Excerpt from ICO Matters, Summer 2023 – ICO and the OD/MD Alliance

All kidding and nostalgia aside, in 1997, Charles Mullen, OD, ICO’s fourth president, forged an alliance with the neighboring University of Chicago Hospital and Department of Ophthalmology that has flourished in the decades since. For over twenty-five years, the two institutions have worked to improve care and access to services for Chicago’s South Side that Dr. Mullen recently described as the ‘gold standard’ of vision care.

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Mergers of Optometry Colleges and Schools were originally proposed in 1990 by the eminent educator, Professor Thomas Lewis. Given declining enrollments in Higher Education, his three decades old proposal in now being re-considered with a sense of considerable urgency. The following Discussion Outline is posted to assist optometric leadership in deliberations concerning mergers/consolidations of optometry colleges and schools.

Discussion Outline

Current State of Higher Education/Optometric Education

• Higher Education is in crisis with institutions closing and mergers/consolidations proactively pursued because of declining enrollments.
• 2.9 million fewer undergraduate age students than in 2008. Projected to continue until 2030.
• There is too much student capacity in optometric education, and not enough demand. Six new schools founded since 2008.
• Applicants to optometry colleges and schools have essentially not increased in a decade.
• Repayment of debt is 14.9% of income, highest of all professions and twice medicine.
• Colleges of Optometry are now unable to fill entering classes with qualified students. GPA, OAT and NBEO data indicate some Optometry Schools are admitting less qualified students.
• Independent Optometry Colleges are dependent on tuition revenue to support operations, and decreasing enrollments threaten their survival.
• Financial reserves and selling of assets can only sustain College operations for a relatively short period of time.
• The signs of a pending crisis in enrollments have been present for years, however, only recently viewed with a sense of urgency.

Options to Survive/Thrive in Crisis

1. Student marketing may increase applicants, however effective advertising requires substantial funding (3-5% of projected revenue) which is not realistic without external support.
2. Affiliation with a university for Independent Optometry Colleges is not likely as the current enrollment decline would not be acceptable to university officials.
3. Although university-based schools of optometry will likely be supported in the short term by university officials, long term enrollment declines will be problematic.
4. Continue as currently operating and allow market forces to determine the fate of the College or School.
5. Merge/Consolidate with another Optometry College or School

Benefits of Mergers and Consolidation

1. Increased enrollment which is large enough to sustain operations as a merged/consolidated College.
2. Brings unique strengths of two Colleges/Schools together.
3. Leveraging of a greater size and scale.
4. Financial savings in long term.
5. Renewed commitment of the governing board.
6. Re-engaging and re-energizing institutional stakeholders.

Costs of Mergers and Consolidation

1. The process of merging is painful.
2. Ideally, mergers should not be considered in time of crisis, but rather as part of a larger strategic plan.
3. Discordance in timing between gains and costs. Financial gains take time to develop while costs of merger come due immediately.
4. Costs include: building refurbishments, transition costs, addressing human capital needs, communications, branding, college relations, expenditure of political capital, slowing of programmatic growth, disruption to leadership and merger/consolidation consultants.

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Osteopathic Health Sciences Centers across the Nation currently offer innovative curricula in medical and other health care professions’ education, and now have a unique opportunity to develop and offer an innovative program in optometric education and residency training that would prepare optometrists to provide medical eye care. Such a new program would replace the traditional optometric curriculum where clinical training is contained within the four year degree program. Having no requirement for postgraduate clinical training, optometry is not eligible for the multi-billion dollar Graduate Medical Education (GME) program.

Optometrists are classified as physicians under Medicare and are judged by medical standards including specialty clinical training and board certification. Optometric education must now align with national standards and guidelines derived from medical education.

Such a proposed restructuring plan is politically challenging with numerous sensitive professional and educational issues. Implementation of the plan requires bold leadership. I look to Osteopathic Health Sciences Centers with their tradition of leadership and innovative programs to lead the change in optometric education. This proposal recommends restructuring optometric education and postgraduate training by placing it in parallel with medicine.

