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Show VIEWPOINT The Human Resource Crisis in Neuro-Ophthalmology Larry P. Frohman, MD Abstract: Neuro-ophthalmology is facing a serious human resource issue. Few are entering the sub-specialty, which is perceived as being poorly compensated compared with other subspecialties of ophthalmology. The low compensation comes from the fact that 1) non-procedural encounters remain undervalued, 2) efforts that benefit other medical specialists are not counted, and 3) the relatively low expenses of neuro-ophthalmologists are not factored into compensation formulas. Mission-based budget-ing, which forces academic departments to be financially accountable without the expectation of fiscal relief from medical schools or practice plans, has exacerbated the compensation issue. Solutions must come from within neuro-ophthalmology, aca-demic departments, medical schools, and medical practice plans. They include 1) providing educational resources so that neuro-ophthalmologists need not spend so much time teaching the basics, 2) factoring into compensation the impact of neuro-ophthalmol-ogists in teaching and on revenue generation by procedure-based specialists, 3) improving the effi-ciency of neuro-ophthalmologists in their consulta-tive practices by providing ample clerical support and other measures, 4) providing contractual salary compensation by departments such as neurosurgery to recognize the contributions made by neuro-ophthalmologists, and 5) reorganizing the academic clinical effort as multidisciplinary rather than de-partmental. (J Neuro-Ophthalmol 2008;28:231-234) In 2004, Peter McDonnell, MD wrote an article in Ophthalmology Times regarding how training and patient care might suffer if the human resource issues in neuro-ophthalmology were not addressed (1). The article was an alert to the looming crisis of retention and recruitment of neuro-ophthalmologists for academic departments of oph-thalmology. His article prompted me to write an editorial in Ophthalmology (2) that proposed remedies. My view is that human resource issues can be solved by allowing the discipline to remain respected and by making it financially viable. HUMAN RESOURCE ISSUES The North American Neuro-Ophthalmology Society (NANOS) and the American Academy of Ophthalmology (AAO) have developed unpublished data suggesting that, based on past usage patterns, the United States needs approximately one full-time equivalent (FTE) clinical neuro-ophthalmologist per 1.2 million people or 250 FTE neuro-ophthalmologists. We estimate that there are now 200 FTE neuro-ophthalmologists, which explains why most of us are so busy. Assuming that the average person practices 35-40 years after completing training, we will lose 5-7 FTE neuro-ophthalmologists each year. An unpublished NANOS survey has suggested that neuro-ophthalmologists spend about 50% of their time in clinical neuro-ophthalmology. So if we lose 5-7 FTE per year, we will need to train 10-14 replacement neuro-ophthalmologists per year (assuming that they remain in the United States and devote 50% of their professional time to the practice of neuro-ophthalmology). Over the past several years, we have been well below this replacement level, training approximately 5 neuro-ophthalmologists per year. Not only must these trainees examine patients, but they must also train the next generation of neuro-ophthalmologists. SHORTAGE OF NEURO-OPHTHALMOLOGIST TRAINEES Why are fewer people training in neuro-ophthalmology? There is no apparent lessening in passion for the discipline. Most trainees interviewed consider it as fascinating and professionally rewarding as ever. The problem is rather that the role a neuro-ophthalmologist is typically asked to play Department of Ophthalmology, New Jersey Medical School, Newark, New Jersey. This work was supported in part by grants from Research to Prevent Blindness, Inc. and the Lions Research Foundation of New Jersey. This article is based on a presentation delivered at the annual meeting of the Association of University Professors of Ophthalmology, January 2008. Address correspondence to Larry P. Frohman, MD, Department of Ophthalmology, New Jersey Medical School, 90 Bergen Street, Newark, NJ 07103; E-mail: frohman@umdnj.edu J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 231 in an ophthalmology department is not in concert with the financial reality of academic neuro-ophthalmic prac-tice, which in turn is based upon the undervaluation of ‘‘cognitively based'' (non-procedural) encounters. There is also a perception that neuro-ophthalmologists must give up surgery to avoid competing with other ophthalmology department members and referring doctors and to build a consultative practice. The mismatch between the expect-ations in terms of job description and financial performance often leads to neuro-ophthalmologists doing everything demanded of themyet judged as underperforming financially. Most ophthalmologists who elected a career in academic neuro-ophthalmology did so knowing that they would be receiving less income than their colleagues. But the reimbursement gap has been growing. The application of more quantitative measurements of financial performance within ophthalmology departments increasingly leads to a false perception that neuro-ophthalmologists are not pro-viding enough value. Some report that they have to beg to receive reasonable compensation even if they are working very hard. This development is partly the result of a payment method biased toward procedures. In a medicine depart-ment made up almost entirely of non-surgeons and in which most of the medical practice is consultative, this deval-uation of non-procedural effort is not a problem. But in procedure-based departments such as ophthalmology, the lower accrual of relative value units (RVUs) by neuro-ophthalmologists may be misconstrued as producing less relative value. Some years ago, there seemed to be a trend toward developing a higher proportion of neuro-ophthalmologists trained in neurology rather than ophthalmology and that this development might solve the human resource problem. But as