Introduction
With the publication of the Review of Optometry feature article “Diploma Deluge” on February 15, 2018, and current graduation rates nearly doubled in the past 15 years while qualified applicants continue to decline and yet three more new optometry schools planning to open (Tusculum, Wingate, Highpoint), it seems time to revisit the two 2014 Lewin Group Reports on eye care manpower and the misinterpretation of those findings by the AOA.
The complete text of the inaccurate press release sent to AOA members in 2014, “Study Finds Eye Care Workforce is Adequate to Meet Projected Demand” is below with comments by Dr. Myers.
Inside Optometry – June 2014 – Emailed to all AOA members (AOA Website)
Study finds eye care workforce is adequate to meet projected demand
The just-completed National Eye Care Workforce Study was designed to help answer critically important questions about how America’s eye health needs will be met over the next decade and beyond.
Jointly launched by the AOA and the Association of Schools and Colleges of Optometry (ASCO), the study is based on the most current survey and health sector data and a computer model developed by the Lewin Group, a firm widely recognized for its health care policy research.
This is the most ambitious, comprehensive and forward-looking study of eye care supply and demand ever undertaken.
“The results clearly point to a supply of eye doctors – optometrists and ophthalmologists – that is adequate to meet the current and future eye health and vision care needs of the American people,” says Steven A. Loomis, O.D., vice president of the AOA. “The study also demonstrates the opportunities for optometry to further expand its role in the delivery of medical eye care services for seniors, working adults and children.”
In A Nutshell
Lewin’s supply-demand computer model (for the period 2014-2025) initially predicted future shortages of ophthalmologists and continued large surpluses of optometrists. To reduce the optometry surpluses a revised, final model assumed optometrists had the same scope of practice as ophthalmologists and 1.36 surplus optometrists would fill each future ophthalmologist shortage.
Lewin called this final model a “unified eye care marketplace” in which an “eye doctor” was an optometrist, an ophthalmologist or a surplus optometrist filling a vacant ophthalmology position. In this model surplus optometrists filled all future ophthalmologist shortages by providing the same services as ophthalmologists… yet there still remained a considerable optometrist surplus.
The final model made unrealistic assumptions yet the AOA accepted it and spun it into good news claiming there will be adequate “eye doctors” through 2025, which is as far as the model predicted.
Want More Details?
Lewin had initially predicted increasing shortages of ophthalmologists but current and future surpluses of optometrists (called “over capacity or under utilization”). For example, its National Survey of practicing optometrists in 2012 reported the average optometrist could see 32% additional patients without adding staff, equipment, space or office hours. That amount of empty “chair-time” represented a significant surplus.
But Lewin’s final model of a “unified eye care market” with “eye doctors” masked the optometry surpluses by assuming ophthalmologists and optometrists were interchangeable “eye doctors” providing the same services (despite state practice laws), differing only in that 1.36 optometrists were needed to provide the care of one ophthalmologist.
With this unrealistic assumption, future shortages of ophthalmologists were filled by surplus optometrists which somewhat reduced future optometry surpluses.
Lewin’s sleight of hand; turning optometrists and ophthalmologists into “eye doctors” with identical scopes of practice (why did the optometry advisors not object?) was an effort to hide optometry surpluses and ophthalmology shortages.
So, predicting “adequate” numbers of future “eye doctors” rather than a surplus of optometrists, based upon this Lewin computer projection, seems unwise and very misleading.
The Lewin “unified eye care marketplace” assumption that future optometrists will become “eye doctors” with scopes of practice equal to ophthalmologists seems too unrealistic to be believed.
The dictionary definition of “adequate” is “sufficient to satisfy a requirement”. To say an adequate supply of future “eye doctors” will exist mixes up different types of eye care providers having different scopes of practice and hides the true state of future supply Lewin initially predicted – a shortage of ophthalmologists and a large surplus of optometrists. The “eye doctors” the AOA references are a pipe dream.
(AOA press release continues)
Highlights of the study findings include:
There appears to be an adequate supply of eye doctors, optometrists and ophthalmologists, inclusive of projections of new doctors, to meet current and projected demand for eye care services through 2025.
Please see comments above.
(AOA press release continues)
Demographic trends as well as public health and policy factors, including growth and aging of the U.S. population, an increased prevalence of Type 2 diabetes, expansions in health insurance coverage and the designation in Federal law that coverage for eye health and vision care is essential for children are all projected to contribute to an increasing demand for optometric services through 2025.
The Lewin “unified eye market” did include all the above factors that could increase demand for future eye care. Yet even using 1.36 optometrists to replace each ophthalmologist shortage assumed in the Lewin computer model still predicted a large surplus of optometrists. And the current administration is cutting back some of those federal programs.
