If optometry is to maintain its position as the Nation’s leader in primary eye and vision care in a rapidly evolving health care system… we have a responsibility to frame our own future.

Abstract

The following slide presentation describes an eight step plan to comprehensively restructure the profession of optometry to meet the expectations of private, Federal and State insurers, external certifying agencies, and credentialing and privileging boards by placing optometry in parallel with medicine.

Significant changes to optometric education, clinical training, licensure requirements, board certification and accreditation are described (1) to qualify optometry for inclusion in the Graduate Medical Education Residency Program (GME), a $10 billion annual program which currently funds post graduate training for physicians, dentists and podiatrists, and (2) to meet Federal insurance compliance guidelines for teaching programs.

A Strategic Framework for Optometry and Optometric Education (PDF)

A Strategic Framework for Optometry and Optometric Education (PPT)

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

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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

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Strategy to Include Optometry in the Graduate Medical Education Program (PPT)

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Thank you for this high honor.

Trustees, President Augsburger, colleagues, honored guests and above all doctoral degree candidates.

I know you are eager to receive your degrees and celebrate your hard earned achievements, however, as tradition dictates, there will be no degrees until the old guy speaks.

Congratulations on earning your Doctor of Optometry degree.

Today, I join with your families and friends in sharing the pride of your outstanding accomplishments.

Your future is bright with unparalleled practice opportunities.

You have been fortunate for the past four years to be touched by the uncommon power of the ICO experience.

This experience ensures your success in a changing health care environment.

An outstanding faculty has prepared you well for opportunities in the areas of public health, patient care and clinical education.

In the area of public health there is an increasing awareness of unmet visual health needs in medically underserved areas.

And there are opportunities for you to meet the needs of special populations: for those who live in poverty, the homeless, the frail elderly, the homebound, the developmentally disabled and the visually impaired.

The Illinois Eye Institute’s community outreach to the underserved population of Chicago serves as an outstanding example of collaborative medical care.

I hope you will use your ICO training to help others in need.

In patient care, opportunities are available to you in interdisciplinary care as optometrists manage more complex clinical conditions and diseases, requiring close coordination with other professionals.

Also, telemedicine technologies and electronic health records provide the means for more effective patient management.

ICO’s commitment to excellence in patient care is affirmed by grant awards from prestigious organizations and corporations.

The College’s network of over 150 clinical training sites in 47 states and abroad is one of the most extensive in optometry.

In clinical education, there are opportunities for you, as preceptors, by sharing your experiences in: patient-centered education and cooperative clinical training between optometry and ophthalmology.

ICO’s support from external sources for clinical training is the highest of all optometric institutions and is an acknowledgement of the College’s excellence in clinical education.

My education, like yours, prepared me not only to be a competent clinician but also to contribute to the profession’s future.

Your professional status will also provide entree to numerous social, civic and political activities.

In the past, it has been the foresight and persistence of many dedicated individuals to move the profession forward.

You are now called upon to make such a contribution.

Given the aging population, uncertain optometric manpower needs and the impact of national health care reform, there is a need for broad based strategic planning including professional, academic and corporate participation.

I encourage your active involvement at the local, state or national level in planning for your profession’s future.

Current Board Certification and Continued Professional Competency initiatives require your attention and understanding of their place in your profession.

There are unprecedented opportunities for optometry to seek inclusion in three major Federal programs while the federal budget is being re-structured.

These programs could potentially benefit the current generation of optometrists as well as future optometric students, residents and graduates.

The first initiative which is already in progress is the expansion of optometry’s impact in the community health care system.

Community health centers provide accessible and cost effective primary medical care to 20 million Americans in rural areas and poor urban neighborhoods.

However, only 20% of federally qualified health centers offer eye care services, despite the growing need in rural and inner-city America.

Federal funding is required to establish optometric services in all of the Nation’s community health centers.

It is estimated that 5,000 optometrists would be needed in the Nation’s underserved areas over the next decade providing not only new practice opportunities, but also additional student and resident clinical training placements.

The second program is the National Health Service Corps.

Efforts must be made to attract more optometrists to medically underserved areas through financial incentives, such as tax free student loan repayment, by including optometrists in the National Health Service Corps.

Classification of optometry by the Federal government as a Primary Care Profession is a necessary next step to qualify for this program.

Third and long overdue, is optometry’s inclusion in the Graduate Medical Education program, GME, the clinical educational component of Medicare.

Optometrists have been included in the Medicare program since 1987 and currently provide $970 million in services annually to Medicare beneficiaries.

