Federal Financing of Optometric Clinical Training

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Additional Resources:
• NEEI Compliance Protocol to Meet Medicare Guidelines for Optometric Training Programs
• Graduate Medical Education (GME), Medicare and Optometry
• Optometry Students, Medicare Regulations and Third Party Plans
• Development of a New Clinical Training Model
• Ideas Submitted to President Obama’s Citizens’ Briefing Book

Ideas Submitted to President Obama’s Citizens’ Briefing Book

A National Model of Community Based Eye Care and Education
Access to eye care services is limited in most inner-city and rural areas with only 20% of community health centers providing eye care services, despite the growing disparities that exist for rural and inner-city Americans. Optometry’s first program to collaborate with community health centers to improve access to eye and vision care services and enrich optometric clinical education was developed in Boston, by the New England College of Optometry in the late 1960’s, in cooperation with three community health centers. Today, the program has grown to include 14 health centers and 30 other affiliations and inner-city programs. It was also the first collaborative model between the optometry and ophthalmology in the Nation. This community based program is now managed by the College’s subsidiary, the New England Eye Institute, and has evolved into a national model demonstrating the compatibility of a commitment to community service and clinical education. While few inner-city and rural health centers have eye care services, nearly all Boston health centers provide these services. President Obama, please consider emulating this highly effective model in other under-served areas of our Country

Now is the Time for Federal Financing of Optometric Clinical Training
Optometry has been included in Medicare since 1987 and currently provides nearly $900 million in services annually to Medicare beneficiaries. However, optometry is excluded from the Graduate Medical Education (GME) program, the educational support component of Medicare. With the aging population and the projections for rising numbers of Medicare beneficiaries, optometric clinical teaching facilities will be providing significantly more care to to the elderly and disabled. With increasing clinical training requirements and training costs, more than ever, there is a need for federal support for optometric clinical training. The inclusion of optometry in GME addresses: the need for workforce development (supply), the growth of the population demand for eye care services and increasing clinical training requirements and costs. All are consistent with current financing policies of Medicare which are intended to anticipate and address these issues. The Social Security Act needs to be amended to include optometry in the GME program of Medicare.

Include Optometrists in the National Health Service Corps (NHSC)
Visual health is recognized by HHS as a critical unmet need, particularly in rural and inner-city areas. Only 20% of federally qualified health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans. President Obama is requested to address the barriers to improving access to eye care services. Optometrists are reluctant to practice in rural and inner-city areas because of high levels of graduate indebtedness combined with high overhead costs of providing optometric care. Efforts must be made to attract more optometrists to rural and inner-city areas through financial incentives such as student loan forgiveness, equipment purchasing grants and loans, and support to the health centers in establishing eye care clinics. In addressing shortage area needs, inclusion of optometrists in the National Health Service Corps is essential to attract optometrists to these areas. HRSA and HHS need to amend their policies and regulations to include optometrists in the NHSC and to provide funding for equipment and facilities costs.

Visual Health as a Critical Unmet Need in Rural and Inner-City Areas
Visual health is a critical unmet need, particularly in rural and inner-city America. HHS’ Healthy People program identified the most significant threats to visual health and established goals to reduce those threats. However, these goals can only be achieved when all Americans and, particularly those in rural and inner-city areas, have access to eye care services. Only about 20% of federally qualified community health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans. President Obama is asked to address the barriers to improving access to eye care services. Efforts must be made to attract more optometrists to rural and inner-city areas. Including optometrists in the National Health Service Corps, funding for optometric training through the GME program and support to the health centers for the provision of patient services in rural and inner-city areas are potential means to address access to eye care services.

Combat Eye Trauma and Vision Impairment Caused by TBI
Serious combat eye trauma is now the third most common injury only behind PTSD and Traumatic Brain Injuries (TBI). Of the service members with TBI, many have post traumatic visual impairment as well. An overall plan needs to be developed and implemented that ensures a seamless transition from DOD facilities to the VA for those with eye trauma and visual impairment caused by TBI. Initial care must be timely and comprehensive and follow-up care monitored and assured for all servicemen and women with eye trauma and vision impairment. All too often well-developed plans do not have accompanying evaluation processes and mechanisms to take corrective action once the plan is implemented. The effectiveness of the plan needs to be evaluated by a continuum of outcome measures both in DOD and the VA. Identified areas of concern need to be promptly and decisively addressed by a single office vested with the power to take corrective action whether problems exist in DOD or VA.

Medicare Policy to Permit Students to Contribute to Billable Services
Medical, dental, optometric and podiatric students are an intelligent and well trained component of the health care workforce. However, current Medicare policy does not permit students to perform services that can be billed to Medicare. In order to more effectively utilize this enormous workforce, Medicare policy should be changed to permit students to participate in the Medicare program. This is particularly important in under served areas where students often receive their clinical training.

