Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Changes in the Department of Veterans Affairs and Their Implications for Optometric Education

In the coming years the veterans’ health care system will be affected by powerful societal and health care industry dynamics. These factors will influence the manner in which the VA accomplishes its mission and they provide the context in which it must operate.

My discussion of the future of the veterans’ health care system is based on the following assumptions:

  • The role of the federal government in American society will continue to be reevaluated, and competition for federal government funding will become even more intense.
  • Most health care in the United States will continue to be provided by the private sector.
  • There will continue to be marked turmoil among and consolidation of medical groups, hospitals, health maintenance organizations, and other elements of the private sector.
  • Managed care within integrated delivery systems will become the most common mode of health care delivery in the United States.
  • Medical and scientific information will continue to grow at an astonishing rate.
  • Technological innovations will continue to revolutionize clinical practice. In addition, the trend of providing care in nonhospital settings will continue, and even accelerate, as concern about health care costs continues.
  • Advances in information and communication technology, and imaging systems in particular, will open up many new opportunities for improving the delivery of health care.
  • Integrated information systems will be the key to success for future health care systems.
  • Nonphysician providers will be increasingly used in health care systems of the future.
  • Health care organizations will be increasingly expected to prevent disease and promote community wellness, in addition to treating individual cases of illness.
  • There will be increased demand for accountability in health care and increased emphasis on health care outcomes and measurements.
  • While the rate of increase of health care costs has diminished in recent years, health care costs will continue to be a major driving force in the industry. Nonetheless, quality of care and customer service will become more important issues.
  • The veteran population eligible for care at VA facilities will continue to age and decrease. However, the need for both acute and long-term care services for this aging population will rise disproportionately to the decrease in users due to greater health care needs associated with aging.
  • In addition to the “macro” issues, there will be local and regional dynamics impacting individual VA facilities and networks.

In envisioning the veterans’ health care system of the 21st century, it is assumed that the future is unpredictable and that the VA must be flexible enough to rapidly respond to unforeseen circumstances.

The mission of the veterans’ health care system is to serve the needs of America’s veterans by providing specialized care for service-connected veterans, primary care, and related medical and social support services.

To accomplish its mission, the Veterans Health Administration (VHA) should be a comprehensive, integrated health care system that provides excellence in health care value, excellence in service as defined by its customers, and excellence in education and research. It also should be an organization characterized by exceptional accountability.

There are numerous changes underway in the VA which specifically affect optometric education and they present both challenges and opportunities – opportunities for significant gains if optometric institutions are proactive and significant losses if they are passive. The VA is currently:

  • Reengineering the operational and management structure of the veterans health care system.
  • Implementing the Veterans Integrated Service Network (VISN) management structure. This new structure has resulted in a shift of operational control and some policy development to the local level.
  • Management Assistance Councils consisting of external advisors are either operational or being established in all Networks.
  • Restructuring VHA headquarters.
  • Implementing multidisciplinary “service line” rather than discipline-specific clinical care in recognition of the Transdimensional nature of health care today. Optometry and ophthalmology have been placed in the HQ Primary and Ambulatory Care Strategic Health Group forming the eye care program. This is likely to be emulated in VA field facilities.
  • Standardizing clinical processes (e.g., with nationally developed clinical guidelines) and delegating clinical care responsibility to nonphysician providers.
  • Exploring ways of improving the accessibility, quality, and cost-effectiveness of VA’s special emphasis programs, e.g., VICTORS.
  • Increasing the proportion of the VA’s work force providing primary care.
  • Developing tailored training/retraining programs in primary care.
  • Reducing the variation in professional staffing that exists among facilities and services having similar missions and work loads.

