Charles F. Mullen

Introduction

This paper provides an overview and a list of recommended actions for two major opportunities and nine essential challenges that have or will significantly impact optometric education.

Two Major Opportunities

1. Inclusion in the Graduate Medical Education (GME) Program
2. Participation in Federal Scholarship and Loan Repayment Programs

Nine Essential Challenges

1. Increased Clinical Training Costs with No New Revenue Sources
2. High Graduate Debt vs. Potential Income
3. Declining Student Applicant Pool
4. Impact of Corporate Optometry
5. Potential Loss of Medicaid Clinic Revenue and Clinical Teaching Encounters
6. VA Threatening to Outsource Optometry Services
7. Inflated Enrollments and Excess Graduates
8. Significant Oversupply of Optometrists
9. 2017 Tax Reform and 2018 Spending Bill Projected Deficits Threaten Entitlements such as Medicare and Medicaid

Two Major Opportunities for Optometric Education

The following opportunities would have a significant positive impact on addressing many of the challenges impacting optometric education. An overview of each major opportunity and actions necessary for inclusion in these key programs are described below.

1. Inclusion in the Graduate Medical Education (GME) Program

• Clinical education in every health care discipline is inherently inefficient and expensive.
• The Federal government recognizes the inefficiency and high cost of clinical training and subsidizes medical, podiatric and postgraduate dentistry clinical training through the $16 billion Graduate Medical Education Program (GME).
• GME pays an average of $100,000 per medical resident annually to the teaching hospitals. Payments vary with the clinical specialty and teaching hospital.
• Optometry schools and colleges expend over $100 million annually on clinical training with no Federal Support for clinical education.
• Yet, 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 hospital-based specialty postgraduate residencies.
• GME is the educational component of Medicare. Although optometrists are included as a physicians in Medicare, optometry is not included in GME.
• HHS does not recognize current optometry residents as equivalent to medical residents as most 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.
• A small number of optometrists have achieved Specialty Board Certification in Medical Optometry after postgraduate training.
• Curriculum reform that allows GME standards to be met would provide a new source of substantial revenue needed to offset clinical training costs.

Recommended Actions

At the School and College Level

• 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). Also:

• Develop a demonstration optometry postgraduate clinical training model that mirrors medical training to be conducted in affiliated community health centers and/or college-operated clinical facilities. Federal grants may be available for this innovative training program.
• The demonstration model should include metrics that define the health benefits to society, and the benefits derived by the Federal government for including optometry in GME.
• GME payments are made to the clinical training facility, currently teaching hospitals. It may be necessary for optometry college-based clinics to have a separate legal structure.
• 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. Osteopathic institutions are well positioned and experienced with postgraduate medical education to facilitate optometry’s inclusion in GME. Osteopathy has an effective lobbying staff.

At the Federal and State Levels

• Position Optometry at the Federal and State levels for Inclusion in the Multi-billion Dollar Graduate Medical Education Program (GME) by:

• Stress that Optometrists advanced medical training is more cost effective than surgical ophthalmology since most eye conditions can be treated medically, and optometrists with advanced training could provide the needed medical care while significantly improving access for Medicare eligible patients and others.
• Amending the Social Security Act to include optometry in GME and authorize outpatient clinical training. Currently, only hospital training is authorized.
• 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.
• Well prepared and funded lobbying is necessary at both Federal and State levels.

At the Professions Level

• The professions leadership should create a dedicated strategy to achieve GME eligibility for optometry supported by well prepared and funded lobbying.

• Support the demonstration grant applications by stressing 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.
• Encourage the formation of additional Specialty Certification Boards in Low Vision Rehabilitation and Pediatric Eye Care. Only the Medical Optometry Specialty Board is operational.
• 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.
• 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.
• Recommend to HHS to grandfather current residents into GME and designate them as (PG-2,3).
• 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.

2. Participation in Federal Scholarship and Loan Repayment Programs Including:

• 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

• As with GME, persistent, organized and well funded lobbying by AOA, ASCO and individual schools and colleges of optometry is required.

• ASCO should make, “Advocacy at the National Level” its top priority, and allocate most of its resources to Governmental Affairs and develop its own lobbying capability, ensuring a high priority for educational initiatives.

Nine Essential Challenges for Optometric Education

The following factors significantly impact optometric education. An overview of each factor and initial actions that should be taken are listed below.

