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Board Certification Is The Topic

March 14, 2009

Folks there are several comments from readers on the topic of board certification. I apologize for not responding earlier, but travels have gotten in the way. Please be sure to read everyone’s posts and my replies and feel free to respond with your own comments.

I also encourage everyone to visit www.aoa.org/jbcpt.xml frequently for the latest Q & A’s on the process and the latest information on the proposed model.

The executive committee of the AOA had a very excellent meeting with state leaders last week at SECO and a lot of good ideas were raised that I believe will further improve the model that is being presented.

My hope is that NO STATE ASSOCIATION will tie the hands of their leaders that attend the AOA House of Delegates this year. Those in attendance at the House of Delegates will need the lattitude to hear all the arguments for and against and make an informed decision for the future of our profession.

Until next time…
Pete

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95 comments

  1. It’s time to understand and accept the simple truth; government, citizen’s groups, institutions and third-party plans are in the position to choose, and they are demanding competent, board certified practitioners. Optometry is the only doctor-level health profession without board certification.

    The Board Certification initiative presents each of us with two very different decisions to make; one is a choice for our profession and the other is strictly a personal choice. For our profession, I am convinced that we need to support the BC initiative starting with a “Yes” vote by the AOA in June.

    Why the sudden strong support? I was not fully persuaded until I attended the Joint Board Certification Project Team presentation at SECO. The presentation could not have been more inclusive, more transparent and more explanative. Every concern of every doctor present was welcomed and answered as completely as possible.

    The commissioners were questioned, challenged and personally queried on possible conflicts. To a person, the commissioners responded openly and candidly. Dave Cockrell went through valid reason after valid reason for BC, Tom Lewis discussed the process that went into the JBCPT Report point by point and Randy Brooks answered every challenge openly and honestly.

    Here’s a major point; you and I need to understand that a “yes” vote in June will be the starting point. An affirmative vote will put in motion the means for the new organization to seek out the input of the entire profession before approving and implementing a process for board certification.

    You read that right – The AOA vote in June is “the starting point” to “seek out the input of the entire profession before implementing the process.”

    Clearly the job done by the JBCPT has not been anything less than solid, well-considered, selfless, time-consuming work – and every member of the joint commission deserves our thanks. Sadly, in a room that had at least 500 seats, only 40 to 50 ODs attended when SECO registration was 8000. There were no excuses for not being in that room – nothing on the SECO agenda conflicted with the JBCPT meeting. You can carp and complain here and on every other Internet site about not being heard, but you also need to accept that the 400+ empty seats in that room spoke volumes.

    I am a tough old bird, and I have no illusion that board certification is the universal remedy for all that needs fixing in optometry. I’m pretty sure that having board certification won’t magically open every government, third-party or citizen’s group door. What I am sure of is that there is a strong possibility that if we make the wrong choice, optometry may lose any chance of having a seat at the vision and eye care table.

    If board certification is rejected, we will be sending a clear message that optometrists don’t value their profession enough to warrant continuing competency. Those who wish us ill will have proof that optometrists don’t think that we should have the same level of quality assurance that other “Doctors” offer the public.

    We must not let that happen. A “yes” vote in June will establish that optometrists confidently accept board certified continuing competence just as other physicians have done. Once we stand together for our profession, then each of us will have the opportunity to decide what is best for ourselves.

    Mike Cohen, OD, FAAO

    http://www.mikesod2od.com


  2. Mike,
    You make a point that gov., citizens groups, and third party payors are demanding us to be continually competent. Do you have any articles that we can read that would support this claim? I don’t feel that I am not continually competent and I am sure that many other ODs feel the same way. Please take a moment to read Ken Meyers article on ODwire.org. He sums up my and many other OD feelings on this issue. I think you might change your opinion on this process after reading it.
    Best Regards,
    Ryan


  3. After reading the JBCPT proposal, Dr. Kehoe’s column in the March 9, 2009 AOA News, Dr. Myers’ article on ODWire, and many other opinions, I agree with those who feel that this proposal is seriously flawed.

    I am in favor of a system to ensure continued competence. I believe the proposed certification is an ambitious and genuine step to improve optometry’s delivery of health care, but calling it “board certified” is disingenuous at best and misleading at worst.

    General dentistry (not Family Practice medicine) is the best parallel to optometry. They have overwhelmingly rejected board certification. Since it’s inception well over 20 years ago, the Amwewrican Board of General Dentistry has only certified around 700 of 136,000 currently practicing DDSs. Is this a “clear message” that dentists “don’t value their profession enough to warrant continuing competency?” I doubt it.

    I, too, would like to hear from an actual third party player who believes ODs should pursue board certification.

    I would urge ODs to direct their state associations to ask the AOA and the JBCPT to pursue continuing competency under a name other than “board certification.”

    -Donald W. Furman O.D.


  4. I think this whole board certification business has to do with basically 2 main things: The first being politics and second being the inferiority complex of certain optometrists. Has absolutely nothing to do with the public or third parties. Majority of the public doesn’t even know the difference between ophthalmologist, optometrist or an optician. That is the reality, let alone the difference between board certified optometrist and one who’s not. I’m just not quite sure what we are trying to prove here and to whom?? Making things so tedious and unnecessary, just so certain egos will be satisfied.

    Thank You,

    Hripsime Shirvanian, O.D.


  5. “If board certification is rejected,we will be sending a clear message that Optometrists don’t value their profession enough to warrant continued competency” (???!!) – That may be the most ridiculous statement made yet in this controversy.

    Bob Gradisek


  6. It is amazing to me that a handful of political and academic optometrists can pursue board certification when a significant majority of the doctors they supposedly represent oppose the idea. I thought this was a democratic organization when I joined and started paying dues 30 years ago so I can’t imagine how a small group can dictate their wishes to the masses. There is no definitive benefit to certification. This appears to be part of a plan to turn optometry into a four year program and a one year residency. Currently approximately 20% of grads go into a residency program and that number is expected to rise. Our political leaders feel the need to try and elevate the rest of us to their residency/board certification status. As these AOA leaders have asked I have done my homework and view the certification program as severely flawed. Hopefully enough like minded doctors will be represented at the convention and the JBCPT will be dissolved into there is a need for such.


  7. Board certification, as I understand it, will do nothing for the practicing Optometrist in regards to becoming a panel member of an IPA or HMO to have access to deliver primary Eyecare. As a paneled member of at least 8 IPA’s, I’m still limited on many panels to routine care while on others I can provide primary eye care. In my opinion the board is making a big mistake in attempting to get board certification as a remedy. The board should first get the profession of Optometry on a level playing field and demand provider equity, or any willing provider status before board certification. Now is a great political time to be demanding provider equity since we are generally a lower cost provider with greater access to care. Board certification prior to equity could result in it being demanded by HMO’s or IPA’s as a barrier as well as proof that general Optometry is not qualified to deliver primary care because we said so by adding board certification. Remember that barriers to primary care are not much a quality of care issue as a turf war. I believe that Optometry should model itself more after dentistry, which is fully paneled because there is no turf war with Medical Profession. General Optometry should have equity all by itself, if we want to add certification in a sub specialty that should be up to us. We should not do it for the Medical Profession acceptance which will not be forthcoming.

    Dr. Steven Chiana O.D.
    PS. Hey Pete just my feedback from a fellow ICO 84 grad


  8. The message we have been proclaiming in the 50 state legislatures since 1976 is: “Optometrists are thoroughly educated and trained in diagnosing and managing eye anomalies and that through continuing education we, as a profession, continue to not only provide competent care for our patients, but exemplary care.” The current proposal for “board certification” basically invalidates what we have been proclaiming for the past 33 years. We are essentially admitting that we are NOT as well trained and educated “as we could be.” I do not think this is a wise message to send. Also, we are guaranteeing that those optometrists who choose not to be board certified will INDEED be excluded from certain insurance panels. This is currently not the case and I have not seen a compelling argument that without board certification optometrists “could” be left off panels in the future. Who exactly would see these tens of millions of patients if the insurance plans were to suddenly demand “board certification?” That simply is not logical. I am NOT against the concept of board certification for certain “specialties” within optometry (e.g. Low Vision), but what purpose does throwing a “big umbrella” over all O.D.’s achieve? If you are going to have board certification, it should be within defined specialties. I appreciate the hard work and good intentions of all those who have devoted their time and energies to this endeavor, but please do not assume that the rank and file private practice optometrists across this country endorse this current proposal. I have read ALL of the reports on the AOA website and I am not convinced that the current proposed board certification is in the best interest of our profession. In fact, I suspect if it goes forward you will see the same “participation” as that of dentistry.


  9. I think board certification is just another way to split up optometry to more and more factions. It will NOT help us be more proficient nor get us on any Medical Panels.

    Instead of spending all this time and resources on an issue that may break up optometry, we should try to get our profession recognized at the federal level so that we can use our licenses in all states rather than being regulated by each individual state.


  10. The process seems flawed on many levels. For example, how can a recent graduate (with minimal competency [their definition}) armed with a 12 month residency in a very narrow area be automatically eligible for the testing? Yet an optometrist with years of experience and continuing education be made to jump through a number of hoops before being deemed testing eligible? If implemented, I hope that an optometrist can opt to take the test at any time and then follow the continuig education requirements for re-certification 10 years later. I also hope that this certification will allow an optometrist to practice in any state without being subjected to the whims of the state boards.


  11. After having thought long and hard, the hundreds of online posts, Art Epstein’s editorials and poll results, I can say that the future does not appear too bright for the House of Delegates. Quite frankly, the only way I foresee this project receiving a PASS vote in the House of Delegates is by the state leaders voting for the AOA and not for the members they were elected to represent.

    One thing that we should all keep in mind is that ARBO is hell bent on making board certification a reality. Anyone who has sincerely dealt with the intricacies of COPE approval will tell you that ARBO is a difficult organization to work with; that they are control freaks who overly inflate their contribution to society.

    My point in saying this is, it is better to have AOA at the table for this board, rather than AOA rejecting it, the process continuing, and then we won’t have any voice at the table. ARBO will not back down from this project, I can assure you.

    Using the exact published verbage of the NC Board of Optometry: “Board Certification is a solution in search of a problem.” NO SINGLE ENTITY HAS EVER DENIED AN OPTOMETRIST BECAUSE OF LACK OF BOARD CERTIFICATION. Is suddenly the sky going to fall, and on a given date all optometrists will be suddenly dropped from all medical carriers because we do not have a board cert process? Absolutely not. HOWEVER, if a board cert program is put into place –be it voluntary or not–, I can assure you that a date will be set that if you are not board cert, then you’ll be dropped.

    One way or another, this will come back to bite us whether we pass it or not. The question is when . . . and I think it’ll bite us faster if it passes. I can see the preemptive value of this process, but remember the law of unintended consequences.

    You would be hard pressed to find a more knowledgeable, educated, and articulate OD than Art Epstein. I guaruntee you, optometrists know Dr. Epstein a lot more than they know Drs. Kehoe or Brooks. If Art is against this process, whose opinion do you think our constituents are going to listen to? The CL guru who appeared on the Today show at the AOA’s request during the CL solution drama two years ago, or AOA – insiders who want to see board certification pass?


