Click here to see a selection of photos from this special event.

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.

Honored guests.

This morning, I would like to share with you the beginnings of optometry’s first program to collaborate with community health centers to improve access to eye and vision care services and enrich optometric clinical training.

I will attempt in my brief remarks to relate the common elements of the initial program to the new corporate structure and community governance model of the New England Eye Institute. I plan to outline the challenges which, I believe, still lie ahead for the new organization and finally, with your permission, offer a few observations or suggestions from my years of experience in interprofessional cooperation.

In the late 60′s and the early 70′s, the New England College of Optometry decided to expand and enrich the clinical training environments to which its students had access.

We knew that optometry students would benefit from health care environments in which the optometrist was one of many health care professionals contributing to the care of the patient.

Inner-city demographic data suggested that students would have the opportunity to participate in the care of patients with serious eye and vision problems unlike the university students they typically examined at the College’s Kenmore Square Clinic.

We wanted students to learn in a quality health care environment and not a teaching clinic as was customary at that time. Quality clinical training could only be achieved in a quality health care setting.

Coincident with our educational mission and not at all incompatible with it was a commitment to providing eye and vision care services to inner-city residents who were unable to meet this health care need in their own communities.

We concluded that the most promising scheme for fulfilling both our educational and community service objectives was to form an innovative network of affiliations with existing health care centers. Innovation was an important element in the development of the clinical network as it is today for the New England Eye Institute.

As we began to develop the program, any illusions we may have had about the ease of executing our new strategy were quickly dispelled. We learned a lot about skills we thought had nothing to do with eye care or optometric education: about convincing skeptics, compromising, introducing safeguards, planning, and negotiating.

In the first place, there was a reluctance on the part of health center administrators to permit students to participate in their programs.

Historically, the health center community was disenchanted with receiving its health care in the emergency rooms of large teaching hospitals and our proposed program, they thought, was precisely what they were seeking to escape.

Our second problem revolved around the reluctance of medical staffs at some health centers to work directly with optometrists, since the physicians had little experience working with us.

It was necessary to convince the medical staff at a very fundamental level of the ability of optometrists to function in and contribute to an interdisciplinary environment.

We also encountered considerable political pressure from the ophthalmological society which opposed cooperation between optometry and ophthalmology in the new eye and vision care model to be developed in the community health centers.

I am always reluctant to single out individuals for fear of omissions, but I would be remiss without citing the bold leadership of a few who were responsible for the success of the 70′s community eye care initiatives: Health Center administrators, Jim Hooley, Dorchester House, Mel Scovell and Tris Blake of the South End Community Health Center and Bob Morgan of the Dimock Community Health Center in Roxbury. Bill Baldwin, President of the New England College of Optometry for granting me the opportunity to participate in the development of the clinical network.

The optometrists who were willing to pioneer a new approach to interprofessional collaboration: faculty from the New England College of Optometry–Ralph Levoy, Jerry Selvin, Matt Garston, Jeff and Neal Nyman and the young Barry Barresi.

And, three courageous ophthalmologists, David Miller from Beth Israel Hospital and Harvard and Marc Richman and Andre Quamina from Boston University, who believed in the new model and were committed to providing comprehensive eye and vision care to the community health center clients. They withstood the persistent political pressure and the new optometric-ophthalmological interactional model was implemented at the South End and Dimock Community Health Centers and the Dorchester House for the first time in the United States. Bold leadership was as important then as it is now.

This eye care protocol has now evolved throughout the country, more recently into a comprehensive affiliation among the Illinois College of Optometry, the University of Chicago Medical School and its University Hospital System for the provision of ophthalmic care, medical and optometric education and research.

And, the fourth problem had to do with the antagonism our new eye care model aroused among private optometric practitioners, many of whom were our own alumni and friends. They felt that we were intruding into an area that is rightfully theirs.

I was pleased to learn that this issue has been largely resolved through the leadership of the Massachusetts Society of Optometrists.

The common element that emerged throughout the development process was the importance of effective collaboration among all of the constituencies. Community health center boards and community advocacy groups at first were skeptical, then later became strong supporters of the effort. Their support was critical to the success of the program.

The College and health center collaboration soon began to develop into a successful story of mutual respect and aligned missions. These were the key ingredients in improving community access to eye and vision care services in the 70′s, as they are today.

After successfully negotiating a mutually acceptable agreement with the Dorchester House Multi-Service Center and after strengthening our affiliation with the U.S. Public Health Services Hospital in Brighton, we went on to develop additional relationships in Boston. The South End Community Health Center, Dimock Community Health Center, Eye Research Unit of the Joslin Diabetic Foundation, the Kennedy Hospital in Brighton, Cotting School for Handicapped Children, Department of Veterans Affairs Outpatient Clinic, and the Gundersen Eye Clinic at Boston University.

Other institutions, upon hearing of the success of our collaboration and new eye care model, asked for assistance in establishing eye and vision services. These included: the Massachusetts Institute of Technology, Harvard Community Health Plan and the University of Massachusetts at Amherst.

All of these organizations were willing then to take the risks of new programs and innovative approaches to community eye and vision care as the New England Eye Institute member organizations are willing to take the risks of new programs and innovative approaches in this exciting new venture.

In 1976, upon leaving for Philadelphia, I wrote in an article later published in the Journal of the American Optometric Association on my assessment of the initial phase of the program.

We have reason to believe that we have achieved most of our clinical development goals to a greater degree than we ever could have anticipated.

Over 45,000 eye visits were provided to community residents in 1976. Many community residents had never before received eye or vision care.

Our students are seeing more challenging patients than their predecessors saw.

They have learned from and worked effectively with ophthalmologists and with professionals in pediatrics, internal medicine, nursing, psychology, and low vision.

Faculty and students were successful in convincing many that optometrists can make an important contribution in an interdisciplinary health care setting.

A very workable eye care protocol involving technicians, optometrists and ophthalmologists was developed and implemented.

Our graduates have very different professional aspirations as a result of their community health center experience. Some went on to work in community health centers and some have become deeply involved with the whole issue of public health and some are seeking to broaden their education and assume roles in health care policy. We have a living example here today in Barry Barresi.