1. 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 student-directed patient care increases costs and risks of CMS violations and associated fines.
• 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 centers, government facilities and externships are more cost effective.
• 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/preceptors 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
Immediate

• Implement a Preceptor-Driven Medical Model to improve efficiency, teaching and minimize risk of CMS violations.

• Outsource clinical training to alternative training sites such as affiliations with community health centers, medical facilities and externships.
• High cost specialty (Low Vision & Pediatrics) clinical training should be outsourced whenever possible.
• Implement Medical Model Student Clerkships in conjunction with a faculty practice plan which is fully integrated into the patient care/clinical teaching program. 2nd and 3rd year students to be given limited patient care responsibilities, closely overseen by attending faculty.

Two to Five Years

• AOA, ASCO and schools and colleges should implement a collaborative strategy to achieve GME eligibility for optometry.

2. 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 limits practice options. Although no national data are available on recent graduates practice placements, individual colleges of optometry informally report increasing numbers of graduates are selecting commercial optometry employment and other commercial relationships.

Recommended Actions

• Intense lobbying by AOA and ASCO 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, postgraduate 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.
• Early admission is most efficiently accomplished by developing or expanding agreements with undergraduate institutions for accelerated optometry programs.

3. Declining Student Applicant Pool

• Paradox: While the demand for optometrists by the corporate sector is at an all time high, applicants to optometry schools continue to decline.
• ASCO reported a 19% decline in student applicants in 2017. So far in 2018, applications are down another 15% and OAT takers are declining each year. There is no evidence to suggest a reversal of the decline, and it is likely this trend will continue in the coming years.
• In 2017 there were 2687 applicants for 1913 seats or 1.4 unduplicated applicants per seat. And applicants are not necessarily qualified for admission.
• The decline in the student applicant pool continues to threaten the ability to recruit qualified applicants and threatening the financial stability of some optometry colleges.
• Recent ASCO data indicates significant variations in admissions standards among optometry schools.
• A 2018 AOA article expressed concern about poor NBEO examination performance for students from developing optometry schools. This revelation could further depress the applicant pool.
• 500 entering seats have been added, intensifying competition for qualified students.
• U.S. birth rate has been declining since the 1990s.
• Enrollments at undergraduate colleges has declined by 500,000 since 2012.
• Historically, two of the most appealing aspects of an optometric career to prospective students: (1) entering private practice immediately after graduation and (2) a relatively low cost professional education. Unfortunately, they no longer exist for most students.
• Educational debt vs. potential income is likely a major cause for the static student applicant pool as a optometric education may no longer be perceived as a sound investment.
• 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. It is unclear as to whether the Travel Ban(s) will affect enrolled optometry students.
• 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

• ASCO should hold a Summit on “The Future of Optometric Education” to develop an aggressive strategy to address the student applicant decline as well as the other opportunities and challenges delineated in this paper.

• 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.
• Increase participation in Optometry Clubs at Undergraduate Colleges.
• Curriculum reform that replaces many classroom courses with on-line instruction is necessary to appeal to Millennials. Courses should be taught on-line by national scholars or clinical experts when practical.
• Marketing should be targeted by individual optometry schools and colleges of optometry as national public relations campaigns have not proven effective at reaching Millennials who consume much less “traditional” media than previous generations. For example, with Facebook a school could target “…all college students within a specific state or Canadian province who are majoring in the sciences…”
• Optometry college marketing programs should leverage available technology and fully utilize current and trending social media platforms including: Facebook, Twitter, Instagram and Linkedin.
• College web sites should be mobile compatible.
• No longer require only the OAT (Optometry Admissions Test). Accept GRE (Graduate Record Exam) to attract more applicants. 600,000 students annually take the GRE.
• Explore mergers or consolidations among optometry schools and colleges to develop regional optometric institutions.

4. Impact of Corporate Optometry

• There is high demand for optometrists in the corporate sector reported by optometry school officials and it likely to increase as more retail stores open eye care services.
• 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.
• Advances in eye care technology are also changing the practice of optometry. Technology has permitted the expanded the use of technicians and other ancillary personnel in providing eye care.
• The proliferation of corporate practice has diminished the desirability of an optometry career and recognition of optometrists as medical eye care providers.
• 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.

