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

• Explore mergers of optometry schools and colleges.
• Diversify educational offerings to the high demand professions such as:
• Primary Care Medicine (MD) or (DO)
• Physicians Assistants
• Consider innovative programs with established universities or Health Sciences Centers (HSC). See: ICO and University of Chicago Affiliation and Opportunity for Osteopathy to Develop Innovative Optometry Degree Program.

Primary References

The Legal Profession

• Lowering the Bar: Law Schools Compete for Students Many May Not Have Admitted in the Past. Inside Higher Ed. 2015.
• Crop of New Law Schools Opens Amid a Lawyer Glut. Jennifer Smith, The Wall Street Journal. 2013.
• Job Market for Would-Be Lawyers Is Even Bleaker than It Looks. M Hansen, American Bar Association Journal. 2013.
• In Defense of Law Schools Hiring Their Own Graduates. Above the Law, by David Lat. 2013.
• Law School Transparency (lawschooltransparency.com)

The Optometry Profession

• Report on 2012 National Eye Care Workforce Survey of Optometrists. The Lewin Group. 2014.
• Eye Care Workforce Study: Supply and Demand Projections. The Lewin Group. 2014.
• A Quantitative Analysis of Optometry Density. K J Myers, Ph.D., O.D. Editorial. 2014.
• Lewin Survey Finds Large Optometry Surpluses. K J Myers, Ph.D., O.D. Editorial. 2014.
• Unresolved Matters of Importance to Optometric Education. C Mullen, L Walls. 2011.
• Assessing the Need for On-Site Eye Care Professionals in Community Health Centers. P Shin, B Finnegan, George Washington University. 2009.
• Reducing Visual Health Disparities in At-Risk Community Health Center Populations. Journal of Public Health Management. S Pimo, R Wilson, et al. 2009.
• Abt. Associates Inc., Workforce Study of Optometrists. A J White, C White, T Doksum. 2000.
• RAND, Estimating Eye Care Provider Supply and Workforce Requirements. PP Lee, CA Jackson, DA Rolles. 1995.

The post Is Optometry on the Same Path as the Legal Profession? – Full Article appeared first on Charles F. Mullen.

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.

The post Federal Support for Optometric Education is Essential appeared first on Charles F. Mullen.

New England Eye is the Patient-Centered Care and Clinical Education Affiliate of the New England College of Optometry.

The Teaching Compliance Protocol for New England Eye (PDF) describes the practical implementation of NEE Health Insurance Teaching Compliance Policy.

Authors: Senior Management Staff, NEE.

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We must not let anyone else write our future.

– Dr. Ronald Hopping, President AOA

Restructuring the Profession of Optometry (PDF)

Restructuring the Profession of Optometry (PPT)

Charles F. Mullen
Roger Wilson
Janice E. Scharre
David S. Danielson

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

Background

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

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

Page 3 of the Teaching Guidelines state:

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

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

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

Compliance with CMS Teaching Guidelines and EHR Procedures

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

Student Notations Risks with Electronic Health Record (EHR)

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

Self Disclosure

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

Teaching Physician-Centered Model

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

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

This model is successfully utilized in medical student clerkships.

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

Optometry schools and colleges must ensure:

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

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

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

Reference Documents

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

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Thank you for this high honor. It is a distinct privilege to join my fellow honorees, Dr. Joan Exford and Dr. David Reynolds on the dais this morning.

Trustees, President Scott, colleagues, honored guests and above all doctoral degree candidates.

I know you are eager to receive your degrees and celebrate your hard earned achievement. However, as tradition dictates—there will be no degrees until the old alumnus speaks.

Today, I join with families and friends in sharing the pride of an outstanding accomplishment—your Doctorate in Optometry.

You have been fortunate for the past four years to have received your professional education at an institution that is a leader in community-based clinical training and collaborative medical care.

Your future is bright with unparalleled opportunities in a rapidly evolving health care environment.

An excellent faculty and clinical attending staff have thoroughly prepared you for success in the areas of public health, patient care and clinical education.

In the area of public health—There are opportunities for you to meet the needs of special populations in medically underserved areas.

Those who live in poverty, the homeless, the frail elderly, the homebound, the developmentally disabled and the visually impaired.

The College’s subsidiary, New England Eye’s network of affiliations serves as the National model for outreach to special populations.

In patient care, practice opportunities are available in interdisciplinary care as optometrists manage more complex clinical conditions and diseases.

Telemedicine technologies and electronic health records provide the means for more effective patient management.

The model of inter-professional collaboration between optometry and ophthalmology pioneered at the New England College of Optometry formed the basis for affiliations between optometry colleges and medical schools in Philadelphia and Chicago.

The College’s nationally recognized research programs provide valuable insights to clinicians in the diagnosis, treatment and prevention of eye and vision conditions.

In clinical education, there are opportunities for you, as preceptors, to share your experiences in:

• patient-centered clinical education
• and clinical training in interdisciplinary facilities.

The College’s externship program is the most extensive and diverse in optometric education.

My education, like yours, prepared me not only to be a clinician, but also to contribute to the profession’s future.

Your professional status will provide entree to numerous civic and political activities.

In the past, the foresight and persistence of dedicated optometrists expanded the profession’s responsibilities by including pharmaceuticals, advanced clinical procedures, creation of the VA Optometry Service and participation in Medicare.

You are now called upon to make such a contribution.

Important matters face the profession of optometry.

Board Certification and Continued Competency initiatives require your attention and understanding of their place in your profession.

I encourage your active participation at the local, state or national level in planning for your profession’s future.

With major changes expected in health care policy at the Federal level, there are unprecedented opportunities for optometry to seek inclusion in three major Federal programs.

First and already in progress, is the expansion of optometry’s impact in the community health care system.

The New England College of Optometry was the first optometric institution to recognize its responsibility to the medically underserved community by developing affiliations with Boston Area community health centers.

Today, 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.

It is estimated that 5,000 optometrists would be needed in the Nation’s underserved areas over the next decade.

Federal funding is required to establish optometric services in all of the Nation’s community health centers.

Second, 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.

Third is optometry’s inclusion in the Graduate Medical Education program, GME, the clinical educational component of Medicare. Participation in this $10 billion program would address:

• the increasing costs of clinical training as the scope of optometric practice continues to expand.
• and growth in the demand for eye care services by the Medicare population.

Optometrists have been participating physicians in the Medicare program since 1987 and currently provide $1 billion in services annually.

Now is the time to join medicine, dentistry and podiatry as a recipient of GME funding for clinical training.

Your participation in advancing initiatives in Community-Based Eye Care, the National Health Service Corps and the Graduate Medical Education Program is essential to their success.

Although the work ahead will be challenging, optometry’s inclusion in these three major Federal programs would provide eye care to tens of thousands of underserved Americans, new practice opportunities, and forever change the clinical training and financial landscapes of optometric education.

I am confident that the profession’s future leaders are in the auditorium 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 excellence is a mandate not an option.

Values will always be a source of strength. Character and contribution will define your success.

For in the final analysis, it is neither about financial rewards nor power, but pride in your professional and personal achievements.

Thank you and congratulations.

The post New England College of Optometry Commencement Remarks appeared first on Charles F. Mullen.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

Q: 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.

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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

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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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Federal Financing of Optometric Clinical Training (PPT)

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