A new level of innovation and collaboration has been introduced in the 21st century to build on a program created in the 70′s.

A major step was taken by the New England College of Optometry by reallocating its clinical assets into a community governed organization. Even with a history of over 30 years of collaboration, much work is still needed to be done to truly transform the New England Eye Institute into a leading community services organization for Greater Boston and a model for other cities around the country. Several challenges can be identified.

Educational programs need to be expanded to include trainees not only in optometry, but also ophthalmology, medicine, nursing, and other health care professionals, such as occupational therapists, social workers, low vision and blind rehabilitation specialists.

It will not be sufficient to provide only eye and vision services, for the New England Eye Institute needs to embrace a community oriented approach to health promotion and prevention.

The new organization must be flexible and integrated to truly meet the public need. It must position the Institute to meet the needs of special populations – the homeless, the frail elderly, the home bound, the developmentally disabled, the severely visually impaired, and others.

The quality of care must be monitored and maintained with appropriate mechanisms and oversight.

And, development efforts need to be aggressive in seeking the necessary operating and capital funds to support the Institute.

Finally, I would like to conclude with a few observations based on my many experiences in interprofessional collaboration that could be applied to the New England Institute.

The key ingredients in any successful collaboration are mutual respect and aligned missions.

Innovation must be proceeded by careful planning and boldness tempered by fiscal reality.

There are few cities better positioned than Boston to achieve excellence in collaboration to meet the public need in eye and vision care services, in health professions education, and health promotion and prevention.

I urge the many collaborators in this new initiative to reflect on the approaches and successes of a few bold individuals who in the 70′s were willing to take risks of new programs and innovative approaches and apply the same persistence, commitment and risk taking to the New England Eye Institute.

Thank you for remembering me.

Dr. Charles F. Mullen
Kennedy Library, Boston, MA
May 14, 2003

Today’s optometry students take for granted their ability to train at settings including neighborhood health centers and Department of Veterans Affairs (VA) facilities as part of their clinical education. Yet, these doors were not always open to them. While there were many people who contributed to this welcome change, the man with the vision to know where the profession was going and how to get there is Dr. Charles F. Mullen ’69.

Dr. Mullen, who recently retired as President of the Illinois College of Optometry, spent his entire career designing and reshaping the delivery of clinical education for optometry students and residents. He has advanced clinical education with his keen foresight and forceful leadership. In doing so, he has opened up eye care services to many previously underserved patients.

From 1970-1976 Dr. Mullen served President William Baldwin at The New England College of Optometry (then Massachusetts College of Optometry) as Special Assistant for Clinical Development. Baldwin appointed him shortly after his 1969 graduation.

Between 1976-1990, Dr. Mullen served as executive director of the Eye Institute at the Pennsylvania College of Optometry (PCO). He then directed the Optometry Service at the Department of Veterans Affairs in Washington, DC, from 1990-1996 and in 1996 was selected president of the Illinois College of Optometry (ICO).

Beginning with NECO, Dr. Mullen was able to plant the seeds of moving optometry into the forefront of primary eye care by developing a system that optimally served patients. Perhaps best known for clearly seeing the potential of expanding the scope of the practice of optometry, Dr. Mullen recognized in the early 1970’s that optometrists would be treating eye disease and the necessity for students in the clinical system of NECO to develop new skills. Think of how difficult this was without a single diagnostic or therapeutic drug law in place…

Working to implement new clinical protocols, Dr. Mullen creatively developed teaching affiliations with Boston’s system of neighborhood health centers and other multidisciplinary settings. He did this by partnering with a progressive team of optometrists and ophthalmologists in caring for patients in special and underserved populations as a way of enhancing the education of future doctors of all disciplines.

In the words of Dr. Mullen, “We had a need and wanted to enrich the students’ clinical experience and give them more exposure… we also saw an opportunity to provide eye care services to those who were underserved in the Boston area.”

Breaking Down the Barriers
To reflect back on the 1970s, when Dr. Mullen began his career in optometry, is to see a radically different time than today. Co-management was not the norm, as it is today. Diagnostics and therapeutic pharmaceuticals were the sole province of the medical profession.

Early in his career, Dr. Mullen understood that ophthalmology and optometry were complementary. However, integrating a different model in a resistant health care field would require both conviction and persistence. He and other clinicians saw an opportunity to introduce a primary care system into clinical education and, in 1970, circumstances allowed him to begin his mission.

In 1972, the College was commissioned by the State of Rhode Island to develop the clinical curriculum and certify its Optometric State Board in the use of diagnostic and pharmaceutical agents. Dr. Mullen directed the implementation of the clinical component for the first diagnostic pharmaceutical course and along with Dr. Matt Garston ’66 certified the first diagnostic pharmaceutical certified optometrist in the United States.

Following that milestone, Dr. Mullen collaborated with a team of neighborhood health care and public policy leaders: Tres Blake of the South End Community Heath Center; Bob Morgan of Dimock Community Health Center and the Harvard School of Public Health; Mark Richman, M.D. of Boston University and the South End Community Health Centers; and David Miller, M.D., of Beth Israel and Harvard Medical School. All were committed to enhancing ophthalmologic clinical education and services.

The ophthalmic community and private optometric practitioners were skeptical, but the group stayed the course. Over time, local neighborhood health centers formed partnerships with the College and integrated optometric services and students into their clinical programs. Dr. Mullen is still viewed as the architect of the local model used in Boston and duplicated elsewhere to this day.

Dr. Barry J. Barresi ’77, Vice President for Clinical Care and Services at New England Eye Institute (NEEI), testifies to that fact. “Even today as we meet with Boston’s health care leaders to further expand the NEEI system of community-based clinical sites, many of them vividly recall the innovative leadership of Dr. Mullen some 30 years ago. With his colleagues, he built a strong foundation of community health partnerships. Today these collaborations are fueling continued innovation and growth in the College’s mission of excellence in patient care, clinical education and research.”

Dr. Gerald Selvin ’73, Professor of Optometry at NECO and National Education Chair for the Optometry Service Field Advisory Group of VA Central Office considers Dr. Mullen to have had the largest impact on his development than anyone else in optometry. While still a student, he remembers two particular proclamations made in 1972 which not only greatly influence his practice life but all of optometry.

