Introduction
There have been significant changes in optometric education in the last decade. Seven new optometry schools were founded and total graduates increased by over 530 per year. Nationwide there is an excess of over 12,600 optometrists with geographic variations as reported in the AOA/ASCO sponsored 2014 analysis of optometric manpower. Nationally, optometrists are practicing at only 68% of capacity.
Commercial optometry has increased its impact on employment and income. The direction optometry takes, whether commercial in nature or further expansion of the scope of medical practice, will significantly affect optometric education.
The student applicant pool (1.4 applicants per entering seat) is static. Educational costs along with debt versus income potential are likely the deciding factors for most student applicants.
As clinical training costs increase so does tuition and student debt. Unfortunately, there is no Federal support for clinical training as optometry is not eligible for the multi-billion dollar Graduate Medical Education (GME) Program. Inclusion of Optometry in the GME Program may be a necessity for optometric education.
The VA threatens to outsource the Optometry Program, eliminating the largest optometry student and resident clinical training program in the Nation. In addition, Congress threatens changes to the Medicaid Program which would significantly reduce college and affiliates patient services revenue and clinical teaching encounters.
Technology, online providers of eyeglasses/contact lenses, and utilization of physician extenders in providing eye care change the traditional practice of optometry and will eventually affect optometric education.
Ten Challenges for Optometric Education
The following factors significantly impact optometric education. An overview of each factor and initial actions that can be taken are listed below.
- Significant Oversupply of Optometrists
- Inflated Enrollments and Excess Graduates
- High Graduate Debt vs. Potential Income
- Static Student Applicant Pool
- Impact of Corporate Optometry
- Potential Loss of Medicaid Clinic Revenue
- VA Threatening to Outsource Optometry Services
- Exclusion from Many Key Federal Scholarship and Loan Repayment Programs
- Increased Clinical Training Costs with No New Revenue Sources
- Exclusion of Optometry from the Graduate Medical Education Program
1. Significant Oversupply of Optometrists
- Lewin Study (2014) indicated an excess supply of 12,672 FTE with geographic variations. Nationally, optometrists function at only 68% of capacity.
- Previous studies by Rand (1995) and Abt. (2000) also found an excess supply.
- The Lewin Study indicated that 46% of optometry school graduates under 30 years old practice at two or more part time locations, suggesting limited availability of full-time employment or part-time employment is preferred by a large segment of recent graduates.
- In the long term, market corrections will balance supply and demand. Unfortunately, in the short term, it leaves many young optometrists with significant debt in an overcrowded eye care provider market.
- The Bureau of Labor Statistics (BLS) regularly publishes an optimistic report which contradicts Lewin, Rand and Abt findings. Several institutions cited the report as rationale for founding a new optometry school.
Recommended Actions
- Lewin’s recommended solution to oversupply is to further expand the scope of practice into advanced medical treatment and compensate for the shortage of ophthalmologists.
- Increased clinical training requirements, state practice laws changes, insurance reimbursement, and political opposition are significant challenges and will take years to reconcile.
- Immediate measures are also needed and delineated later in this document.
- AOA/ASCO should challenge the source of BLS data and methodology used in projecting a need for 11,000 optometrists over next ten years given the projection contradicts three credible consulting firms including the recently AOA/ASCO sponsored Lewin Study.
- Revisit the 1993 concept developed by NECO/Tufts Medical School which described a blending of optometry and ophthalmology clinical postgraduate training with two distinct tracks: medical and surgical leading to separate Board Certifications.
2. Inflated Enrollments and Excess Graduates
- The proliferation of new schools of optometry is compounding the oversupply of optometrists.
- Seven new optometry schools were founded (2008-2016) in CA, AZ, TX, MA, KY, IL and WVA increasing the number of schools from 17 to 24, an alarming 41% increase.
- Also several existing schools have increased their entering class sizes.
- As a result 500 entering seats have been added, intensifying competition for qualified students.
- The number of graduates has increased from 1127 in 1997 to 1666 in 2016. Graduates will further increase once all new schools are fully operational.