Although we may experience reductions at certain facilities, overall continued growth in optometry is projected. Since 1990, VA Optometry Service has added 86 FTEE staff and residents. This growth has facilitated our involvement in the following activities:

  • Increased sharing of activities with academic affiliates and the Department of Defense.
  • Promoting a VHA culture of ongoing quality improvement that is predicated on providing health care value.
  • Establishing a VA clinical “Centers of Excellence” program to celebrate and disseminate best practices and to foster studies that identify organizational characteristics that lead to performance excellence.
  • Promulgating customer service standards and ensuring that they are known by both staff and patients, e.g., 30 days maximum wait for eye care.
  • Decreasing waiting times for appointments. Although reduced from over 100 days in 1990 to the current level of 47, it still is far from acceptable.
  • Ensuring the VHA’s educational offerings emphasize areas of greatest societal need and are responsive to the needs of veterans today and in the future.
  • Convening Residency Realignment Advisory Committees for physicians and other health professionals to provide guidance in ensuring the VA’s postgraduate training programs are responsive to the needs of the VA and the nation. Possible overall reduction in optometry positions could result from general downsizing. Also, the lack of formal requirements for optometric residency training increases the vulnerability of the program. Most likely there will be a reduction in multiple resident placements.
  • Increasing the proportion of trainees in primary care disciplines.
  • VA facilities are reevaluating their affiliation(s) in light of VHA’s restructuring and vision of the “new VA,” and the present educational role of VA. Affiliation agreements should defend the prerogatives of VA, control the use of VA resources, and protect the interest of VA patients.
  • Initiating review and renegotiation of all academic affiliation agreements.
  • Reassessing the role and function of Deans Committees in light of today’s changed health educational environment and effect changes where needed.
  • Academic affiliations and residents are likely to be negotiated on a Network basis.
  • Clinical credentialing and privileging will probably be conducted on a Network basis.

The VA’s Current Contributions to Optometric Education

There are currently 155 academic affiliation agreements at 103 facilities. Five hundred thirty optometry students annually rotate through VA facilities. Seventy-five residents and 9 WOC are currently funded at 44 program sites. A significant increase in requests for “without compensation placements” (WOC) has been noted. There is a potential of 400,000 annual clinical teaching encounters. Research opportunities abound with currently over 7.0 million in funded optometric research.

There is a corps of well-qualified clinical preceptors with some VA optometrists released to teach at affiliates. VA clinicians are also active contributors to the literature and national continuing education programs.

What Can Individual Schools and Colleges Do to Preserve VA Affiliations?

  • Above all, be an active partner.
  • Assist VA facilities with Quality Improvement activities.
  • Assist VA facilities in improving staff productivity and reducing waiting times for appointments. Low productivity will likely result in loss of residency funding and possibly staff FTEE. Chronic long waiting times could result in local frustration and contracting out to commercial providers. This is already a reality in one Network.
  • Seek appointment of school-based optometric faculty as consultants at VA facilities.
  • Enter into contractual “sharing’ arrangements, e.g., VICTORS, Eye Care Centers of Excellence.
  • Seek appointments to Network Management Assistance Councils. Already, Drs. Haffner, Hopping, and Walls have been appointed and I have received positive feedback on their contributions.
  • Increase awareness of VA affiliations by publicizing your institution’s activities.
  • Seek new academic affiliations within your Network.
  • Prepare thoroughly for COE accreditation visits and address problems before COE visits. Less than full accreditation will likely result in loss of VA funding.
  • Seek cooperative research projects with VA affiliates.
  • Consider WOC residency programs as a means to initiate new programs.
  • Understand the new JCAHO accreditation standards and survey process and their implications to optometry.

What Can ASCO Do Collectively?

ASCO should implement the recommendations agreed to in the 1992 AOA/ASCO/NAVAO Strategic Plan. For example:

  1. In cooperation with the VA, assist in the development of and implementation of a system wide Total Quality Improvement Program.
  2. Improve management of affiliations programs by: participation on Network Management Assistance Councils. (Originally the Deans’ Committees.)
  3. Stimulate research proposals in cooperation with VA medical centers.
  4. Review faculty appointment procedures and benefits for VA preceptors and enhance them wherever permitted by institutional governance.
  5. Residency expansion in VA should be carefully managed to assure well-balanced clinical educational programs nationwide.
  6. ASCO should endeavor to publicly promote its relationship with the VA, increasing positive support of VA activities and accomplishments and increasing the public and the government’s knowledge of optometry.
  7. Monitor affiliations through the ASCO Committee on Residencies and Externships and through COE reports.