“Optometrists will be treating eye disease routinely, so we are going to start to teach you how now.”;

“There are no welfare patients, no poor patients, no rich patients… there are only patients, and each individual will be treated with dignity and respect.”

These principles are what Dr. Charles Mullen has always placed above all else…take care of patients compassionately and with expertise. Never having lost sight of these principles is what made Dr. Mullen the visionary he is. And those optometrists who have had the good fortune to be directly influenced by him can imprint these values on a new generation of doctors, continuing his legacy.

The Eye Institute
Then it was time for another professional challenge. In 1976, Dr. Norman Wallis, former president of Pennsylvania College of Optometry (PCO) and now executive director of the National Board of Examiners, approached him about developing an integrated clinical system at PCO for the soon to be built Eye Institute. Dr. Wallis felt that Dr. Mullen was the only person capable of handling this daunting assignment. Dr. Wallis explained to Perspective that PCO’s objective was to establish an enterprise that resembled an “eye hospital.” It would combine the three O’s (opticianry, optometry, and ophthalmology) under one roof. This innovation in eye care education would completely change the character of the clinic, and – ultimately – eye care delivery.

With his characteristic methodical approach, Dr. Mullen set out to implement the model, which would greatly expand the scope of educational and training resources available at PCO. Dr. Wallis recalls why it was so successful.

“Charlie organized the clinic like a military campaign. Every aspect was covered to the greatest detail. It was like Operation Desert Storm.”

In the 1980’s, Dr. Mullen saw changes taking place in the profession and made great efforts to merge the interests between optometry and the medical community. He wrote that, “the impetus comes from outside parties – particularly third-party payers, health care policymakers and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define the roles themselves.”

He knew that the mutual interests could form a bond. Therefore, he initiated several affiliations with medical facilities in the Philadelphia region. The hallmark would be PCO’s affiliation with Hahnemann University, a Philadelphia-based medical college. The two combined their resources and worked to develop “unique approaches to ophthalmic education, eye care provision, and optometric research.”

Meeting More Professional Challenges
In 1990 Dr. Mullen left PCO to head the Optometry Service of the Department of Veterans Affairs in Washington, DC. With this post, he became the highest-ranking civilian optometrist employed by the government. A former Navy officer himself, he was familiar with the need for change in the VA system. True to from, he began a process of systematic restructuring. Under his stewardship, he implemented protocols for clinical privileging and standardized the educational component system-wide at the VHA. These guidelines are the principle force driving policy decisions today. He was also responsible for the sizable growth of the student and residency programs.

Many colleagues, including those at the Department of Veterans Affairs, feel that he was a perfect representative for the optometric profession in Washington. Described as a “visionary,” a “poised ambassador,” and an “executive’s executive,” he based his entire career on teamwork. When asked about his leadership style, Charles Mullen credits Dr. Wallis. “Norman taught me the ability to empower the people who work for you – to trust them and how to delegate authority.”

Another term that is often used in reference to Charles Mullen is “turn-around specialist.” In 1996, he accepted the challenge of the presidency at the Illinois College of Optometry. The institution had gone through a difficult time and needed to be restored to its previous stature.

Dr. Mullen confronted the issues head on, turning ICO into a thriving and stable institution. He implemented a strategic management plan, “Commitment to Excellence,” which restructured the college to address the challenges of the future.

Commenting on what he views as the most significant transformation at ICO during his tenure, Dr. Mullen is quick to state that “it has been the institutional culture. We initiated the process by focusing on the CORE four-year program and utilized tools to evaluate outcome assessment and national board performance. Change has permeated the institution.”

The list of accomplishments at ICO is noteworthy. ICO has increased its endowment, raised its clinical revenues, significantly improved student national board performance, frozen tuition, improved its student retention rate and increased student and faculty involvement in institutional governance. The outcome of Dr. Mullen’s taking charge is remarkable.

You can also see his trademark in the clinical programs at ICO. When he arrived there were only nine clinical affiliates. That number has grown to 137 sites throughout the United States and abroad. This has significantly impacted students’ access to patient encounters. In 1997, ICO formed an affiliation with the University of Chicago that has strengthened both institutions. ICO is now in the process of expanding that relationship further and plans are underway to move the University of Chicago’s ophthalmic surgical practice to the ICO campus.

With his retirement recently from ICO, you might expect Dr. Mullen to contemplate his golf handicap or other hobbies. But instead, he is thinking of returning to federal service. You can expect that wherever he heads next, his vision and leadership will do nothing short of transforming that entity.

The New England College of Optometry
Perspective Magazine. Spring 2002.

The agreement, only the second of its kind in the United States, brings together faculty from separate, often competing, professions.

This affiliation emphasizes the complementary roles of each profession. It is intended to increase mutual awareness, improve and expand the training of both types of providers, and coordinate and enhance patient care.

“This far-reaching and quite unusual cooperative agreement brings together the disciplines of optometry and ophthalmology in a productive and rational way,” said Charles F. Mullen, OD, president of ICO. “Optometry students and residents, medical students, and ophthalmology residents will train side by side, learning a new respect and appreciation for each other’s disciplines.”

“The best eye care requires cooperation between doctors providing that care at multiple levels,” said Terry Ernest, MD, PhD, chairman of Ophthalmology and Visual Science at the University of Chicago. “As technology advances and financial pressures multiply, the optimal system for providing the broad range of eye care has grown beyond the scope of any single provider.”

Under this cooperative agreement, which has been in practice since September 1, 1997, University of Chicago faculty will teach and faculty physicians and residents will see patients who may require specialty care at the Illinois Eye Institute, the College of Optometry’s clinical facility.

The affiliation will expand training and clinical experience for students in each program. Students from ICO will come to the University for scientific and clinical training.

The two institutions will also create a joint OD/ PhD program, which will prepare optometrists to combine their clinical practice with eye care research.

