Current and Future Eyecare Needs w/ Richard Edlow

Podcast

[00:00:00] Chris Wolfe: I’ve spent, I spent about six or seven years, about seven years, um, helping doctors and students prepare for their board examinations. And one of the things that I noticed was that while they were really well-trained they had, so they come out of school really well-trained but they had like, uh, no understanding of how to get paid for those services that they were providing.

[00:00:21] And then, so you started wondering like, why did this happen? How did this work this way? And, and so my, my approach is always that I think it’s. With optometrist, I don’t think it’s outwardly financial. The reasons that you’re coming to the summit, the conclusions probably for a lot longer than I have, but is, is not consciously financial, but I think it’s subconsciously financial.

[00:00:42] They, they understand that they don’t treat a lot of medical conditions because they don’t understand the revenue behind it and they really get. Routine exam refraction sell a widget routine, examined fraction, sell a widget, and then they do that for so long. Most of them when they come out of school, unless they have really good mentors that when they start deciding, Hey, I don’t want to practice this way anymore.

[00:01:03] I want to take care of patients. They, they, they can’t get out of that routine because they don’t know the value of those services and they don’t know how to have a patient back and how to have a conversation about copays and deductibles. And, and so it just becomes way too complex. And so I think that’s why that’s my suspicion on the why maybe I’m tainting our conversation.

[00:01:22] Richard Edlow: I think you’re on target there. It’s it’s interesting because you and I are two different generations of optometry. I believe you’re a young guy. I graduated in 1980 for PCO and the, the mentality was we were almost apologetic. If we had to bill for something medical or. Bring them back, or we have to get a copay versus just running them through the widget of the routine refractive exam.

[00:01:49] And as such it’s, it’s been a very difficult transition and, and not to disparage optometry at all. I think it’s a great profession, but it goes from the, from the jewelry store, ugliest days to where we are today and something never transitioned through. To feel like we’re a part of that healthcare, medical community, that, and patient perception is as big a problem as the doctor’s perception of it.

[00:02:21] Um, and there are very few ODS that I know that are broken through that barrier to have a. Uh, medically oriented practice, where the patients respect that and have an understanding that you’re a doctor taking care of their eye problems, whatever it may be from my opiate to that you’re aware retinal traction from diabetes or with eyecare needs.

[00:02:43] Chris Wolfe: Yeah, I think, and what’s always astounding to me. What really made me reach out to you is your number is your analysis. I don’t want to kind of cover some of that within CMS data. Um, but your analysis was striking to me because I think golly, I’ve been doing this specifically, uh, working with practices to try to get them to do, to understand that value, to communicate that value to payers for five years.

[00:03:07] Um, and, uh, You know guys like you and John, Ron Pacas and you know, all these slew of people behind me, um, have been doing it for so long. And then you look at the data 2016 data to 2019 data has moved much. So talk about the data and talk about kind of your aggregation of that data. And. Hello and welcome crystal podcast on ICO media.

[00:03:32] This is the beginning of our fourth year doing this for years going on. And, um, I had a lot of fun with this conversation with Dr. Ed Lowe and he, I think it was a really great one for us to project forward into this new year, by thinking about how our profession is going to be needed really needed in both routine and medical eyecare service.

[00:03:53] Over the next 10 years and even beyond. So I had a great conversation with Dr. Ed Lowe. I really enjoyed it. Please enjoy our conversation and as always be sure to subscribe to the podcast, write a review, share it with your friends and support those who support us. I want to talk about the MyDay multi.

[00:04:09] For a second. It’s just coming out and we had the opportunity to do a preclinical trial with this lens this last summer. And there were a couple of things that I thought were really helpful. The first one is that it is different than a lot of the multifocals that we’ve used before in our practices where patients, especially early emerging presbyopes really manage the, it didn’t cause a lot of additional, uh, distance blur for them.

[00:04:33] And the other thing that was really helpful. Because we’ve never been involved in a clinical trial before was to understand, uh, the sort of questions that we might ask our patients. We ask our patients a lot of questions about their patient, about their satisfaction with a contact lens. But what we weren’t doing was actually having them score that themselves.

[00:04:51] So one of the parts of this that was really interesting to me was asking patients on a scale of one to 10, how would they would score their vision, how they would score their comfort in their current lenses. And then how they would do the same on their new lenses. And it showed me a lot of times where patients would say they were happy rate their vision as a six or a seven.

[00:05:11] And, um, and then it also reframed their thinking about their current satisfaction in their lenses and allowed me to. The door to offering other solutions. So if you haven’t tried something like that in your clinical practice, I would encourage you to, and I would also encourage you to try it the mighty multi-focal for your patients.

[00:05:34] Richard Edlow: So my, so my focus for years and years has been, uh, looking at the data, looking at the trending that the data shows and demonstrates so that it helps with. The profession and helps prac tissue or running a practice to help them strategically plan for where things are headed. And I’ve been doing this for years.