This is a time of great change in the VA. It presents many challenges, but also many opportunities. The shift of control to the Networks (local) level makes it more important than ever that every affiliated optometric institution be an active partner with its VA affiliated facilities and Network leadership. There is the possibility for significant gains if there is local initiative and likewise the possibility for significant losses if the schools and colleges of optometry are inactive.

At the time this article was written, Dr. Mullen was Director of the Optometry Service, Veterans Health Administration. This article is based on the VA’s new strategic plan entitled Prescription for Change. Dr. Mullen is currently the president of the Illinois College of Optometry.

The Journal of the Association of Schools and Colleges of Optometry.
Optometric Education, Volume 22, Number 3. Spring 1997.
Charles F. Mullen, O.D.

by Charles F. Mullen

Optometry’s Role in National Health Care Reform (Clinical Eye and Vision Care Article)

Health care reform is currently being debated in the U.S. Congress, in state legislatures, and by nearly every element of the health care system. The reasons for change need little elaboration: Upward of 40 million Americans are without health insurance and facing restricted access to health care services, and health insurance premiums are reaching levels that neither employers nor low- and middle-income families can afford. Health care costs now represent 14% of the nation’s output of goods and services. The quality of care is inconsistent, and excessive health care resources, including training programs, are positioned in specialty areas, while major deficits exist in much needed primary care services and clinical training.

How must health care in America change? I believe that we must and will have universal entitlement – health care security for all Americans, but major changes are also required in all aspects of the current system. We must reach a proper relationship between the numbers of primary care health providers and specialists, improve access to health services, control costs, and assure quality of care, and any new health plan must support training of primary care providers, including optometrists. Ten states have recognized the need for change and already have some type of health reform legislation in place. As a health care administrator, I am frequently asked about President Clinton’s health care reform initiative. I believe that it is the right plan for the American people and the best plan for optometry. The President’s proposal explicitly provides eye/vision care benefits and recognizes optometry’s role in primary care.

In 1973, doctors of optometry were first granted the legal right and responsibility for administering pharmaceutical agents. Now, optometrists in 40 states are clinically privileged in the management of diseases and conditions of the eye. The progress of the optometric profession over the past 20 years has been dramatic. I attribute this success to a sincere desire on the part of practitioners nationwide to provide more accessible and cost-effective eye care to their patients and the expansion of the clinical practice of optometry to include the management of eye diseases and prescriptive authority that has been essential to optometry’s primary care role. As a result of this dramatic progress, I believe that optometry is now positioned to assume the role of primary eye care provider under national health reform.

Today’s optometrist is uniquely qualified to meet the challenge of national health care reform. Optometrists are the nation’s most accessible eye care providers, practicing in more than 6800 municipalities throughout the United States. In more than half of these communities, they are the only eye care providers available. Optometric clinicians are often the point of contact in the health care system for many people and their training qualifies them to serve in a role for patients with systematic health problems that manifest in the eye. This is particularly important in medically underserved areas.

Vision and eye health problems are among the nation’s most prevalent disorders affecting more than 140 million people. Vision problems inhibit the ability of children to learn, adults to work, and the elderly to live independent and productive lives. Regular eye examinations are also an essential preventive measure for the early diagnosis and prompt treatment of eye diseases, which, if undetected, result in individual suffering and added societal costs. A recent study by the Georgetown University Medical Center concluded that over 100,000 new cases of blindness yearly are preventable through timely detection and treatment and would result in an estimated annual savings to the federal budget of one billion dollars.

The demand for services of primary care providers in the United States continues to exceed the supply of manpower resources available. Health care reform provides an opportunity to restructure the delivery and health educational systems in ways that make better use of America’s available health care resources through the use of cooperative approaches to health delivery and training. Enhanced primary care training for optometrists is consistent with the current emphasis on primary care in federal health care policies.