  12. Ryan and others,
    Another comment that has me wondering a little bit. Two very prolific opponents are suggesting that continued competence should be tied to relicensure. Does everyone understand what that means? Board certification and continued competence in all other professions are currently not tied to relicensure and no state boards have tied continued competence to relicensure. If we go down the path that some of our optometric colleagues are suggesting – to tie continued competence to relicensure – once again we would do something to our profession beyond what the rest of health care has done. Do we want that?
    Pete


  13. Don,
    We are often compared to dentistry – but my question is – who is their “competition” for the same patients? Optometry has ophthalmology that is getting back in to primary eye care in a big way – they are board certified!
    Also, dentistry does not participate much in health insurance or Medicare and very little in Medicaid.
    Continued competence is the “end goal” – hopefully NOT tied to relicensure – but we need the initial board certification to have a starting point in time.
    I like to use family practice as a better parallel to optometry and if my memory (and I’m in a hurry to make this post) serves – when they first started their board certification they did not require residencies – similar to when ophthalmology started theirs.
    Thank you for understanding the value of continued competence.
    Pete


  14. Hripsime,
    Board certification for optometry has nothing to do with personal agendas or egos. It has everything to do with making sure that optometry is positioned for the future changes that are coming in health care.
    I just returned from Washington, DC and both sides of the aisle absolutely believe that health care will dramatically change in the next few years. Quality and value-based healthcare is the buzz word in Washington and with private insurers. Continued competence is currently a default definition for quality and value. Optometry has no means to demonstrate continued competence.
    Thank you for your comments but please understand that my passion (and that of the state and national leaders) is for the future of our profession. Our profession has evolved over the years because we had leaders that could see the future and prepare us for the changes ahead. Unfortunately back in the 1960’s we didn’t see the value of optometry to participate in Medicare and it took us 22 years to finally be recognized in Medicare! Let’s not let that happen in the “NEW” healthcare system.
    Pete


  15. Alan,
    Actually the leaders within the profession are trying to insure that optometry can FULLY PARTICIPATE in the changes that are on the horizon in healtcare. That is the motivation.
    Pete


  16. Steve –
    From your fellow ICO 84 grad – hope to see you in September at ICO. I think your comment about dentistry has the wrong premise. Dentistry doesn’t have a medical (physician) competitor for the patients. That is much easier to deal with and be full participants. However, in optometry as you suggest, we have ophthalmology that is competing for the same patient base.
    Most of the issues you describe are state law issues – AWP, non-discrimination etc. Currently in regular medicare – there is no discrimination between optometry and ophthlamology – that is the ideal model – however, with quality and value as the new buzzwords in medicare and other governmental programs – I don’t want the lack of “continued competence” or board certification (which needs to come first) to CREATE a discrimination within Medicare and other governmental programs or private insurers.
    Keep your eyes and ears open to the news on health care changes – while the crystal ball is never perfect – we have to do our best at insuring that we are full participants in the future.
    Pete


  17. Tim,
    I don’t agree that moving forward with continued competence and board certification will invalidate the claims we’ve made. It represents a natural evolution for our profession.
    If we were to start with specialty certification only – that would really cause divides in our profession. We are trying to make sure the family optometrists throughout the country have all the tools they want to pursue to insure full inclusion in the impending changes in the health care system.
    Pete


  18. B. Na
    No licenses for any health care professions are “national”. Scope of practice will likely always be debated at the state level. However, as far as participation and payment – Medicare does treat optometry equal in all states and equal to ophthalmology – we want that to continue!
    Pete


  19. Patrick,
    Thank you for your comments and I agree with your comments and I’m confident that the AOA representatives to the American Board of Optometry will continue to try to improve the process as it evolves if the HOD approves the formation in June.
    As for license mobility – I personally believe that have a board certification and continued competence program for optometry will help moving between states. Even if you practice in a state that doesn’t have a scope as broad as a state you want to move – how can a state argue that if you have been a good practitioner in your state and demonstrated through a standardized process that you have current knowledge – how could they keep you out. With a daughter graduating in 2011 – I hope optometric board certification and continued competence will allow much better inter-state movement of our profession.
    Thanks,
    Pete


  20. Pete, I truely hope you did not mean what I think you did when you said, “My hope is that NO STATE ASSOCIATION will tie the hands of it’s leaders that attend the AOA House of Delegates this year.”
    In Wisconsin, we have taken a poll of the membership; I have not seen the outcome, nor do I know what it is, but I would expect our delegate vote to exactly represent the feelings and directives of our membership. The pros and cons of Board Certification are easily read, and explicitly clear to anyone who has done their homework. Any implication that the delegates should not represent the membership makes me doubt the motives and credibility of this process all the more.
    Les Thornburg, O.D.


  21. I am writing in response to my own post on Dr. Kehoe’s blog. As a board member for NMOA, I participated in a JBCPT Webinar with AOA President-elect Randy Brooks. As a SWCO executive board member, last night I had a one-on-one conversation with AOA Trustee David Cockrell. Tonight I had the pleasure of exchanging emails with AOA President Pete Kehoe.

    Without going into all the details of these multiple conversations, I can tell you that I am now a proponent for BC. The North Carolina Board of Optometry stated that BC “is a solution in search of a problem.” I initially concurred with this statement. However, the irony is that 11 days ago, the South Carolina Medical Association testified against House Bill 3303 that optometry “is not board certified.”

    This recent action, coupled with CMS’s pilot Home Study expressly excluding Optometry AND non-Board Certified MDs and DOs, and the forthcoming pay-for-performance changes has convinced me that the AOA has gotten it right this time. The AOA is pre-emptively and proactively addressing a future issue.

    Do not misunderstand me, the process is not a panacea for optometry. There are other issues that directly affect each and every one of us on a daily basis that the AOA must address. As a leader in the NMOA and SWCO, I will continue to address such issues.

    I want to personally thank Drs. Brooks, Cockrell and Kehoe for hearing my concerns and taking the time to speak with me. I know that each of us has our own concerns, and I am sure that these leaders of our profession would love to talk to each of us individually if they could.

    I ask each doctor to research both the pros and cons of BC, and I implore the AOA to expeditiously release to the membership a copy of the video of the SCMA testifying that ODs are not board certified. Let it be a wake-up call to each OD.

    Thanks,
    Brent


  22. As the Immediate Past President of the AOA, I am responding to the comments posted by Dr. Brent Shelly on April 4th.

    I appreciate your comments on the proposed board certification process. Let me first say that THERE IS NO RUSH to adopt this proposal just for the sake “getting board certification”. It is imperative that rank and file AOA members understand why respected leaders—people who are very knowledgeable on the issue of the demonstration of competence and how board certification relates to that topic—feel that now is the time for optometry to adopt a board certification model. I want to emphasize that NO ONE on the AOA Board of Trustees, the Joint Board Certification Project Team, or any of the member organizations WANTS board certification. Believe me, I only wish that it were not necessary to proceed. However, imminent changes in health care, due to “Value Driven Health Care Reform”, create an urgency to act. Optometry, unlike other health care professions, is unprepared for the requirement of on-going, demonstrated competence and transparency that health care reform demands. Even if the model is adopted in June, we are years from beginning to certify optometrists—and health care changes may begin to appear soon. Your state leaders have an obligation to “listen to the membership”—yes, but they also have an obligation to prepare the profession for the future. The House of Delegates will be the place—as it always has been—where substantive issues like this will be decided.

    Members of ARBO have clearly expressed an interest in board certification and tying such certification to licensure. You are correct in assuming that tying board certification to licensure will have dire consequences for optometrists and will not result in any additional protection for the public. In fact, board certification has nothing to do with licensure in any other profession. Contrary to the North Carolina position paper, board certification does not interfere with the right to practice optometry; nor does it interfere with licensing boards. This is not the case in medicine and would not be the case for optometry. Ophthalmologists may perform cataract surgery because their medical license authorizes them to do so—not because of board certification. If we tie board certification, or continued competence to licensure—play this out—if you don’t pass your re-certification exam at the end of 10 years, you don’t go into your office the next day, because you will not be relicensed. By the way, Dr. Epstein has supported tying maintenance of competence to licensure.

    Regarding your comment on “the sky is falling”—let me be clear, no one is claiming, nor have we ever claimed that anyone has been denied panel membership or hospital privileges because we do not have board certification. The AOA and the JBCPT member organizations are convinced, however, that optometry’s lack of a program to demonstrate competence beyond entry level and on an on-going basis puts the entire profession at a disadvantage for the current and future health care environment.
    The issue of board certification has been discussed in optometry for over 40 years. Both general and specialty certification has been proposed—but always in the abstract without a specific plan. This time, the six participating organizations agreed that we would charge the project team with a model that had been vetted through the six organizations (organization that were highly critical of the ABOP approach 10 years ago), before it was released for general comment.

    A general certification model was proposed because like ophthalmology, optometric practice is limited to the eye. Optometric specialties are really more like sub-specialties in ophthalmology (cornea, retina, pediatrics, glaucoma). Sub-specialties are not recognized by the American Board of Medical Specialties (ABMS). If we certify sub-specialties like contact lenses, and a critical mass of optometrists become BC CL specialists, where will your contact lenses patients have to go to have CL care covered by a plan? If you carry this thinking out for the 10 residency areas accredited by the Accreditation Council on Optometric Education (ACOE), what exactly would a general optometrist do? I can’t imagine anything that would be more divisive for the profession. No, the JBCPT felt that as with ophthalmology, general certification was appropriate for the profession.

    Addressing your comment as to “who should optometrists listen to?”—may I suggest that the “AOA insiders” you refer to are duly elected by the AOA membership after a long vetting process that involves interviews, caucuses and private meetings with each state. AOA board members are knowledgeable, experienced clinicians, educators and administrators. Many are well known, well published and lecture internationally. All of the AOA board members have years of experience in private practice and come from the “rank and file”. Unlike Dr. Epstein, each AOA board member must stand before state membership and leadership up to 150 days per year explaining the positions of the AOA, defending our policies and programs and articulating our vision of the future of the profession.

    Dr. Epstein is certainly educated and articulate. I would respectfully suggest however, that being articulate in the delivery of your message does not necessarily make your message correct. Dr. Epstein enjoys a private platform—a “bully pulpit” if you will—where he may say anything he likes, unchallenged. Whether this is healthy for the profession or not, only time will tell. (For the record, Dr. Epstein was asked to do the Good Morning American piece as the Chair of the AOA Cornea and Contact Lens Section).

    It is easy to stand on the sidelines and take shots at the team. I can assure you that it would be much easier for all of us on the AOA Board to simply ignore this issue; to “take that poll”—as if we don’t already understand that optometrists don’t want board certification, don’t want to take another test nor do they want to take more CE. The hard part of leadership is to look ahead and, based on the facts, do what is right to prepare our profession for the future—not just take the popular view because it is comfortable, easy or “plays to the crowd”.

    I will close with the comment that I think the polls that have been already been taken asking optometrists if they want board certification are asking the wrong question. I think that rather than asking ODs whether we want board certification, we should be asking our patients—“do you believe your optometrist should be able to demonstrate competence on an on-going basis?” I’ll bet the results will be quite different. I’ll bet they think we are already doing it now.


  23. Dr Alexander,

    Thank you for well-written and articulate response. While I do not agree with you entirely, as is mentioned in a latter post you did not reference, I am in fact now a proponent of BC.

