Charles F. Mullen - Opportunities and Challenges in Optometry and Optometric Education

Opportunities Lost – Opportunities Regained

Two consequential decisions have delayed by 30 years the comprehensive development of specialty clinical training and board certification for optometrists, denied eligibility for Federal support for postgraduate residency training, and placed Schools and Colleges of Optometry in a tenuous position with increasing clinical educational costs, increasing student debt, and a static student applicant pool.

Decision One

In 1987 with Optometry’s Inclusion in Medicare, It Was Decided Not to Pursue Inclusion in the Graduate Medical Education (GME) Program, the Educational Component of Medicare.

It was decided not to pursue Optometry’s inclusion in GME, the multi-billion dollar educational component of Medicare which supports postgraduate residency programs. Optometry receives no direct Federal assistance for clinical training, and schools and colleges of optometry continue to pass along the high cost of clinical education to students in the form of high tuition and significant debt.

Recognizing their need for postgraduate clinical education, 30% of new graduates now enroll in residency programs, many in the Specialty of Medical Optometry funded by the VA. Inclusion in GME would increase residency and fellowship training opportunities for optometrists, not only in the Specialty of Medical Optometry and its associated subspecialties (Cornea/External Disease, Glaucoma, Neuro, Retina), but also in Pediatrics and Low Vision.

Podiatry wisely decided to seek inclusion in GME in 1972, and later changed its State practice laws requiring postgraduate training for licensure, revised the curriculum and clinical training model, and developed Certification Boards to qualify for GME payments. Podiatry was successful in creating new residency positions to accommodate their graduates, many in the VA. Podiatry currently receives $111,000 per resident per year in GME payments.

Seeking inclusion in GME will be politically more challenging now than in 1987, but achievable with conformance to GME postgraduate training standards as Podiatry so aptly accomplished, and by a persistent and professional lobbying effort. It should be stressed to Members of Congress that there is a growing need for residency trained optometrists as the number of ophthalmologists is not adequate to meet the increased demand for medical eye care and low vision rehabilitation. It will also be challenging for Optometry to create additional resident positions, however, GME payments would provide an incentive for potential host institutions in the private sector to offer Optometry residency programs.

Decision Two

At the 1992-93 Georgetown Conference on Optometric Education, It Was Decided Clinical Training Would Continue to Take Place Within the Four Year Curriculum.

Clinical training is the most expensive component of the Optometry four year curriculums resulting in high tuition and significant educational debt. Optometry graduates now face the highest debt repayment as a percentage of income of all professions at 14.9%. Twice the payments of medicine. Applicants for admission to Optometry Schools and Colleges have essentially not increased in 10 years, and educational debt as compared with potential income is likely a causative factor.

The decision to keep clinical education in the four year curriculum also delayed Optometry’s development of postgraduate specialty clinical training model which is necessary to qualify for inclusion in the multi-billion dollar Graduate Medical Education (GME) Program. If included in GME, clinical training with the exception of clerkships would be moved from the four year curriculum to postgraduate residencies, significantly reducing the cost of the optometric curriculum, and providing Federal support for postgraduate clinical education.

Opportunities Regained

Regain decades of lost opportunities to the Profession of Optometry and Optometric Education by reversing the above two decisions, and by

Amending State practice laws to require postgraduate clinical training for licensure
Restructuring the four year curriculum by moving clinical education to postgraduate specialty residencies
Adding new residency positions
Developing additional specialty certification boards

Notes

Clerkships or rotations to health care facilities would take place in 2nd and 3rd years. Current 4th year would become the first postgraduate year (PG-1).

Mergers and Consolidations of Optometry Colleges and Schools

Introduction

Mergers of Optometry Colleges and Schools were originally proposed in 1990 by the eminent educator, Professor Thomas Lewis. Given declining enrollments in Higher Education, his three decades old proposal in now being re-considered with a sense of considerable urgency. The following Discussion Outline is posted to assist optometric leadership in deliberations concerning mergers/consolidations of optometry colleges and schools.

Discussion Outline

Current State of Higher Education/Optometric Education

Higher Education is in crisis with institutions closing and mergers/consolidations proactively pursued because of declining enrollments.
2.9 million fewer undergraduate age students than in 2008. Projected to continue until 2030.
There is too much student capacity in optometric education, and not enough demand. Six new schools founded since 2008.
Applicants to optometry colleges and schools have essentially not increased in a decade.
Repayment of debt is 14.9% of income, highest of all professions and twice medicine.
Colleges of Optometry are now unable to fill entering classes with qualified students. GPA, OAT and NBEO data indicate some Optometry Schools are admitting less qualified students.
Independent Optometry Colleges are dependent on tuition revenue to support operations, and decreasing enrollments threaten their survival.
Financial reserves and selling of assets can only sustain College operations for a relatively short period of time.
The signs of a pending crisis in enrollments have been present for years, however, only recently viewed with a sense of urgency.