NEEI Compliance Protocol to Meet Medicare Guidelines for Optometric Training Programs

The New England Eye Institute (NEEI) is the Patient Care and Clinical Education Subsidiary of the New England College of Optometry. Click here for The NEEI Comprehensive Eye Exam Form (.pdf)

To assure compliance with Medicare requirements for billing and reimbursement of comprehensive exams for new and established patients (CPT codes 92004 and 92014), NEEI adheres to the CPT definition of a comprehensive exam. CPT 2008 defines a comprehensive eye exam as follows:

Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

From this definition NEEI interprets the essential elements of a comprehensive eye exam (for which the attending doctor is personally responsible for performing except 1.b. and 1.c. below) to include the following minimum data set:

1. Comprehensive eye and health history and history of present illness

   a. History of present illness, physical exam findings and medical decision making must be documented by attending doctor.

   b. Optometry students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.

   c. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

2. General medical observation
3. External ophthalmic examination
4. Ophthalmoscopic examination
5. Gross assessment of visual fields
6. Sensorimotor assessment
7. Diagnosis
8. Treatment

Optional features of a Medicare compliant examination include:

1. Biomicroscopy
2. Dilated ophthalmoscopic examination
3. Tonometry

NEEI’s interpretation of Medicare rules for a comprehensive eye exam does allow for the involvement of optometry students in portions of the exam. However, to be Medicare compliant, the attending doctor is required to personally perform (or repeat) the essential parts of the examination listed above, except for the review of systems and/or past family/social history which may be documented by students.

Furthermore, the diagnosis and treatment plan must be supported by procedures actually performed by the attending doctor.(For example, a diagnosis such as glaucoma would require tonometry – in most cases – and thus tonometry would have to be performed (or repeated by the attending doctor.)

It must be clear from a record audit that the diagnosis and treatment were arrived at solely based on the attending doctor’s examination. The attending doctor must be able to advocate the position that the student’s findings were not considered in making decisions.

Additionally, NEEI’s compliance protocol states that the history of present illness, diagnosis, and treatment are essential exam components and thus the accompanying documentation of these essential elements are to be completed by the attending doctor, either by handwritten notes, through dictation and typed record, or via computer generated and typed method.

The NEEI Medicare compliance protocol does not require that the attending doctor repeat non-essential elements of the exam or elements that are not covered by Medicare, such as refraction.

The NEEI Comprehensive Eye Exam Form (.pdf)

The NEEI comprehensive eye exam form has a column for the attending doctor to document essential elements. The form also has space for exam procedures such as biomicroscopy and other elements of an exam that would be repeated by the attending doctor as a matter of course.

The section for the student’s assessment and plan are placed on a separate sheet at the end of the exam form, after the attending doctor’s assessment and plan. This is to assure compliance with Medicare guidelines and the independence of the attending doctor’s conclusions from those of the student.

Mark O’donoghuem
Roger Wilson
Charles F. Mullen

Development of a New Clinical Training Model

Fall 2008 PowerPoint Presentation (.ppt)

Fall 2006 Journal of Optometric Education Article (.pdf – same as below)

Background
Since the 1970’s, optometry has been in a state of metamorphosis with the introduction of pharmaceuticals and advanced clinical procedures. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice. However, the traditional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.

The profession of optometry has benefited from inclusion in the federal program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric education, however, does not conform to medical terminology nor the medical training model. Federal agencies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the educational component of Medicare. The Federal Government appropriates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.

The premise behind why GME payments are made to financially support clinical training of physicians, dentists and podiatrists is that clinical training is inherently inefficient. All clinical training for optometry students, however, must take place in the four-year curriculum and not in post graduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optometry student in the form of higher tuition. Inclusion of optometry in GME would provide additional revenue to optometric clinical facilities to partially offset the cost of these inefficiencies.

Medicare bases its regulations on the medical teaching model. Optometry’s traditional teaching model and terminology is not analogous to the medical model. However, functionally optometry’s model is consistent in several important aspects with the medical model. Current Medicare regulations regarding student supervision significantly impede optometry students from acquiring patient evaluation and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fellows, however, can contribute to billable services and have ample opportunity to acquire patient evaluation and management skills without significantly affecting the efficient provision of health care.

Realignment of the traditional optometric clinical training model and terminology is necessary to facilitate inclusion in and compliance with major federal programs and to reflect the current functional reality.

Objectives of a New Clinical Training Model
The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regulations pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable services regulations and facilitate inclusion in and compliance with these programs. Participation in GME and NHSC would provide significant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective training in patient evaluation and management (E/M) by placing optometric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.

