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[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

Health care financing and provision are issues that affect virtually every individual in the United States today. As health care costs continue to rise, providers, third-party payers, and patients alike actively seek more effective and efficient provision systems. If providers fail to provide quality and cost-effective health care, they will be left behind in the increasingly competitive market. Similarly, if patients and third-party payers do not use more effective and efficient systems, they will assume an even greater share of the rising health care expense.

Affiliation between professional institutions presents numerous opportunities for enhancing the educational and clinical training of students, residents, and practitioners. Institutions that are developing their respective professions can collaborate in many ways of mutual interest.

Two Philadelphia health care institutions, located within 9 miles of each other, HU and PCO, cognizant of the changing health care environment and the possible benefits of collaborative education, have begun to explore new approaches to patient care provision and ophthalmic education. On March 2, 1988, the two institutions signed an agreement for an affiliation. The agreement, effective July 1, 1988, proposes that the professions of medicine and optometry combine resources to develop unique approaches to ophthalmic education, eye care provision, and ophthalmic research.

The Context and the Decision to Affiliate
Ophthalmology and optometry have existed as separate, often antagonistic, professions since their inceptions, so why affiliate now? The impetus comes from outside parties – particularly third-party payers, health care policymakers, and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define these roles themselves. The ophthalmology community maintains that the diagnosis and treatment of eye disease should be restricted to physicians. The optometry community, on the other hand, proposes that optometrists should be the primary eye care providers and should offer an even greater range of eye care services than they do now. Interprofessional disputes involving the treatment of eye disease by optometrists, preoperative and postoperative management, and the use of laser technology in refractive treatment remain unresolved in many areas of the country. Debates in journals and in legislative chambers, however, may or may not produce satisfactory outcomes for either profession. In our opinion, the time has come for ophthalmologists and optometrists alike to acknowledge that through collaborative efforts the two professions can define a future for eye care provision that will satisfy their needs as well as those of patients and policymakers.

Pennsylvania College of Optometry, which graduates approximately 140 optometrists each year, and HU, comprising a medical school, graduate school of health sciences and humanities, and a teaching hospital, considered the potential benefits of a cooperative arrangement between the professions of medicine and optometry. In 1987, they began to explore the possibility of an affiliation. Such an affiliation was unprecedented and, given the political environment, highly controversial. Therefore, before agreeing to proceed with the affiliation discussions, representatives from both institutions considered the following issues:

1. How will the professional communities respond to the affiliation?
2. How will alumni and other constituencies respond?
3. Should the services rendered under the affiliation be marketed? How will the professional communities react to joint marketing efforts? Will the managed health care systems accept a joint provision model?
4. What are the roles of ophthalmology and optometry in primary care?
5. How will patients be managed under the terms of the affiliation agreement?
6. Will the model of patient care provision defined by the affiliation be in compliance with state and federal laws and regulations?
7. Will the affiliation create competition between ophthalmology residents and optometry students for primary care encounters?
8. How will the introduction of new technology, such as lasers, be administered under the terms of the affiliation?
9. What is the proper and ethical role for each institution in the areas of patient management and financial agreements?
10. What are the positive and negative consequences of such an affiliation?

Of these issues, those involving the reactions of health care communities were perhaps the most sensitive. Some ophthalmologists feared that the affiliation would undermine ophthalmology’s role in primary eye care. Locally, some ophthalmologists threatened to refer patients elsewhere if HU proceeded with the affiliation; in fact, a number of ophthalmologists did stop referring patients after the affiliation took effect. Nationally, some ophthalmologists voiced their disdain for a cooperative agreement between medicine and optometry (Argus. November 1988:8, June 1989:4, and December 1989:22). Optometrists nationwide questioned whether or not the affiliation would place their profession in a subordinate role to ophthalmology.

Alumni of HU voiced their disagreement with the affiliation through letters, telephone calls, and refusals to continue to support the school financially; PCO alumni, on the other hand, tended to view the affiliation positively.

