05/04/2023

Understanding Access to Eye Care and the Need for Scope Modernization in Ohio

By Dr. Tim Fries, OOA Secretary-Treasurer 

The term “access” is often misunderstood when it comes to healthcare and is usually defined as having adequate income or health insurance.  These are definitely important factors in determining access, however they are not the only aspects of it.  Access is a multidimensional concept that has been defined as “those dimensions which describe the potential and actual entry of a given population into the healthcare delivery system.”  Access is viewed as a general concept which summarizes a set of more specific areas of interaction between a patient and the healthcare system.  Five specific areas have been identified: Availability, Accessibility, Accommodation, Affordability, and Acceptability.  

Availability is the relationship of the volume and type of existing providers and services to the patients’ volume and types of needs.  It refers to the adequacy of the supply of healthcare providers, facilities, clinics, and programs.  

Accessibility is the relationship between the location of supply (healthcare providers) and the location of demand (patients), taking account of patient transportation resources and travel time, distance, and cost.  

Accommodation refers to the relationship between the way the healthcare providers’ resources are organized to accept patients, including appointment systems, hours of operation, telephone and internet services, and the patient’s ability to accommodate to these factors and their perception of their appropriateness.   

Affordability is the relationship of prices of services and providers’ insurance or financial requirements to the patients’ ability to pay, income and insurance.  Patient perception of value relative to the total cost of services may be a concern here, as patients; knowledge and understanding of prices and total cost are often confusing and misunderstood.   

Acceptability equates to the relationship of patients’ attitudes towards personal and professional characteristics of providers as well as to provider attitudes about acceptable personal characteristics of patients.  It traditionally refers to patient reaction to provider age, sex, ethnicity, type of facility, neighborhood of facility, or religious affiliation.  Providers also have attitudes about patients and/or their financing mechanism.  Providers may be unwilling to care for certain types of patients, for example those on Medicaid or other low-income health plans, or through accommodation, making themselves more or less available to certain patient population types.    

Availability – Patient and Provider Volume, Both in Number and in Services Provided 

According to the State of Ohio Vision Professionals Board, there are 1,993 optometrists practicing in the state of Ohio.  This equates to one optometrist per 5,850 people.  There are 670 practicing ophthalmologists in Ohio, most of whom practice in an urban/metro area.   This equals one ophthalmologist per 17,400 people.  

With the proven disconnect between rising demand of eye care and a diminishing supply of ophthalmologists, optometrists practicing in states with expanded scopes of practice can improve overall availability to needed eye care.  It has been shown that more providers per capita leads to better availability to care, and better availability to care leads to better health outcomes.    It has also been shown that increased utilization of eye care services leads to increased health status and lower rates of vision loss. 

Accessibility - Geographic Distribution of Optometrists & Ophthalmologists in Ohio 

A good way to look at the distribution and density of eye care providers in Ohio is to show the county-level availability of providers.  Maps show that only 10 of the 88 counties in Ohio have medium-high to high availability of ophthalmologists.  Optometrists, on the other hand, show medium-high to high availability in 42 counties.  They also demonstrate a higher level of availability in most every county in the state.   

Affordability - Financial Access of Optometrists vs. Ophthalmologists 

Research has shown that optometrists charge considerably less than ophthalmologists for routine eye care nationwide.  The price gap has also been shown to be even larger in rural areas.  We know that insurance and managed care also plays an important part in determining financial access to care.  Optometrists are more likely to be providers and accept payment assignment from public health plans such as Medicare and Medicaid than are their ophthalmology counterparts.  This gap is even more pronounced in rural areas across the country as nearly 75% of rural optometrists accepted patients with Medicaid, while only 39% of ophthalmologists reported doing the same. 

Accommodation – Appointment Availability of Optometrists vs. Ophthalmologists 

Anecdotal results show optometrists provide better calendar availability as compared to ophthalmologists. Access via accommodation typically refers to appointment availability for the provider in question.  On average, the number of days for the earliest available appointment with an optometrist nationwide is 5 days as compared to 20 days for an ophthalmologist.  Appointment availability has been shown to be drastically different among the two practitioner types with an appointment being made with an optometrist within 6 days in 80% of all optometric practices but in only 34% of all ophthalmology practices.  Statistics show 29% of all ophthalmologists had a wait time of 3 weeks or more compared with only 3% of optometrists.   

It should also be noted that 75% of optometrists had evening or weekend hours, while less than 25% of ophthalmologists were available for services during these times.  In rural areas, 72% of all optometrists had evening and weekend hours, as compared to only 12% of ophthalmologists. 

Acceptability – Patient’s Attitudes Towards the Provider Types 

The improved calendar, financial and geographic access for patients in seeing an optometrist versus an ophthalmologist can help to reduce patient waiting times and offers an opportunity for these two groups of eye care professionals to collaborate in providing localized care for the benefit of patients.  The improvement of all other types of access has been shown to result in more favorable patient satisfaction scores, showing patients are more satisfied and have better experiences with optometrists.  Wait times to see a physician are getting longer, more physicians are burned out and leaving their employers, and patients are displeased. 

In Summary:   

Optometry, like all medical professions, is a legislated profession that relies on the passage of statewide bills for its scope of practice.  In recent years, economic, demographic, educational, and technological advances have primed the way for optometrists to be able to fill the void and need that will exist in the healthcare system, both in Ohio and the United States.  Successful scope expansion in several states has proved that all types of access to care improves, and quality of care is maintained, when optometrists are allowed to practice to their full licensure and training. 

Ohio’s large population and geography, which includes both significant rural and urban areas, means the state will need to make changes to its scope of practice laws in order to meet future patient-care demand.  A Modernization of Optometry Act is needed to guarantee all Ohioans have access to the eye care they need and to ensure Ohio is able to continue to attract and retain high-quality optometrists.   

Sources available upon request.