neurologists have developed procedures (sleep studies and video electroencephalograms), the same financial factors have cropped up in those departments, and they are keeping people from choosing a career in neuro-ophthalmology. For whatever reason, the percentage of NANOS members who are neurology-trained has not significantly risen in the past several years, so there is not much evidence that neurology-trained neuro-ophthalmologists will be a viable option for academic departments of ophthalmology. MISSION-BASED BUDGETING The financial issue became intensified as mission-based budgeting (MBB) came to be adopted in U.S. medical schools in the past 10 years. MBB organizes revenue and expense accountability by the department rather than by the medical school or by overall clinical effort. There is a dis-crepancy here. The delivery of health care in the academic health care center, or elsewhere, is often not organized by department. The amount of interdisciplinary effort has been increasing markedly, particularly as concerns neuro-oph-thalmologists. Their maximal financial impact is often in departments other than their ‘‘home'' department, where their financial accountability is measured. So even when the clinical enterprise as a whole perceives a financial benefit from neuro-ophthalmologists, their home departments may not see this benefit. MBB is often blind to downstream revenue. Academic medical centers do not do a good job of tracking admissions or procedures that one faculty member gen-erates for another service. For example, when neuro-ophthalmologists send third cranial nerve palsy patients for aneurysm treatment, which generates a large revenue for another department, they receive no credit. BILLING CODES Another issue is the undervaluation of neuro-ophthalmologists' work in the RVU system, which has become a standard in computing reimbursement. Years ago there was a move to create level 6 and 7 consultation codes to reward the intensive work performed by specialties such as neuro-ophthalmology. That move has stalled. As a result, neither the work done during the patient visit nor the follow-up and coordination of care with other specialists is compensated. For example, the time spent by neuro-ophthalmologists in reviewing brain images, for which the radiologist is amply compensated, does not typically enter into the neuro-ophthalmologists' reimbursement. EXPENSE ACCOUNTING Another financial issue is that ophthalmology depart-ments often base salary compensation on a fixed percentage of collections from patient consultations. The expenses incurred by the individual physician are often not factored in. The typical neuro-ophthalmic practice requires relatively lowexamination room usage and technician and receptionist support and less capital equipment. Other department mem-bers who have shorter encounter times often require much greater equipment and personnel resources to run several examination rooms, as well as more capital equipment for their practices. Furthermore, the surgical members of an ophthalmology department generate much of their revenue in the operating room, the expenses for which they are never charged! In the past, when reimbursements were relatively high for all medical practices, department chairs had ample funds to compensate the non-procedural members of the department. But as reimbursements have dropped across all ophthalmic service lines, this traditional solution is no longer viable. 232 q 2008 Lippincott Williams & Wilkins J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 Frohman MEASURING VALUE Ophthalmology departments need neuro-ophthalmol-ogists for reasons that go far beyond the requirements of the accrediting bodies. Not having a neuro-ophthalmologist would have a ripple effect upon the ability of others in the department to generate revenue. Here is how. As MBB has made clinical time expended equate with money lost, patient throughput has become paramount, and the theme is often to shunt the patients with complex prob-lems to the neuro-ophthalmologists. As neuro-ophthalmol-ogists do not have other activities that yield higher revenue per unit time, they are viewed as the least expensive method of handling these patients to increase the throughput of the rest of the department members. So here is a hidden value of neuro-ophthalmologists. In accepting time-consuming cases from other members of the department, they free up their colleagues' time for revenue-generating activities. How many fewer retinal procedures would be performed if retinal surgeons had to be out evaluating the patients with cone and rod dystrophy and those with unexplained visual loss who are initially sent to them for consultation? According to a colleague of mine, one ophthalmology department has apparently calculated, in an unpublished study, that its intradepartmental referrals to neuro-ophthalmology freed up the other members of the department for 1,200 more visits per year in their own specialties, yielding significantly greater revenues for all other department members Finally, in many departments of ophthalmology, neuro-ophthalmologists have a heavy teaching role. The first four winners of the AAO's prestigious Straatsma award were neuro-ophthalmologists. This non-revenue-generating role is not acknowledged when RVUs are totaled. SOLUTIONS To ensure the viability of neuro-ophthalmology and other non-procedural specialties, some reform of revenue or expense valuation must occur. Solutions must come from three sources: NANOS, departments of ophthalmology, and the medical schools or clinical practice plans. Attracting neuro-ophthalmologists. NANOS can help by showing residents who have not committed to a specialty what neuro-ophthalmology is. The society is sponsoring travel grants to five residents per year so that they may attend the annual NANOS meeting. NANOS has also initiated young member programs, and last year started a young investigator grant program that will provide one to two members a year with seed funding for research. Decreasing the time required of neuro-ophthalmol-ogists to discharge teaching duties. NANOS is doing this by expanding