[00:05:56] And for, for 15 plus years, I was chair of the aways information, data committee who developed a state of professionals. Um, it got in the way in like a day job. So I stopped doing that, but I I’m now actually clinically retired, uh, devoting more time just because I’m a numbers geek. And I like looking at this stuff.

[00:06:15] So, um, so I track the data and I, I try to capture as much data as possible and probably the most valuable on. Services provided that I can find in the public domain is when CMS releases its Medicare utilization payment data each year. So I use that as a proxy to show how involved optometry is in the aggregate with respect to medical eyecare needs.

[00:06:42] Now there are a lot of fallacies. You punch a lot of holes in the numbers, but it’s the best that. Um, I, the Medicare utilization and payment data is Medicare fee for service. So it does not look at the Medicare advantage programs, which now makes up 34% of our Medicare patients. Uh, so there’s a large component there and it looks at just the 65 and older elderly population for the most part and does not look at the commercial population.

[00:07:09] So over the years, I’ve taken, um, a clink in the Medicare fee for service stuff. I apply a correctly factor for the Medicare advantage programs. And I apply another correction factor for the commercial population. Uh, and just depending on whether it’s glaucoma or cataract or diabetes, that correction factors typically approximately 20% of.

[00:07:36] Of if a hundred Medicare cataracts are performed, 20 commercial cataracts are performed. Um, and I put all that data together and I take a snapshot of a given year, and then I apply to that, uh, census data so that we can project out for the future. So I can look at it. My current numbers are looking at 20, 20 to 2030 to give us a sense of where are we this decade and where are we going?

[00:08:02] 10 years out. Um, in addition to that, I, uh, so that’s the demand side. That’s, uh, utilization side of services and the demand for eyecare projected out based on

[00:08:13] Chris Wolfe: census data. Pause there, hold on. Cause I know where you’re going with this, but I want to pause there and say, okay. So when you analyze that data for Medicare, Uh, for optometrists specifically.

[00:08:26] Tell me about how you’re knowing whether or not you’re classifying this as medical eyecare, like a truly medical eyecare service versus somebody that is just billing something occasionally to Medicare.

[00:08:37] Richard Edlow: Yeah. Great question. So we can have a philosophical debate on this probably for a couple of weeks, but here’s what I do.

[00:08:44] Just trying to cut through it all and make it simple. Uh, and I readily agreed. There are a lot of arguments that could be made to look at it differently. But the way I view this as the way Medicare is you need a medical diagnosis to bill Medicare. So typically a, um, a 70 year old patient who comes into an optometrist office.

[00:09:07] Regardless of what this setting is. I don’t care about that. Um, and 70 year old patient and I’ve yet to meet as the practitioner for 40 years, I’ve yet to meet a 65 or older patient that doesn’t have a medical eyecare needs diagnosis.

[00:09:26] Chris Wolfe: It’s crazy that this idea that we’re going to need to have Medicare cover eye exams it’s, or that we’re going to sell them some sort of supplement to cover their vision. It’s a nightmare in practice. And you probably know that from your days when patients come in and they’ve never had, you know, managed vision care and they’ve always been a medical patient.

[00:09:45] And now all of a sudden they’ve got this VSP plan or I’m ed plan or whatever that they think they need to use. And it’s like, you don’t, you’re not routine. You don’t have those. You don’t even need that.

[00:09:55] Richard Edlow: So, so, so first I’ll leave back up for one second. Um, in a lot of the, um, the data that I report on in the, in the optometric literature, uh, I look at routine exams and medical exams and my diet, my, my differentiation is a routine exam.

[00:10:13] Is that the diagnosis code is refractive codes, myopia, presbyopia, astigmatism. Um, that is the routine refractive and anything that has a medical, um, ICD 10 code two. It is a medical visit. And so the 70 year old comes in and guarantee the 70 year old has one of, and probably multiple keratitis sicca, nuclear sclerosis, some kind of character of conjunctivitis.

[00:10:41] Somebody has something that’s medical, even though they came in because I’m having trouble. I can’t see so well at my glasses. Things are a little blurry driving at night. It’s a little tougher, whatever it may be, the optometrist. There’s one of two philosophies there. So one is the, the ODI who, um, has been seeing this patient for decades, giving them new glasses or contacts every other year, every year sees a patient.

[00:11:09] They have a little, uh, nuclear sclerosis and a little myopic shift. They give them a new pair, a new prescription. Um, the diagnosis is nuclear sclerosis. The medical competitor on a nine to oh one, four is built for the medical exam and 92 0 1 5 patient responsible retraction. The office probably isn’t even charging for the retraction, but they shouldn’t be in the front down.

[00:11:31] That’s a

[00:11:31] Chris Wolfe: big, it’s a huge, it’s not just a no-no, but it’s a huge undervalue of the services that you’re providing. I mean, for, for, for goodness sake, visibly values of, uh, basically, uh, a subjective vision test at 25 bucks. Right. I mean, it’s just crazy.

