July 15, 2009
Regina Benjamin, M.D., M.B.A.
United States Surgeon General (designate)

Dear Dr. Benjamin:

Please allow me to extend my most sincere congratulation on your nomination as Surgeon General. Given your credentials, unique experience and dedication, you are ideally suited for this challenging position at a critical time for health care in our nation.

I am sure you are aware of the numerous health care issues facing inner-city and rural America. One issue that I find particularly troubling is the unmet need for programs to address preventable threats to visual health. The Department of Health and Human Services Healthy People Program identified the most significant threats to visual health and established goals to reduce those threats. The program addresses visual impairment due to eye disease/conditions including glaucoma, diabetic eye disease, cataract, amblyopia and refractive error and recommends: regular eye examinations for children and adults, vision screening for preschool children, eye injury prevention, and low vision examination.

These visual health goals can only be achieved when all Americans and, particularly those in rural and inner-city areas, have access to eye care services. Only about 20 to 30 percent of all federally qualified health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans.

Efforts must be made to attract more optometrists to rural and inner-city areas through financial incentives such as student loan forgiveness and equipment purchasing grants and loans. Inclusion of optometry in the National Health Service Corps (NHSC) is essential to the placement of optometrists in these areas. I was most interested when you proudly spoke of your experience in the NHSC during your nomination speech and how it shaped your career path.

Federal and state governments should also encourage visual health education, describing the benefits of regular eye examinations for adults and children, including vision screening for preschool children and eye injury prevention. These efforts should be provided through culturally sensitive and appropriate materials and venues.

Optometry’s first program to collaborate with community health centers to improve access to inner-city Americans was developed in Boston by the New England College of Optometry in the late 1960’s, in cooperation with three community health centers. Today, the program has grown to include 14 health centers and 30 other affiliations and inner-city programs. It was also the first collaborative model of care between optometry and ophthalmology in the Nation. This community based program is now managed by the College’s subsidiary, the New England Eye Institute, and has evolved into a national model demonstrating the compatibility of a commitment to community eye care and clinical education. While few inner-city and rural health centers have eye care services, nearly all Boston health centers provide these services. Once you are sworn in as the next United States Surgeon General, you may want to review this highly effective model for possible application to other parts of our country.

Thank you for willingness to take on the challenge of Surgeon General and again congratulations.

Sincerely,

Charles F. Mullen, O.D.
Member, Board of Trustees
New England College of Optometry

Download Presentation: Federal Financing of Optometric Clinical Training.ppt

Additional Resources:
• NEEI Compliance Protocol to Meet Medicare Guidelines for Optometric Training Programs
• Graduate Medical Education (GME), Medicare and Optometry
• Optometry Students, Medicare Regulations and Third Party Plans
• Development of a New Clinical Training Model
• Ideas Submitted to President Obama’s Citizens’ Briefing Book

Now is the Time for Federal Financing of Optometric Clinical Training
Optometry has been included in Medicare since 1987 and currently provides nearly $900 million in services annually to Medicare beneficiaries. However, optometry is excluded from the Graduate Medical Education (GME) program, the educational support component of Medicare. With the aging population and the projections for rising numbers of Medicare beneficiaries, optometric clinical teaching facilities will be providing significantly more care to to the elderly and disabled. With increasing clinical training requirements and training costs, more than ever, there is a need for federal support for optometric clinical training. The inclusion of optometry in GME addresses: the need for workforce development (supply), the growth of the population demand for eye care services and increasing clinical training requirements and costs. All are consistent with current financing policies of Medicare which are intended to anticipate and address these issues. The Social Security Act needs to be amended to include optometry in the GME program of Medicare.