    The current model, despite two years of tooling, is inherently flawed on the premise that the JBCPT equates the model to Family Medicine. Family Medicine requires a residency, and the lack of any credible, established residency requirement negates the effort to establish professional parity.

    I am in agreement that the profession needs MOC, but the format needs to be credible. Lest we forget that the stated goal of JBCPT was to make the board certification process “credible” and “attainable.” The process is most definitely attainable, but does fall short of its credibility goal.


  24. Les,
    Thank you for your comments and I actually did mean what I stated. The reason is that for anyone who has participated in the AOA House of Delegates, they realize there are many potential motions, amendments and other actions that can be taken on a particular agenda item. If a delegation took a poll and the outcome simply gave the leadership a yes or no vote, the leadership has no leeway in using the information they’ve learned from the membership and making an informed decision on the actions of the moment. I absolutely believe the delgates should represent the membership, but not with a simple yes or no vote, which is what many of the polls that are currently being conducted through a variety of methods are asking. We will shortly be sharing a survey that state leaders could use with their membership that will gain significant insight into the thoughts of the membership about a variety of issues that relate to board certification and continued competence. It should give a framework for the state leaders to really understand their membership concerns and expectations. Stay tuned for more information.
    Thanks,
    Pete


  25. Brent – Thank you for your comments and willingness to listen with an open mind – the sign of a true leader!
    Pete


  26. Brent,
    I believe that Family Medicine (and even ophthalmology and possibly other branches of medicine) did not require residencies when they first started board certification. Because optometry doesn’t have residencies available for all graduates and graduates of the past, a credible program to establish a baseline of competence had to be created and I believe the JBCPT came up with a reasonable, defensible and credible alternative to residencies for optometry to become board certified so we can then demonstrate continued competence.
    Pete


  27. Dr. Kehoe,

    It would seem that a lot of the discord I am reading from the various forums is the lack of residency training required for the proposed model.

    If family practice, and indeed ophthalmology, did not initially require residency training, then it would seem most prudent for the leadership to rebut the naysayers with this valuable piece of information.

    In that vane, it would seem prudent and plausible to establish a general timeline for the development of sufficient residency positions, so that the profession could in fact transition to such a medical model.

    Thank you for your prompt and courteous response to my previous post.


  28. Dr. Shelley-

    Thanks for your response regarding the American Board of Family Medicine and residency training. I would like to respond to your request to “rebut the naysayers” on the point that “if you don’t have a residency requirement, our program is not credible”.

    (By the way, no one has suggested that our program is “identical” to the ABFM, but rather “modeled” after it—especially in term of the CE required and the Maintenance of Certification component. Semantics—maybe, but the truth non-the-less.)

    Regarding residency training and other specialties, perhaps you might be interested in the history of ophthalmology in this regard. I call your attention to the excerpts below from “History of the American Board of Ophthalmology”, by Drs. Cordes and Rucker, Tr. Am. Ophth. Society, Vol 59, 1961, p 320 & p 330

    Drs. Cordes and Rucker write:

    “The chief “first”, in my opinion, and the one that has had the widest influence, is the establishment of the Board of Ophthalmology in 1916….At first, there was considerable resentment against the idea that a self-constituted body should set itself up as judge of the competency of its peers. The original Board wisely forestalled much opposition by inviting outstanding ophthalmologists to become certified without examination. But those who were not among the elite were vociferous in their opposition. In time, they became loyal supporters.”

    And this, on “time in training”– “At first a year in one of the various eye and ear infirmaries was deemed satisfactory.” — “As changes have taken place the Board has changed its requirement to meet the present tendency and has required three years of formal training since 1957”

    So, just for the record, the American Board of Ophthalmology went 41 years before it required a 3-year residency.

    I do not think we will be ridiculed by other specialty boards, as they went through the same development we are going through years ago.

    Another interesting point—in 30 years we have established only 230 accredited residency programs in optometry. Just to take care of our new graduates will require another 1200 programs. This will take more than a generation to achieve.

    As we consider Board Certification for the profession, we must not forget that we are a young, developing specialty that lags the more established specialties by several years.

    Thanks for the thoughtful dialogue, Dr. S!


  29. Dr. Alexander

    It is obvious that “leadership” to the JBCPT means that you recognize that the vast majority of rank-and-file ODs are opposed to BC, but you would push it through anyway because you all know “what is best for the profession.”

    You are correct on one issue – certainly our patients want us to be competent. If we don’t maintain competency, we would not be in practice for long. Our patients can only judge our competence by what we do for them. That’s how it works in the real world.

    Another certificate on the wall (BC) really means nothing to our patients.

    Bob Gradisek


  30. Bob,
    You are correct that it is ALWAYS what is best for our patients. However, don’t you agree that the majority of optometric patients, including yours and mine have someone else (managed vision plans, managed health care, private insurance or government insurances (such as Medicare/Medicaid) that are paying part or all of their fees for your professional services? Unfortunately, the insurers of the past, and more importantly, the future – are looking for ways to insure that they are paying for value-based healthcare. Our patients have little input into the process, and since true outcome measures are challenging – the insurers are looking for ways to assume competence and that equals value in their world. The Medicare demonstration project in several states is a great example – ONLY board certified physicians are allowed to participate. Non-board certified MD’s, DO’s and optometrists are not allowed in the program.
    As leaders, we try to learn as much about the future as possible and do our best to insure that the majority of optometrists will be able to FULLY participate in the future healthcare system that is being developed in America.
    In the end, I’ve never heard an optometrist that didn’t agree that after upgrading to DPA’s, TPA’s or orals wasn’t a better doctor after the process than before – and ultimately the patients will be better served by optometrists that go through the BC process and maintain their continued competence.
    Thanks for your comments,
    Pete


  31. Pete,
    I have a couple of questions.
    1. Do you feel that if we as a profession do not have a BC process all insurance panels will kick us off?
    2. You mention the board has made changes to the current proposal. Can we get a copy of the changes? Or are they just keeping them from the members and giving you the copy. I am sure you can just post them on this forum.
    Best Regards,
    Ryan


  32. Ryan — An article covering the changes to the board certification model, made in response to AOA member suggestions, is here in the April 13 AOA News, page 7. There are also three pages of letters about board certification. We’re working hard to ensure AOA members are fully informed about the process.


  33. Dr. Gradisek

    If you think board certification is about “another certificate on the wall”, I respectfully suggest you miss the point.

    Leadership to me doesn’t mean that “we know what’s best for the profession”. It also does not mean that we just take a poll and do what everyone wants. You elected me to the AOA Board to be actively engaged in advancing the profession. After 10 years of intensely studying the issue of continued competence, meeting with government agencies, testifying before governement and non-government agencies regarding optometry’s participation in the health care system, your AOA Board believes this is an issue that is important. Yes, we knew that many would not want this–I was in the room when members voiced their opposition to DPAs and TPAs–but I would think you would EXPECT me to bring this issue to the membership and do my best to educate as to why this is important.

    YOUR leadership cannot “push this through”. We can only put forward an idea and leave it to the House of Delegates to decide. If we are not successful in convincing optometrists that this issue is critical to their future–it is OK with me–I’ve done my job bringing this issue forward.

    Kevin


  34. Dr Alexander,
    Yes, we did elect you to the AOA board to REPRESENT US as a profession. I would hope the board would represent the wishes of their own members not just their personal views. Like it or not we should all have a say in this matter, would you agree? Pete’s quote went something like this “My hope is that NO STATE ASSOCIATION will tie the hands of their leaders that attend the AOA House of Delegates this year.” This quote is not a democratic view this is saying the AOA will strongly influence the state associations to NOT do what their members want but what the AOA wants. That my friend is scary. I pay my dues just like every other member and if my collegues and I feel that this is not the way we want to proceed then so be it. I also respect your point of view and if the majority would like to proceed then so be it but please don’t say that the AOA cannot push this through because that is a false statement. The leaders of the AOA have been nothing but pro board certification. They have been sending out all their trustees to state meetings across the country to try and push this thing through.
    As an aside. How does the AOA plan on reaching the optometrists out there that are not AOA members on this issue? Are they just out of luck?
    Best regards,
    Ryan


  35. Dr. Kehoe,

    I graduated UH in 1989 and completed my disease residency at Omni eye center in Atlanta under Paul Ajamian at a time when Georgia was just starting TPA’s. I feel I’am a strong supporter of the advancement of Optometry as a medical profession. I have since then been in private O.D. group practice and practice at a high medical level. I’am not convinced the BC process holds any value for me. I currently see it as a waste of time and money especially when our current administration wants to reduce payments to doctors and increase taxes on those making over $250k. That hits me on both sides.

    I see Podiatry as a profession included at the same level as M.D.’s. They have hospital privileges and are included on all insurance panels. Do they have a long drawn out expensive BC process?

    I have not been convinced this process will help my inclusion in the new medical insurance model. Our biggest detractors and opposition have always been the Ophthalmology lobby. I see my time and money better spent combating the real reason for our exclusion.

    If the BC process as proposed is inacted I see it as alienating and divisive at a time when Optometry has to be unified and strong.

    Phil


  36. My biggest fear is that if BC is approved, against the will of the majority of AOA’s members, that there will a large exodus of members from AOA. Since the state and local optometric association membership is linked to AOA membership that also means those organizations would lose several members.
    We need all of these organizations to be strong to protect our legislated profession so we don’t lose the ability to practice to the greatest extent possible for the benefit of our patients. If they are weakend through approval of this BC process, against the will of the majority, we’ll only go backwards.
    I know that the BC proposal is being modified based upon input from our members. However, showing us the “final” version at the AOA meeting in June, or at a time when our members can’t have enough time to properly evaluate it, is not the way to do things. The vote on BC needs to be tabled for another year so the JBCPT can “get it right” before our members are asked to vote on BC.
    Estimates are that it’ll take at least 4 years to get the process in place and start to see the first BC’d ODs. What’s the harm in waiting another year to get a process which is acceptable to the majority of our members versus fracturing our profession and weakening its representative organizations?


  37. I think it would be appropriate to take a poll on the AOA website and see what the memebers have to say on this important matter.


  38. Dr. Stephens,

    Podiatrists do go through a board certification process. I don’t know if it’s lengthy, but it sure looks lengthy. They also have to complete 2-3 years of residency: http://www.abps.org/content/members/Pathway.aspx

    Everyone else,

    Let’s go through some pros and cons of this whole thing.

    1) Time consuming educational requirements.
    – Can someone give us a figure here? I mean actual hours of my time. Does 1 hour of CE equal 1 point?

    2) If I don’t choose to become board certified if/when it becomes available, I may be rejected by panels who now require it but didn’t require it before it was offered.

    3) It will cost me a lot of money.
    – Can someone give us a figure here?

    4) “It may harm legitimate advanced competency and existing board certification processes such as those offered by the AAO Diplomate programs, the International Examination and Certification Board (IECB) of the College of Optometrists in Vision Development (COVD), NORA’s Neuro-Optometric Rehabilitation Skill Building Program and the American Board of Medical Optometry (ABMO).”
    – What makes the AOA/JBCPT necessary if board certification is already offered? What’s the difference? How will the American Board of Optometry (ABO) harm existing processes?

    5) “The AOA/JBCPT proposal offers meaningless credentialing, which could be viewed by both the public and insurers as purely self-serving while offering potent ammunition to our enemies.”
    – What makes it meaningless compared to the aforementioned existing board certification processes?