Given the emotional nature of the affiliation, the marketing issue was all the more troublesome, and the planning stages proceeded with deliberation. The first efforts at marketing involved educational radio announcements, simply informing the public that the two institutions now offered joint services. These proved successful in piquing the interest of potential patients and third-party payers, such as health maintenance organizations. Marketing in the future will use both radio and newspaper media.

Issues regarding the provision of services and the roles of ophthalmologists, optometrists, students, and residents are addressed in a series of protocols, which will be discussed in greater detail below. Currently, these protocols are in draft form and are revised as necessary. However, they still constitute the backbone of the affiliation, and set the rules by which we operate. If care is not provided according to the terms of the protocols, the affiliation will fail, perhaps causing irreparable damage to the future of relationship between ophthalmology and optometry.

Recognizing a mutual desire to influence the future direction of the eye care professions, the two institutions decided to move ahead with the affiliation despite the risks and expected negative reactions. A primary goal of the affiliation is to define the role each profession will play in the changing environment before third-party payers and regulatory agencies mandate new policies. By engaging in curriculum discussions and in joint research efforts, the institutions hoped to enhance their own educational and research programs and, at the same time, design a health care provision system that would become a national model acceptable to all parties: ophthalmologists, optometrists, patients, and policymakers.

The Agreement
Philosophically committed to the affiliation, representatives of the two institutions began to define the elements of the agreement. It was decided that the firm foundation and base of the agreement would be education, on which other aspects of the agreement would be built. Many months of negotiations culminated in the written agreement to affiliate. Salient aspects of the agreement are summarized below:

1. Each institution will retain autonomy over its operations and finances.
2. An Affiliation Executive Committee will provide guidance, advice, and oversight on matters relating to the affiliation, including education, research, clinical, and administrative issues.
3. The Chairman of the Department of Ophthalmology at HU and the Dean of Academic Advancement at PCO will be responsible for administering the affiliation.
4. Appointments to the faculty or staff of either institution will be made in accordance with the policies and procedures of each institution.
5. On request, the clinical faculty and house staff at HU will provide consultative subspecialty medical/surgical services to the patients of PCO in a location dedicated to subspecialty care. Consultative subspecialty services will be provided for a full spectrum of medical ophthalmic conditions, including, among others, cataracts, cornea and external disease, diseases of the ocular adnexae, diseases of the retina and vitreous, glaucoma, neuro-ophthalmic disease, ocular trauma, pediatric ophthalmic disease, and strabismus. In addition, HU will provide continuous emergency medical/surgical backup services to patients of PCO.
6. Clinical faculty, residents, and other staff at PCO will provide consultative optometric, vision rehabilitative, and other services to patients of HU on request. Consultative optometric services will include contact lens evaluation and fitting, low-vision rehabilitation, eyeglass dispensing, orthoptics, and learning and disability evaluation and treatment.
7. Patients will be referred to HU or to PCO, as appropriate, when such referrals are in the best interest of the patient, are agreed to by the patient, and are consistent with applicable laws and regulations, such as those mandated by the Medicare and Medicaid programs and by professional ethics.
8. Students at HU, with approval from the dean of the School of Medicine, may take courses taught by PCO faculty. Likewise, PCO students, with the approval of their dean of Academic Advancement, may take courses taught by HU faculty.
9. The faculties of both institutions will engage in joint educational programs, such as didactic and continuing education lectures, clinical preceptorships, seminars, electives, and grand rounds.
10. The faculties of both institutions may participate in joint research efforts. Joint research programs will be approved and administered in accordance with the polices and procedures of each institution.
11. The faculty and administration of both institutions will seek to develop new and innovative health care provision systems.
12. All publicity, marketing, and fund-raising materials regarding the affiliation must be approved by the Affiliation Executive Committee.
13. Neither institution will use the affiliation for its own or its profession’s political gain.
14. All health care providers operating under the affiliation must have appropriate and adequate professional liability insurance as required by law.
15. Each institution will make available to the other institution, on request, all pertinent information regarding legal, financial, contractual, managerial, and other issues relevant to the affiliation. All such information will be held strictly confidential.