Recommended Actions
- Mandatory enrollment reductions may be necessary if the applicant pool does not improve or if there is precipitous drop in applicants as occurred in 1997, when the number of applicants decreased by 25%.
- For independent optometry colleges, a reduction in class size would require a corresponding reduction in operating expenses, likely from workforce downsizing.
- The ACOE needs to accredit new optometry schools to a fixed maximum enrollment and strictly apply its own standards ensuring adequate clinical teaching encounters are available before granting accreditation.
3. High Graduate Debt vs. Potential Income
- Graduate debt vs. potential income is likely the main consideration for optometry school applicants.
- Graduate debt (undergraduate plus optometry school) now exceeds $200,000 for many of the private optometry college graduates. Increases in clinical education costs are often passed on to students in the form of higher tuition and increased debt.
- Although optometry graduate debt is similar to medical and dental graduates, potential income is not comparable.
- High graduate debt restricts practice options as acquiring additional debt to establish a new private practice is not always possible.
Recommended Actions
- Intense lobbying to include optometry in Federal scholarship and loan repayment programs.
- Reduce the length of the curriculum to 3 years for OD degree followed by a year of intense postgraduate clinical training. If included in GME, trainees would be paid stipends and not required to pay tuition.
- Encourage admission to optometry school after three years of undergraduate study. Award a baccalaureate degree after meeting curriculum requirements.
4. Static Student Applicant Pool
The static student applicant pool continues to threaten the ability to recruit qualified applicants.
- 500 entering seats have been added, intensifying competition for qualified students, and threatening the financial stability of some optometry colleges.
- The current year ratio was 2687 applicants to 1913 seats or only 1.4 unduplicated applicants per seat, and not all applicants are necessarily qualified for admission. Seats increased by 5.2% and applicants decreased by 4.4%, an effective decline.
- Enrollments at undergraduate colleges has declined by 500,000 since 2012.
- Educational debt vs. potential income is likely a major cause for the static student applicant pool.
- The impact of the DACA (Dreamers) rescission is unclear both on applicants and any current optometry students.
- Concern about the President’s Executive Order Travel Ban will likely affect foreign student applicants.
- Private optometry colleges are largely dependent on tuition revenue to support operations, while university-based schools can draw upon university resources in times of reduced enrollments.
Recommended Actions
- Although marketing may increase applicants in the short term, the fundamental issues of: 1) cost of education vs. potential income, and 2) an oversupplied provider market need to be addressed before long term improvement in the applicant pool will be realized.
- Independent colleges of optometry should explore mergers with universities and academic medical centers. Osteopathic institutions are particularly receptive to relationships with optometry. Currently, there are 6 such relationships.
- Explore mergers or consolidations among optometry schools and colleges.
5. Impact of Corporate Optometry
- Optometry appears to be following the same course as pharmacy where employment conditions and practitioner income are determined by corporate interests. Oversupply of optometrists may also drive down income.
- Corporate recruiters indicate a significant need for more optometrists, contradicting the Lewin Manpower Study.
- Optometry is at an important juncture, to either return to its mercantile origin or accelerate its efforts to further expand the scope of practice into advanced medical care as recommended in the Lewin Study.
- If the direction optometry takes is to expand medical practice, it will significantly impact optometric education, particularly clinical training.
Recommended Action
- Academic leadership should take the lead and sponsor a national conference on the direction of optometry – “The Future of Optometry: Mercantile or Expanded Medical Practice?”
6. Potential Loss of Medicaid Clinic Revenue
- Threats to the Medicaid Program persist in the Congress. Medicaid is often a very large source of revenue for teaching clinics. Any significant reduction in the Medicaid program would significantly reduce optometric patient services revenue and clinical teaching encounters.
Recommended Action
- Intense lobbying is needed to inform Congress of the importance of this program to provide eye care to inner-city and rural citizens and to train future optometrists to care for the increasing number of the Nation’s elderly with eye conditions.
7. VA Threatening to Outsource Optometry Services
- VA plans to outsource optometric services to commercial providers, resulting in the loss of optometry’s largest clinical teaching program with student extern placements for 70% of all optometry students and funding for 215 residents.