[00:11:48] Richard Edlow: Yeah. And, and, and, you know, I don’t know if we can discuss in this kind of, um, um, medium discuss fees.

[00:11:57] Chris Wolfe: I suspect if you were talking about Medicare national averages, I think that would be totally fine.

[00:12:03] Richard Edlow: So, so with three fraction fees, averages could run anywhere from $15 for a nine to oh one, five retraction type. I’ve seen it a hundred or $120, which is probably more apropos to the equipment and the expertise and everything involved in it.

[00:12:20] Um, I don’t know if you just saw the recent, uh, curvier enthusiasm episode with, uh, Larry David having a refraction with an optometrist. It’s great. But anyway, I digress. Um, and then. So the patient, so this patient is seen, they got some nuclear sclerosis, the dark Bill’s a night, 2 0 1 4. And they do that all day long and all year long with all of their 65 year old, older Medicare patients.

[00:12:45] And that’s all the doc does the doc never institutes and a medical treatment for. Um, they might obviously they’re doing a glaucoma test or doing a fundoscopy, but they never initiate. If they see some early background of diabetic retinopathy, it’s right out to the retina doc. If they see visually reducing sclerosis, it’s out to the cataract surgeon,

[00:13:11] whatever it may be the referring out, referring out, referring out, and they’re just basically. Old time, optometry, refractive care, but billing some medical. So to that point in 2016, 61, if you look at the utilization and payment data from Medicare 61% of all licensed ODS in the country, 61% billed Medicare for some exam medical exam, a 99.

[00:13:40] Thousand code or 92,000 code for an exam? Uh, 61% even just if it was just one time, that’s all it takes. That’s my that’s. My barrier entry is one. Um, so in 2016, I went from 61% to 2019 and went to just shy of 63%. So it increased a little over one and a half percent of all ODS over a three-year period.

[00:14:06] Billing Medicare for just a medical exam. So one could argue. Okay, well, that’s optometry’s involvement in providing medical eye care in the country. As a short example of how to grasp it. But what I would I say is that for me, the proxy of, of actually providing medical eyecare is you got to go beyond just doing that exam.

[00:14:28] You need to do some diagnostic testing, some interpretation and reporting and maybe Institute some treatment for something. And so the minimum that I look at is you’re either doing the doc is either performing a visual field or an OCT. Interpreting it reporting it and billing it. And if I look at that as the, um, as a proxy for how engaged optometry as a whole is in providing medical eyecare, the numbers drop precipitously.

[00:14:58] So in 2016, 27.2%, 27.2% of ODS build one or more visual fields. All it takes to build one visual field that year interpret bill it and. You’ve done medical eyecare.

[00:15:14] Chris Wolfe: What percentage of ODS do you think have a visual field machine in their practice? It’s got to be higher than.

[00:15:21] Richard Edlow: It’s gotta be higher than that.

[00:15:23] And it’s interesting. There was just some ODS on Facebook guy, Alan Glazer’s site. He was just asking yesterday, how many of you have an OCT in your practice or plan on buying one? Um, and that there’s some data back when I was doing the AOA. Uh, surveys. I don’t have it in front of me and I don’t remember the actual numbers, but my guess is it’s gotta be 60% or more of a visual have a visual field.

[00:15:48] Um, even if it’s like an FDT kind of screening field machine, they’ve got something, but they’re not billing it. They’re not doing it. They’re not billing. Um, so it went from 27.2% in 2016 to Medicare’s latest data. We just, sadly, 2019 it’s as close as it gets. I went from 27.2 to 29.5%. So a slight increase in OCT is, um, optic nerves and OCT went from 24 to 27%.

[00:16:18] So to me about 25 to 30% on average optometrists are really actively engage in providing what we would consider medical eyecare to the population. They’re examining patients have medical diagnosis, they’re doing diagnostic testing and probably instituting some treatment or at least a followup regimen.

[00:16:41] And

[00:16:42] Chris Wolfe: then you would even kind of parse that further because you could look at prescription data, uh, prescriptions written to see how many are actively treating. Cause cause you could make the argument even once you have that 27% and assuming that it was not just one, you know, there’s a big proportion of that.

[00:16:56] That’s not just one field, but. But it’s likely to assume that if somebody is comfortable enough running one field and billing it and interpreting it and ordering it, then probably they’re doing, uh, uh, fair enough, at least a few of them, but then you think, okay, well, what about prescription data? I’ve looked at these numbers.

[00:17:12] Have you looked at these numbers for like glaucoma prescriptions or.

[00:17:17] Richard Edlow: I haven’t looked at me in years, but I know that’s probably the more

[00:17:22] Chris Wolfe: accurate yeah, I think that’s it. So I think my point is is that, you know, we can talk about those numbers, but I think what’s interesting, um, is that now you’re, you know, there’s, there’s probably people that are maybe taking care of glaucoma.