(AOA press release continues)
The data collected indicates that with increases in productivity, optometrists currently view themselves as able to accommodate much of the expected increase in demand. Responding optometrists reported that they could see an average of 19.8 additional patients per week if completely booked without adding hours to their practice schedule.
Yes, optometrists reported this to the National Survey. This is what Lewin described as the current (2012) optometry underutilization or overcapacity or a 32% “surplus” that Lewin ignored until incorporating it into its final, “unified eye market” model that assumed this optometry surplus would replace ophthalmologists.
(AOA press release continues)
The trend of optometrists to provide an increasing number of medically necessary eye care services correlates closely with projections for an increasing demand for these services, especially among senior citizens and those at risk for Type 2 diabetes.
This incredible Lewin assumption that by 2025 a magic wand will have turned optometrists into ophthalmologists is so unlikely I re-read the Lewin Reports several times to be sure I wasn’t imagining it. This assumption is what the AOA bases its statements on, that an “adequate supply” of “eye doctors” will exist in the future while denying an optometry surplus exists because, if it does exist, it’s a good thing as optometrists will be able to fill ophthalmology shortages.
(AOA press release continues)
Jennifer Smythe, O.D., M.S., ASCO president says, “While the study offers a snapshot of the workforce at this moment in time, one of the most important aspects of this project is that the Eye Care Workforce computer model will allow for continued analysis of the eye care market as external factors affecting both supply and demand change or other factors are introduced. Workforce studies often generate as many new questions as they answer, and we can see some intriguing new avenues for investigation as we seek to advance optometry’s ability to meet the demand for services.”
I hope the Lewin “computer model does allow for” adjustments such as the fact optometrists have yet to be converted into ophthalmologists (2025 is now only 7 years away) and there are another three optometry schools planning to open.
(AOA press release continues)
Mitchell T. Munson. O.D., AOA president, says, “Without a doubt, this is the most ambitious, comprehensive and forward-looking study of eye care supply and demand ever undertaken. It fully recognizes both optometrists and ophthalmologists as providers of the eye health and medical services, including diagnosis, treatment and management of an array of diseases and disorders, which will be increasingly needed by Americans in the years to come.”
Yes, it fully recognizes ophthalmologists and optometrists on the basis 1.36 optometrists provide the same treatments as 1.0 ophthalmologist despite the fact state licensing laws do not permit this.
(AOA press release continues)
AOA and ASCO organized the study project for which funding was provided by ophthalmic industry sponsors, including Alcon, Essilor, HOYA Vision Care, Johnson & Johnson Vision Care, Inc., Luxottica, TLC Vision, and Transitions Optical.
Further comments, notes and references
The following individuals were appointed by the AOA to interface with and supervise the work of the Lewin Group.
Workforce Study Project Team
Randolph E Brooks, O.D. (chair); Kevin L. Alexander, O.D., Ph.D.; Mamie Chan, O.D.; Elizabeth Hoppe, O.D., M.P.H.; Dr. P.H.; David I. Rosenstein, D.M.D., M.P.H.; and Jennifer S. Spangler, M.B.A., M.P.H.
Expert Panel Members
Randolph E. Brooks, O.D.; Mark K. Colip, O.D.; Michael Duenas, O.D.; Edwin C. Marshall, O.D., M.P.H.; Jeffrey C. Michaels, O.D.; John C. Whitener, O.D., M.P.H.; Gary L. Robins, CAE; Mort Soroka, Ph.D.; Jennifer S. Spangler, M.B.A.; M.P.H.; Roger Wilson, O.D.; Christopher W. Wroten, O.D.; Robert Zeiss, Ph.D.
Free Copies of AOA Report and Executive Summary
To get all three documents from the National Eye Care Workforce Study go to aoa.org/marketplace.
- National Eye Care Workforce Study: Supply and Demand Projections Executive Summary
Digital Copy:
Members: Included in membership ($0)
Nonmember charge is $15
- Report on the 2012 National Eye Care Workforce Survey of Optometrists (Released in 2014)
Printed Book:
Members: Included in membership ($0)
Nonmember charge is $125
- National Eye Care Workforce Study: Supply and Demand Projections Final report
Printed Book:
Members: Included in membership ($0)
Nonmember charge is $625
Lewin Group Reputation
Source Watch states “The Lewin Group has a reputation as the ‘go to’ firm for beleaguered organizations in need of reports and research to support controversial positions and issues.” [SourceWatch]. Lewin Group is located inside the I-495 Washington Beltway in Falls Church, Va.
Whose Interests are Being Protected?
By 2000, after studies by the RAND Corp. and Abt. Group predicted future optometry surpluses, concern began growing among practicing optometrists about a future oversupply.