- Also, the VA is also the largest employer of optometrists in the Nation with over 700 staff optometrists positions threatened.
- Optometry residents receive unique specialty training in Medical Eye Care and Low Vision Rehabilitation, important specialties given that millions of elderly Americans have serious eye conditions and low vision. The VA clinical programs are essential to realizing further expansion in the scope of medical practice as recommended by Lewin.
Recommended Actions
- Intense lobbying by AOA/ASCO is needed to preserve the VA Optometry Service and its essential student and resident clinical training programs.
- Outsourcing of optometric services to commercial providers is problematic, since many of the 1.4 million veterans seen by VA optometrists have eye and/or medical conditions beyond the capabilities of commercial optometrists. These patients require coordinated consultations and treatment among ophthalmologists, low vision optometrists, and other medical specialists. Coordinated care is more efficiently and economically provided within VA facilities.
- Lobby Members of Congress and VA leadership and stress the importance of the VA in training the Nation’s Optometrists in the specialties of Medical Eye Care and Low Vision Rehabilitation to compensate for the shortage of ophthalmologists.
8. Exclusion from Many Key Federal Scholarship and Loan Repayment Programs Such as:
- The National Health Service Corps (NHSC) provides loan repayment and scholarships for health professions working in underserved areas.
- Title VII, Section 747, which provides scholarships and loan repayment for students who agree to work in underserved areas, also supports minority graduates, residents and faculty.
- The Public Service Loan Repayment Program is a complicated program, and it is unclear if optometrists qualify. The Education Secretary wants to remove “doctors and lawyers” from the program.
Recommended Actions
- Persistent, organized and well funded lobbying by AOA, ASCO and individual schools and colleges of optometry is required.
- AOA has traditionally been responsible for advancing educational initiatives. However, optometric education needs its own advocacy capability.
- ASCO should make, “Advocacy at the National Level” its top priority, and allocate most of its resources to Governmental Affairs.
- ASCO should develop its own lobbying capability, ensuring a high priority for educational issues.
- A large portion of dues paid by ASCO members should be earmarked for advancing educational initiatives by effective advocacy at the Federal and State levels.
9. Increased Clinical Training Costs with No New Sources of Revenue
- Unlike medicine, clinical training for optometry entry-level practice is contained in the four year curriculum and largely supported by student tuition.
- Traditional optometry clinical education is the most costly component of the curriculum, and increased costs are often passed on to students in the form of higher tuition and increased debt.
- Placing 2nd and 3rd year students in direct patient care increases costs and risks of CMS violations and associated fines. Medical Model Student Clerkships, where students are given limited patient care responsibilities, closely overseen by attending doctors or residents is a prudent alternative.
- Optometry clinical training is often conducted in costly campus-based clinics. The current academic accounting method does not accurately portray the total cost of clinic operations. The actual cost per primary care teaching encounter is excessive and specialty encounters are often 3 to 4 times greater.
- Alternative training sites such as affiliations with community health centers, medical facilities and externships are more cost effective.
- High cost specialty (Low Vision & Pediatrics) clinical training should be outsourced whenever possible.
- Increases in scope of practice of state practice laws have resulted in increased demands on clinical training facilities, faculty and staff.
- Center for Medicare/Medicaid Services (CMS) regulations prohibit students from providing billable services. Licensed faculty/residents must perform/repeat the examination and document results without referring to student’s findings.
- CMS billing regulations also apply to affiliated facilities and externships. Informing affiliates and extern preceptors of CMS regulations is essential.
- Optometry clinics are now billing Federal and private insurance carriers; however, the current optometry student clinical training model is not always congruent with billing regulations.
- In busy teaching clinics, the current Student-Driven clinical training model continues to pose a high risk for CMS violations with associated fines and other sanctions. Two optometry schools were fined $700,000.
Recommended Actions
- Implement a Preceptor-Driven Medical Model to improve efficiency, teaching and minimize risk of CMS violations.
- Outsource more clinical training to less costly training venues.
10. Exclusion of Optometry from the Graduate Medical Education Program
- A new source of substantial revenue is needed to offset clinical training costs.