[00:17:35] So they might be writing glaucoma prescriptions. Chances are, they’re probably also paying attention to dry eye, but maybe not. Um, but, but even then there’s those there’s components of people that are already running fields running OTTs and then they’re just, I don’t know. I’m not sure if I need to start this patient on treatment, it doesn’t look exactly right.

[00:17:54] I know I have the wherewithal to bill it, but I need somebody else to take a look at this and bless it. And then they’re not writing the prescription.

[00:18:01] Richard Edlow: Yeah. Yeah. So it’s, it’s um, Yeah, the numbers, um, the numbers are less than we would like then we’re led to believe what’s been done that way. Then we’re led to believe by let’s say the AOA or state association, uh, or what we read in the literature.

[00:18:18] Uh, and their variety of reasons for that one is it’s the setting and the equipment and the staffing that you have. And, you know, you can only do what you can do the old saying. If all you have is a hammer, everything looks like a nail. Uh, you’re doing fractions all day. Um, but, but my, my messaging from all of this, um, is that there’s this tsunami of medical eyecare coming that ophthalmology is not going to be able to deliver.

[00:18:49] Chris Wolfe: That’s the part, two of the, of the big thing that you’re looking at. And so who

[00:18:54] Richard Edlow: you going to call? Um, I just saw my grandchildren Ghostbusters too. So who are you going to call it? You’re going to call the optometrist. Um, it’s interesting in, in, uh, getting ready to have this discussion with you and looking at the CMS data that I look at, I, I slice it and dice it by optometry and ophthalmology by CPT code by, um, uh, by state by name.

[00:19:19] So for example, I looked up. What you did with 2000, 2019 with Medicare,

[00:19:28] how much Medicare paid you have? How many, a tear, film osmolarity as you did, which was very good way above average. Nice job. Um, how many exams, how many visual fields you did and how many OTTs you, bill Medicare for it? Um, so anyway, good job. Yeah.

[00:19:42] Chris Wolfe: Interesting. But you know why, you know, why. Um, it’s, you know, I get to do stuff like this and exercise my brain like outside of that.

[00:19:50] But the main reason is if you’re taking care of those things and you’re, and you’re really managing the total patient, you don’t, you can, you don’t have to see 30 patients a day or 40 patients a day. You, you can make a very good and I, and I don’t need to, I just want to take care of patients that I want to take care of, and we’ll just address all those things.

[00:20:11] Richard Edlow: Yep. Yeah, it can be done. And you know, one of the, um, I guess one of the concerns that you and I kind of taught us around at the beginning is how well are we training our students to work within this medical model to work. I think that we’ve, we as optometrists never really learned how to delegate. Well, um, we, uh, we should be delegating a whole lot more and really doing the brain power.

[00:20:43] Decision-making the diagnosing and treating a portion of the exam, not so much the data collection, um, You know, obviously I’ve seen in some, in some practices where the doc is actually performing those CT or the visual field, which is just crazy. Um, but, um, It’s the training, you know, obviously you have to learn in optometry school.

[00:21:09] One has to learn how to do a Fjord, how to do an OCT before you even learn how to interpret it. But it, it ought to be stressed that you’re doing this, not to do it in the future, but you’re doing it just so you understand the basics of it and that your job in the future will be interpreting the results that someone in your office does.

[00:21:29] Uh, And that’s the efficient model of doing it. It’s your point of, you know, the billing and the coding and all those things that, um, that are so critical to running an efficient, profitable practice. Uh, all those things are maybe handed down or taught as well as they ought to be while the dot while the student is still in the optometry program.

[00:21:51] Um, so that’s a concern.

[00:21:54] Chris Wolfe: Yeah. I mean, I think that the challenge is, is they’re trying to do everything they can do to get them to be really comfortable managing diseases, right? Managing diseases, passing boards, taking care of patients. And, and this, this, you know, the idea of, you know, how do you actually do this in a practice?

[00:22:10] Uh, it gets pushed to the wayside because they’re, they have to be safe. Right. That’s the, that’s the biggest thing. And I actually think, you know, You know, I certainly could come off as being, um, Hottie in this. And I, and I don’t mean to, because I think that the reality is, is I think there’s room for docs to practice the way they want to practice.

[00:22:28] And I don’t think that means that it’s bad care. And I don’t think that it means that it’s, um, you know, that we shouldn’t be expanding our scope of practice because I think there’s a lot of people that would listen to our discussion right now, probably on some of the social media sites that you referenced that would say, well, this is an exact reason why we shouldn’t be doing X, Y, Z.

[00:22:44] I mean, because we’re not even using it all at first, but then, you know, you can say that about, you know, ophthalmology, right? There’s a very small percentage of ophthalmologists that are doing probably the majority of the cataract surgeries in the country. And, you know, the rest of them are doing what I do all day long.

