Optometric Care in Rural America

The first thing that comes to mind when I think of rural America is the John Denver song, Take Me Home, Country Roads. “Country roads, take me home, to the place, I belong.” My second thought is about the desperate need for accessible eye care in small towns across the United States. I currently see patients in an underserved area of the Midwest, and I can proudly say that practicing in a rural location is special and rewarding. This article will highlight some of the challenges and opportunities associated with being an optometrist in a small town.

THE CHALLENGES

I practice in a town with 40,000 residents and provide fill-in services in two even smaller towns, with populations of 3,000 and 8,000 people. Many areas of similar size have only one optometrist, and some rural practices are open only a few days per week. I split my time between the three offices, although each is busy enough to warrant having its own full-time optometrist. This brings me to one of the biggest challenges for small town optometric offices: staffing.

Many rural optometric business owners have expressed to me how difficult it is to find optometrists who are willing to move to a small town. They also struggle with hiring qualified staff from a small applicant pool. There is truth in the notion that less populated areas have fewer amenities to offer, and that many young ODs prioritize activities and entertainment in their lifestyles, which can be accessed more easily in bigger cities.

Another aspect of providing eye care in rural settings that may be perceived as a challenge is that many people who live in small towns tend to have a lower socioeconomic status and, thus, use Medicaid health insurance coverage or something similar. Unfortunately, few states have Medicaid or state programs that adequately reimburse optometrists for their products and services. Consequently, many optometrists do not accept Medicaid, not because they prioritize profit over patient care, but because accepting state plans with poor reimbursement is simply not financially sustainable. This issue is compounded by the fact that patients with state insurance often have higher no-show rates.¹

Several optometrists have told me that they have pleaded with their state governments for years to increase reimbursements so that they could provide care for patients without losing money. Their requests were repeatedly denied, forcing many patients to drive much farther away to be seen at clinics that do accept their insurance plans.

THE OPPORTUNITIES

In my opinion, the pros of practicing in a small town outweigh the cons (see Practicing in a Small Town). One of the biggest perks of working as an optometrist in a rural setting is the lack of competition due to low doctor saturation. This means that rural practices are generally less affected by problems that offices in densely populated areas are struggling with today, such as online competition for glasses and contact lens sales.

Because there tend to be few eye clinics in small towns, many optometrists also have the opportunity to practice to the fullest scope of the profession, with an emphasis on medical eye care. The common mentality of ODs working in small towns is to diagnose, treat, and manage any case they are presented with and to refer usually only when a patient requires surgery. Severe eye infections, large central foreign bodies, debilitating uveitis, and microorganism culturing are well within the treatment realm for many small town optometrists. I have recently cared for patients with corneal ulcers, idiopathic intracranial hypertension, proliferative diabetic retinopathy with clinically significant macular edema, a suspicious-looking choroidal nevus, Axenfeld-Rieger syndrome, corneal edema secondary to Fuchs endothelial dystrophy, painful uveitis, and corneal metallic foreign bodies, to name a few.

In addition, rural optometrists are often the primary referral source for other health care providers in their respective areas. This “all-in-one” mindset leads to more profit for eye care business owners, as medical billing often provides superior reimbursement to vision plans, potentially offsetting some of the financial strain described above. Patients also appreciate being able to go to one office for their eye care, rather than being shuffled between offices and having to travel farther away. Overall, small town optometrists provide high-quality and convenient medical and vision care for patients who need and deserve it. This results in a rewarding professional life with loyal patients.

Another aspect of rural eye care that may be appealing to optometrists is the chance to earn a higher salary. More often than not, small town clinics pay their optometrists more than urban locations simply due to supply and demand. Because less populated areas are less saturated with eye care practitioners, there is a higher demand for them. Therefore, employers tend to offer better compensation packages to entice optometrists to join their practices. It is not unheard of for a rural OD to make more than $1,000 in a day, including fill-in work.

A WORTHY PRACTICE CONSIDERATION

If someone had told me as an optometry student that I would practice in a small Midwestern town, I would have laughed. Oddly enough, it’s been one of the best decisions I have made in my young optometric career. Much to my surprise, I have enjoyed practicing in less populated areas much more than I have in larger cities. Practicing optometry in a small town can provide a rewarding, challenging, and profitable career of seeing loyal patients in tight-knit communities. There is a huge unmet need for eye care in the rural United States. To colleagues and current optometry students, I would say that practicing in a small town is absolutely worth considering.