How to Position Optometry for Inclusion in the Graduate Medical Education Program (PPT)

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To assure compliance with Medicare requirements for billing and reimbursement of comprehensive exams for new and established patients (CPT codes 92004 and 92014), NEEI adheres to the CPT definition of a comprehensive exam. CPT 2008 defines a comprehensive eye exam as follows:

Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

From this definition NEEI interprets the essential elements of a comprehensive eye exam (for which the attending doctor is personally responsible for performing except 1.b. and 1.c. below) to include the following minimum data set:

1. Comprehensive eye and health history and history of present illness

   a. History of present illness, physical exam findings and medical decision making must be documented by attending doctor.

   b. Optometry students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.

   c. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

2. General medical observation
3. External ophthalmic examination
4. Ophthalmoscopic examination
5. Gross assessment of visual fields
6. Sensorimotor assessment
7. Diagnosis
8. Treatment

Optional features of a Medicare compliant examination include:

1. Biomicroscopy
2. Dilated ophthalmoscopic examination
3. Tonometry

NEEI’s interpretation of Medicare rules for a comprehensive eye exam does allow for the involvement of optometry students in portions of the exam. However, to be Medicare compliant, the attending doctor is required to personally perform (or repeat) the essential parts of the examination listed above, except for the review of systems and/or past family/social history which may be documented by students.

Furthermore, the diagnosis and treatment plan must be supported by procedures actually performed by the attending doctor.(For example, a diagnosis such as glaucoma would require tonometry – in most cases – and thus tonometry would have to be performed (or repeated by the attending doctor.)

It must be clear from a record audit that the diagnosis and treatment were arrived at solely based on the attending doctor’s examination. The attending doctor must be able to advocate the position that the student’s findings were not considered in making decisions.

Additionally, NEEI’s compliance protocol states that the history of present illness, diagnosis, and treatment are essential exam components and thus the accompanying documentation of these essential elements are to be completed by the attending doctor, either by handwritten notes, through dictation and typed record, or via computer generated and typed method.

The NEEI Medicare compliance protocol does not require that the attending doctor repeat non-essential elements of the exam or elements that are not covered by Medicare, such as refraction.

The NEEI Comprehensive Eye Exam Form (PDF)

The NEEI comprehensive eye exam form has a column for the attending doctor to document essential elements. The form also has space for exam procedures such as biomicroscopy and other elements of an exam that would be repeated by the attending doctor as a matter of course.

The section for the student’s assessment and plan are placed on a separate sheet at the end of the exam form, after the attending doctor’s assessment and plan. This is to assure compliance with Medicare guidelines and the independence of the attending doctor’s conclusions from those of the student.

Mark O’donoghuem
Roger Wilson
Charles F. Mullen

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Background

In a decisive effort to move into the mainstream of health care and to address concerns about the legal exposure of an educational institution providing services to Medicare and Medicaid beneficiaries, The New England College of Optometry (NECO) in 2002 spun off its clinical system and its assets into a separate subsidiary corporation, the New England Eye Institute (NEEI). This was the first time a private college of optometry was to form an optometric analog to the medical school/teaching hospital structure. The new clinical corporation has its own Articles of Incorporation, By-laws, Board of Directors and administration similar to those of a teaching hospital. NEEI’s governance documents reflect considerable oversight by NECO. A detailed position description for the CEO was written which incorporated the elements of the incorporation documents. NEEI has made significant progress in realizing the potential of this new structure and has demonstrated that the oversight mechanisms in place have been effective. This summary outlines the advantages of a separate clinical corporation, supports the advantages with available data, restates the College’s oversight processes to assure added value and mission alignment, and notes concerns and misunderstandings that need further discussion…

Distinct and Separate Legal Structures for Clinical Programs of Schools and Colleges of Optometry (PDF)

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From the Preface

Over the past four years, members of the Illinois College of Optometry community have witnessed the College’s progress in meeting broad institutional goals and objectives initially articulated in “Prescription for Excellence” and in meeting specific performance targets described later in “Journey to Excellence.”

The latest version of the strategic plan “Commitment to Excellence” continues the process of transformation of the institution outlined in the earlier plans with further emphasis on measurement systems and quantified strategic and annual performance targets…

Commitment to Excellence (PDF)

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My discussion of the future of the veterans’ health care system is based on the following assumptions:

• The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
• Most health care in the United States will continue to be provided by the private sector.
• There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
• Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
• Medical and scientific information will continue to grow at an astonishing rate.
• Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
• Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
• Integrated information systems will be the key to success for future health care systems.
• Nonphysician providers will be increasingly used in health care systems of the future.
• Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
• There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
• While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
• The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
• In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.

In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.

The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.

To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.

There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:

• Reengineering the operational and management structure of the veterans health care system.
• Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
• Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
• Restructuring VHA headquarters.
• Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
• Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
• Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
• Increasing the proportion of the VA’s work force providing primary care.
• Developing tailored training/retraining programs in primary care.
• Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.

Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:

• Increased sharing of activities with academic affiliates and the Department of Defense.
• Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
• Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
• Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
• Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
• Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
• Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
• Increasing the proportion of trainees in primary care disciplines.
• VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
• Initiating review and renegotiation of all academic affiliation agreements.
• Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
• Academic affiliations and residents are likely to be negotiated on a Network basis.
• Clinical credentialing and privileging will probably be conducted on a Network basis.

The VA’s Current Contributions to Optometric Education

There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.

There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.

What Can Individual Schools and Colleges Do to Preserve VA Affiliations?

• Above all, be an active partner.
• Assist VA facilities with Quality Improvement activities.
• Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
• Seek appointment of school-based optometric faculty as consultants at VA facilities.
• Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
• Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
• Increase awareness of VA affiliations by publicizing your institution’s activities.
• Seek new academic affiliations within your Network.
• Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
• Seek cooperative research projects with VA affiliates.
• Consider WOC residency programs as a means to initiate new programs.
• Understand the new JCAHO accreditation standards and survey process and their implications to optometry.

What Can ASCO Do Collectively?

ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:

1. In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
2. Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
3. Stimulate research proposals in cooperation with VA medical centers.
4. Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
5. Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
6. ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
7. Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.

This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.

At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.

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