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Thank you President Scott for your gracious remarks.

I am deeply honored to be awarded the New England College of Optometry’s Presidential Medal in recognition of my tenure as Director of the VA Optometry Service.

It is also a distinct privilege to join my distinguished colleagues and long time friends — Drs. Myers and Haffner in this evening’s tribute to the VA Optometry Service.

As an educator, I am grateful to the VA for its enormous contribution to the clinical training of this country’s optometry students and residents.

And as a veteran I am most appreciative of the excellent eye care VA optometrists provide each year to over one million of our most deserving citizens, the Nation’s veterans.

The comprehensive eye care provided to veterans by VA optometrists in collaboration with ophthalmologists is clearly among the best in the United States.

Optometry clinics are among the busiest of VA services, providing 1.5 million eye care visits annually.

The VA Optometry Service was the first in the country to develop and implement an effective model of interdisciplinary eye care in a large national system.

VA optometrists lead the profession in the management of patients with age related macular degeneration, diabetic retinopathy and glaucoma.

Prestigious professional journals are replete with publications by VA optometrists affirming VA’s leadership in advancing ophthalmic care.

During my tenure as Director, I witnessed the growing importance of VA optometry in the provision of primary eye care and low vision rehabilitation services.

However, my experience pales in comparison to the dramatic increase, over the past 12 years, in optometry staff, students and residents including numerous quality improvement initiatives.

The VA’s Eye Care Quality Improvement Program is recognized as one of the most comprehensive and effective in health care.

It is a unique system of checks and balances.

For overall guidance, the VA adopted the clinical practice guidelines of the American Optometric Association and the American Academy of Ophthalmology, the recognized standards for both professions.

The VA’s clinical credentialing and privileging process is precise and meticulously applied ensuring that every clinician’s education, clinical training and licensure are appropriate for the clinical privileges granted.

A robust system of clinical reviews, practice evaluations and peer review programs ensure that every veteran receives the highest quality eye care.

The quality, timeliness and seamless provision of eye care services by 675 VA optometrists and over 175 residents and fellows is now often cited as the gold standard for optometric care.

In addition to primary eye care, optometrists provide rehabilitative care in VA special programs such as low vision clinics, VICTORS programs and blind rehabilitation centers.

65 additional low vision optometric specialists have been appointed in recent years and placement of mid level and advanced low vision programs, in each of the 21 nation-wide VA Integrated Service Networks, is planned.

The Department of Defense-VA, Center of Excellence is an outstanding program for the management of servicemen and women who have sustained significant eye injuries as well as vision problems resulting from traumatic brain injury. At this center, optometrists, ophthalmologists and rehabilitation specialists ensure seamless transition for the patient from military service to the VA.

The innovative Boston VA based Teleretinal Imaging Program has already assessed 700,000 veterans for the risk of vision threatening disorders. Another example of optometry’s leadership and of effective collaboration among eye care providers, primary care physicians and IT personnel.

A special note of acknowledgement to my VA colleagues for your commitment to excellence in eye care and for your dedicated service to our Nation’s Veterans.

Thank you for recognizing my service as Director. It was an honor to have served with so many outstanding optometrists.

What do you, as former president of a private college of optometry, consider the most important issues facing the profession of optometry?

The absence of a current optometric manpower study and a comprehensive assessment of the state of optometric education.

The last optometric manpower study was completed in 1999 by Abt Associates, Cambridge, Massachusetts. The last study of optometric education was in 1993 at the Georgetown Summit. A current optometric manpower study and a comprehensive assessment of the state of optometric education are needed given the expanded scope of optometric practice, proliferation of new schools of optometry, national health care reform, the aging population and uncertain optometric manpower needs.

The high cost of optometric education.

Private optometry colleges’ endowments and sources of revenue other than tuition are not sufficient to support college and clinic operations and increased costs are often passed on to the student in the form of higher tuition, resulting in higher educational debt. This may also apply to public institutions although my experience is largely in private colleges. Currently, the cost of an optometric education is a sound investment, however continuing increases in educational costs measured against the income potential of optometrists will likely diminish the attractiveness of an optometric career in the future. Graduate debt is excessive, over $200,000 at some optometric institutions.

Why are optometric educational institutions so dependent on student tuition to support clinical training when medicine and podiatry receive substantial federal support?

