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An Eight Step Plan for Optometry’s Future

Charles F. Mullen

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Forward

• AOA President Ronald Hopping stated on June 30, 2012, ”We must not let anyone else write our future.”

• The proposed plan is politically challenging with numerous timing and sequencing issues.

• However, there is no easy path, 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.

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Restructure the Profession of Optometry

• Comprehensively restructure the profession of optometry, including the core professional curriculum and postgraduate training, by placing optometry in parallel with medicine.

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Achieve Synergism

• The eight step plan is designed to facilitate synergism among state licensure requirements, optometric curricula, postgraduate clinical training, board certification, maintenance of certification and accreditation.

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Meet Mandates

• Optometry must meet the mandates of private/Federal/State insurers, external certifying agencies, credentialing and privileging boards and the Graduate Medical Education Residency Program (GME).

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Step One

• Amend all State optometric licensing laws to include one or two years of mandatory postgraduate clinical training for licensure.

• Consider mandatory board certification in General Optometry for licensure.

• New Mexico requires board certification in a specialty approved by ABMS for medical license by endorsement.

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Step Two

• Restructure optometric curriculum by awarding the Doctor of Optometry (OD) degree after three years and reclassifying the 4th year as the first year of residency.

• Re-designate 4th year externship rotations as residencies.

• To meet Center for Medicare/Medicaid Services (CMS) insurance compliance requirements, a major paradigm shift is also required where clinical faculty are in charge of the patient rather than in charge of students.

• This is the successful medical training model.

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Step Three

• Adjust National Board of Examiners in Optometry (NBEO) examination schedule to accommodate the new curriculum and mandatory postgraduate clinical training.

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Step Four

• One year of postgraduate clinical training required for board certification in General Optometry (ABO),

-Two years for specialties of Medical Optometry (ABCMO), Pediatrics (COVD), Vision Rehabilitation and Cornea & Contact Lenses and

-Three years for sub-specialties of Anterior Segment/Glaucoma and Neuro-optometry.

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Step Five

• Set consistent standards among various certification boards by establishing an oversight board analogous to medicine’s American Board of Medical Specialties (ABMS).

• Designate the oversight board as the American Board of Optometric Specialties (ABOS).

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Step Six

• Only postgraduate clinical training programs accredited by the Accreditation Council on Optometric Education (ACOE) would be recognized for board certification.

• ACOE is analogous to medicine’s Accreditation Council for Graduate Medical Education (ACGME).

• Re-instate the Council on Clinical Optometric Care (CCOC) to ensure quality care is provided in all clinical training venues.

• CCOC is analogous to the Joint Commission on Accreditation of Health Care Organizations (JCAHCO).

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SevenParallel with Medicine

• With completion of steps 1-6, optometry would be parallel with medicine and consistent with current and anticipated Federal/State health care policies, external certifying agencies, credentialing and privileging boards and private insurers’ requirements.

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Step Eight

• Optometry’s clinical training model, state licensure requirements and board certification process would meet GME expectations,

-and address 4th year trainees compliance with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents.

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Why Restructure the Profession of Optometry?

• Rather than systemic restructuring of the profession in accordance with a comprehensive strategic plan, changes to optometric practice laws and Federal/State current and anticipated health care policy have been addressed:

- by incremental changes to state licensure requirements, clinical education, postgraduate training and board certification,

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Why Restructure Optometry?(continued)

• Consequently, unaddressed structural issues persist and weaken optometry’s position as the major provider of primary eye/vision care in a third party regulated health care system.

• Since optometrists are classified as physicians under Federal law, they are (or will) be judged utilizing the medical model as the standard.

• Optometrists will be (are) expected to demonstrate clinical competence by board certification and maintenance of competence by re-certification.

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Mandatory Postgraduate Training for Licensure

• There is no mandatory postgraduate training required for state optometric licensure with the exception of Arkansas and Delaware.

