The tranquilizing drug of incremental progress – Anonymous

Background

Over the past 40 years, changes to optometric practice laws and Federal/State current and anticipated health care policy have been addressed by specific, incremental modifications to licensure requirements, clinical education, postgraduate training and advanced competency certification/re-certification rather than systemic restructuring of the profession in accordance with a comprehensive strategic plan.

Consequently, unaddressed structural issues persist and weaken optometry’s position as an independently licensed profession in a third party dominated health care system. Also, structural issues prevent optometry from receiving Federal support for clinical training. Currently, clinical training costs are often passed on to the optometry student in the form of higher tuition resulting in additional graduate debt.

Since optometrists are classified as physicians under Federal law, they are (or will) be judged by Federal and State governments, external certifying organizations, credentialing and privileging boards of medical facilities and third party insurers utilizing the medical model as the standard. Optometrists, like physicians, will be/or are already expected to demonstrate clinical competency by board certification and maintenance of competency by re-certification.

Also, all optometric clinical teaching venues are expected to comply with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents.

A eight-step approach is recommended to comprehensively restructure the profession by placing optometry in parallel with medicine.

Most Important Events of the Past 40 Years

• Expansion of optometric state laws, initiated in Rhode Island in 1972, authorizing the use of pharmaceuticals and advanced clinical procedures.
• Creation in 1976 of the Department of Veterans Affairs Optometry Service, now the largest optometric patient care and clinical training program in the country with 675 VA optometrists providing 1.5 million visits annually. And clinical training provided for 80% of optometric students and over 50% of all residents.
• Inclusion in Medicare in 1987, now $1.0 billion in optometric services are provided annually.
• Optometry’s broad-based inclusion in the Affordable Care Act (ACA) will likely be another significant event. Participation in the ACA will also facilitate inclusion in other Federal Programs such as the Graduate Medical Education Program (GME) and the National Health Service Corps (NHSC).

Although these were major achievements, the absence of a visionary plan at the time resulted in missed opportunities:

• to advocate for the passage of broadly drafted state optometric practice laws that would allow for the future expansion of the scope of practice without further amendments,
• to agree on the purpose of optometric post graduate clinical training. Was it intended to qualify for state licensure and/or board certification or just advanced training?
• and to include optometric clinical training support (GME) in the Medicare component of the Social Security Act.

Three Major Challenges Facing Optometry

1. Optometry is (or will) be judged by Federal and State governments, external certifying organizations, credentialing and privileging boards and third party insurers utilizing the medical model as the standard.
2. The $10 billion Graduate Medical Education (GME) program is based on the medical clinical training model and optometry’s clinical training, licensure requirements and advanced competency certification/re-certification do not meet GME expectations for participation.
3. The Center for Medicare/Medicaid Services Guidelines for Teaching Physicians, Interns and Residents prohibit optometric students from providing billable services in all training venues.

Detailed Structural Issues and Missed Opportunities

Postgraduate Clinical Training and Advanced Competency Certification

• No mandatory postgraduate training is required for optometric licensure with the exception of Arkansas and Delaware.
• No nationwide acceptance of optometric postgraduate specialty training, board certification and maintenance of certification presently exists, however, the American Board of Optometry(ABO) has been recognized by the Center for Medicare/Medicaid Services (CMS) for bonus payments (PQRS) and the American Board of Certification in Medical Optometry (ABCMO) has been recognized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) as a certifying agency.
• Although a significant provider of Medicare services ($1.0 billion annually), optometry is not included in the Graduate Medical Education Program (GME) the educational component of Medicare because optometry’s clinical training model does not meet GME expectations.
• Because of the above, current optometric residents are not recognized by the Department of Health and Human Services (HHS).
• No expeditious route presently exists for board certification in General Optometry for most new optometric graduates. In 2012 there were only 367 available resident positions for 1600-1800 graduates.

Education

• The increasing costs of optometric clinical training are passed on to students in the form of higher tuition.
• Debt is too high for optometry school graduates averaging $140,000 (public) to $175,000 (private) vs. median annual income of $95,000.
• The Bureau of Labor Statistics is projecting a 33% increase in demand for optometrists or 11,300 additional optometrists for the period (2010-2020), however, the student applicant pool is declining.
• The declining student applicant pool for optometric schools (only 1.0 unique applicants per entering seat) is exacerbated by the proliferation of new schools (five schools added in recent years) and by expanded enrollments in existing schools. This is significant problem now and will likely be continued in the future. High debt to potential income and increasing commercialization of the profession are likely contributing factors.
• Schools and colleges of optometry perpetuate a curriculum where optometric clinical training required for licensure is contained within the basic curriculum. GME only supports postgraduate clinical training and paid an average of $95,000 per medical resident to hospitals in 2010.