Other objectives include increasing participation in Medicare, increasing the number of community-based training sites, and controlling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resource and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based training sites. Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control student debt.

Functional Reality of Current Optometric Training Model
Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric education has evolved into an intense clinical experience in response to the expansion of patient management and treatment responsibilities of optometric practice and is analogous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical training has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optometry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)

Table 1: Comparison of Optometric Clinical Training Model to Medical Model

Optometric Model (Traditional)		Medical Model
Optometry Residents	function as	Medical Attending or Fellows
Qualified to: Bill for Medicare services when licensed No GME No NHSC		Qualified to: Bill for Medicare services Receive GME Payments Qualify for NHSC
Optometry 4thyear students	function as	Medical Residents
Qualified to: Cannot contribute to Medicare billable services No GME No NHSC		Qualified to: Contribute to Medicare billable services Receive GME Payments Qualify for NHSC
Optometry 3rd year students	function as	Medical Interns
Qualified to: Cannot contribute to Medicare billable services No GME No NHSC		Qualified to: Contribute to Medicare billable services Receive GME Payments Qualify for NHSC
Optometry 1stand 2nd year students	function as	Medical Students
Qualified to: Cannot contribute to Medicare Billable Services No GME No NHSC		Qualified to: Cannot contribute to Medicare Billable Services No GME No NHSC

Actions Required to Realign the Optometric Clinical Training Model
The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry students would be redesignated as interns and current fourth year students would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric residents would be reclassified as PG-2, PG-3 or Fellows. First and second year students would remain classified as students. Since fellows, residents and interns can contribute to Medicare billable services, optometric trainees in this new configuration could receive meaningful and cost-effective training in patient evaluation and management (E/M), while in full compliance with Medicare billable services regulations.

In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clinical training of optometric interns and residents (PG-1 – PG-3), including resident stipends. Existing law/regulations need to be amended to direct HRSA to include optometry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.

Conclusion and Recommendation
The traditional optometric training model and terminology are not consistent with the functional reality, with medical terminology and federally-supported programs and present obstacles to inclusion in and compliance with major Federal programs. There is a need to comply with Medicare regulations regarding student billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thoroughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optometry in GME and NHSC.

Journal of Optometric Education
Volume 32, Number 1, Fall 2006
Charles F. Mullen, O.D., F.A.A.O.

Graduate Medical Education (GME), Medicare and Optometry

Federal Support from the Graduate Medical Education Program of Medicare (GME) – A Critical Initiative for Optometry

Introduction

Optometry has been included in the federal Medicare program since 1987 and receives, as other physicians, payment for Medicare services. Over the past 20 years, optometrists have become a significant health care resource for the elderly and disabled. In 1988 optometry provided $81 million in diagnostic and treatment eye care services to Medicare beneficiaries. Medicare services provided by optometrists have grown to nearly $900 million for the current fiscal year.

However, optometry is excluded from the Graduate Medical Education (GME) program, the educational support component of Medicare. In the late 1960’s, when the GME program was developed, optometrists were not recognized by Medicare as health care providers. GME was created to ensure sufficient workforce development (supply) of health care professionals to meet the needs of Medicare beneficiaries by partially offsetting the hospital costs of clinical training. The Medicare program spends over $8 billion annually for GME, but optometry is not eligible for these funds, since only programs in disciplines specifically mentioned in the law qualify. Although not originally included in GME, podiatry was added in 1972 by amendment to the law.

Since the 1970’s with the introduction of pharmaceuticals and advanced clinical procedures optometry has been in a state of transformation. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice far beyond the traditional role of the profession to prescribe eyeglasses and contact lenses for the correction of refractive error, significantly increasing clinical training requirements and training costs. With the aging of the United States (US) population and the projections for rising numbers of Medicare eligible beneficiaries, optometric teaching facilities will be providing significantly greater care to Medicare beneficiaries. More than ever, there is a need for federal support for optometric clinical training.

GME payments are made to support clinical training of physicians, dentists, podiatrists, nurses and certain allied health professionals, because clinical training is inherently inefficient when compared with the provision of care in non- teaching sites. Since optometry does not receive GME payments, the financial burden for the inherent inefficiencies in optometric clinical training, along with costs associated with increased training requirements, is placed upon the optometry student as a cost of education in the form of higher tuition and resulting in higher educational debt. Many optometry students incur debt in excess of $100,000. This increased financial burden measured against the income potential of optometrists threatens the supply of optometrists entering the profession. Inclusion of optometry in GME would provide much needed financial resources to optometric teaching facilities to partially offset the cost of these inefficiencies and costs of increased clinical requirements.

