Charles F. Mullen

Opportunities and Challenges in Optometry and Optometric Education

Guest Editorial: Lewin Survey Finds Large Optometry Surpluses

In the following comprehensive analysis, Dr. Kenneth Myers critiques the Eye Care Workforce Study prepared by Lewin Associates and released by the American Optometric Association (AOA) and the Association of Schools and College of Optometry (ASCO) in 2014. The Lewin Study (when “excess capacity” of 32% is taken into account) is consistent with previous eye care workforce studies, including Rand (1995), Abt. (2000) and Myers (2014), in finding an excess of optometrists. The most revealing finding of the Study is that optometrists function only at 68% of their practice capacity.

Lewin states “In fact, our estimates indicate that there is a significant excess supply (12,672 FTE in 2012) and though it declines modestly over the forecast period it remains substantial at about 9,000 FTE by 2025. Accounting for two of the factors that could increase demand, increases in insurance coverage under the ACA and increased prevalence of diabetes excess supply is reduced substantially to 4,000 FTE by 2025.” Dr. Myers questions the plausibility of these Lewin predictions “that could increase demand”, as well as Lewin’s assumption all ophthalmology shortages will be filled with surplus optometrists at the rate of 1.36 FTE optometrists filling 1.0 FTE ophthalmology shortage. He also believes the effective optometry surplus will approximate 11,000 FTE in 2025.

The author discusses the Bureau of Labor Statistics (BLS) prediction of a 24% growth in employment or 8,100 additional optometrists by 2022. This prediction is obviously not consistent with the Rand, Abt. Myers and Lewin studies. This optimistic prediction has been cited as the rationale for the development of new schools of optometry. The reliability of the data and methodology used by BLS in making this prediction need to be evaluated and reconciled with the findings of the previously cited eye care workforce studies.

The author attributes the optometry surplus to a significant increase in the number of graduates from optometry schools and colleges. Since 2006, six new schools in CA, AZ, TX, MA, KY and VA have been founded and three more are under consideration in IL, NC and WI. Already, the number of graduates has increased from 1029 in 1985 to 1600 in 2014. When all new schools reach full enrollment, the number of annual optometry graduates will further increase to 1900. Also, the addition of new optometry schools dilutes the already flat student applicant pool.

All academic leaders in optometry are encouraged to read the entire Lewin Study and draw their own conclusions about the optometry workforce. The terminology used in the publicity associated with the Lewin Study’s release was ambiguous with no reference to an excess or surplus of optometrists. “Adequate” is not the same as surplus. It is also suggested that the leadership review the current oversupply situations in veterinarian medicine and the legal profession and the impact on employment opportunities for graduates and number of applicants for admission in these two professions.

The unmet need for optometric services in rural and inner-city America was not addressed in the Lewin Study. Presumably, this omission occurred since inclusion of optometry in key Federal incentive programs such as the National Health Service Corps and Title VII would be necessary to be a realistic practice option. Only 20% of Federally Qualified Community Health Centers provide eye care services.

Lewin Survey Finds Large Optometry Surpluses (PDF)

Lewin Survey Finds Large Optometry Surpluses (DOC)

by Charles F. Mullen

Guest Editorial: The Optometry Surplus – A Quantitative Determination of Excess Densities

The following scholarly paper concentrates only on the supply of optometrists and it is suggested readers draw their own conclusions about whether increases in density of optometrists, caused by increases in optometry graduates, would result in an oversupply of optometrists.

While supply can be quantified, demand requires too many predictions or guesses to be accurately calculated including the degree Federal, state and private insurance plans provide eye and vision care coverage, co-payment amounts, state of the economy and political climate.

The author, Dr. Kenneth Myers provides strong evidence of a current and future oversupply of optometrists. With detailed calculations and charts, he demonstrates the increase in density of optometrists per 100,000 in the U.S. population. He attributes the increase in density to a significant increase in optometry school graduates. The number of graduates has increased from 1127 in 1997 to approximately 1600 in 2014 and will likely reach 1900 by 2018, when all new schools reach full enrollment. Dr. Myers calculates that density has increased from 11.5 per 100,000 in 1997, when it was considered that supply equaled demand, to the current level of 12.8. He acknowledges that local densities vary. The author further projects density peaking at 15-17.