Optometry and ophthalmology are complementary eye care professions in the Department of Veterans Affairs and nationwide. However, interprofessional controversy over certain issues persist. These issues include the extent of clinical privileges for optometrists, the role of the optometric clinician in pre- and postoperative patient management, and the use of laser technology by optometrists. Such sensitive issues are not easily resolved. However, there are many areas of mutual agreement, and I believe that the eye care professions can, and should, cooperate in patient care programs, education, training, and research. Cooperative programs already exist in some health care institutions in the nation, but on a limited basis.

The success of cooperative programs between optometry and ophthalmology is evidence that joint efforts can be advantageous to both medicine and optometry and that optometrists and physicians can work together as colleagues. In cooperation with affiliated health professions schools, I believe that properly constructed and thoroughly evaluated eye centers of excellence could serve as models that promote preventive care, while at the same time provide state-of-the-art treatment and rehabilitative services. These models could be emulated throughout the national health system.

The future can take us into a new era of accessible, affordable, and quality health care and lead optometry into an arena of greater responsibility for the eye care needs of all Americans.

Acknowledgements

I gratefully acknowledge the contributions of A. Norman Haffner, O.D., Ph.D., President, State College of Optometry, State University of New York, and James Holsinger, M.D., Ph.D., Chancellor, University of Kentucky Medical Center, to the preparation of this speech and the advancement of VA optometry. This editorial is taken from Dr. Mullen’s speech given June 2, 1994 at the graduation ceremonies at The Southern College of Optometry.

Clinical Eye and Vision Care.
Volume 6. Number 3. 1994.
Charles F. Mullen, O.D.

by Charles F. Mullen

An Affiliated Educational System for Optometry with the Department of Veterans Affairs

An unprecedented opportunity exists for the Department of Veterans Affairs (VA), the Association of Schools and Colleges of Optometry (ASCO), and the American Optometric Association (AOA) to develop jointly a large scale affiliated optometric educational system. Coordinated strategic action would establish and direct the dynamics of interaction among VA, ASCO member institutions and AOA, and could result in enhanced optometric patient care, education, and clinical research opportunities with the Department of Veterans Affairs.

Veterans Health Administration

The Department of Veterans Affairs includes three distinct organizations: Veterans Benefits Administration, National Cemetery System, and Veterans Health Administration (VHA).

The VHA administers the world’s largest comprehensive health care system for the nation’s 26.9 million veterans. It includes 172 medical centers, plus more than 700 outpatient clinics, nursing home care units, domiciliaries and vet centers throughout the United States and the Philippines. Operating with an annual budget of over $13.5 billion, VHA treats 1.1 million inpatients and records over 23 million outpatient visits annually.

In addition to its primary mission of providing health care to veterans of the U.S. armed forces, VHA has three other roles. First, in times of war or national emergency, VHA serves as the backup health care system to the Department of Defense. Second, VHA trains a broad range of health care providers, including optometrists. Third, VHA works to enhance patient outcomes through clinical research. Each year VHA appropriates over $200 million for medical and prosthetics research. Currently, nearly 6000 investigators are engaged in more than 10,500 research projects located at VA medical facilities.

Optometry Service

In 1974 VHA recognized optometry’s contribution to veterans’ health care and named its first Director of Optometry to address the eye and vision care needs of veterans. Initially, the Director could not attract optometrists to service because of the outdated personnel system and salary schedule. There were just 8 full-time optometrists in the system and no residents.

In 1976 VHA designated optometry a Service and placed staff optometrists under title 38, in the same personnel pay system as physicians, dentists, and nurses. This provided more competitive salaries, created teaching programs, and increased optometric care for veterans. By 1980 there were over 70 full-time optometrists in the VA.

