would be used to broaden optometrists' scope of practice is much deeper, due to the potential economic and professional impact on ophthalmology itself.

If aggressive legislation permits optometrists to perform nearly all ocular surgeries, it will undoubtedly lead to downward pressure in reimbursement. This outcome is predictable, based on straightforward economic theory and history. Surgical expansion would send a clear market signal that optometrists are equivalent to ophthalmologists and would negate the valuable human capital ophthalmologists have earned through their distinct training. This economic premium that ophthalmologists obtain and rightfully benefit from would be disregarded, especially given the government's obsession with curtailing healthcare costs at every opportunity.

If the number of eye care practitioners providing specific eye surgeries increases, as it may initially, it will lead to downward price pressures in saturated markets, given the same overall demand of patients. Moreover, the introduction of permanent new entrants into a market should also cause payments to fall over time.

A Chilling Example

A tangible example of where these factors combined to reduce reimbursements is primary care. In this area, physicians now share huge clinical overlap with both nurse practitioners and physician assistants. This is contributing to an increased supply of providers and substitute providers, resulting in a devaluation of physicians' skill set, since it is reproducible by non-physicians. The relatively low incomes earned by primary care physicians should serve as a warning sign for what could come, sooner rather than later, in ophthalmology.

Not surprisingly, ophthalmology practices — like most professional organizations — tend to act in the long run as profit-maximizing firms and will adopt new practice habits if reimbursement decreases for a particular procedure. Further payment cuts will certainly influence future case selection and quantity of surgeries. Ophthalmologists will assuredly shift towards higher-paying procedures and the number of lower-paying surgeries they provide will decline.

Although the overall repercussions of optometric expansion legislation are as yet impossible to quantify, the impact will be proportionate to the magnitude and setting of compensation cuts. Additionally, the collaborative relationships that optometrists and ophthalmologists now enjoy could be undermined due to self-referrals by optometrists and a resultant decrease in surgical volume. The legislation would almost surely position optometrists to capitalize on less invasive procedures that become approved in the future.

A Misplaced Assumption

Increasing access to quality eye care is the common argument for optometric surgical expansion and is the cornerstone of a politically driven rationale that is both elementary and incorrect.

The need to increase access to eye care is questionable in the first place, while allowing "surgeons" who are not properly trained to perform surgery creates another issue in itself — the real threat of lower quality care.

The view that making more surgeons available must lead to an increase in access to eye surgery is appealing in theory but not so applicable in practice. It is more reasonable to expect that optometric surgical expansion would, paradoxically, lead to a decrease in access to care for those surgeries affected by the legislation. Legislators must be wary of the aforementioned concept of practice substitution because if resultant reimbursement decreases are significant, or there is stagnation in reimbursement growth, many ophthalmologists will simply perform other procedures and/or cut back their workload.

Moreover, even if more eye care practitioners can theoretically perform a greater variety of procedures, decreasing payments for ocular surgeries will increase relative market entry costs and eventually act as a deterrent to entry. This becomes particularly worrisome as access to care will likely be compromised most in the baby boom generation. As the boomers move into their senior years, they will account for the highest percentage of ocular procedures performed. While demand for a variety of ocular surgeries will be increasing in future years, a contraction in provider supply would likely result in the unintended creation of a market shortage and hinder future access to care.

Misguided Reasoning

This hypothesis of negative pressure on ocular surgery reimbursement becomes exceptionally pertinent to the practice of ophthalmology, given its historical economic trends. Despite eye care accounting for only about 2%, or about $23 billion, of total health care expenditures in the United States, ophthalmology has shouldered disproportionate cost cutting over the last two decades. One major example: the unadjusted average allowed charges for cataract surgery dropped from $1,274 in 1991 to $684 in 2005.

Nevertheless, some still maintain that optometric surgical expansion will help curb overall health care costs. Given the countless inefficiencies in the U.S. healthcare system and the fact that more than 98% of total costs lie outside of ophthalmology, a strong focus on cost control in such a small area of medicine is misguided and can at best only lead to negligible results in retarding overall healthcare expenditures. Such a one-dimensional view also does not take into account optometrists' lack of surgical training, quality of surgery and potential misallocation of resources — making optometric surgical expansion as a cost-control mechanism unsettled and ambiguous.

Hopefully, legislators will stop listening to flawed political rhetoric and resort to a more thorough economic analysis that anticipates how physicians respond to market forces, most notably negative reimbursement pressure. If legislators are able to recognize that optometric surgical expansion may destabilize the practice of ophthalmology and lead to undesirable effects on access to care, quality of care and even total health care costs, a huge gaffe might be avoided before it is too late. OM