Options to Survive/Thrive in Crisis

Student marketing may increase applicants, however effective advertising requires substantial funding (3-5% of projected revenue) which is not realistic without external support.
Affiliation with a university for Independent Optometry Colleges is not likely as the current enrollment decline would not be acceptable to university officials.
Although university-based schools of optometry will likely be supported in the short term by university officials, long term enrollment declines will be problematic.
Continue as currently operating and allow market forces to determine the fate of the College or School.
Merge/Consolidate with another Optometry College or School

Benefits of Mergers and Consolidation

Increased enrollment which is large enough to sustain operations as a merged/consolidated College.
Brings unique strengths of two Colleges/Schools together.
Leveraging of a greater size and scale.
Financial savings in long term.
Renewed commitment of the governing board.
Re-engaging and re-energizing institutional stakeholders.

Costs of Mergers and Consolidation

The process of merging is painful.
Ideally, mergers should not be considered in time of crisis, but rather as part of a larger strategic plan.
Discordance in timing between gains and costs. Financial gains take time to develop while costs of merger come due immediately.
Costs include: building refurbishments, transition costs, addressing human capital needs, communications, branding, college relations, expenditure of political capital, slowing of programmatic growth, disruption to leadership and merger/consolidation consultants.

Crisis in Optometric Education – Structural Issues Contributing to Crisis

Higher Education including Optometric Education is in crisis because of declining enrollments. There is too much student capacity and not enough demand. There are 2.9 million fewer undergraduate students than 8 years ago. A number of undergraduate colleges have closed and many more closures are predicted. Mergers and affiliations are now a reality and more are under consideration.

Schools and Colleges of Optometry must act now by developing and implementing strategies to deal with the crisis. The following Power Point slides delineate the:

Causes of the Crisis
Financial Concerns
Marketing Initiatives
Innovative Strategies

Crisis in Optometric Education (PowerPoint)
Crisis in Optometric Education (PDF)

A Unique Opportunity for Osteopathic Health Sciences Centers to Develop an Innovative Optometry Degree Program and Postgraduate Residency Training

The expanded use of technology will significantly alter the traditional role of optometrists over the next 10 years. Large corporations with sophisticated marketing will dominate the multi-billion dollar eye care market. However, there is unmet need for medical eye care in the Medicaid and Medicare populations, and with changes to optometric education and clinical training, this unmet need can be addressed. State and Federal legislative/regulatory advocacy would need to be initiated concurrently with the development of the new optometric educational model.

Osteopathic Health Sciences Centers across the Nation currently offer innovative curricula in medical and other health care professions’ education, and now have a unique opportunity to develop and offer an innovative program in optometric education and residency training that would prepare optometrists to provide medical eye care. Such a new program would replace the traditional optometric curriculum where clinical training is contained within the four year degree program. Having no requirement for postgraduate clinical training, optometry is not eligible for the multi-billion dollar Graduate Medical Education (GME) program.

Optometrists are classified as physicians under Medicare and are judged by medical standards including specialty clinical training and board certification. Optometric education must now align with national standards and guidelines derived from medical education.

Such a proposed restructuring plan is politically challenging with numerous sensitive professional and educational issues. Implementation of the plan requires bold leadership. I look to Osteopathic Health Sciences Centers with their tradition of leadership and innovative programs to lead the change in optometric education. This proposal recommends restructuring optometric education and postgraduate training by placing it in parallel with medicine.

New Program

Three Years for OD Degree + One Year Postgraduate Training = Licensure

Three years of classroom education, laboratory and clinical clerkships to earn the Doctor of Optometry (OD) degree followed by one year of postgraduate clinical training for licensure in General (Traditional) Optometric Practice. This would replace the current 4th year which essentially is the first year of residency training.

One Additional Year of Specialty Clinical Training to Provide Medical Eye Care.

One year of additional specialty clinical training in medical eye care and Board eligibility required by State Optometry Regulatory Boards to provide medical eye care.

Advantages of the New Curriculum and Clinical Training Model Include:

The new model would encourage specialty clinical training and board certification as emphasis would shift from General (Traditional) optometric practice to primarily medical eye care.
By restructuring the curriculum and requiring postgraduate clinical training, optometry would become eligible for Graduate Medical Education (GME) payments to address clinical training costs.

Actions Required

Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to Fund Implementation, Entitled — “Restructuring of Optometric Education and Clinical Training To Meet Unmet Need for Medical Eye Care in Medicare/Medicaid Populations”
Amend States’ optometric licensing laws/regulations to require a minimum of one year of postgraduate, residency training in General/Traditional optometry for licensure.
And require an additional one year of training in specialty medical eye care with Board eligibility to practice medical eye care.
Amend the Social Security Act to include optometry in the Graduate Medical Education Program (GME) and expand GME support of residency training to all optometric clinical training venues.