[00:22:57] And, and I would say not as well as I. And not because I’m Chris Wolfe because I’m an optometrist, but that’s, and

[00:23:05] Richard Edlow: if I were to have, you know, a, uh, a canvas to paint a picture of the ideal optometric practice, it’s a group practice with probably two docs doing all the comprehensive eyecare needs and then referring within the practice to the doc who does the glaucoma, or if the doctor does.

[00:23:22] The retinal work and the diabetes diabetic retinopathy sees. And following those patients before they need to go out for lasers or surgery, depending on what state you’re in. But, um, that really the, um, and that’s another issue of, um, the. The historical, uh, concept that optometry never really referred to optometry much.

[00:23:47] Uh, and, and that could be an issue I could see, um, in a metropolitan area where an ODI has a glaucoma practice and that’s all they do. And they’re relying on optometric referrals from the guys that aren’t quite as comfortable doing it. The women that would brother, you know, let me, that’s going to slow me down.

[00:24:07] Um, and if you remember the, uh, I think it was a visa commercial years ago, a number of years go, and they’re going through like a Starbucks and everybody’s eyecare needs swiping your card, swipe your card, swipe in their car. And the line’s going very efficiently. And then all of a sudden, someone wants to pay cash and the line stops and it stops, you know, everyone gets bogged down.

[00:24:27] And, and one thinks about running a practice and running an efficient practice. There are efficient ways and inefficient ways to do it. And an efficient way to do it might be to have one or two docs of just going through the routine daily, comprehensive, and medical and refractive. Um, and then as soon as you hit that, that visual field, that OCT, that fundus photo, that tear film osmolarity that’s off, they go in a different direction to the doc.

[00:24:57] That’s going to be more efficient at taking care of it. So

[00:25:01] Chris Wolfe: the pushback that people are going to have when they hear you say that, it’s just that, well, that’s not very easy for the patient. They’re going to have to come back and see another doc. Um, and for, for a condition, that’s that plus they’re gonna have to see me for, I mean, I don’t, I mean, I can imagine that’s exactly what somebody will say.

[00:25:20] It’s a

[00:25:20] Richard Edlow: good point. Uh, but that happens in the medical world all day long, um, with a, and that’s, you know, that’s part of optometry’s, um, I’m trying to think of what the right word is, but a predisposition to not wanting to inconvenience anyone, um, which is fine. And you wouldn’t be customer service oriented by all means the best practices I see are customer service oriented.

[00:25:43] Um, but having said that the, um, the best, the decision should first be made on what’s the best care to provide. How do we do that then? How do we do it with a customer service bent to it and do it efficiently? Um, and there’s plenty of room for that comprehensive optometrist. Who’s doing it all. There’s no question about it.

[00:26:05] Um, so I’m not necessarily making a case for one way or another. I ran a practice for, for 20 years. I ran a practice with 26. I docs, I was the CEO of the practice and, um, and we had two retina docs. We had two glaucoma docs, we had oculoplastics and then we had. Uh, a whole team of optometrists who did all the comprehensive routine, uh, along with they would follow some glaucoma patients eyecare needs and follow some diabetics eyecare needs.

[00:26:32] Uh, and it, it was like a, uh, a ballet. It worked out beautifully with all the right people in the right, uh, the right places on the bus. But, um, but it’s a challenge it’s not easy to do. There’s no question about it.

[00:26:46] Chris Wolfe: The, um, but you know, you’re trying to be efficient with them and then you’re starting to say, okay, well, what can I combine?

[00:26:51] Uh, what can I address? And then pretty soon you get to the point, it’s like, um, we have to address, there’s so much complexity to each disease state. We might have to see you back, you know, multiple times per year per disease. Uh, because it gets so complex. And I think if you don’t, if you haven’t thought through that, well, um, on the front end, it’s just a recipe for disaster and a primary care practice.

[00:27:14] I think it can be done. I believe we’re doing it really well in our practice, but, um, but I, I know that if you haven’t thought through it, like you’re talking about where you mold that dance, um, Then people are just going to give up, cause they’re going to hit roadblocks that are uncomfortable and they haven’t thought through, uh, they haven’t, pre-mortem the thing to know what roadblocks are gonna happen and then they fall apart.

[00:27:37] So that, that actually leads me to this other point that, that you liked, that you talk about was is this idea that we have this impending wave of new care. That’s going to have to take place over the next 10 years. You know, what does that look like from a routine standpoint? And what does that look like from a medical standpoint and, and the, the supply or the, the supply of providers that we’ll have available to us?

[00:28:01] Richard Edlow: So to me, the, the two, um, the two biggest disruptors in our eyecare industry over the next 10 to 20 years are one, the increasing demand for age-related eyecare. And number two, the limited supply of eye doctors, especially in ophthalmology. And of course, you know, we’ve all heard the argument. There are too many optometry schools.

[00:28:25] I can’t believe they’re opening another time to school, amazingly enough, as one looks at the macro level, that 30,000 foot view of the industry. They’re not enough optometrist. Uh, as a matter of fact, if one were to ask anyone, looking to hire an optometrist today, they’re having a real tough time finding ODS to hire.