In the early 1970s, the VA also began establishing successful and innovative affiliations with schools and colleges of optometry. For instance, the nation’s first clinical education program for optometry students began at the Birmingham VA medical Center, in affiliation with the University of Alabama School of Optometry. Also, the nation’s first VA optometry residency program began at the Kansas City VA Medical Center. By 1980, 12 residency programs had been established.

Providing primary eye care by staff optometrists proved to be cost-effective and efficient, and veterans and veterans’ service organizations enthusiastically endorsed optometric care. This allowed VA Optometry Service to expand steadily and to begin to address the unmet need for primary eye care in the VA.

At present, 220 full- and part-time optometrists (150 FTEE) provide eye care services to veterans at 138 VA medical facilities. Optometrists manage over 300,000 patient visits annually and provide clinical training for 500 optometric students and 53 optometric residents at 79 academically affiliated VA facilities. Since many VA facilities have multiple affiliations, currently 121 affiliation agreements exist among schools and colleges of optometry and VA medical centers.

Included in Optometry Service’s responsibility is the provision of vision rehabilitation services at three Vision Impairment Centers to Optimize Remaining Sight (VICTORS), three Low Vision Clinics, and five Blind Rehabilitation Centers (BRCs).

The Field Advisory Group is an integral part of Optometry Service. Fifteen chairpersons, all optometrists practicing within the VA medical system, head special committees on areas critical to the development of the Service and the delivery of quality eye care, education, and research. They remain in constant contact with the Director and address issues ranging from total quality to improvement of public relations. The chairpersons, representing the dedicated work of their committees, provide invaluable assistance at biannual strategic planning meetings of the entire Field Advisory Group.

With regards to external relations, the Director of Optometry Service maintains liaisons with the AOA, ASCO, National Association of VA Optometrists (NAVAO), and the Special Medical Advisory Group (SMAG) Subcommittee on Eye Care. The Field Advisory Group and representatives from these organizations combine to form a significant network of advisors.

The Opportunities

In the Armed Forces, Health Maintenance Organizations (HMOs), and the private practice sector, the ratio of optometrists to ophthalmologists is a little over two to one. This balance has evolved naturally in response to the need for a cost-effective, logical approach to primary eye care services, subspecialty eye care services, and surgery. In VA, the ratio is reversed; there are at least two ophthalmologists for every one optometrist. An opportunity exists to develop and implement a highly efficient and cost-effective national model for the provision of eye care, a model that minimizes duplication and overlapping of services among the eye care providers.

By the year 2000 the number of Veterans at visual risk will increase from 4.0 to 5.7 million impacting greatly on the total number of eye care visits to VA facilities. Optometry Service presents a cost-effective means of providing primary eye care.

The veteran population of 26.9 million is aging. It is a population with a high incidence of ocular and vision disorders. VA presents opportunities for eye care research in early diagnosis and management of eye disorders in the elderly. Significant clinical studies of age-related macular degeneration, diabetic retinopathy, cataract, and glaucoma could be mounted.

Leaders within VA, ASCO, and AOA have a chance to dramatically shape the future of eye care delivery and optometric education. Opportunities within VA for enhancing patient care, clinical education, and research abound. The climate is right to jointly initiate constructive, strategic action.

Climate

VA has a history of support for sharing agreements and affiliations. VHA medical centers share extensively with academic health care centers demonstrating a history of commitment to clinical education and research. Thousands of sharing agreements exist between the VHA, the Department of Defense, and the Indian Health Service.

VA has an ongoing and active policy of cultivating new affiliations. Within the past two years 18 new academic affiliations have been developed among VA medical facilities and schools and colleges of optometry. Also, three existing programs have been expanded. More affiliations are possible and have been encouraged by various government organizations and VA advisory groups.

Related to this is VA’s high technology sharing program. This allows VA medical centers and its academic partners to purchase expensive equipment jointly and to share in the cost of operation. Technology sharing agreements with schools of optometry should be explored.

The quality and cost-effectiveness of health care delivery is of prime importance to VA. Optometry Service provides quality, cost-effective, and accessible care and is often used as an example of a model program in which high quality patient care is inextricably combined with the training of students and residents.