- Increases in costs of clinical education and tuition will increase student debt and likely impact applicants for admission as graduate debt is often a concern for potential optometry school applicants.
- However, Optometry is not eligible for Federal Support for clinical education through the Graduate Medical Education (GME) Program, because clinical training takes place in the basic 4 year curriculum, and not in specialty postgraduate residencies.
- Current 4th year optometry students are primarily assigned to off-campus clinical rotations and essentially function as residents, yet they pay tuition and do not receive stipends.
- HHS does not recognize current optometry residents as real residents as they do not follow the traditional specialty postgraduate training and specialty board certification path, and are no different than any optometrist with an O.D. degree.
- In the past several years, an important precedent was established when over 400 optometry clinician achieved Specialty Board Certification in Medical Optometry granted by the American Board for Certification in Medical Optometry (ABCMO).
- GME is the educational component of Medicare. Although optometry is included as a provider in Medicare, it is not included in GME.
- Clinical education is inherently inefficient and patient services revenues are inadequate to cover the deficit of optometry clinic operations.
- The Federal government recognizes the inefficiency of clinical training and subsidies medical, podiatric and postgraduate dentistry clinical training through the multi-billion dollar Graduate Medical Education Program (GME).
- GME pays an average of $100,000 per medical resident annually to the hospitals.
- Optometry schools and colleges expend over $100 million annually on clinical training with no Federal Support for clinical education.
- Costly campus-based clinics are largely responsible for the excessive expense. Originally, the only clinical training facilities available, as optometry trainees were not accepted in medical or other health care facilities. Although, there are now opportunities for more cost effective clinical training, traditional campus based clinics persist.
Recommended Actions
- To potentially qualify for GME and maximize financial support, restructure the curriculum to award the O.D. degree in three years, and designate the current 4th year as the first year of mandatory resident training (PG-1).
- Position Optometry at the Federal and State levels for Inclusion in the Multi-billion Dollar Graduate Medical Education Program (GME).
Recommended Additional Actions
- The Social Security Act needs to be amended to include optometry in GME and include outpatient clinical training. Currently, only hospital training is authorized. Well prepared and funded lobbying is necessary.
- To further strengthen optometry’s advocacy position for inclusion in GME, States would need to mandate a minimum one year of postgraduate training for optometry licensure similar to medicine.
- Encourage the formation of additional Specialty Certification Boards in Low Vision Rehabilitation and Pediatric Eye Care. Only the Medical Optometry Specialty Board is operational.
- Develop a pilot optometry postgraduate clinical training model. Federal grants may be available for this innovative training program.
- Stress in the grant applications that optometrists who are residency trained and Board Certified in Medical Eye Care and Low Vision Rehabilitation are needed to compensate for a shortage of ophthalmologists to care for the growing numbers of the Nation’s elderly.
- GME payments are made to the clinical training facility, currently teaching hospitals. It may be necessary for the Optometry College clinic operations to have a separate legal structure.
- To ensure all Specialty Certification Boards have consistent standards, the American Board of Optometry Specialties (ABOS) needs to be recognized and implemented. ABOS is the optometric analog of medicine’s, American Board of Medical Specialties (ABMS).
Outcomes of Inclusion in GME
- The financial future of optometry schools and colleges would be more secure with GME support for clinical education, the most costly component of optometric education.
- Dependency on tuition as the major source of revenue is problematic with a static applicant pool, especially for private optometry schools.
- Inclusion in GME would encourage new clinical placements in preferred venues such as academic medical centers.
- Transition to a new curriculum and clinical training model would present a significant challenge for the optometry college.
- Former fourth year optometry students, now First Year Residents, would be permitted to provide billable services in conformance with the Center for Medicare/Medicaid Services (CMS) regulations.
- Agreements reached with GME eligible resident training sites to accept 2nd and 3rd year optometry students on Clerkship rotations.
- New residents would be paid stipends rather than paying tuition in 4th year of the program (PG-1) thus reducing graduate debt.
- Once GME eligible, optometry clinical training programs become attractive to a variety of health care facilities, and it would decrease dependency on costly college operated clinics.