Include Optometrists in the National Health Service Corps (NHSC)
Visual health is recognized by HHS as a critical unmet need, particularly in rural and inner-city areas. Only 20% of federally qualified health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans. President Obama is requested to address the barriers to improving access to eye care services. Optometrists are reluctant to practice in rural and inner-city areas because of high levels of graduate indebtedness combined with high overhead costs of providing optometric care. Efforts must be made to attract more optometrists to rural and inner-city areas through financial incentives such as student loan forgiveness, equipment purchasing grants and loans, and support to the health centers in establishing eye care clinics. In addressing shortage area needs, inclusion of optometrists in the National Health Service Corps is essential to attract optometrists to these areas. HRSA and HHS need to amend their policies and regulations to include optometrists in the NHSC and to provide funding for equipment and facilities costs.

Visual Health as a Critical Unmet Need in Rural and Inner-City Areas
Visual health is a critical unmet need, particularly in rural and inner-city America. HHS’ Healthy People program identified the most significant threats to visual health and established goals to reduce those threats. However, these goals can only be achieved when all Americans and, particularly those in rural and inner-city areas, have access to eye care services. Only about 20% of federally qualified community health centers provide eye care services, despite the growing disparities that exist for rural and inner-city Americans. President Obama is asked to address the barriers to improving access to eye care services. Efforts must be made to attract more optometrists to rural and inner-city areas. Including optometrists in the National Health Service Corps, funding for optometric training through the GME program and support to the health centers for the provision of patient services in rural and inner-city areas are potential means to address access to eye care services.

Combat Eye Trauma and Vision Impairment Caused by TBI
Serious combat eye trauma is now the third most common injury only behind PTSD and Traumatic Brain Injuries (TBI). Of the service members with TBI, many have post traumatic visual impairment as well. An overall plan needs to be developed and implemented that ensures a seamless transition from DOD facilities to the VA for those with eye trauma and visual impairment caused by TBI. Initial care must be timely and comprehensive and follow-up care monitored and assured for all servicemen and women with eye trauma and vision impairment. All too often well-developed plans do not have accompanying evaluation processes and mechanisms to take corrective action once the plan is implemented. The effectiveness of the plan needs to be evaluated by a continuum of outcome measures both in DOD and the VA. Identified areas of concern need to be promptly and decisively addressed by a single office vested with the power to take corrective action whether problems exist in DOD or VA.

Medicare Policy to Permit Students to Contribute to Billable Services
Medical, dental, optometric and podiatric students are an intelligent and well trained component of the health care workforce. However, current Medicare policy does not permit students to perform services that can be billed to Medicare. In order to more effectively utilize this enormous workforce, Medicare policy should be changed to permit students to participate in the Medicare program. This is particularly important in under served areas where students often receive their clinical training.

To assure compliance with Medicare requirements for billing and reimbursement of comprehensive exams for new and established patients (CPT codes 92004 and 92014), NEEI adheres to the CPT definition of a comprehensive exam. CPT 2008 defines a comprehensive eye exam as follows:

Comprehensive ophthalmological services describes a general evaluation of the complete visual system. The comprehensive services constitute a single service entity but need not be performed at one session. The service includes history, general medical observation, external and ophthalmoscopic examinations, gross visual fields and basic sensorimotor examination. It often includes, as indicated: biomicroscopy, examination with cycloplegia or mydriasis and tonometry. It always includes initiation of diagnostic and treatment programs.

From this definition NEEI interprets the essential elements of a comprehensive eye exam (for which the attending doctor is personally responsible for performing except 1.b. and 1.c. below) to include the following minimum data set:

1. Comprehensive eye and health history and history of present illness

   a. History of present illness, physical exam findings and medical decision making must be documented by attending doctor.

   b. Optometry students may document services in the medical record. However, the documentation of an E/M service by a student that may be referred to by the teaching physician is limited to documentation related to the review of systems and/or past family/social history.

   c. The teaching physician may not refer to a student’s documentation of physical exam findings or medical decision making in his or her personal note. If the student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.

