Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

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

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

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