Despite the recent exhortation of the American Academy of Ophthalmology (AAO) to “build  practice efficiency with highly-trained medical assistants” (written communication, March 15, 2012), the ideal solution for ophthalmology to the manpower crisis facing our specialty requires the physician extender to have a provider number so he/she could bill Medicare, Medicaid and other entities – while under the ophthalmologists supervision; the latter is interpreted in the statues to allow responsible supervision and control, and this requires, “except in cases of emergency, the easy availability or physical presence of the licensed physician…includes the ability to communicate by way of telecommunication.” In addition, this practitioner should be a willing participant in the MD-led healthcare team, have a clinical medical background and harbor no resentment toward ophthalmology and not be interested in practicing independently or engaging in activities for which he or she is not qualified. The practitioner that conforms to all these requirements is the physician assistant (PA).

I am not alone in this conclusion: the prominent Florida ophthalmology consultant Kevin J. Corcoran, the President of Corcoran Consulting Group has voiced these sentiments in a 2008 article in the ASCRS EyeWorld news magazine entitled, “Untapped provider pool for ophthalmology.” Mr. Corcoran pointed out that there will be a much greater demand in the coming years for ophthalmology services because of a marked increase in the number of Medicare beneficiaries due to the retirement of the baby boomers, as well as the fact that every year 23,000 physicians retire or die, while 16,500 students enter medical school. In 2010, 13% of the US population was 65 or older; by 2030, the figure will rise to 20%. Ophthalmology needs to seriously look at the PA as a valuable resource to help meet the increased work load in the coming years. There are 130 training programs for PAs in the US and 5000 graduate yearly. A typical starting salary would be about $45,000.00 for a PA untrained in ophthalmology, and after a sixmonth training period, the salary would be gradually increased to reflect productivity. There are only about 10 ophthalmology PAs in Florida at present.

A significant number of the programs are affiliated with medical schools, but the required clinical rotations during the second year of a 2-year program (for example at the University of Florida Program: internal medicine, emergency medicine, pediatrics, psychiatry, intensive care, ob-gyn) do not include ophthalmology, nor do any ophthalmology residency programs offer clerkships to PAs, as some offer such clerkships to optometrists, i.e., Bascom Palmer Eye Institute. Perhaps in the future such training opportunities will materialize. In the meantime, ophthalmology practices can help in familiarizing PA students to our specialty by contacting one of the nine PA training programs in Florida to offer their students a fourweek clerkship in their offices. Such an experience would be invaluable in prompting these students to eventually work in ophthalmology. Until adequate training is offered during the PA training program, much of his/her experience would be acquired during several months of on-the-job training. Initially, the PA could help by performing a pre-op medical H & P’s (required by state and federal law before surgery) and by helping to manage chronic diseases, such as diabetes and hypertension. A large practice with a high surgical volume could make several times the average annual salary of the PA. In terms of reimbursement, a PA can bill 100% of the Medicare allowable for each follow-up visit when the MD is present or 85% when the MD is not physically on the premises. Aetna has a similar policy. Medicaid has a 100/80 split. Other insurance entities cover the PA and payment policies may vary.

Finally, there are those who have concerns about adding another type of practitioner to our healthcare team. I believe that the PA profession is sincere when they continuously state that they are not interested in practicing outside of our supervision. Indeed, in the 46 years that the PA specialty has existed, there has never been any effort in any state to achieve independent practice privileges; in this case, past experience is an excellent predictor of future behavior. Working with PAs can help ensure the future well-being of our specialty and our patients.

Note: This is an editorial by Seymour R. Rosen, MD. The opinions, beliefs and viewpoints expressed in editorials published in The Florida Ophthalmologist do not necessarily reflect the opinions, beliefs and viewpoints of the Florida Society of Ophthalmology.