Optometrists spend four years in optometry school, after college, studying the diagnosis and treatment of common eye diseases. Ophthalmologists spend four years in medical school, followed by another four to six years of specialized training as residents. Students in the OD/PhD program will combine four years of optometry training with three or more years of study of the basic science of vision and complete a substantial research project in their specialty area.

The only similar agreement was arranged between the Pennsylvania College of Optometry (PCO) and Hahnemann University in Philadelphia in 1988. At that time Dr. Mullen was executive director of PCO’s Eye Institute.

By combining the strengths of each profession, the Illinois affiliation pulls together a range of providers that is ideally suited for the emerging competitive environment of managed care. Primary eye care will be provided by the ICO’s network of optometrists. More complex cases, such as corneal or retinal surgery, will be treated by sub-specialists at the University.

“This arrangement provides the patients of the Illinois Eye Institute and the University of Chicago Hospitals with a closed loop for all eye care needs,” added Dr. Mullen, “from routine exams to the most complicated surgical problems.”

The combined programs now handle nearly 70,000 patient visits per year, more than 45,000 at ICO and another 20,000, including the most complex cases, at the University.

Both institutions are not-for profit. Each will retain autonomy over its operations and finances.

The University of Chicago Medical Center
Office of Medical Center Communications
850 E. 58th Street, Room 106, MC6063
Chicago, IL 60637
Phone (773) 702-6241 Fax (773) 702-3171

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.

How must health care in America change? I believe that we must and will have universal entitlement – health care security for all Americans, but major changes are also required in all aspects of the current system. We must reach a proper relationship between the numbers of primary care health providers and specialists, improve access to health services, control costs, and assure quality of care, and any new health plan must support training of primary care providers, including optometrists. Ten states have recognized the need for change and already have some type of health reform legislation in place. As a health care administrator, I am frequently asked about President Clinton’s health care reform initiative. I believe that it is the right plan for the American people and the best plan for optometry. The President’s proposal explicitly provides eye/vision care benefits and recognizes optometry’s role in primary care.

In 1973, doctors of optometry were first granted the legal right and responsibility for administering pharmaceutical agents. Now, optometrists in 40 states are clinically privileged in the management of diseases and conditions of the eye. The progress of the optometric profession over the past 20 years has been dramatic. I attribute this success to a sincere desire on the part of practitioners nationwide to provide more accessible and cost-effective eye care to their patients and the expansion of the clinical practice of optometry to include the management of eye diseases and prescriptive authority that has been essential to optometry’s primary care role. As a result of this dramatic progress, I believe that optometry is now positioned to assume the role of primary eye care provider under national health reform.

Today’s optometrist is uniquely qualified to meet the challenge of national health care reform. Optometrists are the nation’s most accessible eye care providers, practicing in more than 6800 municipalities throughout the United States. In more than half of these communities, they are the only eye care providers available. Optometric clinicians are often the point of contact in the health care system for many people and their training qualifies them to serve in a role for patients with systematic health problems that manifest in the eye. This is particularly important in medically underserved areas.

Vision and eye health problems are among the nation’s most prevalent disorders affecting more than 140 million people. Vision problems inhibit the ability of children to learn, adults to work, and the elderly to live independent and productive lives. Regular eye examinations are also an essential preventive measure for the early diagnosis and prompt treatment of eye diseases, which, if undetected, result in individual suffering and added societal costs. A recent study by the Georgetown University Medical Center concluded that over 100,000 new cases of blindness yearly are preventable through timely detection and treatment and would result in an estimated annual savings to the federal budget of one billion dollars.

The demand for services of primary care providers in the United States continues to exceed the supply of manpower resources available. Health care reform provides an opportunity to restructure the delivery and health educational systems in ways that make better use of America’s available health care resources through the use of cooperative approaches to health delivery and training. Enhanced primary care training for optometrists is consistent with the current emphasis on primary care in federal health care policies.

Optometry and ophthalmology are complementary eye care professions in the Department of Veterans Affairs and nationwide. However, interprofessional controversy over certain issues persist. These issues include the extent of clinical privileges for optometrists, the role of the optometric clinician in pre- and postoperative patient management, and the use of laser technology by optometrists. Such sensitive issues are not easily resolved. However, there are many areas of mutual agreement, and I believe that the eye care professions can, and should, cooperate in patient care programs, education, training, and research. Cooperative programs already exist in some health care institutions in the nation, but on a limited basis.

The success of cooperative programs between optometry and ophthalmology is evidence that joint efforts can be advantageous to both medicine and optometry and that optometrists and physicians can work together as colleagues. In cooperation with affiliated health professions schools, I believe that properly constructed and thoroughly evaluated eye centers of excellence could serve as models that promote preventive care, while at the same time provide state-of-the-art treatment and rehabilitative services. These models could be emulated throughout the national health system.

The future can take us into a new era of accessible, affordable, and quality health care and lead optometry into an arena of greater responsibility for the eye care needs of all Americans.

Acknowledgements
I gratefully acknowledge the contributions of A. Norman Haffner, O.D., Ph.D., President, State College of Optometry, State University of New York, and James Holsinger, M.D., Ph.D., Chancellor, University of Kentucky Medical Center, to the preparation of this speech and the advancement of VA optometry. This editorial is taken from Dr. Mullen’s speech given June 2, 1994 at the graduation ceremonies at The Southern College of Optometry.

Clinical Eye and Vision Care.
Volume 6. Number 3. 1994.
Charles F. Mullen, O.D.

Veterans Health Administration
The Department of Veterans Affairs includes three distinct organizations: Veterans Benefits Administration, National Cemetery System, and Veterans Health Administration (VHA).

The VHA administers the world’s largest comprehensive health care system for the nation’s 26.9 million veterans. It includes 172 medical centers, plus more than 700 outpatient clinics, nursing home care units, domiciliaries and vet centers throughout the United States and the Philippines. Operating with an annual budget of over $13.5 billion, VHA treats 1.1 million inpatients and records over 23 million outpatient visits annually.

In addition to its primary mission of providing health care to veterans of the U.S. armed forces, VHA has three other roles. First, in times of war or national emergency, VHA serves as the backup health care system to the Department of Defense. Second, VHA trains a broad range of health care providers, including optometrists. Third, VHA works to enhance patient outcomes through clinical research. Each year VHA appropriates over $200 million for medical and prosthetics research. Currently, nearly 6000 investigators are engaged in more than 10,500 research projects located at VA medical facilities.