Funds were recently made available for 35 new optometric staff positions. In an effort to improve accessibility to primary eye care, additional funds for staff expansion are anticipated.

With its Field Advisory Group, Optometry Service already presents a highly qualified team ready for constructive interaction with ASCO, NAVAO, and AOA leaders. This extensive network of advisors covers every aspect of Optometry Service’s operation. Together we will be ready to address the issues. Together we will be ready to face the challenges ahead.

The Challenges

VHA is concerned with health services research and the structure of eye care services delivery in particular. Optometry Service, ASCO, and AOA, along with VA Offices of Quality Management, Health Services Research and Development, and Clinical Programs could respond to the challenge by creating Regional Centers for Eye Care Excellence. These Centers would involve the disciplines of optometry and ophthalmology and their respective academic affiliates in the collaborative provision of eye care, ophthalmic education, and research. They would serve as demonstration and evaluation sites for evolving eye care models.

Within the VA, as in the private sector, sensitive issues surround the respective roles of optometrists and ophthalmologists. A unique, coordinated health services research project which addresses the interaction between optometry and ophthalmology in the VA could be developed.

Such a demonstration project would examine reporting relationships for optometrists and ophthalmologists in VA medical centers. It would also study the extent of clinical privileges granted to ophthalmic clinicians. The project would address the issue of new and developing technologies and Clinical Practice Indicators for VA eye care.

Conclusions defining the practice of optometrists in relation to ophthalmologists and other health care providers could serve as guidance for the entire system.

VA, ASCO, and AOA should move forward in designing and implementing a comprehensive affiliation system. This would, however, present challenges in maintaining quality patient care and integration of educational programs. It is imperative that any system under consideration include guidelines for optometric faculty, resident, and student participation. Appointing all affiliated optometry school deans to VA Deans’ Committees and appointing selected optometry school faculty as consultants and attending optometrists at VA medical centers would assist in maintaining proper integration of patient care and clinical education.

Participants in the September 1991 ASCO Workshop on VA Optometric Academic Affiliations stated that in the development of large scale education initiatives there is a need for consultation by the AOA’s Council on Optometric Education (COE), which has been successful in accrediting and counseling optometric programs within the VA.

In cooperation with the schools and colleges of optometry the VA Optometry Service and Quality Management Office could review and update Optometry Service’s Quality Improvement Program. Further, quality could be insured by encouraging continued review of the VA Optometry Service patient care programs by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). However, optometric representation in JCAHO is essential to the success of the accreditation programs.

The greatest challenge faced by the VA, ASCO, and AOA will be interacting on a comprehensive scale; planning will require foresight and coordination. However the outcome – a newly acquired ability to mount large scale educational initiatives, to evaluate new technology, to test quality assurance mechanisms, and to develop innovative eye care programs – will be worth the effort.

VA, ASCO, and AOA could work to develop or enhance affiliation agreements between ASCO member institutions and key VA facilities. VA medical centers in New York, Philadelphia, Houston, Memphis, Indianapolis, and Boston present significant training opportunities not currently realized by ASCO members.

Summary

The time is right for VA, ASCO and AOA to take action. Cooperative strategic action by the health care system (VA), educational institutions (ASCO), and the professional association (AOA), could lead to the placement of hundreds of new optometric residents and externs in educationally cost-effective and clinically challenging environments.

If the initiative is consistent with the VA’s mission and addresses the challenges previously described, it will succeed. If the initiative creates improved models for optometric academic affiliations and includes discipline specific protocols for resident and extern placements, it will succeed. If the initiative includes innovative models for more accessible, cost-effective and efficient eye care delivery, it will succeed. And above all, if the initiative systematically addresses the eye care needs of our nation’s veterans, it will succeed.

Journal of the Association of Schools and Colleges of Optometry.
Optometric Education. Volume 18, Number 2. Winter 1993.
Charles F. Mullen, O.D.

by Charles F. Mullen