The author cites the Abt, Rand, Project Hope Census Studies and numerous other references listed in the bibliography, but not the recent Lewin Eye Care Workforce Study as his research was completed in advance of the release of the Lewin Study.

Dr. Myers stresses the importance of accurately portraying the current and future oversupply. He describes the potential harm of oversupply to the schools and colleges of optometry and the profession of optometry if the matter continues to be ignored. Dr. Myers expresses concern about the lack of quantitative measures in evaluating new schools for accreditation. He also writes about his concern for the optometry graduate entering a difficult marketplace with high educational debt.

The legal profession ignored the issue of oversupply of lawyers and now is facing the consequences. Only 55% of graduates can find full-time work and applications to law schools continue to decline. The employment crisis and applicant decline show no signs of abating.

The Optometry Surplus: A Quantitative Determination of Excess Densities (PDF)

The Optometry Surplus: A Quantitative Determination of Excess Densities (DOC)

by Charles F. Mullen

Guest Editorial: Types of Optometry Certification

In the following eloquently written article, Dr. Kenneth Myers discusses traditional board certification in allopathic medicine, osteopathy and dentistry and the emergence of board certification in optometry. He delineates the three levels of credentials recognized for physicians, dentists and optometrists at Joint Commission for Accreditation of Health Care Facilities (JCAHO). The article stresses the importance of residency training in achieving eligibility for board certification. And of particular significance to optometry, Dr. Myers thoroughly and precisely describes the difference between Specialty Board Certification and Board Certification of General Practice Optometrists. This is a very important and timely article for the profession of optometry and optometric education.

by Kenneth J. Myers, Ph.D.,O.D.

Introduction

Medicine, osteopathy and dentistry have long had specialty certification boards that issue “board certifications” to those completing residency specialty training in defined specialty areas of each of these professions after licensing. Optometry has one specialty certification board and three boards that issue certifications to general practitioners.

The three boards for general optometry practitioners certify current licensing-level competency rather than specialty competency and differ considerably in their requirements.

All four types of certification are voluntary and not required for licensure, license renewal or the private practice of optometry.

Specialty certification is required, however, of a licensed optometrist seeking credentialing as a specialist at a Joint Commission accredited health care organization.

Specialist Board Certification

ABCMO is an optometry specialty board aligned with the credentialing process used for appointment and credentialing of allopathic and osteopathic physicians, dentists, optometrists and podiatrists practicing at Joint Commission accredited healthcare organizations. In this long-standing credentialing system, board certification recognizes achievement of advanced competency in a specific specialty within one of these professions; an advanced competency that requires completing accredited specialty residency training after licensing, passing a written examination testing competency in that specialty and meeting additional criteria of an appropriate specialty board. This process, termed “board certification” has been used for over 80 years to certify specialist-level competency; i.e. competency above that required for licensure in medicine, osteopathy, and dentistry.

With creation of ABCMO in 2009, there are 74 specialty boards recognized by credentialing committees at Joint Commission accredited health facilities which all require specialty residency training and passage of an examination testing specialty competency.

General Practice vs. Specialist Practice

Since 1986, the Joint Commission has recognized that optometrists, like dentists, qualify for appointment to the medical staff of an accredited healthcare organization for general practice optometry by holding the O.D. degree and state license. Additional professional credentials are also not required for private, general practice optometry by insurance panels or state and federal medical programs.

However, to apply for credentialing as a specialist at an accredited health care organization, physician, dental and optometry practitioners must document completion of residency training in a specialty, passage of an examination in that specialty, and provide the name of the recognized specialty board issuing their certification and its expiration date.

ABCMO formed in 2009 to permit residency trained O.D.s to meet requirements for credentialing as a specialist in medical optometry at accredited health care organizations and is incorporated as a nonprofit specialty board issuing a Level 2 credential.