An interim financial agreement was added as an addendum to the original agreement. A global financial agreement addressing the provision of clinical as well as educational services is still under negotiation. It will supersede the interim agreement as soon as it is finalized.

The faculty, medical staffs, and administrations of both institutions were informed of the affiliation discussions and most supported the initiative.

The Model and the Implementation Process
The model of eye care provision eventually agreed on assumes that ophthalmology and optometry are complementary, and it seeks to emphasize the strengths of each profession. It stipulates that primary eye care provided at PCO is delivered by optometric staff. Patients with conditions requiring subspecialty medical or surgical intervention are referred for consultation, management, or both to the HU ophthalmology staff. After the consultation and any necessary medical or surgical treatment are completed, the patient is referred back to the referring optometrist for ongoing care. Likewise, patients who receive their primary eye care by ophthalmologists at HU and who require contact lenses, low-vision rehabilitation, orthoptics, or learning disability services are referred to PCO optometric staff for treatment. Ongoing medical/surgical care is provided by ophthalmologists. In our opinion, therefore, ophthalmologists and optometrists work in tandem to provide appropriate, cost-effective, and high-quality care.

Educational Programs
A fundamental goal of the affiliation is to develop joint education and research programs. Therefore, much effort has been spent in restructuring existing programs and creating new ones. Basic science and clinical faculty at HU currently offer courses in ocular microbiology/immunology, pharmacology, clinical medicine, and microanatomy at PCO. In the future, HU faculty will be offering courses designed for students of optometry in general and medical pathology and physical diagnosis.

Programs in clinical education also are being redefined. Ophthalmology residents accompany HU faculty on rotation in subspecialty care at PCO’s clinical facility, The Eye Institute. In addition, PCO’s faculty offers ophthalmology residents rotations in contact lens and low-vision rehabilitation services. Similarly, optometry residents and a few students are afforded the opportunity to rotate through ophthalmology subspecialties under the tutelage of the ophthalmology staff. Further, ophthalmology faculty participates in clinical conferences at PCO. Students and residents of both institutions are thus exposed to a broadened clinical base and an array of ophthalmic disorders. The hope is that such exposure will result in a more well-rounded clinical education.

Faculty of PCO have commented that the educational programs have enabled them to enhance their own clinical skills and knowledge base. However, educational programs are not limited to the faculty and students of the affiliated institutions; programs have been designed to benefit community providers as well. Faculty of HU have lectured at PCO grand rounds and have participated in the college’s continuing education seminars. Programs such as these encourage interaction between the professions and therefore, are consistent with the goals of the affiliation.

Clinical Services
Before clinical services were actually provided under the terms of the affiliation, clinical faculty of both institutions worked together to draft patient care management and referral protocols, to outline the management process, and to establish quality assurance standards. To date, protocols have been approved for referral from PCO to HU regarding the following aspects of care: (1) cataracts, including preoperative and postoperative care; (2) cornea and external disease; (3) disease of the ocular adnexae; (4) disease of the retina and vitreous; (5) glaucoma; (6) neuro-ophthalmic disease; (7) ocular trauma; (8) strabismus; and (9) pediatric ophthalmic disease.

When a patient is referred to HU for management, the ophthalmologist assumes ultimate responsibility for treating the disorder. The referring optometrist may observe the operation and may assist in the preoperative and postoperative care. However, medical/surgical care is always rendered personally by the physician. Referrals from HU to PCO may include the following: (1) contact lens care; (2) eyeglass dispensing; (3) orthoptics; (4) low-vision and vision rehabilitation; and (5) learning disabilities.

The protocols define a “closed loop provision system” that enables providers to monitor more effectively the quality of care rendered. Under PCO’s previous program, patients were referred to independent consultant ophthalmologists for medical/surgical treatment. This system was open-ended, and methods of record keeping were informal. In the closed system model, providers are in regular communication, and referral information is compiled and reported on a monthly basis. Furthermore, independent computer systems currently being implemented at both HU and PCO will allow providers to monitor care more effectively and determine when patients miss appointments or leave the system so that appropriate follow-up communication can be initiated.

