Two years ago, the Association of American Medical Colleges (AAMC) published a report that predicted a shortage of 134,000 physicians in the United States by 2034. This information should not be surprising to patients and providers. Articles written to warn the public of the pending medical professional shortages are common in national media and medical literature. These articles, although critically important for policy planning, may falsely reassure individuals that predicted shortages are a future problem and there is still significant time to act. But shortages already are occurring in certain medical specialties. What about addressing today’s physician shortage?
In a recent study, our team attempted to understand how current provider shortages in the U.S., specifically those of ophthalmologists and optometrists, may limit access to basic eye care and reduce adherence to national screening guidelines. We focused specifically on access to the basic eye exam, which is a fundamental tool for the screening, diagnosis and prognosis of many ocular and systemic conditions. Since ocular conditions typically become more common with age, the American Academy of Ophthalmology (AAO) recommends that all individuals over 65 years old, a population primarily insured by Medicare, receive a comprehensive eye exam every 1-2 years.
Using four large, publicly available databases, we identified every practicing United States ophthalmologist and optometrist who performed an eye exam with Medicare beneficiaries in 2019. For every U.S. county where exams were performed, we calculated the number of practicing vision testing providers, percentage of providers classified as ophthalmologists and the number of exams per 100 Medicare beneficiaries. We then used multivariable regression to uncover associations between these markers of access to care and key county characteristics, such as unemployment rates, median household income and literacy rates.
In 2019, we found that 28,937,540 eye exams were performed on Medicare beneficiaries by 46,000 providers in 2,291 U.S. counties. Although this may seem like an impressive number of providers, the data imply that there was not a single practicing optometrist or ophthalmologist in the remaining 800 U.S counties. More than 25% of U.S. counties did not have a single practicing eye care provider. Moreover, there were fewer than seven optometrists and ophthalmologists to care for every 10,000 Medicare beneficiaries in counties with the median number of providers and on average only one of these providers was an ophthalmologist.
We found this significant gap in providers has already impacted eye care access and adherence to clinical guidelines. In the median county, only 34.9 exams were performed for every 100 Medicare beneficiaries; 25% of counties had fewer than 17 exams performed per 100 Medicare beneficiaries. These figures suggest we are falling far short of the AAO recommendation and, consequently, that we are potentially underdiagnosing and undertreating many ocular conditions. Given broader awareness of socioeconomic disparities in healthcare, our regression results were not unexpected. For example, we found that counties with fewer providers and fewer eye exams tended to have lower median household incomes, fewer high school graduates, higher poverty rates and increased rurality.
Our study uncovers significant eye care provider gaps in the United States that already seem to be limiting care access and utilization and reducing adherence to “best-care” guidelines. These provider gaps do not occur randomly, but rather are affected by the county population and location. Consequently, significant policy and provider interventions are urgently needed to promote care of underserved populations and increase access to ophthalmologists and optometrists.
One way to help increase access to eye care is to better leverage the growing usage of telemedicine to reach more patients quickly. This requires increased awareness and training for eye care providers to maximize the utility of this valuable tool. Another way to address the systemic lack of care in certain areas is to promote ophthalmology and optometry to students from underserved areas so that they are more likely to return to serve those communities later in their careers.
Certainly, this will be a difficult process, but one important fact is clear: the provider shortages are not coming. They are already here.
By Anshul Bhatnagar, a third-year medical student at Baylor College of Medicine, Henry Chang Skrehot, a third-year medical student at Baylor College of Medicine, Dr. Masih Uddin Ahmed, assistant professor of ophthalmology and residency program director at Baylor College of Medicine