[00:28:47] There are close to 2000 open positions for optometrists has nothing to COVID and people not wanting to work. Um, there are, uh, if you look at. ISO and I care, you look at the AOA Excel, look at all the, all the job boards for optometry. There are all these open positions that aren’t getting filled.

[00:29:09] Chris Wolfe: It’s mostly like, like what types of positions are they?

[00:29:12] They’re corporate they’re,

[00:29:13] Richard Edlow: I’m mostly steered or more in a, um, in a kind of corporate setting, I believe. Um, I’m, I’m not sure. I don’t look at that specifically. Uh, just have more of the aggregate.

[00:29:24] Chris Wolfe: Yes. The entire year’s worth of Odis. Yeah.

[00:29:28] Richard Edlow: So here are the numbers, um, in optometry, um, let’s look at the supply of doctors and then I’ll tell you about the demand for eyecare.

[00:29:36] So in optometry, there are 1800 to 1900 docs graduating each year, um, from, uh, the schools and colleges of Tom junior, us. So let’s say it’s 1850 and split the difference at 1,850 new docs. There are, um, 1200 exiting each year, retired. Approximately two and a half percent of the profession retires each year, they retire, they exit for whatever reasons it may be.

[00:30:07] Um, but it’s about two and a half percent of the, uh, of the workforce. And when you think about it, 200% equals a 40 year career. No 40 year professional career. And that makes sense. And when we look at data on the average age that optometrists and ophthalmologists retire, it fits that perfectly. So in optometry, the net increase is 1,850 new docs.

[00:30:31] Minus 1200. We have about 650 new optometrists each. 650 for the whole country. All right. Um, and as a, as a percentage, I see. So I’ve got this percentage somewhere, so that’s an increase over a 10 year period of, um, optometrist of 12.8%. From 20, 20 to 2030, wherever having increase of 12.8% ODS in the country that increase in ophthalmology.

[00:30:59] There are 480 residency spots each year. So that means 480 ophthalmologists come out each year, 420 exit each peer for a net increase of 60. And that’s not even looking at full-time equivalency, because if you apply full-time coaches, he told us about 50 FTE new docs each year, but let’s say it’s 60. I can tell you if those 65 are going to go to California.

[00:31:30] If I were going to go to Texas, if I were going to go to Florida five, we’re going to go to New York leaves you 40 new net ophthalmologists for the entire country. EG ear crease in ophthalmologists is 0.3%. It’s 3% over 10 years, 3%. The population is growing. Faster and that even at this low rate, low birth rate, lowest birth rate we’ve ever recorded in the U S the aging part of the population is growing.

[00:32:02] So, so we’ve got a 12.8% increase in ODS over 10 years, not per year, but over 10 years, 3% and ophthalmologists. Having said that now let’s look at the demand side, the equation, um, routine exams, according to vision, watch to the vision council. There are about a hundred. There were 111 million routine conference by exams delivered the 20, 2111.

[00:32:31] Apply the census data, that to project out to 2030, and we’re now going to need to deliver not 111 million, but 113 million routine comprehensive eye exams and increase of 2 million exams that need to be delivered each and every year to now. In medical eyecare. When we look at medical eye care, it’s 60 million medical exams each year, and these are, uh, it can be an intermediate comprehensive, a brief visit, uh, whatever it may be.

[00:32:59] Some form of medical eye exam, glaucoma followup, uh, macular degeneration. Follow-up 60 million by 2030 because of the aging population in the U S it’s going to go from 60 to 76 million. Medical exams that need to be delivered each year for an increase of 16 million with diagnostic testing based on all those same criteria.

[00:33:24] It’s another 10 million diagnostic tests that need to be interpreted. So. In 2030, I’m getting close to 20 in the next 5, 6, 7 years as a, as an industry of Tom tree and ophthalmology collectively mutually need to deliver 2 million routine exams, 16 million medical office space exams, and 10 million diagnostic tests and interpretations each and every year.

[00:33:55] Chris Wolfe: In addition to what we’re doing.

[00:33:58] Richard Edlow: Correct above what we’re doing today. And that doesn’t include cataract surgery, laser surgery, intravitreal, sorry, intravitreal injections, or anything of that sort. So in one of the other numbers that just blows me away is the following number you mentioned earlier about, we know their cataract surgeons that do the bulk of the cataract surgery out there, and they’re all.

[00:34:21] But if we look at the number of cataract procedures that are performed each year in 2020, COVID may put a little dent in this, but the numbers 4.2 million procedures in 2020 4.2 in cataract surgeries, the average ophthalmologist is 400 a year. Of course, some do 4,000 and some girls do 50. But the average is 400 cataract procedures a year and performed 4.2 million in 2020 based on prevalence of cataract national Institute numbers based on census data of agent population in 2030 as a pro as an industry, we need to deliver 5.6 million cataract procedures.