    Items 4) and 5) were taken from Art Epstein’s weekly ejournal “Optometric Physician”.

    6) Offering board certification takes ammunition away from groups that would want to hinder the advancement of Optometry.
    – Let’s face it, the general public often forms irrational opinions. The general public likes guarantees to ease their fears even if their fears are irrational. The fear is that their doctor is not well trained and will screw them up. Board certification is a guarantee to the public.


  39. Okay to reprint comments in AOA News?

    To all who have commented — I appreciate your comments and passion for the profession of Optometry. As you’ve probably noticed, we’ve been running lots of letters in AOA News, both pro and con on Board Certification. I think your fellow AOA members would appreciate seeing the posts on this blog in AOA News, but want to check with you before reprinting. If you’d like your post considered for publication in the AOA News, please send it to the editor (rafoster@aoa.org) with the subject line: “Pete’s blog posting.”


  40. Ryan,
    Thanks for your post. Please understand that the House of Delegates is a very dynamic process. There can be amendments made to motions and can materially affect a decision. If state leaders are instructed to come and vote only yes or no, then your state’s representation is being limited when changes occur. My personal hope is that all the leaders come to the House of Delegates with a full understanding of their membership and what changes would be desired and acceptable rather than not being able to participate in the process.
    Please understand also, that this is NOT personal with any of the AOA board. It is totally about the future of our profession. As leaders we want to be sure we and future optometrists will be able to fully participate in the rapidly developing, value-based healthcare system.
    Please stay tuned for a significant amount of information about value-based healthcare and we believe you’ll see that our crystal ball is pretty accurate.
    As for the non-members, they have full access to the information on the AOA’s website – that section is not password protected and I’m sure much of the information that we send to individual members is being shared on OD-Wire and Optcomlist.
    Thanks and please keep an open mind and think about this quote from John F Kennedy: “There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction”
    Regards,
    Pete


  41. Phil,
    I think Dr. Goodwin answered your question about podiatry, but I’ll add that podiatry actually has THREE different board certification groups. That is a problem for their profession and clearly can divide a profession. Not all podiatrists are credentialed to the same level and I’m not sure if that is because of the different BC programs or training.
    Podiatry does have “competition” for their services from orthopods, similar to our “competition” for our services by board certified ophthalmologists. Please stay tuned for a ton more information coming to your inbox and mailbox that will explain the very likely changes in value-based healthcare.
    Please read the quotes on the internet about how the administration plans to save on healthcare costs by paying those who can not demonstrate “quality” LESS than those who can. Exchange “quality” with “continued competency” (which has to have a starting point – called board certification) and you’ll see why it is in your, and every optometrist that participates in Medicare/Medicaid or likely any health insurance, best interest to continue to learn more.
    Pete


  42. Tom,
    As a long term leader in our profession you are absolutely correct that the AOA and state associations need EVERY optometrist to be a member. Without our current membership, we would not have had the clout to have optometry included in the stimulus package that allows us to access dollars for electronic health records, or back in 1987 to have gained physician status in Medicare.
    My question to you very seriously is….if we waited a year, do you really believe that we could get a “program” that would make everyone happy? Also, if the timeline for value-based healthcare is within 4 years (that would be President Obama’s first term), can our profession afford to spend another year debating this issue?
    Thanks for your continued support,
    Pete


  43. Dr. Wells,
    A simple poll online really doesn’t help because you don’t know if the respondents have really heard the full story. Without the full story, any rational person would say that they didn’t want to do more CE, take a test, spend extra dollars etc. However, once they hear (as many states have found out) the full story in person, they may not like having to do the above, but they at least understand why they need to consider it. This is not really a yes or no question when so much is at stake in the new value-based healthcare system that is being developed.
    Thanks for your comments,
    Pete


  44. “our crystal ball is pretty accurate” – ??????

    Optics 101 will tell you that the image through a crystal ball is upside down. I think there may also be some smoke and mirrors thrown in to the
    push for BC, along with that upside down view!

    Bob Gradisek


  45. To say that an online poll will not be valid since people have not heard the full story is false. Everyone I know has read and searched every piece of information regarding board certification. I think you do not give your members enough credit in that respect. As a 30+ year member I think the AOA is headed for a terrible and long lasting affect from this no matter what the outcome.


  46. Bob and everyone – I hope you had a chance to see the latest that came out of the Senate Finance committee on Tuesday. Maybe it could be said their fortune telling was not through a crysta ball but rather a free-form high definition optics lens. The following is an important part of that report that relates exactly to what is being proposed for our MOC.

    “A new PQRI participation option would be added to the existing options described above. Eligible professionals could also receive PQRI incentive payments for two successive years if, on a biennial (every two year) basis, the physician (1) participates in a qualified American Board of Medical Specialties certification, known as the Maintenance of Certification or MOC, or equivalent programs, and (2) completes a qualified MOC practice assessment”


  47. Optometry has 3 critical areas of failure, 1. We cannot cross state lines. EVERY OTHER health care professional can cross most state lines, once proven they have a current state license in good standing. 2. The excees of optometrists. Only Wal Mart share holders are appauding the opening of 3 new Optometry Schools. I get at least 2 calls a month from Optometrists looking for work. 3. Mandatory live C.E. Every other health care profession can take most if not all C.E. either on line, by snail mail or by phone. Organized Optometry should tackle THESE issues. Half the schools should close and the other half should vastly reduce class size. A license in good standing in one state should automatically be good in another ( regarding different nuances in prescribing privledges – only a fool in todays litigious society would practice above one’ comfort level. All CE OK on line.


  48. As of today (May 8), the Ohio Optometric Association has officially declared against board certification as proposed by the JBCPT. “..we find board certification in optometry to be unnecessary to demonstrate continued competence and divisive to the profession”. Say Hallelujah!

    Bob Gradisek


  49. There are easily obtained membership rolls of the optometrists practicing in each state, so it would be a very simple process to allow one vote by each OD on this devisive issue. Just as it would have been easy for the AOA, and the state organizations, to update their websites to allow discussion.

    I am very suspicious of motives because this is not being done, and am unlikely to remain a member of a group that operates in a non-transparent manner.


  50. Joseph,
    Thank you for your opinions. I’m not sure I understand why you don’t like live C.E. – interestingly many people surveyed a few years ago (members and non-members) felt that the C.E. events at state and national meetings was of great value in helping our profession remain cohesive. While there is a lot of movement toward on-line C.E. – many people say they like the opportunity to network with their colleagues.
    I agree that we need to improve the mobility of licensed optometrists. In fact, I personally believe that a nationally recognized credential (board certification) will go a long way in improving mobility. Even if a doctor practices in a state that doesn’t have a certain scope – if they are in good standing in their own state, and have proven they have the competence of a “modern day optometrist” by passing the BC, or maintenance of certification – I think a state/state board would be hard pressed to argue that the doctor shouldn’t have an opportunity to move to their state.
    As for your comments about too many optometrists. I believe the challenge we face today is really not over supply, but rather distribution of optometry. Unfortunately I hear many doctors who are looking for work (yet few if any are not working if they want to) but they want to work in a very small geographic area. When I graduated in 1984 going to more rural areas was very accepted and encouraged and many of us (me included) went to rural America and have developed very successful full-scope practices. Some how we need to encourage more doctors to consider rural America – a great lifestyle and a great professional opportunity.
    Best of luck to everyone and sorry for the delay in responding.
    Pete


  51. Obviously I don’t agree and since I’ve always considered Ohio as a very progressive and forward-looking association, I am disappointed. In this instance I don’t agree with their opinion and clearly many other states don’t as well.
    Pete


  52. Michael and All –
    The AOA is a federation affilate associations and is organized under the laws of Ohio. We have a very specific process for voting on issues of the association. The vote strength is not as individuals, but is based on the number of members of each affiliate.

    Other than my blog, we really don’t have an “open discussion” available on our website. We did however open up the board certification information to all optometrists – not just members so everyone in the profession would have access to the information as it became available. We’ve tried to take all of the questions and differing opinions and explained our position – we haven’t tried to hide the opposing views, but we didn’t believe it appropriate for the AOA to highlight the opposing views that are on other web-based networks. We have however, included many opposing views in the Letter to the Editor section of the AOA News.

    I’m sorry you don’t feel there has been transparency and I hope you will remain an active member for many years to come. Regardless of the outcome of the vote on board certification, I will always be a member of the AOA because I feel it is my opportunity to have a voice through my state association to the AOA and I also know the value that is delivered to me as a practitioner from the 100 employees and 300 volunteers working on our behalf every day. That is priceless!
    Pete


  53. the great state of Florida (FOA) voted yesterday to oppose board certification at the AOA meeting next month. Of those members who responded to an online survey 77% !!!!!!!!!! voted NO As to why I do not like live CE — too costly and usually to inconvenient. Those who like it can continue to do so and those who don’t should be given the choice. What i feel would be a slam dunk approval rating for BC would be a guarantee for complete, unadultered, mobility between all states. The only 2 requirments being BC and a current active license in at least 1 state in good standing!!


  54. Pete…

    I appreciate your response, but when I see a leader of the AOA encouraging the state directors to vote contrary to the members they represent, I have serious concerns about the process.

    In my opinion, the only way to unite optometry behind certification is through a vote of ALL optometrists. The surreptitious approach was the wrong way.

    Michael Hobuss


  55. Joseph –
    Let me start with the mobility comment. I wish that could be guaranteed. However, as you all know, licensure is a state issue and it will require a coordinated effort among the state associations, state boards and legislators to make that a reality. I do believe a national credential of board certification will help rally everyone around the concept.

    I spoke with the president of FL and in fact, what they did was not oppose BC or MOC, but rather vote to delay the decision for a year. He indicated that most everyone understands the need, but felt waiting a year would help build a model that would be more accepted. A survey that was done prior to the most recent model from the JBCPT (as of May 5, 2009) should bear little significance because the model has evolved so much. The goal of the changes that have come from the JBCPT (and will come from the floor of the House of Delegates I predict) are to make the process more attainable while maintaining credibility for all optometrists at different stages of their careers.

    An example being the CE requirements. As you hopefully know – the current proposed model allows up to 75 points (half of the necessary) for practice experience (3 points/year up to 25 years). If you didn’t have a fellowship or residency, you would need to earn 1/2 of the remaining 75 points with face to face CE (unless the HOD suggests a change on this) in the previous 3 years (about 13 hours per year on average – unless it was tested CE which will count 2 points per hour so you would only need 7 per year). The remaining 1/2 of the points can be earned on-line and many other ways.

    I am confident that the state leaders have been listening to the membership to learn what are important points to consider and whenever possible, the state leaders will bring the member concerns to the House of Delegates for discussion, deliberation and possibly a change to the currently proposed model.

    Stay tuned!
    Pete


  56. Michael,
    I spoke with a state president on Thursday. He shared that at his local society, about 30 doctors were in attendance and when he asked how many had read the most recent materials (the May 5, 2009 model etc.) from the AOA – ONLY ONE DOCTOR raised his hand. To him, and to me, that indicates that most of the “votes” have been based on less than full information.