educational resources and by developing and publishing a curriculum for neuro-ophthalmology. With funds from the National Library of Medicine, Pfizer Pharmaceuticals, and the NANOS membership itself, NANOS has built a hefty online resource library entitled the Neuro-Ophthalmology Virtual Education Library (NOVEL). (See NANOS News feature in this issue of the Journal.) NANOS is also joining educational forces with the American Academy of Ophthalmology (see NANOS News feature in the June 2008 issue of the Journal). Practicing something in addition to neuro-ophthalmology. NANOS is encouraging those interested in a career in neuro-ophthalmology to consider blending it with orbital work, pediatric ophthalmology, glaucoma, or a residency training program directorship. This tactic has been part of the discussions by the Neuro-ophthalmology Fellowship Certification Committee. A consequence of this strategy will probably be that we will need more neuro-ophthalmologists in absolute numbers to achieve the same number of FTEs, as each individual devotes less time to neuro-ophthalmology. An unintended consequence could be that neuro-ophthalmic knowledge and skills would fall below a critical level. Educate neuro-ophthalmologists in appropriate visit coding. This is an area in which neuro-ophthalmologists have been traditionally ignorant. Consider Code 99358, used for reviewing records, telephone consultations, and coordination of care with other specialists. This activity usually takes place when the patient is not present but could be compensated. Reduce neuro-ophthalmic examination time. The traditionally low throughput of neuro-ophthalmologists can be remedied somewhat. For example, lengthy history-taking can be reduced by having the patient complete a mailed or online history form before the visit. The labor of gathering laboratory tests and imaging results can be delegated to a clerk or technician. Redistributing patient revenues. Compensation mod-els could include redistributing pools of funds to lower earners. Recognizing that spine surgery generates much more revenue than cranial surgery, some neurosurgery departments have spine surgeons contribute a relatively large percentage of their earnings to a common pool. Fairer computation of practice expenses. This may be achieved by charging neuro-ophthalmologists a reduced percentage for overhead, reflecting the lesser personnel and equipment use by a neuro-ophthalmic practice, a method already used by some ophthalmology departments. Bonus for teaching and other service. If departmental revenue is allocated based upon RVU generation, RVU credits can be granted to neuro-ophthalmologists for dis-proportionate teaching or committee service. Compensation based on ‘‘downstream revenue generation.'' The medical school or practice plan must try to track downstream revenue. In doing so, attention must be paid to Stark and anti-self referral laws. Departments that 233 Human Resource Crisis in Neuro-Ophthalmology J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 benefit from neuro-ophthalmologists' efforts could finan-cially underwrite those efforts. One example would be to shift the time costs of obtaining pre-authorizations for neuro-imaging to radiology departments, pursuant to local legal review. Neurosurgery departments could agree to reimburse neuro-ophthalmologists' home departments for providing services. Neurosurgeons understand well the benefit that neuro-ophthalmologists bring to their practices in terms of quality and time freed up to spend in the operating room. Medical schools should consider recognizing and compensating cross-departmental education. Neuro-oph-thalmologists may be asked to lecture in several depart-ments, but may only get credit for their activities in their home department. Moving neuro-ophthalmologists to another ‘‘home department.'' Departments of neurosurgery could become the home departments for neuro-ophthalmologists. Reorganizing revenue and expense generation by non-departmental entities. Medical practice plans could be organized as multidisciplinary rather than traditional departmental entities. In that way, neuro-ophthalmologists, as all ‘‘orphan specialties,'' would become the expense of the whole group, thereby better aligning incentives, expenses, and revenue. CONSEQUENCES OF IGNORING REFORM There is some urgency in addressing the financial barriers to retaining and recruiting neuro-ophthalmologists. There are now fewer than 2 FTE neuro-ophthalmologists per medical school or ophthalmology department. (unpublished NANOS survey data). If 6 FTE neuro-ophthalmologists are lost each year to retirement in the United States, and only about 2 FTEs replace them, there will be 4 fewer FT academic neuro-ophthalmologists each year. This dearth will make it difficult for departments to meet their training and service needs. This analysis actually underestimates the human resource crisis in neuro-ophthalmology, as there is now an exodus of established neuro-ophthalmologists from aca-demic departments. An unpublished 2008 survey of neuro-ophthalmic practice economics by NANOS disclosed a large disparity between the relatively higher earnings of neuro-ophthalmologists in community practice and those of their colleagues in academic practice. Community practi-tioners reported 80% greater mean income. This discrep-ancy is present despite the fact that neuro-ophthalmologists in academic practice are working more hours than those in community practice. This reality, coupled with the de-teriorating financial environment for academic neuro-ophthalmologists in ophthalmology departments, is likely to hasten the day when we do not have an adequate number of neuro-ophthalmologists to train the next generation. I hope that creative solutions, such as those described herein, will be applied before that day comes. REFERENCES 1. McDonnell PJ. Is neuro-ophthalmology in jeopardy? Ophthalmol Times 2004;29:4. 2. Frohman LP. How can we assure that neuro-ophthalmology will survive? (Editorial) Ophthalmology 2005;112:741-3. 234 q 2008 Lippincott Williams & Wilkins J Neuro-Ophthalmol, Vol. 28, No. 3, 2008 Frohman |