2. General medical observation
3. External ophthalmic examination
4. Ophthalmoscopic examination
5. Gross assessment of visual fields
6. Sensorimotor assessment
7. Diagnosis
8. Treatment

Optional features of a Medicare compliant examination include:

1. Biomicroscopy
2. Dilated ophthalmoscopic examination
3. Tonometry

NEEI’s interpretation of Medicare rules for a comprehensive eye exam does allow for the involvement of optometry students in portions of the exam. However, to be Medicare compliant, the attending doctor is required to personally perform (or repeat) the essential parts of the examination listed above, except for the review of systems and/or past family/social history which may be documented by students.

Furthermore, the diagnosis and treatment plan must be supported by procedures actually performed by the attending doctor.(For example, a diagnosis such as glaucoma would require tonometry – in most cases – and thus tonometry would have to be performed (or repeated by the attending doctor.)

It must be clear from a record audit that the diagnosis and treatment were arrived at solely based on the attending doctor’s examination. The attending doctor must be able to advocate the position that the student’s findings were not considered in making decisions.

Additionally, NEEI’s compliance protocol states that the history of present illness, diagnosis, and treatment are essential exam components and thus the accompanying documentation of these essential elements are to be completed by the attending doctor, either by handwritten notes, through dictation and typed record, or via computer generated and typed method.

The NEEI Medicare compliance protocol does not require that the attending doctor repeat non-essential elements of the exam or elements that are not covered by Medicare, such as refraction.

The NEEI Comprehensive Eye Exam Form (.pdf)

The NEEI comprehensive eye exam form has a column for the attending doctor to document essential elements. The form also has space for exam procedures such as biomicroscopy and other elements of an exam that would be repeated by the attending doctor as a matter of course.

The section for the student’s assessment and plan are placed on a separate sheet at the end of the exam form, after the attending doctor’s assessment and plan. This is to assure compliance with Medicare guidelines and the independence of the attending doctor’s conclusions from those of the student.

Mark O’donoghuem
Roger Wilson
Charles F. Mullen

Fall 2008 PowerPoint Presentation (.ppt)

Fall 2006 Journal of Optometric Education Article (.pdf – same as below)

Background
Since the 1970’s, optometry has been in a state of metamorphosis with the introduction of pharmaceuticals and advanced clinical procedures. Optometric clinical education likewise has evolved in response to the expanded patient management and treatment responsibilities of optometric practice. However, the traditional clinical training model and terminology is not consistent with the current functional reality and presents obstacles to inclusion in and compliance with major federal programs.

The profession of optometry has benefited from inclusion in the federal program Medicare by being classified in medical terminology as physicians and are treated on a par with other physicians (MD, DO, DMD, DPM) regarding payment for patient services. Optometric education, however, does not conform to medical terminology nor the medical training model. Federal agencies administer health care and health education programs based on the medical model and terminology. While optometry is included in the Health Professions Student Loan programs, it is excluded from numerous special Federal Health Professions Education Programs sponsored by the Health Resources and Services Administration (HRSA) and from the Graduate Medical Education (GME) program, the educational component of Medicare. The Federal Government appropriates billions of dollars per year for the programs, but optometry is not eligible for these funds while all other health professions participate in these programs.

The premise behind why GME payments are made to financially support clinical training of physicians, dentists and podiatrists is that clinical training is inherently inefficient. All clinical training for optometry students, however, must take place in the four-year curriculum and not in post graduate residency programs since the graduate must be prepared to enter practice after graduation. The financial burden for the inherent inefficiencies in clinical training is placed upon the optometry student in the form of higher tuition. Inclusion of optometry in GME would provide additional revenue to optometric clinical facilities to partially offset the cost of these inefficiencies.

Medicare bases its regulations on the medical teaching model. Optometry’s traditional teaching model and terminology is not analogous to the medical model. However, functionally optometry’s model is consistent in several important aspects with the medical model. Current Medicare regulations regarding student supervision significantly impede optometry students from acquiring patient evaluation and management skills, since regulations do not permit third and fourth year optometry students to contribute to billable services. Medical interns, residents and fellows, however, can contribute to billable services and have ample opportunity to acquire patient evaluation and management skills without significantly affecting the efficient provision of health care.