    Doctors are busy with their practices and families and for the most part haven’t taken the time to do the reseach, both pro and con as well as researched the dialogue coming out of Washington, DC on Value-Based Health Care reform. This morning I read the AMA News dated May 11, 2009 and the headline is: “Key Senate panel sets brisk pace for health system reform package”. In the article they marvelled that the “mark ups” will start in June (when we are in DC for Optometry’s Meeting and our Rally on Capitol Hill) with votes to occur PRIOR to the August recess!

    Thank you for your comments and opinion. Unfortunately, like voters who go to the polls on election day, many take the easy vote rather than doing the research to make the hard vote. In this case, change is difficult and frankly concerning to many. However, I can share that as the AOA board has visited state meetings and made presentations, with only a couple of exceptions, after a thorough discussion (not a lecture from us, but a dialogue with the members) nearly every state meeting has gone from negative to neutral or neutral to positive. As one former (TPA era) state president shared with his 100+ members in attendance: “I was 100% opposed, but I now realize that we must move forward – let’s just be sure we get it right!”

    I’m 100% confident that the 400+ leaders that will participate in the HOD discussion on Friday June 26th will take their members concerns and issues to heart and the body of our profession will make the right decision for the future of our profession!

    Pete


  57. Pete,
    The comment by the state leader in the prior email that said “let’s just be sure we get it right” is absolutely correct. To me, since the proposed process is still in a state of flux, it’s too early to vote for a final program at this time.
    You’re asking the deldgates to vote for a moving target and have them assume that the final proposal the ABO will start working on will be “right.”
    I’m sorry, but I just can’t see the rush here in spite of what Congress is doing. You know as well as anyone that nothing happens quickly in Congress nor with Medicare in terms of a final program that is put into place.
    To me, it would be much more prudent to see what Congress comes up with in the area of continued competency requirements and then our program can be molded to fit their exact specifications, if those are even set in this legislation.
    Look at the delays in implementsing the NPI numbers and, even after the date certain passed, the Medicare carriers weren’t ready to process claims using NPIs only.
    Patience is what’s called for here not “damn the torpedoes and full steam ahead.”


  58. Pete, thank you for responding. I was originally under the impression that BC was for specialties in optometry, ie. cornea, retina, low vision etc. I am now aware it is for General Optometry. How absurd!!. The closest model we have to Optometry is Dentistry. THERE IS NO BC IN GENERAL DENTISTRY. It is also my understanding that even the dental subspecailist have non – mandatory BC. While those BC proponents continually emphasize that BC will be optional, in reality it will be required because if and when the process happens those with BC will encourage insurance and government panels to only allow BC members on the panel. To paraphrase the statements form the Maryland Board, we are creating a solution for a non problem. What I really think this is all about, it is a way to end run the problem with the glut of ODs. Perhaps only a very small percent of ODs will get BC and they will sell the idea to the insurance and government panels to only allow these ODs on their panels!! Also, Medicine will once again laugh at us. saying what kind of BC exists without Residency and Internships requirements. To them, there is nothing short of an MD degree that they will respect, so why even try. As far as Fl. is concerned the majority of practioners in the state feel our 30 hours per 2 years and 8 of these must be with tests, is very adequate.


  59. Joseph,
    Actually there is a board certification model for general dentistry, but it is not utilized much because it requires a residency and most importantly, general dentistry typically does not participate in Medicare or private health insurance.

    The facts are the reason for pursuing this: optometry is the only profession defined as physicians in Medicare without the potential of demonstrating continued competence or “maintenance of certification” as is being proposed by CMS and the Senate Finance Committee and other legislative bodies. As you and everyone knows, as goes Medicare, so goes the private payers.

    Unfortunately, our CE, even tested CE is not going to meet the test of “maintenance of certification” as is being presented to the Washigton legislators by the ABMS. The model that is being proposed for optometry will meet the requiriements that are being discussed and will allow us to FULLY PARTICIPATE in Medicare and ultimately the new value-based health care system. Did you realize that the start date for the proposed PQRI bonuse for maintenance of certficiation is 2010! How many millions of dollars will optometry miss out on if we don’t move forward this year? How many thousands of dollars are individual doctors willing to risk by not moving forward this year?

    Change is never easy and not always appreciated in the beginning by everyone. However, in this case – having the opportunity to fully participate is the reason to move forward and will help more appreciate the benefits of change.

    Pete


  60. Pete,
    You say that the model being proposed will meet the criteria by ABMS. Can you tell us where you can find that criteria from the ABMS? I am unaware of any ABMS criteria out there. Maybe if there is something out there that spells out that you have to have this MOC or BC before we are going to accept you on our panel, our members will be able to accept the fact we need BC and MOC. Has the JBCPT submitted our current proposal for BC to the ABMS? If so, have they approved it or do you just think they will approve it?
    Thank you,
    Ryan


  61. Ryan,
    The only information I’ve seen re our proposed BC process and its relationship to an ABMS program is a very luke warm approval from the head of the family practitioner board. Not a ringing endorsement. Remember that ABMS stand for American Board of Medical Specialists, or spmething to that effect.
    Optometry is already a specialty profession and we’re certified to practice the specialty of optometry by the NBEO and any other state testing required of us. This BC proposal WILL NOT certify any specialties within optometry such as contacts, low vision or VT.
    To many people, the term Board Certification is being misused in our situation because, in reality, what the JBCPT is really trying to develop is a way to measure continued competency versus certifying that we are indeed able to practice the specialty of optometry. We’ve already been certified to do that. They’re just trying to use terms familiar to the rest of the medical and insurance community and kind of twisting the true definition of BC to suit their proposed program.


  62. In recent weeks I’ve been reading with great interest various comments and editorials on many web sites and blogs. I disagree with the proposals for Board Certification (BC) and Maintenance of Certification (MOC) as presented. I had the opportunity to visit face to face with Randy Brooks, OD and AOA President-Elect in Albuquerque, NM, at the NMOA convention last week. I’ve also visited face to face with Stanley Woo, OD and Texas Optometric Association President-Elect at a recent meeting in Amarillo, Texas. So, I’m fully informed on the AOA’s and joint committee’s propositions and reasoning.

    The short version of my position is that board certification is unnecessary for a legislated profession whose scope of practice is dictated by state statutes on a state-by-state basis. Further, Optometry appears to be attempting to become something it never was and (in my opinion) doesn’t need to be. If Doctors of Optometry want to become Ophthalmologists they should have gone to med school and completed the appropriate Ophthalmology residency.

    The long version of my position follows…

    The multiple issues swirling around Board Certification and Maintenance of Certification are going to be difficult for all concerned. As much as we’d like to think the issues are relatively clear cut and have academic and professional elements worthy of their own merits, it really seems a little more simplistic and, perhaps, sinister to me. That is, in the end it may be more about $$$ than any of us are willing to admit. And, adding insult to injury, it will most likely divide organized Optometry into the “haves” and “have nots”. Further, it may be “voluntary” in concept, but the reality is that it will become “mandatory” IF you want to be a panel provider on most (if not all) vision plans. Therefore, if enacted, it will be “voluntary” in name only… just like TPA was “voluntary”… until you wanted to be a panel provider for VSP and others who REQUIRED it.

    Back to the $$$… “Value Driven Health Care”… rephrased, the “Cheapest Health Care Possible” is the governmental model. Period. End of statement. COST CONTAINMENT is the driving force behind the “sweeping health care movement” today. It isn’t nearly as much about “quality of care” as much as it is “cost of care”. Affordability and profitability is more important to all third party providers (governmental agencies included) than quality and availability.

    Follow this thinking/reasoning… if Optometry can be forced, coerced or shamed into a “voluntary” board certification process… and IF a significant number of OD’s opt to NOT become board certified, then they can be PAID LESS by all third party payors and/or EXCLUDED from panels to squeeze down the number of patients actually being seen…. saving untold amounts of $$$$.

    Secondarily, medicine (particularly Ophthalmology) would probably LOVE for us to develop a BC and MOC process. It would finally give them ammunition to take to the negotiating table with third party payors as “proof” that we are substandard because our board certification process is not like the CURRENT medical model (regardless of how some of the medical specialties in the past have obtained their BC without a lengthy residency). They can play the “BC” issue from either point of view…. if we don’t have it we “look” inferior, and if we DO have it the PROCESS by which it is obtained will be viewed as “inferior”. Either way, we stand to potentially loose.

    BC and MOC does NOTHING to change, modify or enhance scope of practice. And BC will not change individual state regulations regarding scope of practice since we ARE a LEGISLATED profession. Example: I hold licenses in two adjoining states and practice in both. My education for both is identical. I hold the highest license privileges available by law in both states… yet what I can and cannot do is DIFFERENT based on individual State Legislation restrictions / privileges.

    Speaking of “scope of practice”… it seems Optometry continues to have an identity crisis. In the 40 years I’ve been in practice the definition and scope of practice has continually changed. Perhaps for the better…. yet, I knew full well what an OD could and could not do BEFORE I went to Optometry School. I didn’t want to be an Ophthalmologist then nor do I want to be one now. I’m relatively certain I’m smart enough to have gone to med school and a subsequent Ophthalmology residency. But, I didn’t… on purpose. There has to be some “line in the sand” that will define what Optometry is and does and set it in granite. At some point we must cease trying to kick in the back door of Opthalmology and be content with the definition and limits of our license. If I was an Ophthalmologist I’d probably be offended and irritated by Optometry’s continued intrusion/encroachment into their field of expertise.

    I’m far more concerned at what organized Opticianry is doing with their expanded scope of education and garnering political support than I am about BC and MOC. They can use the exact same logic for performing “refractions only” (advanced education and training) that we use to encroach farther and farther into ocular medicine (advanced education and training). If Opticians gain a legislated “license to refract” for glasses and contact lenses, then every OD can take their BC and MOC and get a cup of pencils to sell on the street corner because OMD’s will hire them by the bushel full as will all the major optical chains. We can then take our BC and MOC and shove it because at that point all we can do that Opticans can’t is treat a red eye, or treat and manage glaucoma (only in select states!) or remove a FB now and then!

    Don’t forget the law of unintended consequences. Some times we make choices and/or do things, rationally or irrationally, without considering unforeseen consequences that could have devastating effects. Who knows what unintended consequences will result from the BC and MOC initiative? For starters, at a minimum it will fracture Optometry into two camps… those with BC/MOC and those without. And there are rumblings of lifelong AOA members dropping their membership… which would have devastating effects on the profession. There are costs to be considered to become BC and maintain MOC… and it won’t be cheap. Some veteran (read older) Doctors of Optometry with 40-50+ years of experience may choose to go without BC/MOC and potentially be financially forced to retire when they had actually planned to remain in practice for an indefinite period of time at a professional level considered equal with their peers. By the admission of advocates for BC/MOC, as many as 10% of OD’s will FAIL the BC exam! That, in my opinion, isn’t something to be taken lightly and is unacceptable.

    So, what do we do? The lion is out of the cage… or is it? So far nothing has actually happened other than some words by people with potentially self serving interests claiming BC/MOC is an inevitable goal of health care reform. That is, at this point, more speculation than fact. Shame on us (collectively and individually) for not making legislators and governmental health care personnel aware that board certification simply “does not apply” to the profession of Optometry because we aren’t a part of conventional/traditional medicine. We don’t have a routine residency program available to all OD’s as part of our formal education process, and as comprehensive Primary Eye Care providers we perform an overwhelming percentage of first contact with the ocular health care delivery system for the public.