[00:35:05] That’s an increase of 1.4 million. Cataract procedures per year, 1 million per year divided by 400 on average means we need another 3,500 ophthalmologists just for cataract surgery in 10 years, 3,500. And we’re having a total of 650 for everything. Yeah. So ophthalmologists are going to be spending more and more time in the surgical facility and not

[00:35:37] Chris Wolfe: do my, not doing minor procedures by the way that they were going to have to do office room office, you know, full on.

[00:35:45] Mechanistic, uh, surgery.

[00:35:48] Richard Edlow: Yes, the, um, so, so that’s just cataracts that doesn’t count intravitreal injections or whatever the latest technology is for treating, um, any kind of retinal issue, uh, that does not include, uh, lasers. And, you know, there are a number of states in our IDs. Rightfully so we’re doing YAG laser.

[00:36:07] Um, uh, for posterior capsulotomies or peripheral iridotomy, but, um, the D so the demand for surgery and medical eyecare is growing exponentially faster than the supply of ophthalmologists, to my point, who are you going to call, you know, who is going to be next? And so, um, it’s gotta be. It should be optometry.

[00:36:32] Now we’ve all seen a lot of practices, a lot of really good ophthalmology practices that have certified atomic techs who were really good at doing what they’re doing and they’re doing it on the Austin sense of the ophthalmologist. And that’s cool. They’re physician’s assistants and ophthalmology practices.

[00:36:47] They’re there. I know physician assistants in New Mexico doing intravitreal injections. Yeah. So someone’s got to provide all this care. Who’s going to do it. Who’s best trained to do it and strategically. So my messaging is strategically. If we look at all this data, if we see this increasing demand, this flat labor supply or decreasing labor supply, depending on how you look at it, um, who’s going to provide all that office space, medical eyecare.

[00:37:19] And how do we prepare to deliver it? How do we make sure that, um, the trainees there, you know, as you’re helping students for boards, you know, do they have that wherewithal in that background to be able to deliver that kind of a care, um, is the infrastructure in place it’s to diagnostic testing? There’s the staffing there?

[00:37:38] Um, so there are a lot, there are a lot of issues that need to be managed. And my concern is, um, that we may be managing it later than, than we knew that, you know, here’s the wake up call. Let’s get ready for

[00:37:52] Chris Wolfe: this. Yeah. Yeah. I mean, so I think, you know, my biggest thing is, you know, I guess the last question I’ll sort of pose to you would be, so how do we get that number from 29% to 50%?

[00:38:08] What is it going to take? You know, because again, going to the schools, because there, I do believe to answer your question. I do believe that that these students are coming out really well-trained the disconnect is, is depending on where they wind up. They’ve learned how to bill and code and value their services on wherever they wind up.

[00:38:32] So if it’s a commercial practice, that’s doing no medical, or if it’s a private practice, that’s run like, you know, this doing no medical. Then, then that doc gets in there and gets in the, the hamster wheel of whatever that practice is doing. And then that’s what they learn. So when they decide they want to open their own practice or do whatever else that they’ve, they just repeat, they just rinse and repeat.

[00:38:53] And so. Um, yeah, I don’t know what the, that’s why I’m asking you. What’s the answer.

[00:39:00] Richard Edlow: I’m where you are. I don’t know, but if we think through it, um, my first. The thought is, um, when I was I’m responsible for hiring docs, we had a large practice and then we had a private equity deal and we got, we had 180 docs and I was project physician recruitment.

[00:39:20] So when I look at hiring an optometrist, who’s trained to provide medical eyecare. I look for a VA residency trained. So let’s look at that for a minute VA residency program that may be an efficient model, although they don’t deal with the billing they deal with, you know, in office, uh, treatment, uh, diagnostic testing, and how to manage the patient.

[00:39:43] Maybe the answer is in the third year of optometry school before they’re sent out on externships, there’s a whole, um, you know, six month program on here’s a thrown into running a medical eyecare practice somehow. Um, I, I would do a lot of, uh, presentations to optometrists who are a couple of years, a year or two out.

[00:40:06] And we were talking about practice management concepts and they would always say, uh, um, they would always say, well, how can we bring up your talk this well, they were. But at that point in your career, you’re interested in all the pathology. You can learn all the treatments, medical stuff that you can learn or behavioral autonomy, or whatever it may be.

[00:40:24] You’re neither interested in billing the coding. But somehow, um, and maybe there’s a mini residency for the first three months before you start practicing. I, I, I don’t know, but it needs to be handled. It needs to be, uh, structured. There needs to be a program. Um, and maybe it’s on a state level, state optometric associations with continuing education that there are special.

[00:40:48] Whether you want to call it medical practice management programs or something of that sort, um, where you have a genre Pacas teaching in the building you code inside of it. And you have someone who’s really adept at interpreting, um, optic nerve, uh OTTs and macular OCT and visual. And you put it on, you put the clinical together with billing, um, in a mini rotation or a mini program, uh, because you’re right.

