Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Affordable Care Act: Opportunity for New Optometry Student Clinical Training Model

I am writing this paper to urge schools and colleges of optometry to change from Student-Driven Clinical Training to a Teaching Physician-Centered Model to facilitate compliance with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents as the Guidelines pertain to Students. With the implementation of the Affordable Care Act (ACA), it is an opportune time for optometry schools and colleges to change to a Teaching Physician-Centered Model and reinforce their CMS compliance policy and Electronic Health Records (EHR) procedures for students. I realize such a dramatic change in optometric clinical training would have significant budgetary implications as teaching physician/faculty expense would increase and patient services revenues would likely decline. However, the current Student-Driven Training Model continues to pose a high risk of CMS violations with associated fines and other sanctions. It is anticipated that audits of Federal Health Care Programs will increase with the implementation of the Affordable Care Act (ACA).

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

by Charles F. Mullen

A Strategic Framework for Optometry and Optometric Education

If optometry is to maintain its position as the Nation’s leader in primary eye and vision care in a rapidly evolving health care system… we have a responsibility to frame our own future.

Abstract

The following slide presentation describes an eight step plan to comprehensively restructure the profession of optometry to meet the expectations of private, Federal and State insurers, external certifying agencies, and credentialing and privileging boards by placing optometry in parallel with medicine.

Significant changes to optometric education, clinical training, licensure requirements, board certification and accreditation are described (1) to qualify optometry for inclusion in the Graduate Medical Education Residency Program (GME), a $10 billion annual program which currently funds post graduate training for physicians, dentists and podiatrists, and (2) to meet Federal insurance compliance guidelines for teaching programs.

A Strategic Framework for Optometry and Optometric Education (PDF)

A Strategic Framework for Optometry and Optometric Education (PPT)

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

by Charles F. Mullen

Eight Strategic Steps to a Secure Future for Optometry

The tranquilizing drug of incremental progress – Anonymous

Background

Over the past 40 years, changes to optometric practice laws and Federal/State current and anticipated health care policy have been addressed by specific, incremental modifications to licensure requirements, clinical education, postgraduate training and advanced competency certification/re-certification rather than systemic restructuring of the profession in accordance with a comprehensive strategic plan.

Consequently, unaddressed structural issues persist and weaken optometry’s position as an independently licensed profession in a third party dominated health care system. Also, structural issues prevent optometry from receiving Federal support for clinical training. Currently, clinical training costs are often passed on to the optometry student in the form of higher tuition resulting in additional graduate debt.

Since optometrists are classified as physicians under Federal law, they are (or will) be judged by Federal and State governments, external certifying organizations, credentialing and privileging boards of medical facilities and third party insurers utilizing the medical model as the standard. Optometrists, like physicians, will be/or are already expected to demonstrate clinical competency by board certification and maintenance of competency by re-certification.

Also, all optometric clinical teaching venues are expected to comply with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents.

A eight-step approach is recommended to comprehensively restructure the profession by placing optometry in parallel with medicine.

Most Important Events of the Past 40 Years

  • Expansion of optometric state laws, initiated in Rhode Island in 1972, authorizing the use of pharmaceuticals and advanced clinical procedures.
  • Creation in 1976 of the Department of Veterans Affairs Optometry Service, now the largest optometric patient care and clinical training program in the country with 675 VA optometrists providing 1.5 million visits annually. And clinical training provided for 80% of optometric students and over 50% of all residents.
  • Inclusion in Medicare in 1987, now $1.0 billion in optometric services are provided annually.
  • Optometry’s broad-based inclusion in the Affordable Care Act (ACA) will likely be another significant event. Participation in the ACA will also facilitate inclusion in other Federal Programs such as the Graduate Medical Education Program (GME) and the National Health Service Corps (NHSC).

Although these were major achievements, the absence of a visionary plan at the time resulted in missed opportunities:

  • to advocate for the passage of broadly drafted state optometric practice laws that would allow for the future expansion of the scope of practice without further amendments,
  • to agree on the purpose of optometric post graduate clinical training. Was it intended to qualify for state licensure and/or board certification or just advanced training?
  • and to include optometric clinical training support (GME) in the Medicare component of the Social Security Act.

Three Major Challenges Facing Optometry

  1. Optometry is (or will) be judged by Federal and State governments, external certifying organizations, credentialing and privileging boards and third party insurers utilizing the medical model as the standard.
  2. The $10 billion Graduate Medical Education (GME) program is based on the medical clinical training model and optometry’s clinical training, licensure requirements and advanced competency certification/re-certification do not meet GME expectations for participation.
  3. The Center for Medicare/Medicaid Services Guidelines for Teaching Physicians, Interns and Residents prohibit optometric students from providing billable services in all training venues.

Detailed Structural Issues and Missed Opportunities

Postgraduate Clinical Training and Advanced Competency Certification

  • No mandatory postgraduate training is required for optometric licensure with the exception of Arkansas and Delaware.
  • No nationwide acceptance of optometric postgraduate specialty training, board certification and maintenance of certification presently exists, however, the American Board of Optometry(ABO) has been recognized by the Center for Medicare/Medicaid Services (CMS) for bonus payments (PQRS) and the American Board of Certification in Medical Optometry (ABCMO) has been recognized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO) as a certifying agency.
  • Although a significant provider of Medicare services ($1.0 billion annually), optometry is not included in the Graduate Medical Education Program (GME) the educational component of Medicare because optometry’s clinical training model does not meet GME expectations.
  • Because of the above, current optometric residents are not recognized by the Department of Health and Human Services (HHS).
  • No expeditious route presently exists for board certification in General Optometry for most new optometric graduates. In 2012 there were only 367 available resident positions for 1600-1800 graduates.