Optometry Service
In 1974 VHA recognized optometry’s contribution to veterans’ health care and named its first Director of Optometry to address the eye and vision care needs of veterans. Initially, the Director could not attract optometrists to service because of the outdated personnel system and salary schedule. There were just 8 full-time optometrists in the system and no residents.

In 1976 VHA designated optometry a Service and placed staff optometrists under title 38, in the same personnel pay system as physicians, dentists, and nurses. This provided more competitive salaries, created teaching programs, and increased optometric care for veterans. By 1980 there were over 70 full-time optometrists in the VA.

In the early 1970s, the VA also began establishing successful and innovative affiliations with schools and colleges of optometry. For instance, the nation’s first clinical education program for optometry students began at the Birmingham VA medical Center, in affiliation with the University of Alabama School of Optometry. Also, the nation’s first VA optometry residency program began at the Kansas City VA Medical Center. By 1980, 12 residency programs had been established.

Providing primary eye care by staff optometrists proved to be cost-effective and efficient, and veterans and veterans’ service organizations enthusiastically endorsed optometric care. This allowed VA Optometry Service to expand steadily and to begin to address the unmet need for primary eye care in the VA.

At present, 220 full- and part-time optometrists (150 FTEE) provide eye care services to veterans at 138 VA medical facilities. Optometrists manage over 300,000 patient visits annually and provide clinical training for 500 optometric students and 53 optometric residents at 79 academically affiliated VA facilities. Since many VA facilities have multiple affiliations, currently 121 affiliation agreements exist among schools and colleges of optometry and VA medical centers.

Included in Optometry Service’s responsibility is the provision of vision rehabilitation services at three Vision Impairment Centers to Optimize Remaining Sight (VICTORS), three Low Vision Clinics, and five Blind Rehabilitation Centers (BRCs).

The Field Advisory Group is an integral part of Optometry Service. Fifteen chairpersons, all optometrists practicing within the VA medical system, head special committees on areas critical to the development of the Service and the delivery of quality eye care, education, and research. They remain in constant contact with the Director and address issues ranging from total quality to improvement of public relations. The chairpersons, representing the dedicated work of their committees, provide invaluable assistance at biannual strategic planning meetings of the entire Field Advisory Group.

With regards to external relations, the Director of Optometry Service maintains liaisons with the AOA, ASCO, National Association of VA Optometrists (NAVAO), and the Special Medical Advisory Group (SMAG) Subcommittee on Eye Care. The Field Advisory Group and representatives from these organizations combine to form a significant network of advisors.

The Opportunities
In the Armed Forces, Health Maintenance Organizations (HMOs), and the private practice sector, the ratio of optometrists to ophthalmologists is a little over two to one. This balance has evolved naturally in response to the need for a cost-effective, logical approach to primary eye care services, subspecialty eye care services, and surgery. In VA, the ratio is reversed; there are at least two ophthalmologists for every one optometrist. An opportunity exists to develop and implement a highly efficient and cost-effective national model for the provision of eye care, a model that minimizes duplication and overlapping of services among the eye care providers.

By the year 2000 the number of Veterans at visual risk will increase from 4.0 to 5.7 million impacting greatly on the total number of eye care visits to VA facilities. Optometry Service presents a cost-effective means of providing primary eye care.

The veteran population of 26.9 million is aging. It is a population with a high incidence of ocular and vision disorders. VA presents opportunities for eye care research in early diagnosis and management of eye disorders in the elderly. Significant clinical studies of age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma could be mounted.

Leaders within VA, ASCO, and AOA have a chance to dramatically shape the future of eye care delivery and optometric education. Opportunities within VA for enhancing patient care, clinical education, and research abound. The climate is right to jointly initiate constructive, strategic action.

Climate
VA has a history of support for sharing agreements and affiliations. VHA medical centers share extensively with academic health care centers demonstrating a history of commitment to clinical education and research. Thousands of sharing agreements exist between the VHA, the Department of Defense, and the Indian Health Service.

VA has an ongoing and active policy of cultivating new affiliations. Within the past two years 18 new academic affiliations have been developed among VA medical facilities and schools and colleges of optometry. Also, three existing programs have been expanded. More affiliations are possible and have been encouraged by various government organizations and VA advisory groups.

Related to this is VA’s high technology sharing program. This allows VA medical centers and its academic partners to purchase expensive equipment jointly and to share in the cost of operation. Technology sharing agreements with schools of optometry should be explored.

The quality and cost-effectiveness of health care delivery is of prime importance to VA. Optometry Service provides quality, cost-effective, and accessible care and is often used as an example of a model program in which high quality patient care is inextricably combined with the training of students and residents.

Funds were recently made available for 35 new optometric staff positions. In an effort to improve accessibility to primary eye care, additional funds for staff expansion are anticipated.

With its Field Advisory Group, Optometry Service already presents a highly qualified team ready for constructive interaction with ASCO, NAVAO, and AOA leaders. This extensive network of advisors covers every aspect of Optometry Service’s operation. Together we will be ready to address the issues. Together we will be ready to face the challenges ahead.

The Challenges
VHA is concerned with health services research and the structure of eye care services delivery in particular. Optometry Service, ASCO, and AOA, along with VA Offices of Quality Management, Health Services Research and Development, and Clinical Programs could respond to the challenge by creating Regional Centers for Eye Care Excellence. These Centers would involve the disciplines of optometry and ophthalmology and their respective academic affiliates in the collaborative provision of eye care, ophthalmic education, and research. They would serve as demonstration and evaluation sites for evolving eye care models.

Within the VA, as in the private sector, sensitive issues surround the respective roles of optometrists and ophthalmologists. A unique, coordinated health services research project which addresses the interaction between optometry and ophthalmology in the VA could be developed.

Such a demonstration project would examine reporting relationships for optometrists and ophthalmologists in VA medical centers. It would also study the extent of clinical privileges granted to ophthalmic clinicians. The project would address the issue of new and developing technologies and Clinical Practice Indicators for VA eye care.

