Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Is Optometry on the Same Path as the Legal Profession? – Full Article

Law schools waited too long before taking action to address the oversupply of lawyers and now face the crisis of a serious decline in student applicants and underemployment and unemployment of recent graduates. Many law schools face serious financial issues, staff and faculty layoffs. Lower-tier law schools are merging and at least one school plans to close. Increases in law school enrollments (53 new law schools opened since 1973) without corresponding increases in demand have resulted in 45% of recent law graduates unable to find full time employment. The top 14 law schools now find it necessary to employ from 4-17% of their graduating classes. As a result, applications to law school continue to decline – down 37% from 2010.

Optometry schools and colleges now face the similar effects of oversupply (12,672 FTE excess) of optometrists including declining student applicants and declining full time employment opportunities. There were seven new optometry schools added and increased enrollments at existing schools in the last six years without a demonstrated increase in demand. Full time positions with sufficient income to service educational debt are difficult to find, and now 40% of recent graduates practice at two or more part time locations. Even for those employed or self employed optometrists function at only 68% of their practice capacity. Like the legal profession, there are no signs of abatement in the poor full-time employment market or decline in optometry school applicants. The decline in applicants is exuberated by continuing expansion of new optometry schools.

To mitigate the effects of an oversupply of optometrists, optometry schools and colleges’ leadership must immediately acknowledge and directly address the serious challenges impacting on the stability of optometry schools and colleges including:

  • Current and future oversupply of optometrist: 12,672 FTE excess now and oversupply remains at 9,000 FTE in the future.
  • Increase in number of optometry schools and increased enrollments at existing schools: Seven new schools added in last 6 years while graduates increased from 1127 in 1997, when supply equaled demand, to 1600 now. At full enrollment of all schools, graduates will increase to over 1800.
  • Decline in the student applicant pool – less than 1.5 applicants per entering seat, while number of entering seats has increased from 1160 to 1763 in six years.
  • High graduate debt – over $200,000 for many graduates vs. income potential to service debt.
  • Decline in college age students – .5 million less than in 2012.
  • Decline in full-time employment opportunities for recent graduates. 40% of graduates practice at multiple part time locations.
  • Lack of Federal support for clinical training, scholarships and loan repayment – Optometry excluded from $11.5 billion Graduate Medical Education Program, National Health Service Corps and Title 7 programs.

In view of the data in the Rand, Abt. and Lewin Optometric Manpower Studies indicating a substantial excess of optometrists, it would be prudent to mitigate the effects of a decline in full time employment of graduates and decline in applicants for admission by the following actions:

Action 1: Proactively Address the Oversupply of Optometrists

  • Reduce enrollments at all schools and colleges of optometry and adjust corresponding revenue and expense projections.
  • Demand clarification and correction of Bureau of Labor Statistics (BLS) projections. It appears these projections are significantly contributing to the oversupply of optometrists by encouraging the development of new schools of optometry. Conflicting data on optometric manpower: Rand Study-1995, Abt.Study-2000 and Lewin Study-2014 all indicated significant surpluses. Meanwhile the Bureau of Labor Statistics (BLS) projects high demand for optometrists. In view of all the evidence and studies to the contrary, it is logical to assume the BLS based their projections on inaccurate or obsolete data.
  • Insist the Accreditation Council on Optometric Education (ACOE) develop quantitative standards similar to medicine and dentistry for evaluating accreditation for new and existing school and colleges of optometry. Only accredit new schools when the quality and quantity of student clinical training opportunities can be demonstrated.
  • Increase demand for optometric services by addressing the underlying public health need for eye care in inner-city and rural areas. Only 20% of federally qualified community health centers provide optometric services. However, Boston community health centers have made a successful and sustained 40 year effort to address unmet need for optometric services in inner-city Boston. See: New England College of Optometry Clinical System. Inclusion of optometry in Federal incentive programs (loan forgiveness, scholarships, National Health Service Corps, etc) is essential to providing optometric services in rural and inner-city America.
  • Conduct cost analysis of all clinical training venues and adjust clinical training placements to reduce overall operating costs. Review Relative Costs per Clinical Teaching Encounter: Campus-based clinics are by far the most costly. ($100-350). Affiliated facilities less ($10-30). Externships least costly ($.50-1.00).
  • Visit/Revisit the advantages of a Faculty Practice, integrated with clinical training, in terms of increased IEI revenue, supplemental faculty income, faculty recruitment/retention and compliance with Medicare/Medicaid Guidelines for Teaching Physicians. Faculty Practice also addresses the Center for Medicare/Medicaid Services (CMS) compliance vulnerabilities by changing from a Student-Centered Clinical Training Model to a Physician-Centered Program. Students cannot provide billable services to Medicare and other insurance plans. Two Optometry Schools fined for violations with current Student-Centered Training Model. Combined fines are nearly $1.0 million.
  • To provide full-time employment for graduates, optometry schools and colleges should fund government related fellowships. These positions would be used to provide experience to graduates in Federal and State health care policy.