    Therefore, a plausible solution: All that is required is an exception/exemption for Doctors of Optometry in the wording of any statute or regulation pertaining to participation or continued participation in ALL third party provider entitlement at an equal level with all other health care providers. A tall order? Yes. But it is the most effective solution because it is academically, clinically and legislatively accurate, tenable, achievable and affordable.

    Couldn’t a Grass Roots effort be made by the AOA leadership and every State Leader and as many of the “rank and file” Optometrists as possible to contact their legislators at all levels of state and federal involvement as well as third party vision care providers to garner support of such an exception/exemption? It isn’t too late and would require FAR LESS EFFORT, time, money and commitment than enacting the proposed BC/MOC project. But it probably would take the combined efforts of EVERYONE to make it happen… not just a select few. And since every OD in this country will be affected, it is in the best interest of every individual to get involved.

    Respectfully submitted for your consideration.

    Sincerely,

    Cled Click, O.D. – Offices in Amarillo, Texas, and Clayton, NM

    Therapeutic Optometrist, Optometric Glaucoma Specialist and Optometric Physician

    Private practice for 38 years and 2 years of Military Optometry


  63. I just received a large postcard/mailing from the AOA that disturbs me greatly. Some quotes from the mailing: “The health care reform train is leaving the station: Don’t be left behind.” “A cornerstone of this health care reform – the price of admission – is the implementation of a national board certification program to demonstrate continued competence and quality measures.” “Using state boards to demonstrate continued competence won’t work and neither will a process serving only the few doctors with a specialty interest or those who have completed residencies.” And then this doozy: “We are being left behind. At stake is nothing less than the future of our profession.” (IN BOLD TYPE, NO LESS!)

    This is just sad. I have NEVER seen the AOA try such a ham-handed approach. It is becoming obvious that mounting opposition has “frightened” the AOA leadership and they have responded with a mailing to try to instill fear in their membership. I have been a proud member of the AOA for 22 years and I have never been ashamed of the actions of the AOA……..until now. No matter what opinion one has on the current board certification proposal, this mailing is ridiculous and pathetic. The AOA has now failed in keeping this debate on a mature, thoughtful level and resorted to “scare tactics.” I am now seriously considering withdrawing my membership in the AOA and that saddens me greatly. I think the greatest mistake that has been made in this current proposal was a lack of thorough surveys of the AOA membership (of whom private practice O.D.’s are the backbone) to determine what form board certification could or should take. As for being “left behind”……please. IF Medicare/”The government” were to madate changes in our maintenance of quality care, then we will have AMPLE time to make the necessary changes (a perfect example: conversion to EMR’s. We will NOT be left out in the cold; who would see these millions of patients?).

    Let’s all take a deep breath and take our time proceeding forward: WE DO NOT HAVE TO REACT TOO QUICKLY OUT OF FEAR!


  64. Ryan,
    I’ll try to clarify a little more and sorry for any confusion. The model has not been “approved” by ABMS and I can’t imagine why we would ever ask for the American Board of Medical Specialties to approve our model. However, the MOC process that has been outlined by JBCPT is very similar to many of the ABMS MOC programs. The important point to consider is that the new PQRI recommendations coming out of the Senate finance committee are very much aligned with the ABMS recommendations. Representing 24 medical specialties, they obviously have a lot of influence in Washington.

    We’ve had a lot of people suggest that we shouldn’t call our process board certification and we should seek prior approval of our plan from someone. I would point out two things to consider: First, CMS has said that that “they will look to the professions” for their establishment of criteria. If we asked anyone for “prior approval” of our plan, and then our plan is changed at the House of Delegates – do we have to go back and ask for approval again. And worse yet, if CMS approves the model and the HOD would reject or delay our BC process, what merit will we use to try to have optometry included in the changes that are likely to start as early as 2010? Neither scenario has a positive outcome for optometry.

    Second, as far as calling our process BC. What do we call our 1-year post-graduate programs? – Residency. For optometry a 1-year residency has been “approved” by ACOE which is “approved” by the US Dept. of Higher Education. However, are there any medical residencies that are only 1 year? They are all 3 to 5 years. Therefore, once again, proof that because optometry is different than medicine, the models that we have created “for our profession” are recognized and accepted by the organizations that matter.

    A long answer to multiple points.
    Pete


  65. Tom,
    Since my answer to Ryan below addresses most of your points, let me challenge your contention that the NBEO “certifies us to practice”. In fact, the NBEO and even ARBO is on record as stating that the NBEO is to assess initial competence for licensure, which is obviously conferred ultimately by each state. Board certification and maintenance of certification by definition is “beyond initial licensure”. We have no way in our profession to asses that after 25 years of practice that I have the knowledge of a modern-day (2009) optometrist – thus: board certification – and no way to demonstrate that I am keeping up throughout my career – thus: maintenance of certification.

    I will restate by position that optometry can and should define board certification (a recognized term) for optometry because our education and ability to practice after our doctoral degree is different than medicine’s model. Just like we have a recognized and accepted model for residency that is different than medicine’s model.

    We shouldn’t be battling over semantics – we must look at the big picture and what is best for all of our profession.

    Pete


  66. Cled,
    Thank you for your comments and since you raised the issue of residency as being a criteria for the definition of BC, let me refer to my comments back to Ryan and Tom. Our model for residency is different than medicine’s yet no one questions it and it is approved by ACOE which is approved by USDOE. It is reasonable to believe that our model will be accepted by the payers – maybe not medicine, but as you say – this is about the payers!

    We can debate the merits and quality that will be drived from “value-based healthcare”. However, since we are defined as physicians in the Medicare system (but not fully included in Medicare Choice and not defined as physicians in Medicaid), it is unreasonable to believe that even if all 30,000+ optometrists and all of our efforts at the state and national association levels were directed at trying to convince the payers to allow us to have full participation in the new system, that they would accept our arguments. In fact, how disingenuine of us as a profession since we spent from 1965 to 1987 convincing Medicare to define us as physicians (not so we could be ophthalmologists, but so that we could be reimbursed the same as ophthalmologists for the same services) and have been trying to get full participation and parity in Medicaid and Medicare Choice.

    Approximately 15% of physicians are not board certified, and since we are the only profession defined as physicians within Medicare that doesn’t have BC/MOC, I would expect all non-BC/MOC physicians to not be able to fully participate which by my definition is parity of reimbursement for same services.

    I won’t hit all of your comments, but let me comment on a few more: First, this is not about trying to become ophthalmologists. In fact I would argue that none of us wanted to become ophthalmologists which is why we became optometrists. However, the progression of optometry into medical eye care was a logical expansion because of the distribution of our profession, our educational evolution and the needs of our patients.

    Second: while BC/MOC will not necessarily change scope of practices as you suggest. I do believe this can help with expansion in some states. As you may know, at least two states have recently had hearings/discussions with legislators and ophthalmology has raised the issue that optometry is “not board certified”. When I was the leg. chair in Illinois during our TPA battles, one of the arguments raised was what about the “seasoned doctors” and how can we demonstrate that they have sufficient knowledge to do no harm. Well, I am now one of those seasoned doctors, having graduated in 1984. It has been 15 years since I did my TPA course/exam and last year we did an orals course/exam. However that was not a standardized curriculum or exam. If the majority of our profession is board certified and maintaining their certification, I think it will strengthen arguments with legislators that expanding our scope in states to be closer to “modern-day optometry” as demonstrated by national credential will be valuable. Obviously just my personal opinion, but I think this has merit.

    More importantly, I personally believe this will help with license mobility between states. As you say, two states, two different scopes, same doctor. With a national credential, moving between states should become more logical and defenseable in state legislatures and state boards.

    Third: I would argue that as a profession – we should NEVER draw a line in the sand and set in granite as you suggest. Our expansion of scope and services should continue to be driven by what has caused us to evolve over the last 100+ years – the needs of our patients and our ability to deliver on their needs.

    As for opticianry expanding into independent refractions. You mention that ophthalmology and retail chains “would hire them by the bushel”. That is probably true, however ophthalmology already has technicians or optometrists doing most of their refractions. I’m not sure they would like independent refracting by opticians (or anyone else) any more than optometry. We all know that a refraction is PART of a comprehensive eye examination and like screenings, a refraction only will give a false sense of security to patients and ultimately a decline in the eye health of millions.

    I do appreciate your perspective and thank you for sharing. In closing, I will agree with you that with almost everything there are unintended consequences. However, I will close with a quote from John F. Kennedy that I believe represents today in optometry as well as the 1960’s, 1970’s, 1980’s and 1990’s in our profession: “There are risks and costs to a program of action but they are far less than the longrange risks and costs of comfortable inaction”

    Pete


  67. Tim,
    Thank you for sharing your thoughts on the postcard. I do hope you will continue to be a valuable member of the AOA and your state association.

    Let me share why that postcard, and others will be coming in the future. For well over two years, we have been trying to keep our membership updated on the reasons why the profession was considering BC/MOC and the workings of the JBCPT. We used the most widely read publication in the profession – AOA News. However, what we discovered in the last several months was that despite our best efforts, the majority of our membership has not taken the time to fully research and understand the changes in health care that are rapidly approaching (I’ll address that later) and why optometry as a profession needs to be prepared. In addition, as shared by a state president who visited his local society last week (and personally seen by our entire board at multiple state meetings) very few members have done their homework. They have either made up their mind based on other’s thoughts or posts, or are taking the easier road and just saying they don’t want to change. However, as shared by MANY state leaders and with few exceptions – after a thorough discussion of the changes in healthcare and an explanation of the proposal – the majority of the group become in favor of moving forward.

    This postcard, as well as all the other tools (video links, AOA News, this blog and even posts on other on-line communities) are an effort to encourage the entire membership to do their homework so they have a full understanding of potential outcomes of moving forward or doing nothing.

    Let me challenge you to research the latest Senate Finance Committe hearing transcripts where they discuss new incentives for MOC. They are talking about 2010 implementation, and even with approval in June 2009 we would be hard pressed to be ready in 2010. I agree that they will not exclude optometry, but I do believe this is but one example of how optometry will lose the parity that we have fought so hard for beginning in 1965, finally achieved in 1987 and defended almost daily in Washington, DC on your and all of our behalf (another reason to remain a member and encourage non-members to start paying their fair share for our efforts). We all know that Medicare leads changes in health care and private payers will follow the lead – if we can’t maintain parity in Medicare, it could be hundreds of millions in lost reimbursements for our profession.

    I was in Washington, DC about a month ago and spent time with a group of senate republicans and house democrats. Both sides were 100% in agreement that President Obama will be able to achieve significant changes in healthcare in 2009! We can not wait for the train to leave the station and try to catch it, we are already behind the 85% of physicians that are board certified and can demonstrate MOC. That is an easy default for payers, and unfortunately we don’t currently have that opportunity.

    Thanks for sharing your thoughts and I agree we don’t want to react out of fear, but this process has been discussed for over a decade and I don’t believe that another year of discussion will get the nay-sayers to agree on a specific model. If you put 100 optometrists in a room, do any of us believe that we could get them all to agree on a specific piece of equipment to buy? Maybe a bad analogy. However, I think that if those same 100 optometrists were already losing 20% of their reimbursements, or were about to, they could come to an agreement pretty quickly. With our annual House of Delegates, we don’t have as much flexibility in timing as we would all prefer.