At the Georgetown Conference (1992-1993), a meeting of all constituents of the optometric profession to discuss the optometric curriculum/clinical training programs, it was decided that optometric education would remain a four year curriculum with no requirement for post-graduate training for entry level into the profession. This conclusion meant that increases in the scope of practice for optometry and the resultant demands on the curriculum and clinical training requirements and related costs had to be contained in the four year educational program.

The four year optometry program is unlike medicine which requires post-graduate clinical training for licensure due to the expanded educational requirements for entry level medical practice. Graduates of medical and podiatry programs are not eligible for licensure until satisfactory completion of post-graduate clinical training. Because medicine and podiatry require post-graduate training, these two professions along with post-graduate dentistry are eligible for $9.5 billion annually in Graduate Medical Education (GME) Residency Program funds while optometry programs are not eligible.

What are the contributing factors to the high cost of optometric education?

Clinical education is the most easily identified cause of increased operating costs and the most significant. There are numerous factors contributing to higher clinical training costs:

Unlike the successful medical patient care and clinical teaching approach, optometry’s clinical model is student centered rather than patient centered. A student centered model increases the patient examination cycle, decreases patient satisfaction and limits faculty practice growth.

Since the 1970’s with the introduction of pharmaceuticals and advanced clinic. procedures, optometry has been in a state of transformation. Optometric education has evolved in response to the expanded patient care management and treatment responsibilities of optometric practice, significantly increasing training requirements and related costs.

Clinical education is inherently inefficient when compared with the provision of care in non-teaching sites and patient services revenues are inadequate to cover the deficit of clinic operations. Unlike medicine, dentistry and podiatry, optometry is not eligible for federal funds (GME) to compensate for training inefficiencies and increased training requirements and costs.

When the amount of charity care provided by college optometry clinics and patient services payment sources are taken into consideration, state, foundation, corporate and alumni support are currently also inadequate to fund clinic operating deficits. (The cost of clinical education is not always considered in the clinic operations accounting model.)

Clinical faculty incentives and/or expectations to increase patient services revenues are usually not usually components of employment contracts and maximizing revenue is not considered a priority by faculty members nor rewarded by colleges. Providing efficient patient services is not emphasized. Faculty and staff training in patient services coding and billing procedures is inadequate.

What are your suggestions to reduce the cost of clinical training?

Federal support for optometric clinical training would have a dramatic and lasting impact on the cost of optometric education. Efforts to include optometry in the Graduate Medical Program (GME) and other federal programs, such as the National Health Service Corps should be intensified. However, in order to qualify for the current GME Residency Program significant changes in the clinical education model would be necessary. Post graduate clinical training (residency), as a requirement for licensure, would need to be included in the optometric clinical education model. A Certification Board would be needed as well. Numerous issues involving state licensing boards, national examining boards, accreditation groups, etc would need to be addressed. The Social Security Act amended to include optometry in the Graduate Medical Education Program GME).

Radical new thinking about optometric patient care and clinical teaching is recommended. A major paradigm shift is required where clinical faculty/attending optometrists are in charge of the patient rather than faculty in charge of the care of the student.

Emphasis needs to be placed on patient care during clinical education sessions. Everything that occurs in the exam room should be to the benefit of the patient and patient satisfaction. Great clinical teaching can only occur in the context of great doctoring and role modeling of exceptional care. If this is the norm, then patient cycle time will be decreased and faculty will retool their thinking to be attending optometrists in charge of the patient rather than faculty in charge of the care of the student. This is the successful medical clinical training approach.

The expectations of these attending optometrists are different than academic optometrists. They are expected to drive the performance of the clinical program, both with volume and revenues and their performance evaluations should be strongly linked to their clinical and operational performance. This enables an institution to recruit and retain the best practitioners at market rate salaries with expectations that their income will be paid through their clinical performance resulting in increased revenues from clinical services.

All clinicians should be held accountable to compliance rules and regulations regarding documentation and clinical testing. Regular training sessions should be held pertaining to patient services coding and billing.

Large campus-based clinical facilities are costly and operating costs often passed on to the student in the form of higher tuition. Colleges should consider less expensive affiliations with proximal health care facilities such as community health centers, medical centers, federal facilities and externship placements for clinical training. New colleges of optometry should not build expensive campus based clinics, but rather establish networks of clinical training sites in existing health care facilities.

Are there other causes for the high cost of optometric education?