While the protocols were being finalized, administrative staff began to define the operation of the provision system. Issues such as scheduling, personnel, space requirements, equipment requirements, medical records management, and billing policies and procedures were addressed. Given the high volume of clinical activity at The Eye Institute, HU employs a full-time office manager at that facility to oversee the Department of Ophthalmology’s clinical and financial operations. This person is responsible for patient scheduling, registration, charge entry, and medical record preparation. Pennsylvania College of Optometry operates contact lens and low-vision services at HU one-half day each week. The Eyewear Center, located at HU, and also operated by PCO, is open 5 days each week and is staffed by PCO employees.

Joint clinical chiefs’ meetings are held regularly to monitor the progress of the affiliation in general and, in particular, to evaluate the protocols, discuss quality assurance issues, and to review clinical programs. These meetings help maintain open communication among the providers and facilitate patient care provision. To date, revisions have been made in the glaucoma and cataract protocols.

Research
The affiliation agreement encourages joint research ventures and, indeed, opportunities for collaborative research are considerable. Approximately 75,000 outpatient visits are recorded each year at The Eye Institute. Likewise, 282,000 outpatient visits for medical problems, including eye disease, are scheduled at HU. As a result of the affiliation, investigators have a large base from which to draw patients for studies. Faculty at both institutions are currently working together on research projects, which include learning disabilities and macular degeneration. Protocols for excimer laser investigations also have been discussed. Should these be pursued, optometrists will engage in basic research while ophthalmologists and other physicians will conduct clinical trials.

Of special note is the fact that research areas have not been limited to eye disorders and disease. Faculty at HU’s Department of Neurology and Psychiatry have joined faculty at the PCO’s Learning (Disabilities) Center in research investigating learning disabilities.

Recent Developments and Future Directions
Over the past year, many of the goals of the affiliation have been realized, and the future looks very bright to us. As participants of the PCO externship program, a few selected optometry students soon will have the opportunity to share in patient care in the Department of Ophthalmology at HU. New projects under discussion include a joint prison eye care program and the establishment of satellite clinics and faculty private offices, which will be structured according to the provision model previously described. Satellite clinics would be geographically located in the Philadelphia area to serve areas populated by the “underinsured” – the working poor who do not have adequate health care coverage. The faculty private offices would be strategically located to enhance the marketing potential of the affiliation.

Marketing initiatives already are underway; efforts will be directed to optometrists in private practice, primary-care physicians, managed-care systems, commercial insurers, and the general population. The opportunities for marketing are perhaps greatest in the managed-care sector. The model of eye care provision developed under the eye care affiliation is consistent with that used by many managed-care systems, i.e., optometrists provide primary eye care, while ophthalmologists provide medical and subspecialty care. The vehicle for marketing services to managed-care systems will be EyePA Ltd, Philadelphia, a for-profit subsidiary of PCO. On a contractual basis, EyePA Ltd provides eye care services to managed-care systems, self-insured corporations, and other insuring entities. EyePA Ltd is a multifunctional specialty organization that (1) manages utilization of eye care services; (2) provides, on a capitated or fee-for-service basis, a full range of professional eye care services through a network of contracted professionals; and (3) credentials specialty eye care providers and institutions.

Comment
Many individuals maintained that doctors of medicine and doctors of optometry could not work together as colleagues sharing the same goals and aspirations.

Looking back over the past 17 months, we believe that the skeptics were wrong. The affiliation has exceeded our expectations and has progressed much more quickly than any of the planners had imagined. Events to date suggest that joint educational, clinical, and research programs have been advantageous to both medicine and optometry, and that teams of medical doctors and optometrists can work together as colleagues in one eye care provision system.

Archives of Ophthalmology
Controversies in Ophthalmology
Volume 109, Number 2. February 1991.
Charles F. Mullen, O.D.
Myron Yanoff, MD
Laura A. Wilson, MS