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CHICAGO -- Ophthalmologists ordered and performed the overwhelming majority of glaucoma-related eye tests in the Medicare population, a disparity that could have major implications for the future of optometry, researchers said here.

The review of five commonly performed eye exams/tests showed that optometrists' share of utilization during 2014 ranged from 15% to 38%, as determined by codes associated with the tests. As a percentage of total services billed, optometrists' code utilization was highest for fundus photography and lowest for gonioscopy and pachymetry.

The disparity in test volume occurred despite optometry having substantially more practitioners who submitted claims to Medicare B during 2014: 26,821 versus 17,817 ophthalmologists, Mark W. Swanson, OD, of the University of Alabama School of Optometry in Birmingham, reported here at the meeting.

"The only test where a greater percentage of optometrists submitted more than 10 claims was fundus photography," said Swanson. "Differences between providers is most stark at the extremes -- no tests done and four to five tests done."

The differences in test volume probably reflected variations in case mix, practice volume, and practice preference. The findings also reflect a disconnect between optometry education and practice and should concern all optometrists, said Swanson.

"We teach a lot but what we teach and what happens in the exam room isn't always the same thing," he said in response to a question following his presentation. "We have to make a sea change in what optometrists do. If we don't change, 25 or 30 years from now there won't be any optometry."

Since 2012, the Centers for Medicare and Medicaid Services has released a public data set for Medicare Part B. Swanson's analysis focused on the 2014 data, which included 38.5 million patients. The analysis homed in on provider utilization and payment data contained in CMS' Physician and Other Supplier Public Use database.

"You can access raw data underlying the aggregated data, by provider," said Swanson. "The data has information on provider type, test done, and location and reports service if more than 10 (tests) are done in a year."

Both optometrists and ophthalmologists use tests to evaluate and manage patients with glaucoma. Swanson evaluated utilization of five diagnostic tests for glaucoma associated with specific diagnostic codes: pachymetry, gonioscopy, threshold visual field, ocular coherence tomography (OCT)-optic nerve, and fundus photography.

The number of optometrists and ophthalmologists who submitted Medicare Part B claims for the rest in 2014 (26,812 versus 17,817) was consistent with estimates of the work fore for the two types of eye specialists. The American Academy of Ophthalmology estimated that 19,310 ophthalmologists were practicing in 2015, and the Bureau of Labor Statistics estimated an optometry workforce of 40,600.

The analysis showed that 66% of optometrists submitted at least 11 claims for glaucoma procedures to Medicare Part B in 2014 compared with 92% of ophthalmologists. The most commonly billed diagnostic test was fundus photography (2,865,260 tests), followed by threshold visual fields (2,775,282), optic nerve OCT (2,316,338), gonioscopy (834,101), and pachymetry (392,642).

Ophthalmologists dominated the volume for the five types of tests included in the analysis:

• Gonioscopy: 84% versus 15.4%; OR 6.7, P<0.001
• Pachymetry: 83.2% versus 16.5%; OR 6.9, P<0.001
• Threshold visual fields: 76.2% versus 23.4%; OR 3.5, P<0.001
• Optic nerve OCT: 77.5% versus 22.5%; OR 3.1, P<0.001
• Fundus photography: 61.2% versus 38.2%; OR 1.04, P<0.04

Evaluation of the proportion of each type of practitioner submitting claims for a specific glaucoma-related diagnostic test showed that more optometrists submitted claims than ophthalmologists for only one type of test, fundus photography. Swanson said 12,318 optometrists submitted claims for fundus photography as compared with 8,539 ophthalmologists. Fewer than 10% of optometrists submitted claims for pachymetry or gonioscopy. A similar proportion of each group submitted claims for each optic nerve OCT and threshold visual fields.

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