Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Three Critical Components for Expanded Scope of Optometric Practice

Introduction

Medical Education leads the Medical Profession by developing the educational structure and clinical training programs in advance of new patient care initiatives. In contrast, State Optometric societies lead the Optometric Profession with Optometric Education reacting to the States’ expanded scope of practice initiatives with specific educational programs. Consequently, there is not a comprehensive educational structure nor a uniform indicator of an optometrist’s knowledge and clinical skills to support all of the States’ expanded scope of practice initiatives.

Requiring postgraduate clinical training in medical eye care for optometrists is not only essential preparation for Expanded Scope of Practice, but also positions optometry for inclusion in the $18 billion Graduate Medical Education Program (GME).

These are the three missing components that need to be developed:

1) Necessary Capacity for Advanced Clinical Training in Medical Eye Care

  • In 1931 Medicine acknowledged that clerkships contained within the four year medical school curriculum were inadequate preparation for rapidly changing medical practice, and instituted mandatory postgraduate clinical training.
  • Even though optometric practice has dramatically and rapidly expanded encompassing medical eye care, clerkships within the four year optometry curriculum remain the only required clinical training component.
  • The current four year curriculum does not provide optometry graduates with the types and quantity of clinical teaching encounters necessary to practice expanded scope of practice in all States.
  • Postgraduate clinical training in medical eye care is now essential preparation for advanced optometric practice.

2) Federal Funding to Support Advanced Clinical Training

  • Optometry is not included in the $18 Billion Graduate Medical Education Program (GME) because clinical education takes place primarily within the four year curriculum, and not in postgraduate residencies.
  • Inclusion in GME, the educational component of Medicare, would not only encourage the development of new residency positions in Medical Eye Care by providing funding to host facilities, but also by providing funding to directly support advanced clinical training.
  • Optometric Education needs to change from providing clinical education within the current four year curriculum to a Postgraduate Clinical Training Model to qualify for GME.
  • Like medicine, clinical clerkships or rotations would take place within the final years of the curriculum.

3) Nationally Recognized Certification Board to Provide a Uniform Indicator of an Optometrist’s Advanced Knowledge and Skills to Practice Expanded Scope of Practice Optometry

  • The American Board for Certification in Medical Optometry (ABCMO) is a well-established Board that meets GME expectations. However, ABCMO serves mostly Department of Veterans Affairs (VA) optometrists, and needs to be recognized by the entire Optometric Profession.

More Information

by Charles F. Mullen

Recommended Briefing Points for Advocates of Optometry’s Inclusion in GME

Background

  • Optometry is a significant provider of medical eye care services to Medicare beneficiaries ($1.33 billion annually) for conditions such as glaucoma, cataracts and retinal diseases, but is not included in the Graduate Medical Education Program (GME), the educational component of Medicare.
  • Medicine, Podiatry and Specialty Dentistry receive $18 billion in GME support annually for postgraduate clinical education. Podiatry was included in GME in 1972 by amendment, and changed its clinical training model in 1990. Podiatry now receives regular GME payments to support resident training.
  • It will be necessary to include Optometry in GME by amendment to appropriate laws/regulations or by inclusion in proposed legislation in advance of the introduction of a new optometry postgraduate clinical education model.

Clinical Training of Optometrists

  • Optometry has traditionally provided clinical education within the four year optometry school curriculum with postgraduate clinical training being optional, thus, optometry’s current clinical education model does not meet GME requirements.
  • Costly, optometric clinical education receives no Federal Support, and is largely financed by student tuition contributing to high graduate debt of approximately $200,000.
  • Optometry graduates have the highest loan payments as a percentage (14.9%) of income of all professions.
  • High debt is a contributing factor in that applicants to optometry schools and colleges have not effectively increased in 10 years.