New Program

Three Years for OD Degree + One Year Postgraduate Training = Licensure

Three years of classroom education, laboratory and clinical clerkships to earn the Doctor of Optometry (OD) degree followed by one year of postgraduate clinical training for licensure in General (Traditional) Optometric Practice. This would replace the current 4th year which essentially is the first year of residency training.

One Additional Year of Specialty Clinical Training to Provide Medical Eye Care.

One year of additional specialty clinical training in medical eye care and Board eligibility required by State Optometry Regulatory Boards to provide medical eye care.

Advantages of the New Curriculum and Clinical Training Model Include:

1. The new model would encourage specialty clinical training and board certification as emphasis would shift from General (Traditional) optometric practice to primarily medical eye care.
2. By restructuring the curriculum and requiring postgraduate clinical training, optometry would become eligible for Graduate Medical Education (GME) payments to address clinical training costs.

Actions Required

1. Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to Fund Implementation, Entitled — “Restructuring of Optometric Education and Clinical Training To Meet Unmet Need for Medical Eye Care in Medicare/Medicaid Populations”
2. Amend States’ optometric licensing laws/regulations to require a minimum of one year of postgraduate, residency training in General/Traditional optometry for licensure.
3. And require an additional one year of training in specialty medical eye care with Board eligibility to practice medical eye care.
4. Amend the Social Security Act to include optometry in the Graduate Medical Education Program (GME) and expand GME support of residency training to all optometric clinical training venues.

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Below you will find a link to Who’s Who – Dr. Charles F. Mullen a biography about Dr. Mullen’s contributions to PCO and early years of the Eye Institute.

Dr. Charles Mullen: Executive Director of PCO ’76 -’90

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Over the past 47 years, State optometric practice laws have been expanded to include more medical procedures, treatments and management of medical conditions but often with restrictions. Individual State regulatory boards have reacted to expanded practice laws by requiring additional clinical training and/or instruction to perform the new clinical privileges granted. Thus, requirements for optometry practice can often vary by State.

State officials and legislators are reluctant to grant the full range of clinical treatments and procedures to optometrists because of limitations in optometrists’ clinical training. There is concern about the number and diversity of clinical encounters currently experienced in the four year optometric curriculum. Medicine and optometry both have four year basic curricula, however, medicine requires postgraduate clinical training while it is optional in optometry.

Optometry Four Year Curriculum

The entire optometry curriculum (academic and clinical) must be completed in just 4 years with no required postgraduate clinical training. Consequently, clinical training is limited, especially in the number of medical clinical teaching encounters, and in diversity of encounters to thoroughly prepare the graduate for the provision of current medical procedures, treatments and management. Also, not all optometry schools have access to sufficient numbers of patients with medical conditions necessary for clinical teaching.

Postgraduate Clinical Training

Medicine introduced postgraduate clinical training in 1930, as one year internships (now considered first year of residency), to compensate for the limited number of student clinical teaching encounters in the Medical School curriculum. One to three years postgraduate (residency) clinical training is now required for medical licensure. Overall, physicians spend an average of 4 years in postgraduate specialty clinical training leading to specialty board certification. See also American Board of Medical Specialties (ABMS).

Recommendation: Mandatory Postgraduate Clinical Training

It is time for optometry to follow medicine’s example by mandating a minimum of one year postgraduate clinical training (residency) in an accredited medical optometry postgraduate program or equivalent for licensure to compensate for limited student clinical encounters in medical procedures, treatments and management in the optometry school 4 year curriculum, and to ensure uniformity in clinical medical training among all states.