5. Potential Loss of Medicaid Clinic Revenue and Clinical Teaching Encounters

Threats to the Affordable Care Act (ACA), Medicaid Expansion and Children Health Insurance (CHIP) Programs persist by the President and Congress. Medicaid is often a very large source of revenue for teaching clinics.

• Affiliated community health centers eye care services would also be threatened.
• Any significant reduction in the Medicaid program would reduce optometric patient services revenue and clinical teaching encounters.

• Although the above threats did not materialize in 2018, all entitlements (Medicare, Medicaid, Community Health Centers, ACA and Social Security) remain subject to reductions as the 2018 Federal Spending Bill and Tax Reform Law significantly increase the National deficit, requiring future substantial cuts to entitlements.

Recommended Actions

• Intense lobbying is needed to inform the President and Congress of the importance of these programs to provide eye and vision care to underserved inner-city and rural citizens.

• There is an increasing number of the Nation’s elderly with vision threatening eye conditions, and children with myopia and other eye and vision conditions which affect school performance.

6. 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.

• Although the VA is not actively pursuing outsourcing of optometry services at this time, AOA and ASCO should be prepared to aggressively address the matter should the VA Secretary again threaten to outsource optometry services.

Recommended Actions

• Intense lobbying by AOA and 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.
• AOA and ASCO should 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.

7. 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.
• The AOA reported in a recent 2018 article that an alarming additional 12 new schools are being considered.
• 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 likely increase to more than 1800 once all new schools are fully operational.

Recommended Actions

• All schools and colleges should voluntarily reduce their entering class size. This is best accomplished by incremental reductions over a period of years to allow for timely expense reductions.

• 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%.
• One optometry college reported significantly less students entering in 2017 than anticipated, and has accordingly decreased the 2018 budgeted class size to maintain high admission standards.
• 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.

8. 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 their rationale for founding a new optometry school. The data used in calculating optometry manpower requirements are questionable.

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 to reduce the oversupply are also needed and delineated above in this document.
• AOA/ASCO should challenge the source of the Bureau of Labor Statistics (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 1973 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.
• The Chinese utilize a similar educational model to the NECO/Tufts concept.

9. 2017 Tax Reform and 2018 Spending Bill Projected Deficits Threaten Entitlements

• 2017 Tax Reform Law and 2018 Spending Bill will significantly increase the Nations deficit, eventually forcing a reduction in funding of such entitlements as Medicare, Medicaid and Community Health Centers. All provide essential, multi-million dollar eye care programs and clinical training components for optometrists.
• Tax Reform also threatens Social Security. The Graduate Medical Education (GME) Program is authorized under the Social Security Act and would likely be affected.
• However, if included in GME, optometry would provide a more cost effective advanced clinical training option than surgical ophthalmology since most eye conditions can be treated medically. GME was created to improve access to medical care.
• The Lewin Study indicated that optometry could improve access for Medicare eligible patients and others by acquiring advanced medical treatment capabilities.
• President Trump in his 2019 budget recommends elimination of Federal support for health professions training.

Recommended Actions

• Although the deficit will not immediately impact entitlements, lobbying by AOA and ASCO should begin now to preserve theses critical patient care/clinical training programs, and advocate for the inclusion of optometry in GME as a cost effective alternative.

Conclusion

Over the past 40 years optometric education has taken full advantage of the opportunities that came with expansion of state practice laws, inclusion in Medicare, introduction of postgraduate residency programs and the inclusion of optometry student and resident training in community health centers, medical facilities and government medical centers. It is now time to also realize the opportunities that will come with inclusion in the Graduate Medical Education (GME) Program and full participation in Federal Scholarship and Loan Repayment Programs.

Of the Nine Challenges discussed in this paper, the Declining Student Applicant Pool and Inflated Enrollments/Excess Graduates are the highest priority challenges, and require immediate and sustained action by all schools and colleges of optometry.

The high demand for optometrists in the corporate sector reported by optometry school officials contradicts the Lewin Study which reported a significant oversupply of optometrists. If high demand by corporate optometry for optometrists is accurate, why then is the applicant pool declining? This matter requires an objective analysis by an external body.

Suggested Additional Reading

• Understanding the Cost of Optometric Clinical Education
• The Perfect Storm: Oversupply of Lawyers, Optometrists and Pharmacists
• Changes Necessary to Include Optometry in the Graduate Medical Education Program (GME)
• Unresolved Matters of Importance to Optometric Education