Reasons Optometry Should be Included in GME

  1. Nationwide expansion of the scope of optometric practice by numerous changes to State Practice laws.
  2. A steadily increasing demand in providing Medicare beneficiaries with medical eye care services – Optometrists currently provide $1.33 billion in services annually managing serious eye conditions of Medicare recipients.
  3. A major increase in optometric management of serious eye conditions will accompany the proposed addition of refractive care (refraction, eyeglasses and contact lenses) in Medicare.
  • The above will require the schools and colleges of optometry to restructure their traditional clinical education approach into a Postgraduate Medical Clinical Educational Model in order to provide the quantity and diversity of clinical teaching encounters necessary to properly prepare optometry graduates for clinical practice.
  • In 1930 Medicine adopted required postgraduate clinical training because the 4 year medical school curriculum did not provide the quantity and diversity of clinical encounters to properly train physicians.
  • Postgraduate optometric clinical education can be provided in cost effective outpatient facilities. GME’s hospital-based training requirement needs to be waived.

Optometry’s Inclusion in GME is Necessary

  • GME is needed to support optometry’s postgraduate clinical education to meet current and future demand for well-trained optometrists in advanced medical eye care practice.
  • GME support will ensure a sufficient number of well-trained optometrists to meet current and projected demand for eye care services of Medicare beneficiaries.

See Also

by Charles F. Mullen

Affordable Care Act: Opportunity for New Optometry Student Clinical Training Model

I am writing this paper to urge schools and colleges of optometry to change from Student-Driven Clinical Training to a Teaching Physician-Centered Model to facilitate compliance with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents as the Guidelines pertain to Students. With the implementation of the Affordable Care Act (ACA), it is an opportune time for optometry schools and colleges to change to a Teaching Physician-Centered Model and reinforce their CMS compliance policy and Electronic Health Records (EHR) procedures for students. I realize such a dramatic change in optometric clinical training would have significant budgetary implications as teaching physician/faculty expense would increase and patient services revenues would likely decline. However, the current Student-Driven Training Model continues to pose a high risk of CMS violations with associated fines and other sanctions. It is anticipated that audits of Federal Health Care Programs will increase with the implementation of the Affordable Care Act (ACA).

The paper does not discuss the educational benefits of the Teaching Physician-Centered Model. However, the model has been successfully utilized in medical student education for many years.

Background

Because the Department of Health and Human Services (HHS) does not consider optometry residents to be “real” residents, I do not address optometry residents’ compliance in this paper since CMS Teaching Guidelines do not technically apply. An optometry resident once licensed is no different than any licensed optometrist. Also, optometry residency programs do not qualify for the Graduate Medical Education (GME) program. Nor does optometry have a trainee classification that qualifies as intern. A teaching physician is defined as optometric school/college faculty, affiliate attending staff, or extern preceptor.

The CMS Teaching Guidelines apply to Medicare, other Federal Health Care Programs, Medicaid in most states, and most major private insurers.

Page 3 of the Teaching Guidelines state:

Evaluation and Management-Documentation Provided by Students—Any contribution of a student to the performance of a billable service must be performed in the physical presence of a teaching physician or resident… the student may document in the medical record. However, the teaching physician may only refer to Review of Systems (ROS) and Past Family/Social History (PFSH)….the teaching physician may not refer to the students findings and must verify and re-document the history of present illness and perform (repeat) and re-document the examination and medical decision making (treatment plan).

Page 7 – Medicare does not pay for any services furnished by students.

I base my recommendation to change the teaching model on research and writing on the subject, consultation with American Optometric Association (AOA) Medicare experts, consultation with teaching physicians, interviews with medical students and residents and ongoing discussions with (AOA) Federal Relations staff and optometric academic administrators and faculty along with viewing the Office of the Inspector General (OIG) False and Fraudulent Claims Report, where CMS Teaching Guidelines violations are reported. I also have extensive experience in optometric clinical education and with Federal Health Care policy. See: Dr. Charles Mullen CV.

Compliance with CMS Teaching Guidelines and EHR Procedures

Failure to fully comply with the Teaching Guidelines and EHR procedures creates self-induced risk which could result in institutional fines, legal fees and other severe penalties. There is also the potential of individual liability and damage to the reputations of faculty members, affiliate attending staff or extern preceptors since Medicare/Medicaid Fraud and Abuse sanctions are reported to the National Practitioners Data Bank. Should an extern preceptor be sanctioned for Medicare fraud or abuse the damage to optometry school/college alumni relations would be extensive. HHS has intensified its efforts to identify and prosecute Medicare fraud by increasing the reward pool for “whistle blowers” to $10 million.