Conclusions defining the practice of optometrists in relation to ophthalmologists and other health care providers could serve as guidance for the entire system.

VA, ASCO, and AOA should move forward in designing and implementing a comprehensive affiliation system. This would, however, present challenges in maintaining quality patient care and integration of educational programs. It is imperative that any system under consideration include guidelines for optometric faculty, resident, and student participation. Appointing all affiliated optometry school deans to VA Deans’ Committees and appointing selected optometry school faculty as consultants and attending optometrists at VA medical centers would assist in maintaining proper integration of patient care and clinical education.

Participants in the September 1991 ASCO Workshop on VA Optometric Academic Affiliations stated that in the development of large scale education initiatives there is a need for consultation by the AOA’s Council on Optometric Education (COE), which has been successful in accrediting and counseling optometric programs within the VA.

In cooperation with the schools and colleges of optometry the VA Optometry Service and Quality Management Office could review and update Optometry Service’s Quality Improvement Program. Further, quality could be insured by encouraging continued review of the VA Optometry Service patient care programs by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). However, optometric representation in JCAHO is essential to the success of the accreditation programs.

The greatest challenge faced by the VA, ASCO, and AOA will be interacting on a comprehensive scale; planning will require foresight and coordination. However the outcome – a newly acquired ability to mount large scale educational initiatives, to evaluate new technology, to test quality assurance mechanisms, and to develop innovative eye care programs – will be worth the effort.

VA, ASCO, and AOA could work to develop or enhance affiliation agreements between ASCO member institutions and key VA facilities. VA medical centers in New York, Philadelphia, Houston, Memphis, Indianapolis, and Boston present significant training opportunities not currently realized by ASCO members.

Summary
The time is right for VA, ASCO and AOA to take action. Cooperative strategic action by the health care system (VA), educational institutions (ASCO), and the professional association (AOA), could lead to the placement of hundreds of new optometric residents and externs in educationally cost-effective and clinically challenging environments.

If the initiative is consistent with the VA’s mission and addresses the challenges previously described, it will succeed. If the initiative creates improved models for optometric academic affiliations and includes discipline specific protocols for resident and extern placements, it will succeed. If the initiative includes innovative models for more accessible, cost-effective and efficient eye care delivery, it will succeed. And above all, if the initiative systematically addresses the eye care needs of our nation’s veterans, it will succeed.

Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 18, Number 2. Winter 1993.
Charles F. Mullen, O.D.

Health care financing and provision are issues that affect virtually every individual in the United States today. As health care costs continue to rise, providers, third-party payers, and patients alike actively seek more effective and efficient provision systems. If providers fail to provide quality and cost-effective health care, they will be left behind in the increasingly competitive market. Similarly, if patients and third-party payers do not use more effective and efficient systems, they will assume an even greater share of the rising health care expense.

Affiliation between professional institutions presents numerous opportunities for enhancing the educational and clinical training of students, residents, and practitioners. Institutions that are developing their respective professions can collaborate in many ways of mutual interest.

Two Philadelphia health care institutions, located within 9 miles of each other, HU and PCO, cognizant of the changing health care environment and the possible benefits of collaborative education, have begun to explore new approaches to patient care provision and ophthalmic education. On March 2, 1988, the two institutions signed an agreement for an affiliation. The agreement, effective July 1, 1988, proposes that the professions of medicine and optometry combine resources to develop unique approaches to ophthalmic education, eye care provision, and ophthalmic research.

The Context and the Decision to Affiliate
Ophthalmology and optometry have existed as separate, often antagonistic, professions since their inceptions, so why affiliate now? The impetus comes from outside parties – particularly third-party payers, health care policymakers, and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define these roles themselves. The ophthalmology community maintains that the diagnosis and treatment of eye disease should be restricted to physicians. The optometry community, on the other hand, proposes that optometrists should be the primary eye care providers and should offer an even greater range of eye care services than they do now. Interprofessional disputes involving the treatment of eye disease by optometrists, preoperative and postoperative management, and the use of laser technology in refractive treatment remain unresolved in many areas of the country. Debates in journals and in legislative chambers, however, may or may not produce satisfactory outcomes for either profession. In our opinion, the time has come for ophthalmologists and optometrists alike to acknowledge that through collaborative efforts the two professions can define a future for eye care provision that will satisfy their needs as well as those of patients and policymakers.

Pennsylvania College of Optometry, which graduates approximately 140 optometrists each year, and HU, comprising a medical school, graduate school of health sciences and humanities, and a teaching hospital, considered the potential benefits of a cooperative arrangement between the professions of medicine and optometry. In 1987, they began to explore the possibility of an affiliation. Such an affiliation was unprecedented and, given the political environment, highly controversial. Therefore, before agreeing to proceed with the affiliation discussions, representatives from both institutions considered the following issues:

1. How will the professional communities respond to the affiliation?
2. How will alumni and other constituencies respond?
3. Should the services rendered under the affiliation be marketed? How will the professional communities react to joint marketing efforts? Will the managed health care systems accept a joint provision model?
4. What are the roles of ophthalmology and optometry in primary care?
5. How will patients be managed under the terms of the affiliation agreement?
6. Will the model of patient care provision defined by the affiliation be in compliance with state and federal laws and regulations?
7. Will the affiliation create competition between ophthalmology residents and optometry students for primary care encounters?
8. How will the introduction of new technology, such as lasers, be administered under the terms of the affiliation?
9. What is the proper and ethical role for each institution in the areas of patient management and financial agreements?
10. What are the positive and negative consequences of such an affiliation?

Of these issues, those involving the reactions of health care communities were perhaps the most sensitive. Some ophthalmologists feared that the affiliation would undermine ophthalmology’s role in primary eye care. Locally, some ophthalmologists threatened to refer patients elsewhere if HU proceeded with the affiliation; in fact, a number of ophthalmologists did stop referring patients after the affiliation took effect. Nationally, some ophthalmologists voiced their disdain for a cooperative agreement between medicine and optometry (Argus. November 1988:8, June 1989:4, and December 1989:22). Optometrists nationwide questioned whether or not the affiliation would place their profession in a subordinate role to ophthalmology.