Additional Benefits of Mandatory Postgraduate Clinical Training

• Mandatory postgraduate clinical training followed by Board Certification in Medical Optometry should convince skeptics at the State and Federal level that optometrists are prepared to comprehensively treat eye disease without restrictions.
• Mandated postgraduate medical clinical training would place the graduate on an expeditious path to Specialty Board Certification in Medical Optometry. See also American Board of Certification in Medical Optometry (ABCMO).
• The Federal Government supports postgraduate training through the Graduate Medical Education (GME) Program. States’ enactment of optometry’s mandatory postgraduate requirement for licensure would be another step toward optometry’s inclusion in the Graduate Medical Education (GME) Program. See also Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)

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Paper/Presentation

Understanding the Cost of Optometric Clinical Education (PDF)
Understanding the Cost of Optometric Clinical Education (PPTX)

Supporting References

Understanding the Cost of Optometric Clinical Education – References (PDF)
Understanding the Cost of Optometric Clinical Education – References (DOCX)

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Paper/Presentation

The Perfect Storm: Oversupply of Lawyers, Optometrists and Pharmacists (PDF)
The Perfect Storm: Oversupply of Lawyers, Optometrists and Pharmacists (PPT)

Supporting References

The Perfect Storm: Oversupply of Lawyers, Optometrists and Pharmacists – References (PDF)
The Perfect Storm: Oversupply of Lawyers, Optometrists and Pharmacists – References (DOCX)

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New England Eye is the Patient-Centered Care and Clinical Education Affiliate of the New England College of Optometry.

The Teaching Compliance Protocol for New England Eye (PDF) describes the practical implementation of NEE Health Insurance Teaching Compliance Policy.

Authors: Senior Management Staff, NEE.

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We must not let anyone else write our future.

– Dr. Ronald Hopping, President AOA

Restructuring the Profession of Optometry (PDF)

Restructuring the Profession of Optometry (PPT)

Charles F. Mullen
Roger Wilson
Janice E. Scharre
David S. Danielson

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The paper does not discuss the educational benefits of the Teaching Physician-Centered Model. However, the model has been successfully utilized in medical student education for many years.

Background

Because the Department of Health and Human Services (HHS) does not consider optometry residents to be “real” residents, I do not address optometry residents’ compliance in this paper since CMS Teaching Guidelines do not technically apply. An optometry resident once licensed is no different than any licensed optometrist. Also, optometry residency programs do not qualify for the Graduate Medical Education (GME) program. Nor does optometry have a trainee classification that qualifies as intern. A teaching physician is defined as optometric school/college faculty, affiliate attending staff, or extern preceptor.

The CMS Teaching Guidelines apply to Medicare, other Federal Health Care Programs, Medicaid in most states, and most major private insurers.

Page 3 of the Teaching Guidelines state:

Evaluation and Management-Documentation Provided by Students—Any contribution of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident… the student may document in the medical record. However, the teaching physician may only refer to Review of Systems (ROS) and Past Family/Social History (PFSH)….the teaching physician may not refer to the students findings and must verify and re-document the history of present illness and perform (repeat) and re-document the examination and medical decision making (treatment plan).

Page 7 – Medicare does not pay for any services furnished by students.

I base my recommendation to change the teaching model on research and writing on the subject, consultation with American Optometric Association (AOA) Medicare experts, consultation with teaching physicians, interviews with medical students and residents and ongoing discussions with (AOA) Federal Relations staff and optometric academic administrators and faculty along with viewing the Office of the Inspector General (OIG) False and Fraudulent Claims Report, where CMS Teaching Guidelines violations are reported. I also have extensive experience in optometric clinical education and with Federal Health Care policy. See: Dr. Charles Mullen CV.

Compliance with CMS Teaching Guidelines and EHR Procedures

Failure to fully comply with the Teaching Guidelines and EHR procedures creates self-induced risk which could result in institutional fines, legal fees and other severe penalties. There is also the potential of individual liability and damage to the reputations of faculty members, affiliate attending staff or extern preceptors since Medicare/Medicaid Fraud and Abuse sanctions are reported to the National Practitioners Data Bank. Should an extern preceptor be sanctioned for Medicare fraud or abuse the damage to optometry school/college alumni relations would be extensive. HHS has intensified its efforts to identify and prosecute Medicare fraud by increasing the reward pool for “whistle blowers” to $10 million.

