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July 15, 2009
Regina Benjamin, M.D., M.B.A.
United States Surgeon General (designate)

Dear Dr. Benjamin:

Please allow me to extend my most sincere congratulation on your nomination as Surgeon General. Given your credentials, unique experience and dedication, you are ideally suited for this challenging position at a critical time for health care in our nation.

I am sure you are aware of the numerous health care issues facing inner-city and rural America. One issue that I find particularly troubling is the unmet need for programs to address preventable threats to visual health. The Department of Health and Human Services Healthy People Program identified the most significant threats to visual health and established goals to reduce those threats. The program addresses visual impairment due to eye disease/conditions including glaucoma, diabetic eye disease, cataract, amblyopia and refractive error and recommends: regular eye examinations for children and adults, vision screening for preschool children, eye injury prevention, and low vision examination.

These visual health 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 to 30 percent of all federally qualified health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans.

Efforts must be made to attract more optometrists to rural and inner-city areas through financial incentives such as student loan forgiveness and equipment purchasing grants and loans. Inclusion of optometry in the National Health Service Corps (NHSC) is essential to the placement of optometrists in these areas. I was most interested when you proudly spoke of your experience in the NHSC during your nomination speech and how it shaped your career path.

Federal and state governments should also encourage visual health education, describing the benefits of regular eye examinations for adults and children, including vision screening for preschool children and eye injury prevention. These efforts should be provided through culturally sensitive and appropriate materials and venues.

Optometry’s first program to collaborate with community health centers to improve access to inner-city Americans was developed in Boston by the New England College of Optometry in the late 1960’s, in cooperation with three community health centers. Today, the program has grown to include 14 health centers and 30 other affiliations and inner-city programs. It was also the first collaborative model of care between optometry and ophthalmology in the Nation. This community based program is now managed by the College’s subsidiary, the New England Eye Institute, and has evolved into a national model demonstrating the compatibility of a commitment to community eye care and clinical education. While few inner-city and rural health centers have eye care services, nearly all Boston health centers provide these services. Once you are sworn in as the next United States Surgeon General, you may want to review this highly effective model for possible application to other parts of our country.

Thank you for willingness to take on the challenge of Surgeon General and again congratulations.

Sincerely,

Charles F. Mullen, O.D.
Member, Board of Trustees
New England College of Optometry

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.

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