Education

  • The increasing costs of optometric clinical training are passed on to students in the form of higher tuition.
  • Debt is too high for optometry school graduates averaging $140,000 (public) to $175,000 (private) vs. median annual income of $95,000.
  • The Bureau of Labor Statistics is projecting a 33% increase in demand for optometrists or 11,300 additional optometrists for the period (2010-2020), however, the student applicant pool is declining.
  • The declining student applicant pool for optometric schools (only 1.0 unique applicants per entering seat) is exacerbated by the proliferation of new schools (five schools added in recent years) and by expanded enrollments in existing schools. This is significant problem now and will likely be continued in the future. High debt to potential income and increasing commercialization of the profession are likely contributing factors.
  • Schools and colleges of optometry perpetuate a curriculum where optometric clinical training required for licensure is contained within the basic curriculum. GME only supports postgraduate clinical training and paid an average of $95,000 per medical resident to hospitals in 2010.

Medicare/Medicaid Compliance

  • CMS Guidelines for Teaching Physicians, Interns and Residents compliance vulnerabilities persist in all clinical teaching venues including externship sites, because optometric students are restricted by regulation from providing billable services. Also, private insurers apply CMS Guidelines. Two optometry schools have already been cited by the Office of Inspector General (OIG) for violations

Eight Strategic Steps to a Secure Future for Optometry

The proposed actions are highly sensitive, politically challenging and replete with timing and sequencing issues. However, there is no easy path, if optometry is to maintain its independence as a doctoral-level prescribing profession in a rapidly evolving health care system.

Again, the states are called upon to lead the profession, as Rhode Island did in the 1970’s. ASCO member institutions, NBEO and ACOE would likely follow with compensatory actions as they have historically done.

The steps are designed to facilitate synergism among State licensure requirements, postgraduate training, board certification/re-certification, optometric curricula; and position optometry to meet the expectations of private/Federal/State insurers, external certifying agencies, credentialing and privileging boards and the Graduate Medical Education Program (GME).

  1. States should mandate one or two years of mandatory post graduate training for optometric licensure. Only Delaware and Arkansas already mandate post graduate training. State Optometric Practice Laws amended to include — “One or (two) years of postgraduate clinical training, in an accredited program leading to Board Certification, is required for licensure.”

  2. It would be necessary for optometric educational institutions to adjust curricula by awarding the O.D. degree after three years and to reclassify the 4th year as the first year of residency.

    Two optometry colleges already offer accelerated programs, the New England College of Optometry offers a two year program and in the past, a three-year program and Salus University a three year program (deferred) while medical schools are now offering three year programs.

    Consolidation of curriculum into three years can be accomplished by moving basic course material to pre-optometry requirements and extending the academic year to twelve months, permitting completion of all competency-based course material in three calendar years. Increased use of on-line instruction would facilitate completion of the accelerated curriculum.

    A three calendar year curriculum would allow reallocation of 1600-1800 current 4th year student placements for postgraduate residency training.

    A three-year O.D. degree program along with GME residency stipends would reduce optometry student debt $30,000 to $50,000 or more.

    U.S. Medical Schools (Allopathic & Osteopathic) Offer 3-Year Degrees.

    In the last five years, at least four medical schools have initiated or are developing three-year programs including Mercer University School of Medicine, Lake Erie Osteopathic College of Medicine, Texas Tech University Health Sciences Center, Louisiana State University School of Medicine.

    Also, three other schools have applied for Federal funds (CMS Innovation Grants) to develop three-year programs: Indiana University School of Medicine, East Tennessee State University Quillen College of Medicine, and the University of Kentucky College of Medicine.

    The Carnegie Foundation for the Advancement of Teaching recommends all medical schools consider a three-year option.

    Two Canadian Medical schools have three-year programs.

    The three-year program will save the medical student $50,000 in debt.

  3. National Board of Examiners in Optometry (NBEO) examination sequencing would need to be adjusted to accommodate new curriculum and mandatory postgraduate training.

  4. One year of postgraduate training required for certification in General Optometry, two years for specialties and three years for fellowship trained sub-specialties.

    Certifications boards need to developed and/or recognized for General Optometry (ABO) and the Specialties of Medical Optometry (ABCMO), Cornea/Contact Lenses, Pediatrics, and Vision Rehabilitation. Also, sub-specialty certification boards for Neuro-Optometry and Glaucoma developed.

  5. To ensure consistent standards among various certification boards, establish an oversight board for all specialty certification boards, the American Board of Optometric Specialties (ABOS).

    There is an immediate need for an oversight board as three newly developed optometric certifying boards, as well as other organizations awarding advanced competency status, have varying standards.

  6. Only postgraduate clinical training programs accredited by the Accreditation Council on Optometric Education (ACOE) would be recognized for board certification. Mechanisms must be established to record resident patient care experiences to ensure the resident has received the quantity and diversity of patient care encounters to qualify for board certification.

    Consideration should be given to accrediting existing and new schools to a maximum enrollment.

    Care (CCOC) should be re-instated to ensure high standards of optometric patient care and sufficient patient volume at all clinical training venues

  7. With completion of Steps 1-6, optometry would now be parallel with medicine and consistent with current and anticipated Federal/State policies, external certifying agencies, credentialing and privileging boards and private insurers’ requirements.

  8. Also, optometry’s clinical training model, licensure requirements and advanced competency certification/re-certification process would meet GME expectations and comply with CMS Guidelines for Teaching Physicians, Interns and Residents. AOA advocacy could now move forward with a credible position.

    Since optometric clinical training is largely in outpatient facilities, GME regulations would need to be expanded from hospitals only to include outpatient patient care/clinical training.

Resources

by Charles F. Mullen