Now it is time to join medicine, dentistry and podiatry as a recipient of GME funding for clinical training.

Optometry’s inclusion in the $9.5 billion program would address: the increasing costs of clinical training and the need for workforce development as the scope of optometric practice continues to expand and growth in the demand for eye care services by the Medicare population.

Although the work ahead will be challenging, inclusion in these three major Federal programs would provide visual health care to tens of thousands of underserved individuals, strengthen the profession of optometry’s position at the national level and forever change the financial landscape of optometric education.

I am confident that the profession’s future leaders are in this Chapel today.

And as those before you, you must move forward with a balance of discretion and audacity.

Be willing to take risks with innovative approaches.

In whatever you do, follow the example of your Alma Mater and strive for pinnacles of excellence.

For in the final analysis, it is neither about financial rewards nor power, but pride in your professional and personal achievements.

Character and contribution will define your success.

Thank you and congratulations.

May 21, 2011

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Dr. Mullen has served the profession with great distinction since earning his doctor of optometry degree in 1969 from the New England College of Optometry. He has tirelessly advocated for the interdisciplinary approach to clinical education and patient care, and he successfully led the initiative to certify the first American optometrists in the use of pharmaceutical agents.

Under his leadership at ICO, Dr. Mullen increased the College’s externship sites from 9 to 144, significantly improved students’ performance on national board examinations, affiliated ICO with the University of Chicago, and developed and implemented a performance-based strategic plan that positioned ICO for future success.

Dr. Mullen has received more than 30 prestigious honors and awards, including being inducted into the National Optometry Hall of Fame for lifetime contributions to the profession. Dr. Mullen serves on the boards of NECO and the Blind and Vision Rehabilitation Services of Pittsburgh and has previously served as chair of the board of directors at the New England Eye Institute.

About the Illinois College of Optometry

The Illinois College of Optometry, founded in 1872 by Dr. Henry Olin, provides excellence in optometric clinical education and is among the world’s leading urban optometric institutions. Located in Chicago, ICO has a distinguished legacy of providing aspiring optometrists the education and experience needed to meet the challenges of a changing health care environment and become leaders who will champion their patients and the profession alike. For more information please visit the Illinois College of Optometry website.

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Federal Financing of Optometric Clinical Training (PPT)

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Development of a New Clinical Training Model (PPT)

Background

Since the 1970’s, optometry has been in a state of metamorphosis with the introduction of pharmaceuticals and advanced clinical procedures. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice. However, the traditional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.

The profession of optometry has benefited from inclusion in the federal program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric education, however, does not conform to medical terminology nor the medical training model. Federal agencies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the educational component of Medicare. The Federal Government appropriates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.

The premise behind why GME payments are made to financially support clinical training of physicians, dentists and podiatrists is that clinical training is inherently inefficient. All clinical training for optometry students, however, must take place in the four-year curriculum and not in post graduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optometry student in the form of higher tuition. Inclusion of optometry in GME would provide additional revenue to optometric clinical facilities to partially offset the cost of these inefficiencies.

Medicare bases its regulations on the medical teaching model. Optometry’s traditional teaching model and terminology is not analogous to the medical model. However, functionally optometry’s model is consistent in several important aspects with the medical model. Current Medicare regulations regarding student supervision significantly impede optometry students from acquiring patient evaluation and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fellows, however, can contribute to billable services and have ample opportunity to acquire patient evaluation and management skills without significantly affecting the efficient provision of health care.

Realignment of the traditional optometric clinical training model and terminology is necessary to facilitate inclusion in and compliance with major federal programs and to reflect the current functional reality.

Objectives of a New Clinical Training Model

The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regulations pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable services regulations and facilitate inclusion in and compliance with these programs. Participation in GME and NHSC would provide significant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective training in patient evaluation and management (E/M) by placing optometric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.

Other objectives include increasing participation in Medicare, increasing the number of community-based training sites, and controlling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resource and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based training sites. Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control student debt.

Functional Reality of Current Optometric Training Model

Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric education has evolved into an intense clinical experience in response to the expansion of patient management and treatment responsibilities of optometric practice and is analogous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical training has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optometry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)

Actions Required to Realign the Optometric Clinical Training Model

The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry students would be redesignated as interns and current fourth year students would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric residents would be reclassified as PG-2, PG-3 or Fellows. First and second year students would remain classified as students. Since fellows, residents and interns can contribute to Medicare billable services, optometric trainees in this new configuration could receive meaningful and cost-effective training in patient evaluation and management (E/M), while in full compliance with Medicare billable services regulations.

