Since the 1970’s, optometry has been in a state of metamorphosis with the introduction of pharmaceuticals and advanced clinical procedures. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice. However, the traditional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.
The profession of optometry has benefited from inclusion in the federal program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric education, however, does not conform to medical terminology nor the medical training model. Federal agencies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the educational component of Medicare. The Federal Government appropriates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.
The premise behind why GME payments are made to financially support clinical training of physicians, dentists and podiatrists is that clinical training is inherently inefficient. All clinical training for optometry students, however, must take place in the four-year curriculum and not in post graduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optometry student in the form of higher tuition. Inclusion of optometry in GME would provide additional revenue to optometric clinical facilities to partially offset the cost of these inefficiencies.
Medicare bases its regulations on the medical teaching model. Optometry’s traditional teaching model and terminology is not analogous to the medical model. However, functionally optometry’s model is consistent in several important aspects with the medical model. Current Medicare regulations regarding student supervision significantly impede optometry students from acquiring patient evaluation and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fellows, however, can contribute to billable services and have ample opportunity to acquire patient evaluation and management skills without significantly affecting the efficient provision of health care.
Realignment of the traditional optometric clinical training model and terminology is necessary to facilitate inclusion in and compliance with major federal programs and to reflect the current functional reality.
Objectives of a New Clinical Training Model
The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regulations pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable services regulations and facilitate inclusion in and compliance with these programs. Participation in GME and NHSC would provide significant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective training in patient evaluation and management (E/M) by placing optometric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.
Other objectives include increasing participation in Medicare, increasing the number of community-based training sites, and controlling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resource and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based training sites. Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control student debt.
Functional Reality of Current Optometric Training Model
Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric education has evolved into an intense clinical experience in response to the expansion of patient management and treatment responsibilities of optometric practice and is analogous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical training has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optometry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)
Actions Required to Realign the Optometric Clinical Training Model
The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry students would be redesignated as interns and current fourth year students would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric residents would be reclassified as PG-2, PG-3 or Fellows. First and second year students would remain classified as students. Since fellows, residents and interns can contribute to Medicare billable services, optometric trainees in this new configuration could receive meaningful and cost-effective training in patient evaluation and management (E/M), while in full compliance with Medicare billable services regulations.
In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clinical training of optometric interns and residents (PG-1 – PG-3), including resident stipends. Existing law/regulations need to be amended to direct HRSA to include optometry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.
Conclusion and Recommendation
The traditional optometric training model and terminology are not consistent with the functional reality, with medical terminology and federally-supported programs and present obstacles to inclusion in and compliance with major Federal programs. There is a need to comply with Medicare regulations regarding student billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thoroughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optometry in GME and NHSC.
Journal of Optometric Education
Volume 32, Number 1, Fall 2006
Charles F. Mullen, O.D., F.A.A.O.