• The traditional board certification process, using the medical model, would likely follow if mandatory postgraduate training is required for licensure.

• Optometry would then be eligible for Federal support under the GME Program.

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Board Certification & Specialty Recognition

• Currently there is no nationwide acceptance of optometric postgraduate specialty training, board certification and maintenance of certification, however,

-ABO is recognized by Center for Medicare/Medicaid Services (CMS) for bonus payments

- and the American Board for Certification in Medical Optometry (ABCMO) as a certifying agency by the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

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Board Certification(continued)

• Currently no expeditious route for board certification in General Optometry for most recent optometry graduates. Only 367 (ACOE) accredited residency positions exist for 1700-1800 graduates.

• Multiple certification boards, as in medicine, can exist as long as an oversight board (ABOS) is in place to ensure consistent standards.

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Why Restructure Optometric Education and Clinical Training?

• Unlike medicine and podiatry, optometry’s clinical training is contained within the core four year curriculum.

• Optometry does not require postgraduate training for entry-level practice nor specialty training for board certification, and therefore is not eligible for GME support.

• GME only funds postgraduate training.• Annual expenditure on optometric clinical

training is over $100 million with no Federal support.

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Why Restructure Clinical Training?(continued)

• Optometry does not receive Federal funds to compensate for cost of training inefficiencies, increased training requirements, pay faculty salaries, resident stipends and other overhead costs.

• Insurance compliance vulnerabilities persist in all clinical training venues including externship sites.

• Current optometry residents are not recognized by U.S. Department of Health and Human Services (HHS), because they do not meet GME criteria.

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Three Year Optometric Curriculum

• Award the O.D. degree after three years and re-designate the current fourth year as the first year of residency.

• A three calendar year curriculum is possible by: removing course redundancies, moving more material to pre-optometry requirements and fully utilizing distance learning capabilities.

• The length of entry-level education does not change as it remains 4 years, however, it does position optometry for inclusion in GME.

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Three Year Curriculum(continued)

• With three year curriculum, GME and VA stipends, student debt could be reduced by $30,000 to $50,000 or more.

• A financial transition plan from 4th year student tuition to GME support would needed to be developed.

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Medical Schools Offer Three Year Programs

• The Carnegie Foundation recommends all medical schools (allopathic and osteopathic) require a three year program.

• Eight U.S. medical schools have or are developing three year programs: Mercer, Lake Erie Osteopathic, Texas Tech, Louisiana Tech, Indiana, Tennessee State, Kentucky and NYU.

• Two Canadian medical schools have 3 year programs.

• “Three year programs to save medical students $50,000 in debt.”

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Clinical Training Costs and Student Debt

• Introduction of advanced clinical procedures and expanded use of pharmaceuticals increase clinical training costs.

• These costs are passed on to the optometry student in the form of higher tuition and debt.

• Optometry is not eligible for Federal funds to compensate for increasing clinical training costs.

• Unlike medical residents, who are paid stipends, 4th year optometry students not only pay tuition but also do not receive stipends during their clinical year.

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Training Costs and Student Debt(continued)

• Optometry student debt is excessive: average of: $140,000-$175,000.

• High debt compared to potential annual median income of $95,500 is a major contributing factor to the declining optometric student applicant pool.

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What is GME?

• The Graduate Medical Education Residency Program (GME) is the educational component of Medicare, and provides $10 billion annually to support postgraduate clinical training for physicians, podiatrists and dentists.

• GME paid an average of $95,000 per medical resident to hospitals in 2010.

• Optometry is not eligible for GME because its clinical training model, licensure requirements and board certification do not meet GME expectations.

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GME(continued)

• Seeking GME support for current residents while leaving the curriculum at four years would provide support for only approximately 180 private sector optometry residents.

• A three year curriculum plus one year of residency would provide support for as many as 1700-1800 trainees, if included in GME.

