Charles F. Mullen

Challenges and Opportunities in Optometry and Optometric Education

Illinois College of Optometry and University of Chicago Affiliation Agreement

Official Press Release

On October 16, 1997, the Illinois College of Optometry (ICO) and the Department of Ophthalmology and Visual Science at the University of Chicago held a ceremonial signing of an affiliation agreement that brings together the educational and patient care resources of both teams of eye care providers.

The agreement, only the second of its kind in the United States, brings together faculty from separate, often competing, professions.

This affiliation emphasizes the complementary roles of each profession. It is intended to increase mutual awareness, improve and expand the training of both types of providers, and coordinate and enhance patient care.

“This far-reaching and quite unusual cooperative agreement brings together the disciplines of optometry and ophthalmology in a productive and rational way,” said Charles F. Mullen, OD, president of ICO. “Optometry students and residents, medical students, and ophthalmology residents will train side by side, learning a new respect and appreciation for each other’s disciplines.”

“The best eye care requires cooperation between doctors providing that care at multiple levels,” said Terry Ernest, MD, PhD, chairman of Ophthalmology and Visual Science at the University of Chicago. “As technology advances and financial pressures multiply, the optimal system for providing the broad range of eye care has grown beyond the scope of any single provider.”

Under this cooperative agreement, which has been in practice since September 1, 1997, University of Chicago faculty will teach and faculty physicians and residents will see patients who may require specialty care at the Illinois Eye Institute, the College of Optometry’s clinical facility.

The affiliation will expand training and clinical experience for students in each program. Students from ICO will come to the University for scientific and clinical training.

The two institutions will also create a joint OD/ PhD program, which will prepare optometrists to combine their clinical practice with eye care research.

Optometrists spend four years in optometry school, after college, studying the diagnosis and treatment of common eye diseases. Ophthalmologists spend four years in medical school, followed by another four to six years of specialized training as residents. Students in the OD/PhD program will combine four years of optometry training with three or more years of study of the basic science of vision and complete a substantial research project in their specialty area.

The only similar agreement was arranged between the Pennsylvania College of Optometry (PCO) and Hahnemann University in Philadelphia in 1988. At that time Dr. Mullen was executive director of PCO’s Eye Institute.

By combining the strengths of each profession, the Illinois affiliation pulls together a range of providers that is ideally suited for the emerging competitive environment of managed care. Primary eye care will be provided by the ICO’s network of optometrists. More complex cases, such as corneal or retinal surgery, will be treated by sub-specialists at the University.

“This arrangement provides the patients of the Illinois Eye Institute and the University of Chicago Hospitals with a closed loop for all eye care needs,” added Dr. Mullen, “from routine exams to the most complicated surgical problems.”

The combined programs now handle nearly 70,000 patient visits per year, more than 45,000 at ICO and another 20,000, including the most complex cases, at the University.

Both institutions are not-for profit. Each will retain autonomy over its operations and finances.

The University of Chicago Office of Medical Center Communications

by Charles F. Mullen

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