Recognized Levels of Credentials for physicians, dentists and optometrists:

The three recognized credentialing levels for medical, osteopathic, dental and optometry practitioners at Joint Commission accredited facilities are:

  • Level 1 – Credentialed as General Practitioner of licensed doctoral profession:

    Degree + license required. Maintenance of license-level competency verified at license renewal as required by practitioner’s state licensing board. [Maintenance of License]

  • Level 2 – Credentialed as Specialist in defined area of licensed doctoral profession:

    Level 1 credentials plus residency training in specialty, passage of specialty examination and specialty board certification required. Specialists usually take part in maintenance of certificate programs to renew their specialty certifications every 10 years.

  • Level 3 – Credentialed as Subspecialist

    Level 1 and 2 credentials plus Fellowship training in a subspecialty required. Competency maintained as specified by subspecialty Society or College.

In this national 3-level credentialing system a licensed health profession is not considered a specialty itself.

Board certification is a Level 2 credential that certifies advanced competency in a specialty of a higher level than that required for licensing or license renewal as a general practitioner.

Types of Optometry Certification

ABCMO issues a Level 2 credential certifying competence in the specialty of medical optometry.

The three boards offering board certification in general practice optometry certify completion of additional, voluntary education and testing in general practice optometry. Such programs are considered additional, voluntary maintenance of license by medicine, osteopathy and dentistry because they are additional certifications of license-level competence and do not certify specialist competency.

Specialty Residency Programs in Optometry

Postgraduate optometry specialization via residency training is relatively new to optometry and began in 1985 within U.S. Department of Veterans Affairs medical centers which operate about one-half of US optometry residency programs. Non-VA residency programs at schools of optometry began in the 1980’s. Optometry residency programs are accredited by the Accreditation Council on Optometric Education. About 20% of newly licensed optometrists choose to serve a specialty residency of which about one-third are in medical optometry and based at VA medical centers.

About 93% of practicing optometrists have not served residencies, are not eligible for ABCMO certification and are in private general practice. The majority of ABCMO applicants practice within, or plan to practice within, accredited health care facilities or private medical practices.

Purpose of Board Certification of General Practice Optometrists

The credentials awarded by the organizations issuing “board certifications” to general practice optometrists require additional education and testing in general practice compared to that required by state licensing boards for renewal of optometry licenses. Optometrists taking these additional steps to ensure their competency in general practice are to be commended.

Confusion Can Exist

The existence of four types of “board certification” for optometrists, however, can produce confusion for credentialing bodies since three certify license-level competency and one certifies specialist-level competency.

Summary

  1. The meaning of “board certification”, as subscribed to by credentialing committees at accredited medical facilities, and ABCMO, recognizes attainment of specialist status from successful completion of an accredited post-licensure specialty residency, passage of a national specialty examination, meeting requirements of practice of the specialty in a suitable setting for a specified period of time and engaging in a maintenance of specialty competency program.
  2. There are significant differences between board certification as a specialist in medical optometry and “board certification in general practice optometry”.
  3. ABCMO believes optometrists voluntarily exceeding state requirements for license renewal are to be commended for doing so. But such achievement does not confer specialist status and is not to be confused with the meaning of “board certification” as used in medicine, osteopathy, dentistry and ABCMO.

Credentialing History

Development of Specialists and Board Certification

Until the 1940’s, medical (MD) and osteopathic (DO} physicians and dentists frequently entered practice with degree and license.

With time, the increasing complexity of healthcare led to residency training of 3-5 years in medical-osteopathic specialties after licensure, that accelerated with the concentration of advanced procedures at hospitals which began to prefer, and often require, residency-trained specialists. Today, the 24 American Board of Medical Specialties recognized specialty boards for MDs all require specialty residency training and written specialty examinations for board certification and osteopaths and dentists have similar specialty boards. Altogether, including ABCMO, there are 74 recognized specialty boards for physicians, dentists, optometrists and podiatrists.