In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clinical training of optometric interns and residents (PG-1 – PG-3), including resident stipends. Existing law/regulations need to be amended to direct HRSA to include optometry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.

Conclusion and Recommendation

The traditional optometric training model and terminology are not consistent with the functional reality, with medical terminology and federally-supported programs and present obstacles to inclusion in and compliance with major Federal programs. There is a need to comply with Medicare regulations regarding student billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thoroughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optometry in GME and NHSC.

Journal of Optometric Education
Volume 32, Number 1, Fall 2006
Charles F. Mullen, O.D., F.A.A.O.

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Introduction

Optometry has been included in the federal Medicare program since 1987 and receives, as other physicians, payment for Medicare services. Over the past 20 years, optometrists have become a significant health care resource for the elderly and disabled. In 1988 optometry provided $81 million in diagnostic and treatment eye care services to Medicare beneficiaries. Medicare services provided by optometrists have grown to nearly $900 million for the current fiscal year.

However, optometry is excluded from the Graduate Medical Education (GME) program, the educational support component of Medicare. In the late 1960’s, when the GME program was developed, optometrists were not recognized by Medicare as health care providers. GME was created to ensure sufficient workforce development (supply) of health care professionals to meet the needs of Medicare beneficiaries by partially offsetting the hospital costs of clinical training. The Medicare program spends over $8 billion annually for GME, but optometry is not eligible for these funds, since only programs in disciplines specifically mentioned in the law qualify. Although not originally included in GME, podiatry was added in 1972 by amendment to the law.

Since the 1970’s with the introduction of pharmaceuticals and advanced clinical procedures optometry has been in a state of transformation. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice far beyond the traditional role of the profession to prescribe eyeglasses and contact lenses for the correction of refractive error, significantly increasing clinical training requirements and training costs. With the aging of the United States (US) population and the projections for rising numbers of Medicare eligible beneficiaries, optometric teaching facilities will be providing significantly greater care to Medicare beneficiaries. More than ever, there is a need for federal support for optometric clinical training.

GME payments are made to support clinical training of physicians, dentists, podiatrists, nurses and certain allied health professionals, because clinical training is inherently inefficient when compared with the provision of care in non- teaching sites. Since optometry does not receive GME payments, the financial burden for the inherent inefficiencies in optometric clinical training, along with costs associated with increased training requirements, is placed upon the optometry student as a cost of education in the form of higher tuition and resulting in higher educational debt. Many optometry students incur debt in excess of $100,000. This increased financial burden measured against the income potential of optometrists threatens the supply of optometrists entering the profession. Inclusion of optometry in GME would provide much needed financial resources to optometric teaching facilities to partially offset the cost of these inefficiencies and costs of increased clinical requirements.

Also at stake is the ability of schools and colleges of optometry to find appropriate venues for the provision of clinical training. While medicine and other professions enjoy relationships with hospitals that receive GME funds for the placement of their trainees, this is not the case with schools and colleges of optometry and their clinical affiliates. The inherent inefficiencies and loss of productivity associated with training optometry students limits the number and diversity of training sites.

The anticipated increase in demand for optometric services by the aging US population requires an assessment of workforce sufficiency, and the increasing training requirements costs. It is time for Medicare to reassess its policy pertaining to financing optometric clinical education.

Background on the Graduate Medical Education Program (GME)

Currently, Medicare supports two types of GME programs providing clinical training for health professionals. The largest program is for physician, dental and podiatric residency training. Annual direct and indirect payments to teaching hospitals total $8.1 billion. Direct payments are made for trainee stipends, teaching faculty salaries and program overhead costs. Indirect payments are for higher patient severity, additional tests and productivity reductions and are a percentage add-on to the Diagnostic Related Group (DRG) rate that reflects the intensity of care required for an inpatient hospital stay.

The second and much smaller program supports nursing and allied health professionals training and payments are based on hospital cost reports. This program makes annual payments totaling $225 million to eligible facilities that are operating these programs.

Optometry’s current clinical training model is not consistent with GME eligibility criteria and current Federal law does not include optometric trainees in either GME program. All clinical training for optometry students must take place in the four year curriculum and not in post graduate residency programs, since the student must be prepared to enter practice immediately upon graduation. Optometry does not qualify for either program as optometric clinical training is not conducted primarily in residencies, nor is optometric student clinical training hospital based, as required in both the Residency Training and Allied Health components of GME.

Options

There are two options regarding inclusion in the Medicare GME program. The first option would be to seek support for 3rd and 4th year optometry students within the current clinical training model regardless of the fact that they are not “residents” and training does not, for the most part, take place in hospitals as defined in Medicare law. The Medicare regulations are written for the teaching hospital and its medical residency training model and translating the regulation language to the current optometric clinical training model is difficult.