Student Notations Risks with Electronic Health Record (EHR)

If student notations are placed in the patient’s record (either written or EHR), they must be clearly delineated and not used to bill for services. Intentionally and knowingly using student examination findings to bill Medicare is considered a fraudulent claim. The Association of Academic Medical Centers (AAMC) issued a Compliance Advisory regarding students and Electronic Medical Records (EMR). The Compliance Advisory cautioned teaching physicians about the risks of student notations in the electronic medical record and delineated procedures to avoid Medicare violations and sanctions.

Self Disclosure

Optometry schools and colleges that suspect Medicare violations in their clinical operations may want to consider Self Disclosure rather than exposing the institution to an uninvited Medicare audit which could result in catastrophic fines, legal fees and severe sanctions. The OIG Self Disclosure program may permit the institution to negotiate any fines and potentially prevent higher fines and more severe penalties such as exclusion from all Federal Health Care Programs. Medicare Fraud and Abuse fines are up to $10,000 to $50,000 plus three times the damages for each violation. The Self Disclosure protocol requires the institution to furnish extensive information on the Medicare/Medicaid violations including how the school/college plans to prevent future violations. Suggested measures to prevent CMS violations are delineated in the next section of the paper.

Teaching Physician-Centered Model

The current optometric Student-Driven Clinical Training Model is not compatible with CMS Teaching Guidelines, while the Teaching Physician-Centered Model is consistent with all of the following CMS compliance expectations:

  1. that the teaching physician is in charge of the patient
  2. that patient care is personally rendered or repeated by the teaching physician and
  3. that the examination is personally documented in the medical record by the teaching physician including history of present illness, diagnosis and management/treatment plan.

This model is successfully utilized in medical student clerkships.

Optometry programs must clearly demonstrate how students are incorporated in the care of the patient to learn and practice clinical procedures and not to provide patient services. Also, programs must demonstrate how students participate when the care of the patient is actively and personally provided by the teaching physician. Schools and colleges should view student clinical placements as clerkships where the student can practice history taking and examination procedures along with assisting the supervising physician, but not provide patient services except ROS and PFSH.

Optometry schools and colleges must ensure:

  1. a CMS compliance policy is in place, including a EHR policy regarding student notations
  2. that the compliance policy is monitored and enforced by annual internal compliance audits
  3. that all clinical affiliates and extern preceptors receive copies of the institution’s compliance policy along with CMS and OIG supporting documents
  4. that regular briefings on compliance by senior school/college officials are presented to all external training venues
  5. that all college faculty and optometry students receive compliance training prior to participating in patient care
  6. that the school/college or teaching clinic has a Compliance Officer
  7. that lines of communications are open

The Veterans Health Administration (VHA) Eye Care Handbook also mandates compliance with CMS Teaching Guidelines in all optometric teaching programs. Annually, 1400 optometry student clinical rotations are available at VA facilities along with 186 residents and 3 research fellows. Although optometry residents are not considered residents by HHS, the VA requires compliance with CMS Teaching Guidelines for both optometry residents and students.

Although implementation of the Teaching Physician-Centered training model would be a major step forward in addressing optometry student compliance with CMS Teaching Guidelines, serious consideration should be given to the overall restructuring of optometric education by placing optometry in parallel with medicine for both student and postgraduate clinical training. Restructuring the curriculum would present the opportunity for inclusion in GME and further enhance CMS compliance. See: Restructuring the Profession of Optometry – The Next Bold Move.

Reference Documents

  1. CMS Guidelines for Teaching Physicians, Interns and Residents (Students)
  2. OIG False and Fraudulent Claims Report
  3. OIG Self Reporting Protocol
  4. Medicare Fraud and Abuse Summary
  5. Veterans Health Administration (VHA) Eye Care Handbook
  6. Restructuring the Profession of Optometry – The Next Bold Move

by Charles F. Mullen