Also at stake is the ability of schools and colleges of optometry to find appropriate venues for the provision of clinical training. While medicine and other professions enjoy relationships with hospitals that receive GME funds for the placement of their trainees, this is not the case with schools and colleges of optometry and their clinical affiliates. The inherent inefficiencies and loss of productivity associated with training optometry students limits the number and diversity of training sites.

The anticipated increase in demand for optometric services by the aging US population requires an assessment of workforce sufficiency, and the increasing training requirements costs. It is time for Medicare to reassess its policy pertaining to financing optometric clinical education.

Background on the Graduate Medical Education Program (GME)

Currently, Medicare supports two types of GME programs providing clinical training for health professionals. The largest program is for physician, dental and podiatric residency training. Annual direct and indirect payments to teaching hospitals total $8.1 billion. Direct payments are made for trainee stipends, teaching faculty salaries and program overhead costs. Indirect payments are for higher patient severity, additional tests and productivity reductions and are a percentage add-on to the Diagnostic Related Group (DRG) rate that reflects the intensity of care required for an inpatient hospital stay.

The second and much smaller program supports nursing and allied health professionals training and payments are based on hospital cost reports. This program makes annual payments totaling $225 million to eligible facilities that are operating these programs.

Optometry’s current clinical training model is not consistent with GME eligibility criteria and current Federal law does not include optometric trainees in either GME program. All clinical training for optometry students must take place in the four year curriculum and not in post graduate residency programs, since the student must be prepared to enter practice immediately upon graduation. Optometry does not qualify for either program as optometric clinical training is not conducted primarily in residencies, nor is optometric student clinical training hospital based, as required in both the Residency Training and Allied Health components of GME.

Options

There are two options regarding inclusion in the Medicare GME program. The first option would be to seek support for 3rd and 4th year optometry students within the current clinical training model regardless of the fact that they are not “residents” and training does not, for the most part, take place in hospitals as defined in Medicare law. The Medicare regulations are written for the teaching hospital and its medical residency training model and translating the regulation language to the current optometric clinical training model is difficult.

The second option would be to seek inclusion in the current regulations for GME Residency Training by changing the structure of optometric education. (see also: Development of A New Clinical Training Model) This option would require enactment of legislation to formally recognize post graduate training programs in optometry and to recognize that optometric training for the most part occurs in out patient facilities. To achieve the most financial support, optometry schools and colleges would need to award the Doctor of Optometry degree after three years so that the 4th year of training would be in a post-graduate residency. It would not be to optometry’s best interest to simply include the current optometry residents in the program for it would result in only a small financial benefit to optometric clinical education as there would be only a small number of non-federal residency programs eligible for GME payments. Current optometry residents, however, could then be re-designated as post graduate trainees/residents, PG 2 and PG 3 and also qualify for Medicare GME payments. Another important benefit of this option is that residents are eligible to bill for Medicare services while students are not. (see also: Optometry Students, Medicare Regulations and Third Party Plans)

There are numerous issues associated with the significant change to the optometric curriculum that the second option requires. However, the financial benefit of inclusion in an $8 billion program would have a much greater and lasting impact on optometric clinical education costs.

The aggregate annual expenditure on clinical education for the 17 schools/colleges is over $100,000,000. The average number of Medicare visits as a percentage of total clinic visits is 14% with a range of 4% to 34%. Optometry students are also placed in a variety of externship sites and the associated costs and Medicare revenues generated accrue to the externship site. These costs and revenues are not included in the above figures. It is difficult to estimate the amount of Medicare revenue that is generated at all externship sites. However, given that optometrists provide nearly $900 million annually in Medicare services, the revenue generated at these sites is likely significant.

Conclusion

Although the benefits of inclusion in the GME program vary among the schools/colleges, the aggregate infusion of GME funding for providing the current level of Medicare services would have a significant impact on the cost of optometric clinical education and the burden of these costs to optometry students. This policy change in GME would ensure a sufficient supply of optometrists to meet the demand for rising number of Medicare eligible beneficiaries and reduce the cost of optometric clinical training.

It is anticipated that Medicare services provided will increase from the current average of 14% to 25% over the next 5-7 years, given the predicted growth of the Medicare eligible population, and GME support for optometric clinical education would anticipate and address future demand for eye care services.

In summary, the inclusion of optometry in GME addresses: the need for workforce development (supply), the growth of population demand for eye care services and increasing clinical training costs, and is consistent with current financing policies of Medicare which are intended to anticipate and address these issues.

References:

Development of a New Optometric Clinical Training Model
Optometry Students, Medicare Regulations and Third Party Plans

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