Alumni of HU voiced their disagreement with the affiliation through letters, telephone calls, and refusals to continue to support the school financially; PCO alumni, on the other hand, tended to view the affiliation positively.

Given the emotional nature of the affiliation, the marketing issue was all the more troublesome, and the planning stages proceeded with deliberation. The first efforts at marketing involved educational radio announcements, simply informing the public that the two institutions now offered joint services. These proved successful in piquing the interest of potential patients and third-party payers, such as health maintenance organizations. Marketing in the future will use both radio and newspaper media.

Issues regarding the provision of services and the roles of ophthalmologists, optometrists, students, and residents are addressed in a series of protocols, which will be discussed in greater detail below. Currently, these protocols are in draft form and are revised as necessary. However, they still constitute the backbone of the affiliation, and set the rules by which we operate. If care is not provided according to the terms of the protocols, the affiliation will fail, perhaps causing irreparable damage to the future of relationship between ophthalmology and optometry.

Recognizing a mutual desire to influence the future direction of the eye care professions, the two institutions decided to move ahead with the affiliation despite the risks and expected negative reactions. A primary goal of the affiliation is to define the role each profession will play in the changing environment before third-party payers and regulatory agencies mandate new policies. By engaging in curriculum discussions and in joint research efforts, the institutions hoped to enhance their own educational and research programs and, at the same time, design a health care provision system that would become a national model acceptable to all parties: ophthalmologists, optometrists, patients, and policymakers.

The Agreement
Philosophically committed to the affiliation, representatives of the two institutions began to define the elements of the agreement. It was decided that the firm foundation and base of the agreement would be education, on which other aspects of the agreement would be built. Many months of negotiations culminated in the written agreement to affiliate. Salient aspects of the agreement are summarized below:

1. Each institution will retain autonomy over its operations and finances.
2. An Affiliation Executive Committee will provide guidance, advice, and oversight on matters relating to the affiliation, including education, research, clinical, and administrative issues.
3. The Chairman of the Department of Ophthalmology at HU and the Dean of Academic Advancement at PCO will be responsible for administering the affiliation.
4. Appointments to the faculty or staff of either institution will be made in accordance with the policies and procedures of each institution.
5. On request, the clinical faculty and house staff at HU will provide consultative subspecialty medical/surgical services to the patients of PCO in a location dedicated to subspecialty care. Consultative subspecialty services will be provided for a full spectrum of medical ophthalmic conditions, including, among others, cataracts, cornea and external disease, diseases of the ocular adnexae, diseases of the retina and vitreous, glaucoma, neuro-ophthalmic disease, ocular trauma, pediatric ophthalmic disease, and strabismus. In addition, HU will provide continuous emergency medical/surgical backup services to patients of PCO.
6. Clinical faculty, residents, and other staff at PCO will provide consultative optometric, vision rehabilitative, and other services to patients of HU on request. Consultative optometric services will include contact lens evaluation and fitting, low-vision rehabilitation, eyeglass dispensing, orthoptics, and learning and disability evaluation and treatment.
7. Patients will be referred to HU or to PCO, as appropriate, when such referrals are in the best interest of the patient, are agreed to by the patient, and are consistent with applicable laws and regulations, such as those mandated by the Medicare and Medicaid programs and by professional ethics.
8. Students at HU, with approval from the dean of the School of Medicine, may take courses taught by PCO faculty. Likewise, PCO students, with the approval of their dean of Academic Advancement, may take courses taught by HU faculty.
9. The faculties of both institutions will engage in joint educational programs, such as didactic and continuing education lectures, clinical preceptorships, seminars, electives, and grand rounds.
10. The faculties of both institutions may participate in joint research efforts. Joint research programs will be approved and administered in accordance with the polices and procedures of each institution.
11. The faculty and administration of both institutions will seek to develop new and innovative health care provision systems.
12. All publicity, marketing, and fund-raising materials regarding the affiliation must be approved by the Affiliation Executive Committee.
13. Neither institution will use the affiliation for its own or its profession’s political gain.
14. All health care providers operating under the affiliation must have appropriate and adequate professional liability insurance as required by law.
15. Each institution will make available to the other institution, on request, all pertinent information regarding legal, financial, contractual, managerial, and other issues relevant to the affiliation. All such information will be held strictly confidential.

An interim financial agreement was added as an addendum to the original agreement. A global financial agreement addressing the provision of clinical as well as educational services is still under negotiation. It will supersede the interim agreement as soon as it is finalized.

The faculty, medical staffs, and administrations of both institutions were informed of the affiliation discussions and most supported the initiative.

The Model and the Implementation Process
The model of eye care provision eventually agreed on assumes that ophthalmology and optometry are complementary, and it seeks to emphasize the strengths of each profession. It stipulates that primary eye care provided at PCO is delivered by optometric staff. Patients with conditions requiring subspecialty medical or surgical intervention are referred for consultation, management, or both to the HU ophthalmology staff. After the consultation and any necessary medical or surgical treatment are completed, the patient is referred back to the referring optometrist for ongoing care. Likewise, patients who receive their primary eye care by ophthalmologists at HU and who require contact lenses, low-vision rehabilitation, orthoptics, or learning disability services are referred to PCO optometric staff for treatment. Ongoing medical/surgical care is provided by ophthalmologists. In our opinion, therefore, ophthalmologists and optometrists work in tandem to provide appropriate, cost-effective, and high-quality care.

Educational Programs
A fundamental goal of the affiliation is to develop joint education and research programs. Therefore, much effort has been spent in restructuring existing programs and creating new ones. Basic science and clinical faculty at HU currently offer courses in ocular microbiology/immunology, pharmacology, clinical medicine, and microanatomy at PCO. In the future, HU faculty will be offering courses designed for students of optometry in general and medical pathology and physical diagnosis.

