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Thank you President Scott for your gracious remarks.

I am deeply honored to be awarded the New England College of Optometry’s Presidential Medal in recognition of my tenure as Director of the VA Optometry Service.

It is also a distinct privilege to join my distinguished colleagues and long time friends — Drs. Myers and Haffner in this evening’s tribute to the VA Optometry Service.

As an educator, I am grateful to the VA for its enormous contribution to the clinical training of this country’s optometry students and residents.

And as a veteran I am most appreciative of the excellent eye care VA optometrists provide each year to over one million of our most deserving citizens, the Nation’s veterans.

The comprehensive eye care provided to veterans by VA optometrists in collaboration with ophthalmologists is clearly among the best in the United States.

Optometry clinics are among the busiest of VA services, providing 1.5 million eye care visits annually.

The VA Optometry Service was the first in the country to develop and implement an effective model of interdisciplinary eye care in a large national system.

VA optometrists lead the profession in the management of patients with age related macular degeneration, diabetic retinopathy and glaucoma.

Prestigious professional journals are replete with publications by VA optometrists affirming VA’s leadership in advancing ophthalmic care.

During my tenure as Director, I witnessed the growing importance of VA optometry in the provision of primary eye care and low vision rehabilitation services.

However, my experience pales in comparison to the dramatic increase, over the past 12 years, in optometry staff, students and residents including numerous quality improvement initiatives.

The VA’s Eye Care Quality Improvement Program is recognized as one of the most comprehensive and effective in health care.

It is a unique system of checks and balances.

For overall guidance, the VA adopted the clinical practice guidelines of the American Optometric Association and the American Academy of Ophthalmology, the recognized standards for both professions.

The VA’s clinical credentialing and privileging process is precise and meticulously applied ensuring that every clinician’s education, clinical training and licensure are appropriate for the clinical privileges granted.

A robust system of clinical reviews, practice evaluations and peer review programs ensure that every veteran receives the highest quality eye care.

The quality, timeliness and seamless provision of eye care services by 675 VA optometrists and over 175 residents and fellows is now often cited as the gold standard for optometric care.

In addition to primary eye care, optometrists provide rehabilitative care in VA special programs such as low vision clinics, VICTORS programs and blind rehabilitation centers.

65 additional low vision optometric specialists have been appointed in recent years and placement of mid level and advanced low vision programs, in each of the 21 nation-wide VA Integrated Service Networks, is planned.

The Department of Defense-VA, Center of Excellence is an outstanding program for the management of servicemen and women who have sustained significant eye injuries as well as vision problems resulting from traumatic brain injury. At this center, optometrists, ophthalmologists and rehabilitation specialists ensure seamless transition for the patient from military service to the VA.

The innovative Boston VA based Teleretinal Imaging Program has already assessed 700,000 veterans for the risk of vision threatening disorders. Another example of optometry’s leadership and of effective collaboration among eye care providers, primary care physicians and IT personnel.

A special note of acknowledgement to my VA colleagues for your commitment to excellence in eye care and for your dedicated service to our Nation’s Veterans.

Thank you for recognizing my service as Director. It was an honor to have served with so many outstanding optometrists.

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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

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.

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

My remarks today pertain to the impact that the current restriction on Massachusetts optometrists treating glaucoma has on the clinical education of students enrolled at the New England College of Optometry. From a national perspective, this restriction places the College and its faculty at a competitive disadvantage for the best and brightest applicants for admission. Upon learning of the restriction in the treatment of glaucoma, many highly qualified applicants and, for that matter, many highly qualified optometrists seeking a faculty appointment at the New England College of Optometry choose other Colleges of Optometry – simply because Massachusetts cannot offer the comprehensive opportunities they are seeking. No other optometry school across the country faces this problem.

Forty-nine states permit optometrists to treat glaucoma. It is now the national expectation; if not the standard. Students of the New England College of Optometry are expected upon graduation to be fully prepared to treat eye disease; including, the management of patients with glaucoma. Yet, without the ability to practice in Massachusetts, the New England College of optometry must seek training venues outside the Commonwealth or in federal facilities where the treatment of glaucoma is permitted. This is ironic given that Massachusetts is known to be a world leader in health care education. Forty-nine states and the federal system allow for optometrists to treat glaucoma, but the home state of one of the best optometry schools does not. Again, no other optometry school in the Nation is so limited.

Nationwide, optometrists provided $846 million in eye care services to Medicare beneficiaries in 2006. As the incidence of glaucoma increases with age and with the onset of the “baby boomer” retirement, graduates of the New England College must be fully prepared to meet the health care needs of the rapidly growing elderly population. This means they must be able to treat glaucoma.

I can assure you that optometric education and the profession of optometry are constantly evolving. Advances in the biomedical and visual sciences impact both the methods of treating patients and the methods of educating students. Given this quickly changing environment, it is essential that optometrists in Massachusetts be granted the authority to treat glaucoma – allowing both the New England College of Optometry and its students to remain competitive on a national level.

Thank you for the opportunity to testify before the Joint committee on Public Health. Accordingly, I respectfully request that this Committee release SB 1255 with a favorable report.

Testimony of Charles F. Mullen, O.D.
Delivered May 2, 2007

My discussion of the future of the veterans’ health care system is based on the following assumptions:

• The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
• Most health care in the United States will continue to be provided by the private sector.
• There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
• Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
• Medical and scientific information will continue to grow at an astonishing rate.
• Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
• Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
• Integrated information systems will be the key to success for future health care systems.
• Nonphysician providers will be increasingly used in health care systems of the future.
• Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
• There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
• While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
• The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
• In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.

In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.

The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.

To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.

There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:

• Reengineering the operational and management structure of the veterans health care system.
• Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
• Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
• Restructuring VHA headquarters.
• Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
• Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
• Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
• Increasing the proportion of the VA’s work force providing primary care.
• Developing tailored training/retraining programs in primary care.
• Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.

Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:

• Increased sharing of activities with academic affiliates and the Department of Defense.
• Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
• Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
• Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
• Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
• Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
• Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
• Increasing the proportion of trainees in primary care disciplines.
• VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
• Initiating review and renegotiation of all academic affiliation agreements.
• Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
• Academic affiliations and residents are likely to be negotiated on a Network basis.
• Clinical credentialing and privileging will probably be conducted on a Network basis.

The VA’s Current Contributions to Optometric Education
There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.

There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.

What Can Individual Schools and Colleges Do to Preserve VA Affiliations?

• Above all, be an active partner.
• Assist VA facilities with Quality Improvement activities.
• Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
• Seek appointment of school-based optometric faculty as consultants at VA facilities.
• Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
• Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
• Increase awareness of VA affiliations by publicizing your institution’s activities.
• Seek new academic affiliations within your Network.
• Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
• Seek cooperative research projects with VA affiliates.
• Consider WOC residency programs as a means to initiate new programs.
• Understand the new JCAHO accreditation standards and survey process and their implications to optometry.

What Can ASCO Do Collectively?
ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:

1. In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
2. Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
3. Stimulate research proposals in cooperation with VA medical centers.
4. Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
5. Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
6. ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
7. Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.

This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.

At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.

This speech was delivered during Graduation Ceremonies at the Southern College of Optometry, June 1994. See also the previously published article Optometry’s Role in National Health Care Reform.