Medicare/Medicaid Compliance

• CMS Guidelines for Teaching Physicians, Interns and Residents compliance vulnerabilities persist in all clinical teaching venues including externship sites, because optometric students are restricted by regulation from providing billable services. Also, private insurers apply CMS Guidelines. Two optometry schools have already been cited by the Office of Inspector General (OIG) for violations

Eight Strategic Steps to a Secure Future for Optometry

The proposed actions are highly sensitive, politically challenging and replete with timing and sequencing issues. However, there is no easy path, if optometry is to maintain its independence as a doctoral-level prescribing profession in a rapidly evolving health care system.

Again, the states are called upon to lead the profession, as Rhode Island did in the 1970’s. ASCO member institutions, NBEO and ACOE would likely follow with compensatory actions as they have historically done.

The steps are designed to facilitate synergism among State licensure requirements, postgraduate training, board certification/re-certification, optometric curricula; and position optometry to meet the expectations of private/Federal/State insurers, external certifying agencies, credentialing and privileging boards and the Graduate Medical Education Program (GME).

1. States should mandate one or two years of mandatory post graduate training for optometric licensure. Only Delaware and Arkansas already mandate post graduate training. State Optometric Practice Laws amended to include — “One or (two) years of postgraduate clinical training, in an accredited program leading to Board Certification, is required for licensure.”

2. It would be necessary for optometric educational institutions to adjust curricula by awarding the O.D. degree after three years and to reclassify the 4th year as the first year of residency.

   Two optometry colleges already offer accelerated programs, the New England College of Optometry offers a two year program and in the past, a three-year program and Salus University a three year program (deferred) while medical schools are now offering three year programs.

   Consolidation of curriculum into three years can be accomplished by moving basic course material to pre-optometry requirements and extending the academic year to twelve months, permitting completion of all competency-based course material in three calendar years. Increased use of on-line instruction would facilitate completion of the accelerated curriculum.

   A three calendar year curriculum would allow reallocation of 1600-1800 current 4th year student placements for postgraduate residency training.

   A three-year O.D. degree program along with GME residency stipends would reduce optometry student debt $30,000 to $50,000 or more.

   U.S. Medical Schools (Allopathic & Osteopathic) Offer 3-Year Degrees.

   In the last five years, at least four medical schools have initiated or are developing three-year programs including Mercer University School of Medicine, Lake Erie Osteopathic College of Medicine, Texas Tech University Health Sciences Center, Louisiana State University School of Medicine.

   Also, three other schools have applied for Federal funds (CMS Innovation Grants) to develop three-year programs: Indiana University School of Medicine, East Tennessee State University Quillen College of Medicine, and the University of Kentucky College of Medicine.

   The Carnegie Foundation for the Advancement of Teaching recommends all medical schools consider a three-year option.

   Two Canadian Medical schools have three-year programs.

   The three-year program will save the medical student $50,000 in debt.

3. National Board of Examiners in Optometry (NBEO) examination sequencing would need to be adjusted to accommodate new curriculum and mandatory postgraduate training.

4. One year of postgraduate training required for certification in General Optometry, two years for specialties and three years for fellowship trained sub-specialties.

   Certifications boards need to developed and/or recognized for General Optometry (ABO) and the Specialties of Medical Optometry (ABCMO), Cornea/Contact Lenses, Pediatrics, and Vision Rehabilitation. Also, sub-specialty certification boards for Neuro-Optometry and Glaucoma developed.

5. To ensure consistent standards among various certification boards, establish an oversight board for all specialty certification boards, the American Board of Optometric Specialties (ABOS).

   There is an immediate need for an oversight board as three newly developed optometric certifying boards, as well as other organizations awarding advanced competency status, have varying standards.

6. Only postgraduate clinical training programs accredited by the Accreditation Council on Optometric Education (ACOE) would be recognized for board certification. Mechanisms must be established to record resident patient care experiences to ensure the resident has received the quantity and diversity of patient care encounters to qualify for board certification.

   Consideration should be given to accrediting existing and new schools to a maximum enrollment.

   Care (CCOC) should be re-instated to ensure high standards of optometric patient care and sufficient patient volume at all clinical training venues

7. With completion of Steps 1-6, optometry would now be parallel with medicine and consistent with current and anticipated Federal/State policies, external certifying agencies, credentialing and privileging boards and private insurers’ requirements.

8. Also, optometry’s clinical training model, licensure requirements and advanced competency certification/re-certification process would meet GME expectations and comply with CMS Guidelines for Teaching Physicians, Interns and Residents. AOA advocacy could now move forward with a credible position.

   Since optometric clinical training is largely in outpatient facilities, GME regulations would need to be expanded from hospitals only to include outpatient patient care/clinical training.

Resources

• American Board of Certification in Medical Optometry
• American Board of Optometry