An Eight Step Plan for Optometry’s Future

1. An Eight Step Plan for Optometry’s Future Charles F. Mullen

2. 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.

3. 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.

4. 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.

5. 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).

6. 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.

7. 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.

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

9. 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.

10. 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).

11. 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).

12. 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.

13. 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.

14. 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,

15. 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.

16. 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.

17. 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).

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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.”

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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).

34. 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.

35. 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.

36. 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.

37. 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.