The second option would be to seek inclusion in the current regulations for GME Residency Training by changing the structure of optometric education. (see also: Development of A New Clinical Training Model) This option would require enactment of legislation to formally recognize post graduate training programs in optometry and to recognize that optometric training for the most part occurs in out patient facilities. To achieve the most financial support, optometry schools and colleges would need to award the Doctor of Optometry degree after three years so that the 4th year of training would be in a post-graduate residency. It would not be to optometry’s best interest to simply include the current optometry residents in the program for it would result in only a small financial benefit to optometric clinical education as there would be only a small number of non-federal residency programs eligible for GME payments. Current optometry residents, however, could then be re-designated as post graduate trainees/residents, PG 2 and PG 3 and also qualify for Medicare GME payments. Another important benefit of this option is that residents are eligible to bill for Medicare services while students are not. (see also: Optometry Students, Medicare Regulations and Third Party Plans)

There are numerous issues associated with the significant change to the optometric curriculum that the second option requires. However, the financial benefit of inclusion in an $8 billion program would have a much greater and lasting impact on optometric clinical education costs.

The aggregate annual expenditure on clinical education for the 17 schools/colleges is over $100,000,000. The average number of Medicare visits as a percentage of total clinic visits is 14% with a range of 4% to 34%. Optometry students are also placed in a variety of externship sites and the associated costs and Medicare revenues generated accrue to the externship site. These costs and revenues are not included in the above figures. It is difficult to estimate the amount of Medicare revenue that is generated at all externship sites. However, given that optometrists provide nearly $900 million annually in Medicare services, the revenue generated at these sites is likely significant.

Conclusion

Although the benefits of inclusion in the GME program vary among the schools/colleges, the aggregate infusion of GME funding for providing the current level of Medicare services would have a significant impact on the cost of optometric clinical education and the burden of these costs to optometry students. This policy change in GME would ensure a sufficient supply of optometrists to meet the demand for rising number of Medicare eligible beneficiaries and reduce the cost of optometric clinical training.

It is anticipated that Medicare services provided will increase from the current average of 14% to 25% over the next 5-7 years, given the predicted growth of the Medicare eligible population, and GME support for optometric clinical education would anticipate and address future demand for eye care services.

In summary, the inclusion of optometry in GME addresses: the need for workforce development (supply), the growth of population demand for eye care services and increasing clinical training costs, and is consistent with current financing policies of Medicare which are intended to anticipate and address these issues.

References:

Development of a New Optometric Clinical Training Model
Optometry Students, Medicare Regulations and Third Party Plans

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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.

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The decision-making process concerning affiliation must include a careful cost benefit analysis. Evaluation should include a best and worst case scenario, and a timetable for implementation, perhaps in a step-like fashion to permit both parties to assess the effectiveness and impact of the relationship.

Analysis should be of sufficient depth so as to insure that all facets of the affiliation have been thoroughly explored in both quantitative and qualitative fashion, as it relates not only to educational and patient care factors, but also to finance, research and public relations.

Obviously, the most desirable affiliation for an educational and public image perspective would be with the most prestigious medical school. Geographical accessibility is another factor. Financial strength and quality of medical and ophthalmological staff and resultant patient care are also important factors.

The integrity and qualifications of the administration and faculty who are involved in negotiating the agreement and who will be directly involved in the joint programs are of paramount concern in order to protect the college of optometry from an adverse outcome in either the short or long-run.

Benefits of a Medical School Affiliation

Education

1. Increased access by optometric students and resident to patients with eye disease, systemic disease and pre- and post-ophthalmic surgical cases.
2. Increased interaction by students, residents and faculty with ophthalmic and other health care professionals via grand rounds, workshops, seminars, conferences and observation.
3. Lectures by medical school faculty in areas not currently taught by optometric faculty, and in areas currently taught where qualitative and/or quantitative improvement is possible – eye disease management, patient interviewing, gerontology.
4. Increased educational opportunities and research capabilities through the creation of joint centers or institutes in such areas as glaucoma, neuro-ophthalmic disease, cataract/aphakia, corneal physiology/contact lenses; immunology/allergy; pediatric and geriatric eye care.
5. Opportunities for advanced specialty training for optometric students, residents and faculty.
6. Expanded continuing education program in eye disease management through increased ophthalmological participation.
7. Medical school faculty appointments for optometric faculty.