    Please stay positive and keep the entire profession in mind in this process. The AOA has been communicating with state leaders throughout the country for over two years and very extensively since January on this topic. Many of the changes in the model since first announced in January are directly related to the comments and suggestions from the membership. I believe that state leaders will make suggested changes to the current model at the AOA HOD based onthe feedback they’ve had from their members and we must all remember that the make up of the American Board of Optometry will include at least two appointees from the AOA and they will be the voice of our members.

    Thanks for engaging in the process!
    Pete
    The Future of Optometry is in OUR Hands…..GRAB HOLD!


  68. Dear Pete,

    Thank you for the courtesy of a reply and addressing many of my comments. However, I respectfully disagree with the need to change an entire profession for the sake of conformity to a medical model we’ve never embraced as a profession.

    “Board Certfication” simply means something different in medicine than it does for Optometry… regardless if they “accept” our proposal for board certification or not. We don’t do residencies in our formal training, and until the VA project provided the opportunity for a select few to complete a one year “residency” we couldn’t begin to comply with the medical model.

    As for expanding scope of practice, I’m hard pressed to think of any other doctorate level medical or para-medical profession that has to go through any kind of legislation to modify their scope of practice. Most, if not all, other professions have their scope of practice pretty clearly defined and seem relatively content to practice within those parameters.

    Why, then, do we continually try to expand our scope of care? You say we should “NEVER” be content with our established scope of care and should continually seek to expand our services for the needs of our patients. To what extent? LASIK? Surgery? Ocular injections? Do we (as a profession) really want/need that level of care and/or liability? I’ll grant that some aggressive personalities in our profession would probably like to duplicate Ophthalmology… but does mainstream Optometry want to be come surgical Optometrists?

    I fear the BC/MOC process is going to “throw a lot of older OD’s under the bus”. We say it is “voluntary” BC, but we all know in reality it will become “mandatory” almost immediately to participate in third party provider panels. So, in reality it will be financially mandatory.

    IF NBEO is going to design the test, my best guess is that 10-25% of older OD’s will FAIL the exam! If you haven’t taken an NBEO test recently, I suggest you try it. After 36 years of private practice I took 225 hours of TMOD courses at UH and NSU and took the NBEO TMOD exam in 2005. I missed passing it the first time by 5 points but persisted and passed it later. I studied for 18 months and spent approximately $20,000 for the two courses, travel, hotel/motel, and 14 days out of the office. Is every OD in the USA willing to spend THOUSANDS OF DOLLARS for board certification that does nothing to change HOW they practice?

    I don’t mind the concept of proving maintenance of COMPETENCE, but that is a completely different subject than maintenance of CERTIFICATION. I, too, am annoyed at ODs sleeping in CE courses, or reading newspapers/magazines/books… or texting or playing solitaire on a cell phone (all of which I witnessed at the NMOA State Convention in Albuquerque last month)… not only there but at SWCO in Dallas and TOA in Austin. Not only is it RUDE to the speakers, but it demonstrates complete contempt for the CE process as part of state licensure. I’d heartily endorse a testing of CE courses for credit. Pay attention or don’t get credit. However, I suspect non-attention occurs in most, if not all, professional CE courses… regardless of profession (unless testing is required).

    Well, I won’t attempt to sway you from your reasons and progressive position regarding BC. Those who are for it have their reasons, and those who are against it have theirs. Neither is likely to sway the other very much. The unfortunate part is that the minority who are “pro” are dogmatic and in a position to virtually “force” those who are “against” to comply if BC is passed at the HOD later this month. Because, if passed, the “voluntary BC” will be “mandatory BC” in practicality.

    Thank you again for providing a forum to discuss these matters. We can agree to disagree and still be professional colleagues. I suspect only a very small percentage of ODs will read either of our positions.

    Respectfully,
    Cled Click, O.D.


  69. Pete, Cled makes some very valid points, the MOST concern is for older ODs like myself. It is totally unfair to change rules in the middle of the game! If you and yours really believe we will be left out in the cold if we do not have BC, then that is fine. Anyone who is currently in practice should be grandfathered in automatically for the first 10 years. Grandfather clauses are very common when rules are changed in the middle of the game.


  70. I am in agreement with Cled and Joseph, and for the record, this is the same argument I made to Dori Carlson in May 2008, to Randy Brooks, David Cockrell, and Pete Kehoe earlier this year.

    Even ophthalmology has a grandfather clause! I am pro-MOC, but I am not pro-throwing older ODs under the bus. VSP threw them under the bus 10 years ago; let’s not do the same.


  71. Cled,
    Thanks again for your thoughts. I would like to address a couple of points. Wouldn’t you agree that nursing has also significantly evolved into nurse practitioners and physician assistants. And dis you know that psychologists are actually trying to gain authority to prescribe medications? The scope for dentistry is prettty similar throuthout all 50 states and medicine is the only “unrestricted” healthcare profession. Podiatry and chiropracty are different in many states.

    Prior to 1965 as a profession we chose NOT to participate in Medicare. Shortly after the launch the profession realized we made a mistake and it took us 25 years to gain physician status in the Medicare system. I would argue that we are part of the medical model – not all of us practice in that model but we have the opportunity and if BC passes, then those who want to do BC would have that opportunity.

    As for expansion of scope. I hope my memory is correct, but when Oklahoma passed their laser bill, ophthalmology was in 3 counties in Oklahoma and optometry was in all counties. The reason to expand the scope was to deliver care to the patients in an efficient and effective manner from well-trained optometrists. It made sense. Access to quality care will continue to expand our profession, because it will benefit our patients. Who knows where we will be in the future, but to say today that there should be an “end” just doesn’t make sense. A profession mandates a “lifetime of learning” and as things change, so should our profession.

    No one likes to take a test. However, I just had a 4th year student tell me that the patient management section of the NBEO was extremely fair and reasonable. He was sharing this story with me and a few “seasoned optometrists”. The other doctors said: “that is what you did – heck I can do that”! The exam will NOT be like the Part 1 and 2 of years gone by. This will be very patient centered and it is anticipated that the pass rate will be equal or similar to the part 3 of the current NBEO’s. 94% on the first attempt!

    I wish more would see our string of discussion as well. Hopefully you’ll send your colleagues this way so we can share our thoughts. I will close with a comment that the “majority” of doctors that attend meetings typically become at least “OK” with the concept. Not thrilled, but certainly more understanding. I now fully believe that of the doctors that have had an open mind and done their research – the majority of them are ready to move our profession into the next phase of our development and are accepting of board certification for optometry.

    Thanks again for participating in the discussion.
    Pete


  72. Joseph,
    Please remember that this will be voluntary and NOT tied to licensure. However, if you want to fully participate in the new healthcare system, it won’t be up to us to allow grandfathering – and I don’t think the payers would agree with grandfathering.

    Vision Plans didn’t immediately require TPA once the majority of our profession became TPA certified. However, they ultimately did require TPA’s. They didn’t allow grandfathering.

    I will share a story of my senior doctor in my practice however because I think it is relevant to BC as well. Larry came out of retirement at 67 to cover for me when I ran for the AOA board. He was not TPA certified and I encouraged him to do it so he could really cover for me. He did take the 120 hour course and passed the test. He has shared with many of his contemporaries that “he was a better doctor after the TPA course than ever in his career whether he ever wrote an Rx and he wished he had done it earlier.”

    While no one really wants to do more and take a test, we’ll all be better doctors and patients will be better served if we do go through the process. Not the main reason to move the profession forward, but a reasonable outcome none the less.

    Thanks for your comments,
    Pete


  73. Brent,
    Ophthalmology doesn’t have a grandfather clause anymore. And, while they were the first specialty to be board certified, they were one of the last to eliminate grandfathering and one of the last to require maintenance of certification. Those who were grandfathered, never had to take a test ever again – and that wouldn’t meet the requirments of the payers now.

    We don’t want to throw anyone under the bus, and the changes that have been made made the process more attainable for experienced doctors, yet maintaining the credibility.

    Please see my comments to Joseph about my senior doctor in our practice. He is a cheerleader that ALL doctors need to step up and continue their expansion of knowledge regardless the stage of their career – because it is all about the patient!

    Thanks for your continued comments,
    Pete


  74. Pete,

    You used the phrase “moving forward or doing nothing.” That attitude is what bothers me the most about this whole issue. Those optometrists who feel the current BC proposal is flawed are labeled as “wanting to do nothing”/head-in-the-sand fools.

    I am not aware of any significant number of OD’s “wanting to do nothing.” Absolutely MOC is needed and some reforms should occur. But the current BC model (yes, I have kept up with all the AOA info) is still very flawed. So please refrain from the “moving forward or doing nothing” line………it is misleading and, in fact, insulting. I appreciate your incredible time, effort and passion in this endeavor but I am growing weary of the hyperbole going on (admittedly by both sides) with this issue.

    Tim Anderson


  75. Pete,

    For clarity, may I suggest we consider modifying the acronyms to be more clear in the current discussion of board certification (BC), maintenance of certification (MOC) and maintenance of competence… also referred to as (MOC)

    As much as I deplore acronyms (one of my classmates in the TMOD course at UH coined a classic term about acronyms when he said he was developing “acronymblyopia”)… I believe we could use a better way to distinguish between “maintenance of certification” and “maintenance of competence” because they are both being referred to as MOC in all the articles, which is confusing.

    May I suggest using MOCe for “Maintenance of Certification” and MOCo for “Maintenance of Competence” when writing about them?

    Thank you for your involvement in the ongoing debate/discussion that is probably going to fundamentally and permanently change our profession regardless of the outcome.

    Respectfully,
    Cled Click, O.D.


  76. Pete, I enjoy the civil dialogue. Do you and your like minded really believe that at midnight on a specific as of yet undetermined date, that medicare and all other 3rd party payers will exclude optometry because we are not Board Certified?? Overnight 27,000 ( I think this is aprox. number ) eye care providers will be put out to pasture?? Come on now! This is unrealistic. The CE I must take now, 30 hours total with 6 tests every 2 years is more than adequate to keep me updated.


  77. Tim,
    Actually there have been a lot of people in our profession who have argued that we don’t need to do anything, just explain to the payers that Optometry is different and that we should be included. They don’t even want to do the MOC, which is what the payers are really wanting in the long run.

    Please make sure that your state leaders know your thoughts on how to make the BC model better. There will likely be many amendments suggested at the AOA House of Delegates on how to make the model better. However, in the end, do you or I believe that we can create a model that everyone would be happy with? Let’s make it the best it can be at this point in time for our profession so we can get on with the MOC.

    Thanks for continuing to share your thoughts.
    Pete


  78. Cled,
    Thanks for your suggestion and I agree that they get confusing and even the payers use them sometimes interchangeably.

    I agree with you 100% that this topic and the discussion will fundamentally change our profession either way – much like deciding not to participate in the initial Medicare system (and taking 25 years to gain physician stautus) and at one point in the House of Delegates proclaiming that we should remain a drugless profession and then years later the visionaires pushed us in to DPA’ and then TPA’s (there go those acronyms again). This is an historical time in our profession – aren’t we lucky to be part of the discussions?!

    Pete
    The future of optometry is in our hands…..GRAB HOLD!