About 80% of medical-osteopathic physicians are board certified in a recognized specialty and Joint Commission accredited medical facilities require specialists be residency trained and certified by a specialty board. There is no requirement to be board certified for private practice.

Board certification is therefore synonymous with specialization via residency training and with the clinical privileging of specialists at accredited medical facilities.

Defined-license doctoral prescribing practitioners like dentists, optometrists and podiatrists were slower to develop specialties as their training, degrees and licenses prepare them for general practice without additional training or certification.

Dentistry was the first defined-license doctoral profession to establish specialties and now has 8 dental specialties for which residency training and board certification are required. The great majority of licensed dentists remain in general practice however and virtually all of the 377,000 general practice U.S. dentists practice on the basis of degree and license since the American Dental Association (ADA), state dental boards and credentialing committees accept licensure as fully documenting competency in general dentistry. A board exists to offer board certification in general practice dentistry but it is not recognized by the ADA and has certified less than 1% of general practice optometrists.

Optometry began to move to residency training when the Department of Veterans Affairs established optometry hospital residency training programs in 1975. Optometry since then has designated ten specialties for which residency training is appropriate and the Accreditation Council on Optometric Education (ACOE) accredits optometry residency programs. The Advanced Competence in Medical Optometry examination (ACMO) is administered annually by the National Board of Examiners in Optometry (NBEO) since 2005 and the American Board of Certification in Medical Optometry (ABCMO) incorporated in 2009 to offer board certification in the specialty of medical optometry with a maintenance of certification requirement.

There remain, however, non-recognized boards that grant board certification not requiring residency training, to physicians. These “board certifications” are not accepted at accredited medical facilities, nor recognized by the ABMS or the medical credentialing community. Some state medical licensing boards will not permit holders of these credentials to state they are “board certified” [See NC state medical board “Who may claim to be board certified”.]

While in private practice a licensed practitioner may claim to be a specialist from holding a certificate from a “board”, such specialist claim will be disallowed by credentialing committees at accredited health facilities unless issued by a recognized specialty board. This underlines the chief purpose of board certification which is to grant privileges as a specialist to appropriately trained specialists within a licensed health care profession.

Dr. Myers was founding Director of the VA Optometry Service, dean of an optometry school and currently president of the American Board of Certification in Medical Optometry.

by Charles F. Mullen

Federal Support for Optometric Education is Essential

Federal support for clinical training, scholarships and loan forgiveness is essential for optometry to remain competitive in health professions education.

Medical, dental and podiatric education all benefit from Federal financial support while optometry does not, placing optometric education at a competitive disadvantage. Federal financial support will not address all of optometric education’s challenges. However, Federal assistance in financing an optometric education will certainly make optometry a more attractive career option.

The following are serious challenges facing optometric education:

  • Stagnate Optometry Student Applicant Pool: Currently 1.5 applicants per entering seat—qualified for admission likely 1:1. Projection models suggest an actual decline in number of applicants per seat.
  • Significant Increases in the Number of Entering Seats from New Schools and Increased Enrollments at Others: Applicant pool not increasing, although the number of entering seats has increased from 1160 to 1763 or 52% in a decade. Number of entering seats likely to exceed 2000 by 2015-16.
  • Decline in Undergraduate College Enrollments: College enrollment declined by one-half million students in 2012.
  • Optometric Manpower Uncertainty: Conflicting data on optometric manpower: Rand Study-1995 and Abt.Study-2000 both predicted significant surpluses. Meanwhile the Bureau of Labor Statistics projects high demand for optometrists. Hopefully, AOA’s Lewin study-2013 will clarify the matter, but the study has not been released.
  • Full Time Employment Concerns: Anecdotal concerns expressed by recent graduates about the shortage of full time positions with sufficient income to service education debt. — Increases in law school enrollments, without corresponding increases in demand for lawyers, have resulted in that only 55% of recent law graduates can find full time employment.
  • High Graduate Debt vs. Potential Income: Not unusual for student debt to exceed $200,000, while potential annual income averages $95,000. Thus the importance of the opportunity for Federal scholarships, loan forgiveness programs or stipends during final clinical year.
  • High Cost of Clinical Training: Increases in clinical training costs are passed on to the optometry student in the form of higher tuition. Colleges of optometry are burdened by high fixed cost campus-based clinics. Relative costs per Clinical Teaching Encounter: Campus-based clinics are by far the most costly. ($100-350), Affiliated facilities less ($10-30). Externships least costly ($.50-1.00).
  • Medicare Compliance Concerns: Current optometric Student-Directed Clinical Training Model is not compatible with “Medicare/Medicaid (CMS) Guidelines for Teaching Physicians, Residents and Interns (Students)”. Students can not provide billable services to Medicare beneficiaries and other insured patients. Two university- based optometry schools paid significant fines for Guidelines’ violations with the current Student-Centered Training Model.
  • No Standardization of Certification Boards: Newly formed optometric certification boards have different criteria for board certification. It is essential that all boards operate with standardized criteria for recognition by Federal and private agencies and insurers. Medicine has such an oversight board, the American Board of Medical Specialties (ABMS).
  • Lack of Federal Financial Support: Optometric education receives no financial support for clinical training because its clinical training model does not meet Graduate Medical Education (GME) expectations. Furthermore, optometry does not qualify for Federal scholarships and loan forgiveness programs, because the profession is not designated as a Primary Care Profession.

Immediate Action Required

The implementation of the Affordable Care Act (ACA) presents a unique opportunity to pursue Federal financial support for optometric education by:

Aggressively advocating and pursuing optometry’s inclusion in key Federal patient care, educational, scholarship and loan forgiveness programs.

The last serious effort by ASCO/AOA to include optometry in GME was in 2007 and the proposal was rejected because the optometry clinical training model does not meet GME expectations. There also have been periodic efforts to include optometry in Federal scholarship and loan forgiveness programs.

To be effective, advocacy must be organized, consistent, well-funded and managed by knowledgeable individuals, preferably Deans and Presidents of optometry schools and colleges. Unlike optometry, leadership in the medical profession emanates from the Academic Medical Centers and has significantly contributed to success of both medical education and the medical profession.

Specific Initiatives

  1. Create eligibility for the $11.5 billion Graduate Medical Education (GME) program by restructuring the curriculum, changing state licensing requirements and aggressive advocating to amend the Social Security Act to include optometry and its training facilities.

    • Restructure the curriculum to potentially qualify for GME, the educational component of Medicare: New model would consist of 3 years for OD degree + final year of postgraduate training to qualify for licensure and board eligibility.
    • Requiring postgraduate training for state licensure along with Board Certification would place optometry in parallel with medicine and enhance qualification for the GME program. “Best Practices” model would parallel medicine and consist of degree+ postgraduate training = licensure+ board certification. GME pays an average of $100,000 per medical resident annually to hospitals.
    • Eight medical schools (DO & MD) have or are developing three year programs. Salus University/PCO is piloting a three year program. NECO has in the past offered a 3-year program. Only Arkansas and Delaware currently require postgraduate training for licensure.
    • Persuasive leadership is required to convince schools/colleges, state licensing boards, residency programs, certification boards and accreditation groups of the necessity of collaboration in restructuring clinical training.
  2. Apply for a Center for Medicare/Medicaid Services (CMS) Innovation Grant to fund a pilot project of the new curriculum/clinical training model (3 years for OD + 1 year of postgraduate training).
  3. Qualify for the National Health Service Corps (NHSC) by achieving Designation of Optometry as a Primary Care Profession and by Federal Legislative Amendment.

    • Provides loan repayment and scholarships to health care professionals providing primary care in underserved areas.
  4. Include optometry in all aspects of Title VII, Section 747 by designation of optometry as a Primary Care Profession and Federal Legislative Amendment.

    • Provides scholarships and loan repayment to students who agree to work in underserved areas. Also, supports minority graduates, residents and faculty.

by Charles F. Mullen