Patient Care

1. More effective management of surgical patients, whether the surgery is performed at the medical school/hospital or at the optometric facility.
2. More effective back-up for true ocular and general medical emergencies.
3. Increased and more readily available access to sub-specialty care.
4. Enhanced control and direction for optometry school’s medical staff in areas such as patient care protocols, quality assessment/assurance mechanisms, credentialing.
5. Hospital privileges for optometrists.

Constituent and Public Relations

1. An enhanced image which can have a positive effect on student and faculty recruitment, fund raising, grantsmanship, community relations, and professional relations.

Economic Impact

1. Increased census in primary care and optometric specialties.
2. Sharing of revenue from surgical services provided at the medical school/hospital or out-patient surgical facility of the optometry school.
3. Increased practitioner referrals both from the optometric and medical communities.
4. Opportunities for sharing of plant, capital equipment, people, and resources.

Research

1. Increased potential for joint research projects utilizing respective strengths of optometry and medical schools. Access to special populations.

Concerns of a Medical School Affiliation

1. Erosion of optometry school’s mission to train primary eye care clinicians.
2. Competition among optometric students/residents and ophthalmological residents for primary care patient encounters.
3. Danger of optometry being placed in a subordinate position related to ophthalmology.
4. Some loss of control over optometry school’s ophthalmological group/faculty.
5. Restriction on referral patterns due to implied exclusivity of agreement.
6. Loss of opportunities for affiliation with other institutions.
7. Possible negative reaction by alumni or other constituencies.
8. Negative public relations if affiliation does not succeed.

The Affiliation Agreement

The elements of an affiliation agreement or, if a step-by-step process is desired, a memorandum of understanding with intent to affiliate may be broadly stated with detailed attachments added as the various aspects of affiliation are realized. The following elements should be present in the initial document.

1. Statement of support for each other’s educational mission, particularly as it related to the expanding scope of optometric practice.
2. Mutual desire to meet the health care needs of the community in a cooperative manner, desire to provide mutually beneficial and cost effective means for educating health care practitioners, and a recognition of the public benefits of collaborative research in visual and related sciences.
3. Actively encourage and cultivate inter-institutional endeavors in education, research and patient care.
4. Recognize each other’s autonomy as it relates to overall institutional mission, structure and governing authority.
5. Those terms contained in the agreement which specify financial arrangements should not become effective until such arrangements have been mutually agreed to in writing.
6. Facilitate inter-institutional cooperation in education by such means as faculty exchange, discussions on curricula development, teaching and evaluation techniques, seminars, workshops or symposia.
7. The faculties of both schools agree to participate in education programs such as didactic lectures, clinical preceptorship, seminars, electives, grand rounds, and continuing and post-graduate education as deemed appropriate.
8. Encourage cooperative research efforts and the application for external funding in the basic and clinical sciences by means of faculty exchange, sharing of laboratory resources and sharing of technical expertise.
9. Develop a cooperative arrangement in clinical education by reciprocally granting credentialed individuals faculty rank and/or clinical privileges, and by integrating medical and optometric staff, fellows, residents and students into appropriate clinical activities at each other’s institution.
10. Optometry school agrees to recognize the hospital and clinical faculty of the medial schools as the preferred providers of general medical and surgical care, ophthalmic surgical care and associated ancillary services for optometric patients.
11. Medical school agrees to recognize school of optometry and its clinical faculty and residents as the preferred providers of optometric care.
12. Optometry school agrees to make available members of its faculty to provide optometric services at medical school/hospital in accordance with mutually approved policy, protocol and procedures. This would include endorsement and signing of standing orders by appropriate medical director to allow optometric staff to treat eye disease if not permitted by state statue.
13. Medical school agrees to make members of its faculty available to provide onsite services at college of optometry’s clinical facilities.
14. Medical school agrees to make members of its faculty available to provide 24-hour emergency consultation and support services for optometric staff and residents.

The following should also be considered:

• Use of an external consultant experienced in hospital/institution mergers to review the affiliation structure.
• Creation of a third entity for administration of the various joint programs and for resources development purposes, e.g., The Foundation for Optometric/Medical Eye Care.
• Jointly sponsored grant application should be considered to offset start-up costs.

Conclusion

I have attempted in this brief presentation to outline the benefits and potential costs of medical school affiliation. Although there many be alternative means of enhancing optometric education and training with less political risk, affiliation appears to offer an immediate opportunity for quantitative and qualitative improvement in our ability to prepare optometrists to treat eye disease.

Journal of Optometric Education.
Volume 12, Number 2. 1986.
Charles F. Mullen, O.D.

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