Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Is Optometry on the Same Path as the Legal Profession? – Full Article

Law schools waited too long before taking action to address the oversupply of lawyers and now face the crisis of a serious decline in student applicants and underemployment and unemployment of recent graduates. Many law schools face serious financial issues, staff and faculty layoffs. Lower-tier law schools are merging and at least one school plans to close. Increases in law school enrollments (53 new law schools opened since 1973) without corresponding increases in demand have resulted in 45% of recent law graduates unable to find full time employment. The top 14 law schools now find it necessary to employ from 4-17% of their graduating classes. As a result, applications to law school continue to decline – down 37% from 2010.

Optometry schools and colleges now face the similar effects of oversupply (12,672 FTE excess) of optometrists including declining student applicants and declining full time employment opportunities. There were seven new optometry schools added and increased enrollments at existing schools in the last six years without a demonstrated increase in demand. Full time positions with sufficient income to service educational debt are difficult to find, and now 40% of recent graduates practice at two or more part time locations. Even for those employed or self employed optometrists function at only 68% of their practice capacity. Like the legal profession, there are no signs of abatement in the poor full-time employment market or decline in optometry school applicants. The decline in applicants is exuberated by continuing expansion of new optometry schools.

To mitigate the effects of an oversupply of optometrists, optometry schools and colleges’ leadership must immediately acknowledge and directly address the serious challenges impacting on the stability of optometry schools and colleges including:

  • Current and future oversupply of optometrist: 12,672 FTE excess now and oversupply remains at 9,000 FTE in the future.
  • Increase in number of optometry schools and increased enrollments at existing schools: Seven new schools added in last 6 years while graduates increased from 1127 in 1997, when supply equaled demand, to 1600 now. At full enrollment of all schools, graduates will increase to over 1800.
  • Decline in the student applicant pool – less than 1.5 applicants per entering seat, while number of entering seats has increased from 1160 to 1763 in six years.
  • High graduate debt – over $200,000 for many graduates vs. income potential to service debt.
  • Decline in college age students – .5 million less than in 2012.
  • Decline in full-time employment opportunities for recent graduates. 40% of graduates practice at multiple part time locations.
  • Lack of Federal support for clinical training, scholarships and loan repayment – Optometry excluded from $11.5 billion Graduate Medical Education Program, National Health Service Corps and Title 7 programs.

In view of the data in the Rand, Abt. and Lewin Optometric Manpower Studies indicating a substantial excess of optometrists, it would be prudent to mitigate the effects of a decline in full time employment of graduates and decline in applicants for admission by the following actions:

Action 1: Proactively Address the Oversupply of Optometrists

  • Reduce enrollments at all schools and colleges of optometry and adjust corresponding revenue and expense projections.
  • Demand clarification and correction of Bureau of Labor Statistics (BLS) projections. It appears these projections are significantly contributing to the oversupply of optometrists by encouraging the development of new schools of optometry. Conflicting data on optometric manpower: Rand Study-1995, Abt.Study-2000 and Lewin Study-2014 all indicated significant surpluses. Meanwhile the Bureau of Labor Statistics (BLS) projects high demand for optometrists. In view of all the evidence and studies to the contrary, it is logical to assume the BLS based their projections on inaccurate or obsolete data.
  • Insist the Accreditation Council on Optometric Education (ACOE) develop quantitative standards similar to medicine and dentistry for evaluating accreditation for new and existing school and colleges of optometry. Only accredit new schools when the quality and quantity of student clinical training opportunities can be demonstrated.
  • Increase demand for optometric services by addressing the underlying public health need for eye care in inner-city and rural areas. Only 20% of federally qualified community health centers provide optometric services. However, Boston community health centers have made a successful and sustained 40 year effort to address unmet need for optometric services in inner-city Boston. See: New England College of Optometry Clinical System. Inclusion of optometry in Federal incentive programs (loan forgiveness, scholarships, National Health Service Corps, etc) is essential to providing optometric services in rural and inner-city America.
  • Conduct cost analysis of all clinical training venues and adjust clinical training placements to reduce overall operating costs. Review 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).
  • Visit/Revisit the advantages of a Faculty Practice, integrated with clinical training, in terms of increased IEI revenue, supplemental faculty income, faculty recruitment/retention and compliance with Medicare/Medicaid Guidelines for Teaching Physicians. Faculty Practice also addresses the Center for Medicare/Medicaid Services (CMS) compliance vulnerabilities by changing from a Student-Centered Clinical Training Model to a Physician-Centered Program. Students cannot provide billable services to Medicare and other insurance plans. Two Optometry Schools fined for violations with current Student-Centered Training Model. Combined fines are nearly $1.0 million.
  • To provide full-time employment for graduates, optometry schools and colleges should fund government related fellowships. These positions would be used to provide experience to graduates in Federal and State health care policy.

Action 2: Address High Graduate Debt vs. Income Potential

  • Reduce student debt by shortening the length of overall education for the OD degree. 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.
  • Encourage accelerated admissions from undergraduate institutions.
  • Remove course redundancies and move selected course work to undergraduate prerequisites.
  • Reduce student debt by qualifying for Federal scholarships and loan repayment programs, such as the National Health Service Corps and Title 7, Section 747 through a comprehensive Federal advocacy strategy.

Action 3: Federal Funding for Clinical Training

Create eligibility for the $11.5 billion Graduate Medical Education (GME) program by restructuring the curriculum, changing state licensing requirements and aggressive advocacy to amend the Social Security Act to include optometry. 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. Social Security Act amended to include optometry and training in outpatient facilities. GME pays an average of $100,000 per medical resident annually to hospitals. 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 + specialty board certification. See: Changes Necessary to Include Optometry in the GME Program.

  • 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).

Action 4: Investigate Alternative Strategies to Prevent Financial Crises at Schools and Colleges

Primary References

The Legal Profession

The Optometry Profession

by Charles F. Mullen

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 SubspecialistLevel 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