Debate over the findings of the two Lewin Studies issued in 2014 has chiefly centered on Lewin’s prediction of an “adequate supply” of “eye doctors” in its Eye Care Workforce Study: Supply and Demand Projections. The second study, the Lewin National Survey of Optometrists however generated little discussion or comment.
But there was useful information in the Lewin National Survey of Optometrists of such wide scope and sufficient detail to offer accurate insight into how optometrists practiced and viewed their income.
However, for reasons unknown, Lewin choose not to release, but instead obscure, survey findings concerning the types of practices optometrists operated and their degree of dissatisfaction with income while reporting fully the other survey results. Why, one might ask?
The Lewin national survey of optometrists was mailed in 2012 to nearly 4,000 optometrists randomly sampled from 39,580 actively practicing optometrists from whom 726 responses were received. Lewin stated this sample size produced an expected confidence interval above 95% with a margin of error below 5%.
Responding optometrists making up the survey sample were, on average:
1. 60% male and 40% female 2. 62% between the ages of 40-65 3. Race/Ethnicity White 86.0% Asian 8.0% Black 1.4%
Selected pertinent findings of the Lewin National Survey of Optometrists follow.
Notes of Caution
- Lewin did not publish all data it collected. Its survey findings of which of 19 types of practice settings optometrists believed best described their practice was collected but not published. Instead, Lewin only reported two types, the numbers of “self employed” and “employed by others” practices. Failure to report the number practicing at each of the other 17 types of practice settings obscured the degree to which optometry practices have shifted from “private” to “store” settings. (Survey questions #6a and #6b)
- Lewin’s “satisfaction survey” was difficult to assess due to its 6 possible response “bubbles” of which only the end ones were labeled (extremely satisfied, extremely unsatisfied) with no middle bubble to signal satisfied. (Survey question #21)
Survey questions #6a, #6b and #21 are shown in detail below.
The National Survey Findings
Survey Question #21
Percentage Satisfied or Extremely Satisfied with:
Scope of Practice/Autonomy 62% Geographical Location 61% Job Security 60% Career Options/Professional Growth 56% Inclusion in Medical Plans 36% New Care Delivery Models 29% Income/Reimbursement 17%
Lewin states this survey question showed 64% of responding optometrists not satisfied with access to medical plans, 71% not satisfied with new care delivery models and 83% not satisfied with income/reimbursement.
Question #21 contained 6 circles for respondents to indicate varying levels of satisfaction with their income, with “Extremely Satisfied” at the left and “Extremely Unsatisfied” at the right.
Extremely Extremely Satisfied Unsatisfied O O O O O O
But the 4 in-between circles were not labeled so it was not clear to responding optometrists what they represented, especially without a “middle circle” to presumably indicate satisfaction. Lewin stated, however, in its summary of findings that “Only 17% of respondents reported that they were satisfied with their income or reimbursement.” So, among the 83% not satisfied with their income there had to be some who were extremely or somewhat unsatisfied or whatever the 4 unlabeled bubbles were supposed to represent.
To be more precise, Lewin should have labeled and reported the percentages for each of the 6 bubbles to show the degrees to which optometrists were unsatisfied with their income rather than stating 83% were unsatisfied.
There is an important difference between finding 83% were not satisfied with their income and a finding that 83% were extremely less than satisfied. All we can deduce from Lewin’s failure to label the circles and show their percentages is that 83% were a little, some, or extremely unsatisfied with their income while only 17% were satisfied some, a little or extremely satisfied with income.
Survey Questions #6a, #6b
Principle Practice Settings
It was good to see, both for the first time, a national survey and one asking in detail how optometrists actually practiced in situ rather than asking ambiguous questions.
Lewin asked optometrists to select which of 19 types of practice setting best described where they practiced.
A. Those stating they were “self-employed” could describe their practice as:
- Solo owner not affiliated with regional/national (r/n) retail company
- Owner, small group not affiliated with r/n retail company
- Owner, large group not affiliated with r/n retail company
- Solo franchise, affiliated, adjacent to or within a r/n retail company
- Group franchise, affiliated, adjacent to or within a r/n retail company
- Independent contractor/lessee
- Other (specify)
B. Those stating they were “employed by others” could describe their practice as:
- Employed by O.D. in private practice
- Employed by O.D. owned franchise/affiliated with r/n company
- Employed by non-O.D. owned independent franchise
- Employed by ophthalmologist
- Employed by hospital/clinic/health care facility
- Employed by community health center
- Employed by HMO
- Employed by r/n optical company
- Employed by educational institution
- Employed by U.S. or local government
- Employed by ophthalmic industry
- Employed by others (specify)
But Lewin did not report the percentages of each of these 19 practice types.Instead, Lewin only reported that:
- 30% were employed by others (24% male, 40% female)
- 70% were self-employed (76% male, 69% female)
- Older practitioners trended towards self-employment (over age 65, 76% male and 60% female)
Lewin threw away the most accurate information our profession would have ever had on types of settings at which optometrists practice. Why?
Also, Lewin’s sample of just under 400 optometrists came from a combination of three sources; Provider 360, AOA membership lists, and the Provider Enumeration System. But Lewin did not indicate what percentages of its sample were AOA members or if the percentage of AOA members was the same as in the general population of optometrists. That would have been important to know for AOA members practice differently than non-AOA members and only about 50% of practicing optometrists are AOA members.