AOA and academic spokesmen had, in the 1960’s, been lobbying for more schools, claiming there was a shortage of optometrists. But those additional schools established from 1973 to about 1990 were endorsed by their state optometry associations citing supporting demographic data (optometrists per capita) and were approved, and funded, by their state legislatures and became part of public university systems. Examples included the University of Alabama College of Optometry in Birmingham, AL, the SUNY State College of Optometry in Manhattan, NY and the Univeristy of Missouri in Saint Louis, MO.
The new schools since 2000 however did not follow that path and arose “sui generis” without legislative or state association approvals or meaningful studies; often at small, private schools in rural areas, or within existing osteopathic schools or even the same metropolitan area as an existing school. There were no public debates and the sponsoring universities initiated them for their own perceived economic potentials.
These new schools cited U.S. Bureau of Labor Statistics reports that optometry was a rapidly growing profession and/or a new school will promote the creation of local jobs and/or relieve a supposed shortage of optometrists in rural areas. Some of these new schools were in “towns” of under 2,000 people and far from population centers having medical centers or pools of potential patients.
Unfortunately those U.S. Bureau of Labor Statistics reports remain highly questionable from being chiefly based on projections from the schools of optometry and the AOA who continue, to this day, to offer overly optimistic projections of the need for future optometrists. But rural professional schools are unlikely to see their graduates practice there; optometrists per capita are already at a record high, and optometrists, the Lewin National Survey found, reported an average empty chair time of 32%. That survey found that many optometrists must practice at two or more sites and the majority were unhappy with their income.
There should be little doubt of an “Optometry Bubble” or optometry surplus similar to those for attorneys, pharmacists, veterinarians, architects, and graduates in non-STEM and many liberal arts degree holders. And, at the same time, student educational debt has reached over 1.5 trillion dollars, exceeding total credit card debt in the nation.
The question one must ask is why our leaders continued to deny the optometry surplus and felt compelled to “misinterpret” the Lewin Reports (and two previous studies).
They supported the Lewin study’s implausible assumption the scope of optometry care is equal to ophthalmologists, but not as efficient (1.36 optometrists equals 1.0 ophthalmologist) in an effort to explain away the optometry surpluses.
Their summary of the Lewin findings shown earlier, “reassures and soothes” readers there will be “adequate numbers of eye care providers in the future”.
Probable Causes of Optometry Surplus Bubble
- Overly optimistic projected needs for more future optometrists given the U.S. Bureau of Labor Statistics.
- Growth in government guaranteed student loans that remove schools’ risk of non-payment and are “easier” to obtain than in the past.
- Continuing optometry school accrediting standards, when compared to dental/medical schools, lack required quantitative standards for numbers and types of patients seen in teaching clinics.
- Desire of existing schools to increase the pool of qualified applicants to avoid reduced enrollments (one school anticipated the bubble and reduced enrollment) and to better compete for students by investing in student amenities (which raised tuitions) previously unknown to students.
- Concern over declining percentage membership in the AOA as % membership weakens as more optometrists become employed (most independent pharmacies are gone, 5 chains employ 80% of phamacists and AMA membership has fallen from around 85% to 15% as private practices have declined in numbers).
- The decision by small private universities, influenced by 1, to expand their student base by opening optometry degree programs, especially universities with osteopathic schools leveraging existing capital investment.
- Anticipated future enrollment declines as number of high school and college graduates decline.
Who is to Blame?
The Lewin Group is one of countless “research” groups in and around Washington D.C. where over 25,000 registered trade associations and lobbyists live.
It is no secret “findings” are often generated by these “research” groups to buttress the interests of their clients in influencing legislative matters. When one of these “research” groups is retained it is understood where their client’s interest is centered.
In my personal opinion the Lewin group was “urged” to torture the evidence (perhaps the cause for the one year delay in release) to turn the optometry surplus into a “good thing” by inventing a new type of “eye doctor” … an O.D. able to perform as a 1/1.36 ophthalmologist.
That assumed “lower efficiency” of optometrists helped absorb the optometry surpluses as it took away 1.36 surplus optometrists for each replaced ophthalmologist.
It is my personal opinion Lewin was retained and then “guided” by members of the two aforementioned panels assigned to work with Lewin.
Why Ruin a Profession?
Why would the AOA and ASCO for years after past manpower studies predicting surpluses have continued to deny optometry surpluses?
Why did only one school of optometry reduce its enrollment to maintain entrance standards as numbers of qualified applicants began to be diluted by additional schools and declining college graduate numbers?
Why did the profession continue to supply overly optimistic predictions of future manpower needs to the U.S. Bureau of Labor Statistics?
I believe the “Tragedy of the Commons” explains why and how optometry leadership ended up damaging the schools, its students and our profession by pursuing individual best interests.