Action 2: Address High Graduate Debt vs. Income Potential

  • Reduce student debt by shortening the length of overall education for the OD degree. Eight medical schools (DO & MD) have or are developing three year programs. Salus University/PCO is piloting a three year program. NECO has in the past offered a 3-year program.
  • Encourage accelerated admissions from undergraduate institutions.
  • Remove course redundancies and move selected course work to undergraduate prerequisites.
  • Reduce student debt by qualifying for Federal scholarships and loan repayment programs, such as the National Health Service Corps and Title 7, Section 747 through a comprehensive Federal advocacy strategy.

Action 3: Federal Funding for Clinical Training

Create eligibility for the $11.5 billion Graduate Medical Education (GME) program by restructuring the curriculum, changing state licensing requirements and aggressive advocacy to amend the Social Security Act to include optometry. Restructure the curriculum to potentially qualify for GME, the educational component of Medicare: New model would consist of 3 years for OD degree + final year of postgraduate training to qualify for licensure and board eligibility. Social Security Act amended to include optometry and training in outpatient facilities. GME pays an average of $100,000 per medical resident annually to hospitals. Requiring postgraduate training for state licensure along with Board Certification would place optometry in parallel with medicine and enhance qualification for the GME program. “Best Practices” model would parallel medicine and consist of degree + postgraduate training = licensure + specialty board certification. See: Changes Necessary to Include Optometry in the GME Program.

  • Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to fund a pilot project of the new curriculum/clinical training model (3 years for OD + 1 year of postgraduate training).

Action 4: Investigate Alternative Strategies to Prevent Financial Crises at Schools and Colleges

Primary References

The Legal Profession

The Optometry Profession

by Charles F. Mullen

Federal Support for Optometric Education is Essential

Federal support for clinical training, scholarships and loan forgiveness is essential for optometry to remain competitive in health professions education.

Medical, dental and podiatric education all benefit from Federal financial support while optometry does not, placing optometric education at a competitive disadvantage. Federal financial support will not address all of optometric education’s challenges. However, Federal assistance in financing an optometric education will certainly make optometry a more attractive career option.

The following are serious challenges facing optometric education:

  • Stagnate Optometry Student Applicant Pool: Currently 1.5 applicants per entering seat—qualified for admission likely 1:1. Projection models suggest an actual decline in number of applicants per seat.
  • Significant Increases in the Number of Entering Seats from New Schools and Increased Enrollments at Others: Applicant pool not increasing, although the number of entering seats has increased from 1160 to 1763 or 52% in a decade. Number of entering seats likely to exceed 2000 by 2015-16.
  • Decline in Undergraduate College Enrollments: College enrollment declined by one-half million students in 2012.
  • Optometric Manpower Uncertainty: Conflicting data on optometric manpower: Rand Study-1995 and Abt.Study-2000 both predicted significant surpluses. Meanwhile the Bureau of Labor Statistics projects high demand for optometrists. Hopefully, AOA’s Lewin study-2013 will clarify the matter, but the study has not been released.
  • Full Time Employment Concerns: Anecdotal concerns expressed by recent graduates about the shortage of full time positions with sufficient income to service education debt. — Increases in law school enrollments, without corresponding increases in demand for lawyers, have resulted in that only 55% of recent law graduates can find full time employment.
  • High Graduate Debt vs. Potential Income: Not unusual for student debt to exceed $200,000, while potential annual income averages $95,000. Thus the importance of the opportunity for Federal scholarships, loan forgiveness programs or stipends during final clinical year.
  • High Cost of Clinical Training: Increases in clinical training costs are passed on to the optometry student in the form of higher tuition. Colleges of optometry are burdened by high fixed cost campus-based clinics. Relative costs per Clinical Teaching Encounter: Campus-based clinics are by far the most costly. ($100-350), Affiliated facilities less ($10-30). Externships least costly ($.50-1.00).
  • Medicare Compliance Concerns: Current optometric Student-Directed Clinical Training Model is not compatible with “Medicare/Medicaid (CMS) Guidelines for Teaching Physicians, Residents and Interns (Students)”. Students can not provide billable services to Medicare beneficiaries and other insured patients. Two university- based optometry schools paid significant fines for Guidelines’ violations with the current Student-Centered Training Model.
  • No Standardization of Certification Boards: Newly formed optometric certification boards have different criteria for board certification. It is essential that all boards operate with standardized criteria for recognition by Federal and private agencies and insurers. Medicine has such an oversight board, the American Board of Medical Specialties (ABMS).
  • Lack of Federal Financial Support: Optometric education receives no financial support for clinical training because its clinical training model does not meet Graduate Medical Education (GME) expectations. Furthermore, optometry does not qualify for Federal scholarships and loan forgiveness programs, because the profession is not designated as a Primary Care Profession.

Immediate Action Required

The implementation of the Affordable Care Act (ACA) presents a unique opportunity to pursue Federal financial support for optometric education by:

Aggressively advocating and pursuing optometry’s inclusion in key Federal patient care, educational, scholarship and loan forgiveness programs.

The last serious effort by ASCO/AOA to include optometry in GME was in 2007 and the proposal was rejected because the optometry clinical training model does not meet GME expectations. There also have been periodic efforts to include optometry in Federal scholarship and loan forgiveness programs.

To be effective, advocacy must be organized, consistent, well-funded and managed by knowledgeable individuals, preferably Deans and Presidents of optometry schools and colleges. Unlike optometry, leadership in the medical profession emanates from the Academic Medical Centers and has significantly contributed to success of both medical education and the medical profession.

Specific Initiatives

  1. Create eligibility for the $11.5 billion Graduate Medical Education (GME) program by restructuring the curriculum, changing state licensing requirements and aggressive advocating to amend the Social Security Act to include optometry and its training facilities.

    • Restructure the curriculum to potentially qualify for GME, the educational component of Medicare: New model would consist of 3 years for OD degree + final year of postgraduate training to qualify for licensure and board eligibility.
    • Requiring postgraduate training for state licensure along with Board Certification would place optometry in parallel with medicine and enhance qualification for the GME program. “Best Practices” model would parallel medicine and consist of degree+ postgraduate training = licensure+ board certification. GME pays an average of $100,000 per medical resident annually to hospitals.
    • Eight medical schools (DO & MD) have or are developing three year programs. Salus University/PCO is piloting a three year program. NECO has in the past offered a 3-year program. Only Arkansas and Delaware currently require postgraduate training for licensure.
    • Persuasive leadership is required to convince schools/colleges, state licensing boards, residency programs, certification boards and accreditation groups of the necessity of collaboration in restructuring clinical training.
  2. Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to fund a pilot project of the new curriculum/clinical training model (3 years for OD + 1 year of postgraduate training).
  3. Qualify for the National Health Service Corps (NHSC) by achieving Designation of Optometry as a Primary Care Profession and by Federal Legislative Amendment.

    • Provides loan repayment and scholarships to health care professionals providing primary care in underserved areas.
  4. Include optometry in all aspects of Title VII, Section 747 by designation of optometry as a Primary Care Profession and Federal Legislative Amendment.

    • Provides scholarships and loan repayment to students who agree to work in underserved areas. Also, supports minority graduates, residents and faculty.

by Charles F. Mullen