Age and Gender
Age <30 30-39 40-49 50-65 >65 M/F 9/21 75/96 90/72 238/45 68/7
(1,800 in 2018)
Race/Ethnicity of Students
White 56.0% Asian 30.0% Hispanic/Latino 4.4% Black 3.0% Native American 0.4% Pacific Islander 0.2% Other 7.0%
Age and Gender Distribution of Self-Employed
At ages under 30, 29% of males were self-employed compared to 11% of females. But, after age 30, the number of self-employed males and females rose steadily until, at age 65+, females were at 100% and males were at 93%.
Age and Gender Distribution of Employed-by-Others
At ages under 30, 89% of males and 71% of females were employed by others. But, after age 30, the numbers of employed-by-others males and females steadily declined until, at age 65+, females were at 0% and males at 7%.
Total Hours of Practice per Week
The overall average was 40.7 hrs/week with very little variation from this value across age, practice type and years of experience except males averaged 42.15 hrs/week while females averaged 38.55 hrs/week.
Number of Practice Sites
Overall, 66% of optometrists practiced at just one site, 26% at two sites, 4.5% at three sites and 2.8% at four sites.
These percentages declined with age of optometrist until, by age 65+, they became 80% at one site, 20% at two sites, and 0% at three and four sites.
Weeks Worked per Year
Mean weeks worked per year was 47 with very little variation from this number across age, gender and type of practice.
Patient Visits per Week and Hour
Average weekly patient visits were 63 per week with an average of 70 for self-employed and 90 for employed by others.
Average patients per hour were 1.80 with 1.89 for male and 1.63 for female optometrists.
Survey Question #9
Optometrists were asked how many additional patient visits they could provide per week if fully booked with zero no-shows without adding additional hours, staff or equipment.
Overall, optometrists said they had, on average the capacity to see 19.8 more patients per week which Lewin termed an “excess capacity” of about 32%.
In its other report, the 2014 Eye Care Workforce Study: Supply and Demand Projections, Lewin used this “excess capacity” of optometry “chair time” to replace the shortages of future ophthalmologists it predicted by assuming optometrists provide the same care as ophthalmologists and they would replace all ophthalmology shortages. Using this highly unrealistic assumption, Lewin claimed there was no surplus of optometrists but, instead, an “adequate supply of eye doctors”; a seriously misleading characterization of the Lewin Supply and Demand Projections.
To make this claim, Lewin assumed that 1.36 optometrists provided the same services as one ophthalmologist despite state practice laws that do not permit optometrists to hold the same scopes of practice as ophthalmologists. But Lewin made this assumption so it could consider an “eye doctor” to be either one ophthalmologist or 1.36 optometrists and thereby reduce the surplus of optometrists it found by believing they would fill in for shortages of ophthalmologists.
Revenue by Source
Stand-Alone Vision Plan 27% Traditional Insurance 17% Self-Pay 16% Medicare 15% Medicaid/CHIP 11% HMO 4% Other 11%
Median Net Income
Overall $113,000 Self-Employed $113,000 Employed-by-Others $104,000
Age <30 30-39 40-49 50-65 65+ Male $62,000 $113,000 $138,000 $138,000 $113,000 Female $87,000 $87,000 $113,000 $113,000 $100,000
While there is much useful “secondary” information in the Lewin national survey of optometrists, the best survey to date, Lewin chose to not publish its detailed findings of how optometrists practiced or completely reveal their degrees of dissatisfaction with their incomes.
1: Questions #6a and #6b. Lewin did not release its detailed findings on the numbers of optometrists practicing at the 17 different types of practice listed in the survey. This data would have been very enlightening since there have long been debates over whether or not optometry “professionalism” has declined since the FTC removed its ban on advertising by health care providers.
It has seemed since then optometry does not wish to make public how optometrists practice. For example, prior surveys have used terms such as “private practice”, “independent practice”, “commercial practice”, “retail practice”, and “self-employed” vs. “employed” which are overlapping and imprecise practice descriptions.
Why Lewin chose to lump its 19 detailed findings into only “self-employed” vs. “employed by others” was not explained by Lewin nor explained by the two “blue ribbon” panels of AOA selected consultants advising Lewin.
For example, using Lewin’s “self-employed” and “employed-by-others” which is the more professional practice setting?
A salaried staff optometrist at the Wilmer Eye Hospital at Johns Hopkins Hospital (employed-by-others) or an optometrist owning and practicing a mall optical boutique (self-employed).
2. Question #21. This same loss of specificity befell Lewin’s summary of how “satisfied” optometrists were with various aspects of their practice.
Why were 4 of the response “bubbles” not labeled and percentages reported?
While it was clear the great majority of optometrists were “less-than-satisfied” with income, Lewin did not report what percent were “less-than-satisfied”, “somewhat satisfied” or “extremely-unsatisfied” with their income (if that is what those un-labeled bubbles meant).
Lewin’s two studies appear to show manipulation and “obscuring” of data involving:
- Current and future surpluses of optometrists.
- Increases in number of Optometry Schools and Graduates.
- Dissatisfaction with practice incomes.
- The Lewin Executive Summary claim of an “adequate supply of future “eye doctors”.
It has been failures to address these very issues that is causing increasing concern among practicing and academic optometrists. Being told to wait for the “facts” from the Lewin Group and its “blue ribbon” advisors has not made matters better.
So why were the facts either not addressed properly or ignored? Why did the advisory panels not object?
The two Levin reports were missed opportunities to gather pertinent and factual information important to the health of our profession and our patients.