• GME payments will be made to the clinical entity and not a school or college of optometry. A separate legal structure for campus-based clinics is needed.

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Inclusion in GME Addresses

• Work force supply, growth in demand for eye care services and offsets increasing training costs.

• GME support would have a significant and lasting impact on the cost and quality of optometric clinical training.

• Provides for clinical training overhead costs and stipends for 4th year optometric trainees.

• Increases attractiveness of optometric programs at academic medical centers and other health care facilities.

• Enhances the prestige of the profession.

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Inclusion in GME(continued)

• Current residents would become PG-2 & PG-3 and also eligible for GME.

• VA supported residents are not eligible for GME, however, new residents would be eligible for stipends paid directly by the VA.

• Mandatory postgraduate training for state licensure, board certification and a new optometric educational model would need to be in place throughout the country to qualify for GME.

• Eligible for Direct payments (salaries, stipends, etc) and also Indirect payments for hospital based optometry residents.

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Compliance with CMS Teaching Guidelines

• Compliance vulnerabilities with the Center for Medicare/Medicaid Services (CMS) Guidelines for Teaching Physicians, Interns and Residents persist in all optometric clinical teaching venues, including externship sites,

-because optometric students are restricted by Medicare/Medicaid regulations from providing billable services and,

-any contribution of an optometry student to a service must be performed in the physical presence of a physician or jointly with a resident.

• Students may perform a limited case history.

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Compliance with CMS Teaching Guidelines (continued)

• Enforcement of all CMS regulations and guidelines will increase with the implementation of the Affordable Care Act (ACA).

• Residents may provide billable services jointly with the billing physician if properly supervised.

• Private insurers also apply CMS regulations.

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Optometric Manpower Studies

• Abt Study in 1999 predicted a surplus of optometrists.

• Bureau of Labor Statistics (BLS) is now projecting a 33% increase in demand for optometrists or 11,300 additional by 2020.

• Proliferation of new optometry schools at time of declining student applicant pool.

• Lewin Study to reconcile disparity.• Accurate data needed for long range planning

and legislative advocacy.

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Important Events of Last 40 Years

• Expansion of optometric state laws to include pharmaceuticals and advanced procedures. Initiated in Rhode Island in the 1970’s.

• Creation of VA Optometry Service in 1976, largest clinical training program for students and residents.

• Inclusion in Medicare in 1987, now $1.0 billion annually in optometric services provided.

• Anticipated broad-based inclusion in the Affordable Care Act (ACA).

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No Long Range Plan for Optometry

• No visionary plan in the past to take full advantage of these major achievements and we missed opportunities to:

-advocate for broadly drafted state laws to permit scope of practice expansion without future amendments.

-establish purpose of postgraduate clinical training. -include optometry in GME in 1987 when

optometry was included in Medicare.• We must learn from past and have a visionary

plan that positions optometry for future success.

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Recommended Actions by AOA, ASCO and ARBO

• AOA,AOSA, ASCO and ARBO need to collaboratively reach consensus on mandatory postgraduate clinical training, a three year curriculum, specialization, accreditation, board certification, maintenance of certification and compliance with CMS Teaching Guidelines.

• Commit the energy and resources necessary to develop, execute and monitor the implementation of a long range plan for optometry and optometric education to comprehensively address all of the above.

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State Legislative Advocacy

• State optometric licensing laws amended to include:

“One (or two) years of postgraduate clinical education in a program accredited by the Accreditation Council on Optometric Education (ACOE), leading to board certification is required for licensure.”

• Consider board certification in General Optometry as a requirement for licensure.

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Federal Legislative Advocacy

• Federal legislative advocacy advanced to amend the Social Security Act by including optometry in GME.

• Legislative and direct VA advocacy to fund additional optometric residents. New PG-1’s.

• GME payments to hospitals expanded to include all optometric clinical training venues-- (ACOE) accredited outpatient clinics and group practices.

• Podiatry successful in amending the Act in 1972.