[00:41:14] Once they get on that hamster wheel. That’s there done. Um, and, um, and it’s it’s, this is happening th this, this tsunami of demand for services we’re right in the midst of it right now. Uh, we’re seeing it ever so slightly. I can’t wait to see next year as numbers. But, um, oh, and one of the other things that I get a lot of flack on this one, one of the phenomena in the industry that I think is helping in this situation is the vertically integrated.

[00:41:51] I care practices through the private equity firms. So the PE firms are for example, um, uh, I care partners just picked up Cincinnati eye Institute. Uh, so what was the, one of the larger optimistically driven, acquired one of the larger of them logically driven into a vertically integrated model. And these vertically integrated models lend themselves very, very well to having uptown, to provide.

[00:42:19] The bulk of the medical eyecare needs within that practice and, um, under one roof, you’ve got it all. And that, that, again, there’s a lot of pushback and private equity, um, 14 and a half percent of all the time trusts in the U S private equity consolidated model. 12% of all ophthalmologists are tracking. Um, I track that every week and I’ve got every, I try to track every deal that goes on to private equity and look at the market share that is in consolidation.

[00:42:52] So there’s, there’s a, yeah, it’s going to hit some ceiling at some point, but there’s a significant number. And if one looks at those vertically integrated practices, They have a pretty efficient delivery model and billing and coding

[00:43:06] Chris Wolfe: model. Yeah. Well, I mean, I think so. I definitely see that, that point. I would be one that would disagree, I guess, where I, I think from your point on the economics of why we’re seeing the things we see that may be the case.

[00:43:21] My, my thought about it is. Um, I actually believe that there’s, you know, you boil it down to this comprehensive optometrist that understands. Really the, the evidence-base and then you have the, you know, the patient, so to manage glaucoma and dry eye and macular degeneration and, you know, scleral lenses.

[00:43:42] Cause you know, you just did delve into these things and they’re not that challenging, but it also allows you to identify if I’m managing a patient’s Geico. And I, but I’m not aware of ocular surface, you know, the things I’d want to watch for then I’m going to miss it. So I can’t make the referral to the anterior segment guy.

[00:43:57] And so that’s where I would say that the patient’s probably better served in that primary care optometrist role that has dug deep into all of these other things, as opposed to a kind of a spoked referral system. Because if there’s not one person that’s digging into. All of those, like, oh yeah, I’m seeing some Teleric tech vessels and I’m pushing on glands.

[00:44:18] Um, well then those patients are going to get missed. But I do think from, from a standpoint of what you’re saying, uh, you know, because they understand that those private equity firms, they care about dollars, right? I mean, let’s be honest, they care about dollar. So they’re going to figure out a way to squeeze this.

[00:44:34] However they can squeeze it. And that’s one efficient way to score.

[00:44:39] Richard Edlow: The, um, and to your point, I don’t mean to sound wishy-washy about things because I believe in this vertically integrated model model is very efficient, but I also believe the private practice of Tom tree model of three to five docs is probably has more legs than anything because it can provide the comprehensive care and it can do it in a more customer service oriented model than a private equity.

[00:45:05] Looking at just what’s the earth, the EBITDA bottom line earnings. So, so there’s room for both. Um, interestingly patients as consumers select typically what they’re most comfortable with. Right. And, um, and what I find some of the practices that are growing the fastest thriving the most are the smaller private practices that really focused on customer service.

[00:45:34] Now I’m hoping that within those models, it fits your practice modality of that comprehensive eye care and really looking at, you know, both every patient comes in, has a refractive need and a medical need. And how do you manage both of those at the same time? And then how do you appropriately bill for it so that they understand what you’re doing right.

[00:45:55] Is another. To all of that, but there, the opportunities I, I give this presentation on, um, the, uh, uh, economic overview of the eyecare industry and I presented to, um, to a lot of third year optometry students. Um, mostly by zoom past couple of years, and I presented it to, um, uh, optometric societies. Uh, and my messaging is what a great profession, what great opportunities, um, that.

[00:46:28] I graduated PCM 1980 in 1976. I’m sitting in the lecture hall, uh, on our first introduction to the school. And, uh, Tom Lewis, who was the Dean at the time was saying we’re entering the greatest entering grace profession ever. And I’m sitting there in the back row, close to the doors I can exit quickly. And I’m thinking I was like, can be a break, come on now.

[00:46:50] And I think that. That’s that was 45 years ago and no truer words were ever spoken. It’s a great profession. It’s a, it lends itself just phenomenally to taking care of people, needing people. They have a great work-life balance. Um, it’s, it’s factless know there’s nothing better. The opportunity. For if you do it right,

[00:47:15] Chris Wolfe: Richard.

[00:47:15] Hello. Thanks so much for being on. This is great.

[00:47:19] Richard Edlow: My pleasure. I enjoyed the discussion.

[00:47:21] Chris Wolfe: We’re just in touch.