Realignment of the traditional optometric clinical training model and terminology is necessary to facilitate inclusion in and compliance with major federal programs and to reflect the current functional reality.

Objectives of a New Clinical Training Model
The main objective of a new model and terminology would be to position optometry to be consistent with current Federal law and regulations pertaining to eligibility for GME, National Health Service Corps (NHSC), and Medicare billable services regulations and facilitate inclusion in and compliance with these programs. Participation in GME and NHSC would provide significant Federal resources currently not available to optometry. Realignment of the clinical training model would also ensure that third and fourth year optometric trainees receive meaningful and cost-effective training in patient evaluation and management (E/M) by placing optometric trainees in full compliance with Medicare billable service regulations without the need for the attending to repeat all clinical procedures.

Other objectives include increasing participation in Medicare, increasing the number of community-based training sites, and controlling educational debt. Inclusion in GME would result in significant funds paid to optometric clinical facilities for participation in the Medicare program. Given the financial benefit, GME participation would encourage an increase in Medicare services provided. The NHSC would provide significant resource and loan repayment for optometric residents and graduates practicing in federally-qualified health centers. Inclusion in the NHSC would encourage schools and colleges of optometry to increase the number of affiliated community-based training sites. Community-based training has proven to be highly cost-effective. The NHSC provides an opportunity for student loan repayment up to $50,000, thus providing a means to help control student debt.

Functional Reality of Current Optometric Training Model
Optometry residents are not truly residents, but function as medical attending or fellows according to the Department of Health and Human Services (HHS). The fourth year of optometric education has evolved into an intense clinical experience in response to the expansion of patient management and treatment responsibilities of optometric practice and is analogous to medical residency training. Fourth year students are expected to evaluate and manage patients and function as medical residents. Third year optometry clinical training has also increased in intensity in response to the expanded scope of optometric practice. This is the transitional year from classroom and laboratory activity to patient care. Supervised third year optometry students function as medical interns. First and second year optometry students have limited clinical training and function, for the most part, in a manner similar to medical students. (Table 1.)

Table 1: Comparison of Optometric Clinical Training Model to Medical Model

Actions Required to Realign the Optometric Clinical Training Model
The following actions are required to place the traditional optometric clinical training model in conformance with functional reality and medical terminology. Current third year optometry students would be redesignated as interns and current fourth year students would be redesignated as first year residents (Post-Graduate 1 or PG-1). Current optometric residents would be reclassified as PG-2, PG-3 or Fellows. First and second year students would remain classified as students. Since fellows, residents and interns can contribute to Medicare billable services, optometric trainees in this new configuration could receive meaningful and cost-effective training in patient evaluation and management (E/M), while in full compliance with Medicare billable services regulations.

In order to qualify for GME, the Social Security Act needs to be amended to require the Secretary of HHS to make Medicare, Graduate Medical Education (GME) payments to optometric affiliated facilities for certain costs associated with the clinical training of optometric interns and residents (PG-1 – PG-3), including resident stipends. Existing law/regulations need to be amended to direct HRSA to include optometry in the National Health Service Corps (NHSC). Inclusion in the NHSC would provide for resident stipends and educational loan repayment for up to $50,000 as well as other potential resources.

Conclusion and Recommendation
The traditional optometric training model and terminology are not consistent with the functional reality, with medical terminology and federally-supported programs and present obstacles to inclusion in and compliance with major Federal programs. There is a need to comply with Medicare regulations regarding student billable services and significant benefits of inclusion in GME and the NHSC. Formation of a broad-based task force is recommended to thoroughly review the issue regarding clinical training models, terminology and related considerations. Also, the task force would contribute to the political strategy to include optometry in GME and NHSC.

Journal of Optometric Education
Volume 32, Number 1, Fall 2006
Charles F. Mullen, O.D., F.A.A.O.