  79. Joseph,
    I have NEVER said that we will be excluded. I absolutely believe that at some point in time (2010 has already been mentioned for PQRI related to MOC) the 15% of physicians who are not board certified and optometry as a whole could see a sigificant fee reduction becasue we can not demonstrate maintenance of certification.

    Unfortunately, the 30 hours of CE including 12 hours that is tested that I take every two years is not standardized across the country and therefore the payers have no way of knowing that I have the knowledge of how to practice optometry in 2009 in an evidence-based manner. The payers are looking for ways to discriminate in payments and maintenance of certification is one that is intimately linked to value-based healthcare as is evidence-based medicine.

    We are defined as physicians by Medicare. We are the only profession defined as physicians that can’t demonstrate maintenance of certification and that will ultimately cost us all in our offices if we don’t get this right.

    Thanks for your comments,
    Pete


  80. My competance is maintained in the state of Florida by attending 30 hours of continuing education and passing 6 hours of Transcription Quality testing every 2 years.

    THIS maintains my competance continually!!

    In the state of Florida, these requirements allow my patients to see “plastered on my front door” and on all of the literature, letterheads, business cards, etc… that I am Board Certified according to the Florida Board of Optometry. This assures my patients that I am continually educating myself and giving them the best care possible.

    Why do we need more than this other than to muddy the waters? Why don’t we just standardize the amount and quality of ongoing CE credits that are currently ongoing across the country instead of creating an entire new convoluted unnecessary system? We ALL get enough education currently to maintain our competance!!!!


  81. Just read Dr. Newman’s article 6/12 responding to Dr. Legerton’s excellent editorial. The just of Dr. Newman’s response is that Ophthalmology will try and shut us down due to lack of BC. ANYTHING SHORT OF A M.D. DEGREE WILL NOT BE GOOD ENOUGH FOR OPHTHALMOLOGY !!! ALSO IN FLORIDA WE ARE ALREADY ( THOSE OF US WHO ARE THERAPEUTIC LICENSED )BY WAY OF THE STATE BOARD OF THE GREAT STATE OF FLORIDA, BOARD CERTIFIED — IT STATES AS SUCH ON OUR LICENSES!!!!!!!!!!!!!


  82. There is one positive consequence if BC passes the the House of Delegates: All of the dues money that will NOT be sent to the AOA, from the resulting mass membership exodus, will end up stimulating the economy!

    Bob Gradisek


  83. Pete,

    There is one elephant in the room that you have not addressed. We are regulated by our state boards of optometry. We do not know if this form of BC would even be recognized by each state board…….in fact, here in North Carolina, I would suspect not. How can we have Board Certification nationally when we have differing therapeutic laws by state??? That makes no sense.

    But the greatest concern I have is that we are now contradicting what we have been saying in the state legislatures for years: that we are thoroughly well-trained and COMPETENT (and maintain competency) in the diagnosis and management of ocular disease. Now we are admitting that “we really could be doing better.” Not the correct message to be sending to ophthalmology and state legislatures.

    Tim Anderson, O.D.


  84. I feel that board certification is a process used for medical subspecialties. Optometry is a limited license and primary care profession! Attempting to apply board certification is specious if not superfluous. This also further imply that the mechanisms set up to date to monitor competency are inadequate or faulty?! What about those small %age of optometrists who are practising in our later years and are interested in general optometry and the optical aspects…will this changes invalidate our ability to practise Optometry as a unique profession unto it’s own rather than as a facsimile of some form of junior ophthalmology ( which is what optometry is evolving into !)

    Respectfully,
    K.Lim


  85. the following is pasted directly from the AOA web site In addition to their formal, doctoral-level training, all optometrists participate in ongoing continuing education courses to stay current on the latest standards of care and to maintain their licenses to practice. Optometry is one of the only doctoral-level health care professions to require continuing education in every state for license renewal. CAN SOMEONE PLEASE EXPLAIN WHAT THE HECK IS GOING ON HERE?? Also the following is from the AOA web page
    All optometrists are required to participate in ongoing continuing education courses to stay current on the latest standards of care. AND it continues

    Curriculums and continuing education are updated on an ongoing basis to reflect technological advances, including surgery techniques, prescriptive medications and other medical treatments related to eye diseases and disorders


  86. I for one as an optometry student don’t want to be in a position (a few years down the road) to be scrambling to create a board certification if this effort is in vain. Optometry is the “red-haired freckled step child” among independent doctorate level prescribers because we have 4 different levels of licensure, too much variation in scope of practice laws from state to state, more insurance problems than we need, and we have an established medical competitor—> ophthalmology. SO WHY IN THE NAME OF GOD would OD’s out there not desire a board certification like EVERYBODY ELSE? It is only a matter of time before insurers (especially medicare and medicaid) desiring of lowering costs start excluding non-board certified doctors (hmmmmm OD’s). In South Carolina during a hearing to pass a scope of practice bill, medicine countered by saying optometry was inferior because it had no board certification. Board certification will not make one doctor better than the other (there is no evidence of that) rather it is a necessary evil we must all support to keep optometry “in the game.” Please wake up everybody.


  87. Paul,
    Sorry I didn’t get back with you sooner. I was traveling and then had some computer issues. As was discussed last Friday in the AOA House of Delegates, the payers want us to have a standardized maintenance of certification program, not 50 states trying to demonstrate competence 50 different ways.

    I practice in Illinois and also have the same 12 hours of tested CE every two years. Unfortunately, the payers don’t consider that demonstration of maintenance of certification/competence when it is compared to a board certification/maintenance of certification program.

    Please watch for more details coming in the next few weeks about the final model that the AOA House of Delegates approved last week. The discussion was lively, open and very productive for the profession. History was made last week, similar to times like Medicare Physician status, DPA’s and TPA’s.

    Thanks for continuing to watch my blog and we’ll continue to discuss issues of importance to the profession.

    Pete


  88. Joseph,
    See my response to Paul – unfortunately tested CE and the Florida designation as board certified is not what the value-based healthcare payers are looking for.

    This process will not be as overwhelming as some have suggested. Any practicing optometrist that has kept up with changes in our profession and does some review will pass the exam and then the maintenance of certification program will help us all be better doctors.

    Stay tuned for more as this develops.
    Pete


  89. Bob,
    I hope you are incorrect. There was not a mas membership exodus when Rhode Island pushed for drug authority when the AOA House of Delegates voted 49 to 1 against the profession using seeking drug authority.

    We need all optometrists to be members since Health Care reform is MUCH BIGGER than just optometric board certification. We need everyone’s help and resources if optometry wants to be fully included in the changes ahead. I was so proud of the 503 optometrists and students that went to Capitol Hill and visited 535 legislative offices last Wednesday. They were delivering the message that optometrist provide great care to our patients and our patients need access in the new healthcare system being developed and optometry needs no discrimination of reimbursement or scope of practice to provide the best care.

    Now is the time for ALL optometrists to join/remain a member so their voice can be heard and our collective voice can be heard in our state capitols and our nation’s capitol.

    Optometrically yours,
    Pete


  90. Tim,
    Board certification in NO WAY is tied to licensure or the state boards. It is a completely voluntary process for all medical disciplines. Some state laws don’t allow you to call yourself board certified, althouh most of them have an exemption for COVD fellows, so we assume a doctor that has completed the national standarized exam would be allowed to claim that they are board certified.

    We are not contradicting anything that we have been saying to our legislators. We will be creating a new process that is more recognized by payers as a way to demonstrate maintenance of certification/competence. In fact, I think board certification will help us in state legislatures and in Washington, D.C. Most importantly for many of us – it will help us NOT to be discriminated against by Medicare and other payers when compared to ophthalmology.

    Please stay engaged in learning more about the process that will be evolving and continue to submit your thoughts, ideas and concerns.

    Pete


  91. Dr. Lim,
    This will be a voluntary process and until the majority of the profession embraces this, I don’t expect vision plans to require board certification, so depending on the number of years you plan to practice, you may or may not have to participate in the process.

    Our profession has certainly evolved, and I don’t want us to lose our roots in providing our patients the best vision possible. However, time has proven that our role in medical eye care certainly has benefited millions of patients.

    Thank you for your thoughts and stay tuned to AOA News for more details as the board certification program progresses throughout the months ahead.

    Pete


  92. Joseph,
    Please understand that the payers and people developing value-based healthcare do not consider CE as demonstration of maintenance of certification/competence.

    Please watch as the details unfold.

    Pete


  93. As a student – it appears you have done your homework on this issue.

    The GREAT NEWS for our profession is that the delegates on June 27th approved the AOA’s participation and formation of the American Board of Optometry. The program will be credible, defenseable and attainable for any optometrist that is willing to put in the effort. The patients will benefit, our profession will benefit and every optometrist that goes through the program will benefit.

    Thanks for being involved in your profession so early!
    Pete


  94. If laws are being proposed to base provider reimbursement on Board Certification and Maintenance of Certification then our profession should make plans to incorporate these entities. Unfortunately I do not see how we can avoid making this decision if this is the case.

    I believe that Board Certification unto itself is not a necessary process for optometry; however, to mantain parity with ophthalmology in terms of medicare and medicaid payments it may become required.

    I have read the JBCPT’s proposal for Board Certification and Maintenance of Certification. I have also seen the excerpt from the April 28, 2009 Senate Finance Committee which states “A new PQRI participation option would be added to the existing options described above. Eligible professionals could also receive PQRI incentive payments for two successive years if, on a biennial (every two year) basis, the physician (1) participates in a qualified American Board of Medical Specialties certification, known as the Maintenance of Certification or MOC, or equivalent programs, and (2) completes a qualified MOC practice assessment”
    This would mean that the JBCPT’s proposed Maintenance of Certification would not meet these requirements and would need to be changed to accommodate these requirements. The ophthalmology Maintenace of Certification also does not meet the Senate Finance Committee’s proposed requirement.

    In my opinion, BC and MOC are necessary evils.


  95. In reviewing all the blogs provided on this subject the problem that seems to be at the heart of all of this is, that we have no way to regulate/enforce and standardize the quality of CE that is already required by each State Board of Optometry. The problem is not so much certification as it is accountability. We are so broke in California that the State Board couldn’t verify the CE fulfillmant for more than 1% of all optometrists so how will this change with Board Certification?!

    Every three years, as an Air Force Reserve optometrist, I must meet credentialing requirements before seeing patients on a continued basis. In fact, when I first joined I had been in private prcatice for 20+ years and still could not see patients until I was credentialed. This credentialing process requires that I exceed the California state requirement of 50 hour every two years(105 hrs every three years)and dictates the quantity and quality of CE into three catagories. 50% must be in Category 1 which are classes that are sponsored by a recognized educational institution and be COPE certified. ( I am also required to provide a statement of good physical and mental health from three independant optometrists who know/ work with me). This process is/was easy to follow and chart when/if the ARBO card is utilized by the CE courses that we attend. The hours are classified by topic, sponsor and COPE certification and listed on the ARBO website. This format would be simple and effective to institute for every State Board and to follow for every optometrist and would provide an nationwide certification for compentancy and CE quality.

    No extra time out of our offices, no extra travel and expenses to reach the same goal of providing to “payers”, the “public” and the “government” proof that we, as a nation of Optometrists meet the highest standards of care. No need to wrestle with individual State Boards on due process, just the simple use of a verifiable sysytem that is ALREADY in place and just needs to be ramped up at little to no expense.



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