Student Notations Risks with Electronic Health Record (EHR)

If student notations are placed in the patient’s record (either written or EHR), they must be clearly delineated and not used to bill for services. Intentionally and knowingly using student examination findings to bill Medicare is considered a fraudulent claim. The Association of Academic Medical Centers (AAMC) issued a Compliance Advisory regarding students and Electronic Medical Records (EMR). The Compliance Advisory cautioned teaching physicians about the risks of student notations in the electronic medical record and delineated procedures to avoid Medicare violations and sanctions.

Self Disclosure

Optometry schools and colleges that suspect Medicare violations in their clinical operations may want to consider Self Disclosure rather than exposing the institution to an uninvited Medicare audit which could result in catastrophic fines, legal fees and severe sanctions. The OIG Self Disclosure program may permit the institution to negotiate any fines and potentially prevent higher fines and more severe penalties such as exclusion from all Federal Health Care Programs. Medicare Fraud and Abuse fines are up to $10,000 to $50,000 plus three times the damages for each violation. The Self Disclosure protocol requires the institution to furnish extensive information on the Medicare/Medicaid violations including how the school/college plans to prevent future violations. Suggested measures to prevent CMS violations are delineated in the next section of the paper.

Teaching Physician-Centered Model

The current optometric Student-Driven Clinical Training Model is not compatible with CMS Teaching Guidelines, while the Teaching Physician-Centered Model is consistent with all of the following CMS compliance expectations:

1. that the teaching physician is in charge of the patient
2. that patient care is personally rendered or repeated by the teaching physician and
3. that the examination is personally documented in the medical record by the teaching physician including history of present illness, diagnosis and management/treatment plan.

This model is successfully utilized in medical student clerkships.

Optometry programs must clearly demonstrate how students are incorporated in the care of the patient to learn and practice clinical procedures and not to provide patient services. Also, programs must demonstrate how students participate when the care of the patient is actively and personally provided by the teaching physician. Schools and colleges should view student clinical placements as clerkships where the student can practice history taking and examination procedures along with assisting the supervising physician, but not provide patient services except ROS and PFSH.

Optometry schools and colleges must ensure:

1. a CMS compliance policy is in place, including a EHR policy regarding student notations
2. that the compliance policy is monitored and enforced by annual internal compliance audits
3. that all clinical affiliates and extern preceptors receive copies of the institution’s compliance policy along with CMS and OIG supporting documents
4. that regular briefings on compliance by senior school/college officials are presented to all external training venues
5. that all college faculty and optometry students receive compliance training prior to participating in patient care
6. that the school/college or teaching clinic has a Compliance Officer
7. that lines of communications are open

The Veterans Health Administration (VHA) Eye Care Handbook also mandates compliance with CMS Teaching Guidelines in all optometric teaching programs. Annually, 1400 optometry student clinical rotations are available at VA facilities along with 186 residents and 3 research fellows. Although optometry residents are not considered residents by HHS, the VA requires compliance with CMS Teaching Guidelines for both optometry residents and students.

Although implementation of the Teaching Physician-Centered training model would be a major step forward in addressing optometry student compliance with CMS Teaching Guidelines, serious consideration should be given to the overall restructuring of optometric education by placing optometry in parallel with medicine for both student and postgraduate clinical training. Restructuring the curriculum would present the opportunity for inclusion in GME and further enhance CMS compliance. See: Restructuring the Profession of Optometry – The Next Bold Move.

Reference Documents

1. CMS Guidelines for Teaching Physicians, Interns and Residents (Students)
2. OIG False and Fraudulent Claims Report
3. OIG Self Reporting Protocol
4. Medicare Fraud and Abuse Summary
5. Veterans Health Administration (VHA) Eye Care Handbook
6. Restructuring the Profession of Optometry – The Next Bold Move

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