Programs in clinical education also are being redefined. Ophthalmology residents accompany HU faculty on rotation in subspecialty care at PCO’s clinical facility, The Eye Institute. In addition, PCO’s faculty offers ophthalmology residents rotations in contact lens and low-vision rehabilitation services. Similarly, optometry residents and a few students are afforded the opportunity to rotate through ophthalmology subspecialties under the tutelage of the ophthalmology staff. Further, ophthalmology faculty participates in clinical conferences at PCO. Students and residents of both institutions are thus exposed to a broadened clinical base and an array of ophthalmic disorders. The hope is that such exposure will result in a more well-rounded clinical education.

Faculty of PCO have commented that the educational programs have enabled them to enhance their own clinical skills and knowledge base. However, educational programs are not limited to the faculty and students of the affiliated institutions; programs have been designed to benefit community providers as well. Faculty of HU have lectured at PCO grand rounds and have participated in the college’s continuing education seminars. Programs such as these encourage interaction between the professions and therefore, are consistent with the goals of the affiliation.

Clinical Services
Before clinical services were actually provided under the terms of the affiliation, clinical faculty of both institutions worked together to draft patient care management and referral protocols, to outline the management process, and to establish quality assurance standards. To date, protocols have been approved for referral from PCO to HU regarding the following aspects of care: (1) cataracts, including preoperative and postoperative care; (2) cornea and external disease; (3) disease of the ocular adnexae; (4) disease of the retina and vitreous; (5) glaucoma; (6) neuro-ophthalmic disease; (7) ocular trauma; (8) strabismus; and (9) pediatric ophthalmic disease.

When a patient is referred to HU for management, the ophthalmologist assumes ultimate responsibility for treating the disorder. The referring optometrist may observe the operation and may assist in the preoperative and postoperative care. However, medical/surgical care is always rendered personally by the physician. Referrals from HU to PCO may include the following: (1) contact lens care; (2) eyeglass dispensing; (3) orthoptics; (4) low-vision and vision rehabilitation; and (5) learning disabilities.

The protocols define a “closed loop provision system” that enables providers to monitor more effectively the quality of care rendered. Under PCO’s previous program, patients were referred to independent consultant ophthalmologists for medical/surgical treatment. This system was open-ended, and methods of record keeping were informal. In the closed system model, providers are in regular communication, and referral information is compiled and reported on a monthly basis. Furthermore, independent computer systems currently being implemented at both HU and PCO will allow providers to monitor care more effectively and determine when patients miss appointments or leave the system so that appropriate follow-up communication can be initiated.

While the protocols were being finalized, administrative staff began to define the operation of the provision system. Issues such as scheduling, personnel, space requirements, equipment requirements, medical records management, and billing policies and procedures were addressed. Given the high volume of clinical activity at The Eye Institute, HU employs a full-time office manager at that facility to oversee the Department of Ophthalmology’s clinical and financial operations. This person is responsible for patient scheduling, registration, charge entry, and medical record preparation. Pennsylvania College of Optometry operates contact lens and low-vision services at HU one-half day each week. The Eyewear Center, located at HU, and also operated by PCO, is open 5 days each week and is staffed by PCO employees.

Joint clinical chiefs’ meetings are held regularly to monitor the progress of the affiliation in general and, in particular, to evaluate the protocols, discuss quality assurance issues, and to review clinical programs. These meetings help maintain open communication among the providers and facilitate patient care provision. To date, revisions have been made in the glaucoma and cataract protocols.

Research
The affiliation agreement encourages joint research ventures and, indeed, opportunities for collaborative research are considerable. Approximately 75,000 outpatient visits are recorded each year at The Eye Institute. Likewise, 282,000 outpatient visits for medical problems, including eye disease, are scheduled at HU. As a result of the affiliation, investigators have a large base from which to draw patients for studies. Faculty at both institutions are currently working together on research projects, which include learning disabilities and macular degeneration. Protocols for excimer laser investigations also have been discussed. Should these be pursued, optometrists will engage in basic research while ophthalmologists and other physicians will conduct clinical trials.

Of special note is the fact that research areas have not been limited to eye disorders and disease. Faculty at HU’s Department of Neurology and Psychiatry have joined faculty at the PCO’s Learning (Disabilities) Center in research investigating learning disabilities.

Recent Developments and Future Directions
Over the past year, many of the goals of the affiliation have been realized, and the future looks very bright to us. As participants of the PCO externship program, a few selected optometry students soon will have the opportunity to share in patient care in the Department of Ophthalmology at HU. New projects under discussion include a joint prison eye care program and the establishment of satellite clinics and faculty private offices, which will be structured according to the provision model previously described. Satellite clinics would be geographically located in the Philadelphia area to serve areas populated by the “underinsured” – the working poor who do not have adequate health care coverage. The faculty private offices would be strategically located to enhance the marketing potential of the affiliation.

Marketing initiatives already are underway; efforts will be directed to optometrists in private practice, primary-care physicians, managed-care systems, commercial insurers, and the general population. The opportunities for marketing are perhaps greatest in the managed-care sector. The model of eye care provision developed under the eye care affiliation is consistent with that used by many managed-care systems, i.e., optometrists provide primary eye care, while ophthalmologists provide medical and subspecialty care. The vehicle for marketing services to managed-care systems will be EyePA Ltd, Philadelphia, a for-profit subsidiary of PCO. On a contractual basis, EyePA Ltd provides eye care services to managed-care systems, self-insured corporations, and other insuring entities. EyePA Ltd is a multifunctional specialty organization that (1) manages utilization of eye care services; (2) provides, on a capitated or fee-for-service basis, a full range of professional eye care services through a network of contracted professionals; and (3) credentials specialty eye care providers and institutions.

Comment
Many individuals maintained that doctors of medicine and doctors of optometry could not work together as colleagues sharing the same goals and aspirations.

Looking back over the past 17 months, we believe that the skeptics were wrong. The affiliation has exceeded our expectations and has progressed much more quickly than any of the planners had imagined. Events to date suggest that joint educational, clinical, and research programs have been advantageous to both medicine and optometry, and that teams of medical doctors and optometrists can work together as colleagues in one eye care provision system.

Archives of Ophthalmology
Controversies in Ophthalmology
Volume 109, Number 2. February 1991.
Charles F. Mullen, O.D.
Myron Yanoff, MD
Laura A. Wilson, MS