Yes, there are issues involving the academic program and research. Academic leadership is often slow to react to advances in the clinical practice of optometry and reluctant to make significant changes in the curriculum including addressing course redundancies. Course material remains in the curriculum even though it could be made a pre-optometry requirement and not taught in the core optometric curriculum.

State of the art technology such as distance learning is available, however faculty are reluctant to embrace new teaching methods. More emphasis should be placed on self learning by the student.

The current tenure process at private colleges of optometry greatly restricts the institutions ability to react to changing economic conditions and imposes long term financial obligations. Private colleges of optometry do not reserve funds to meet future obligations imposed by tenure.

What solutions do you propose to reduce the costs of the academic program?

A comprehensive review of the curriculum is suggested, specifically to remove redundancies and course material that could be changed to a pre-optometry requirements, more fully utilize current technology and consider distance learning for selected courses. A national faculty of recognized scholars could provide much of the classroom component of the curriculum via distant learning technology.

When the curriculum is completed, regardless of length, post-graduate training would be required. The post-graduate requirement would therefore make optometric education an exact parallel with podiatry and medicine and position optometry to qualify for Federal support (GME).

Private colleges of optometry should review the long term financial liability that tenure imposes, offer alternatives to tenure such as contract tenure or discontinue tenure. Colleges should calculate the long term financial obligation of tenure already granted and apprise the governing board of the magnitude of that commitment. Consideration should be given to reserving funds to cover tenured faculty.

Why do you believe research at private institutions may be contributing to the cost of optometric education?

Meaningful research programs are costly to develop and maintain. External funding is highly competitive and failure to secure new and ongoing funding may lead to absorbing the costs of research personnel and related expenses in the operating budget. Since the budget is largely funded by student tuition, in the absence of external research funds, increases in student tuition would likely be needed or funds would need to be diverted from the core educational program to support research.

What measures should private colleges take to prevent research programs being funded by student tuition should external funding not be available.

Caution should be exercised in investing in expensive research infrastructure as a return on investment can not be assured.

Translational scholarship such as publications, book chapters, presentations and posters at the AAO, leadership positions in the profession, appointments to NBEO and ACOE Boards, community service could replace traditional research as an expectation of faculty.

It should be clear when appointing faculty who are primarily researchers, that he/she must support all research activities and research personnel with external funding. If funding is lost, continued employment can not be guaranteed.

Caution should also be exercised in granting traditional tenure to research faculty.

Are there other matters you would like to discuss?

Even if all the above recommendations were implemented, revenue would still not be sufficient to support quality optometric education without regular increases in student tuition resulting in higher student debt. It is essential that alumni support their alma maters. Financial support from alumni is far from its potential and is critical to sustaining the quality of optometric education and for attracting the best and brightest students. Both are vital to the prestige and long term success of the profession of optometry.

Strategic alliances among the private colleges of optometry are suggested as a means to reduce costs, stabilize enrollments and strengthen their position in a finite student market. Affiliations with public universities should be considered. Affiliations with medical school departments of ophthalmology provide consultation and surgical services for the college’s clinic patients as well as cost effective clinical teaching encounters for optometry students and residents.

Private colleges should not always count on a robust student applicant pool or increased class size to develop operating budgets. The student applicant pool is cyclical and in combination with increased competition for students from new schools, it could leave the college with unfunded expenses without sufficient tuition revenue.

Colleges should consider reorganizing their clinical program into a separate subsidiary of the college. The advantages of this structure are:

• Provides for a reasonable separation of risk.
• Facilitates the appointment of Board members with skills in health care administration.
• Provides for more focused attention to the respective missions of education and patient care.
• Enhances the ability to solicit funds from foundations and other funding sources which do not contribute to educational institutions.
• Participation in GME would require a separate legal structure as payment are made to the clinical entity and not the college.

Externship sites need strict guidelines and oversight. Consideration should be given to the establishment of a central clearing house for extern placements. Only extern sites that comply with guidelines should be included. Some form of accreditation is needed for individual sites.

2011 ICO Commencement Video | Photos

[Transcript of Full Commencement Address:]

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]

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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Additional Resources:

• NEEI Compliance Protocol to Meet Medicare Guidelines for Optometric Training Programs
• Graduate Medical Education (GME), Medicare and Optometry
• Optometry Students, Medicare Regulations and Third Party Plans
• Development of a New Clinical Training Model
• Ideas Submitted to President Obama’s Citizens’ Briefing Book

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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.

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