board certification

Should Optometry Pursue Board Certification?

This month, during the annual meeting of the American Optometric Association (AOA) in Washington, D.C., the AOA House of Delegates will vote on whether to accept a model for a board certification process in optometry. The model was created by the Joint Board Certification Project Team (JBCPT), made up of representatives from the AOA, American Academy of Optometry (AAO), National Board of Examiners in Optometry (NBEO), Association of Schools and Colleges of Optometry (ASCO), Association of Regulatory Boards of Optometry (ARBO) and the American Optometric Student Association (AOSA).

The JBCPT defines board certification as, "A voluntary process that establishes standards that denotes that a doctor of optometry has exceeded the requirement(s) necessary for licensure. It provides the assurance that a doctor of optometry maintains the appropriate knowledge, skills and experience needed to deliver continuing quality patient care in optometry."

What happens next?

If the AOA House of Delegates votes "yes" to the proposed model, the American Board of Optometry (ABO) would refine the model. According to the "JBCPT Questions and Answers Series" on the AOA Web site (www.aoa.org/x11017.xml), the ABO "should accept input from the profession as final details are developed prior to implementation of the plan."

If the House of Delegates votes "no," the AOA will not support board certification, although the AOA notes that another group, "either inside or outside of optometry," could move forward with a board certification process. Details on the model framework of board certification can be found at www.aoa.org/jbcpt.xml.

In this feature, we present two opposing views of board certification. These were written by David A. Cockrell, O.D., AOA and JBCPT member, and Elliot Kirstein, O.D., AOA member. As a disclaimer, the opinions expressed are those of the authors and do not reflect the opinions of Optometric Management.

BY DAVID A. COCKRELL, O.D.
Stillwater, Okla.

YES, certification is critical for participation in the healthcare system of the future.

■ OUR PROFESSION MUST NOT study the issue of board certification in a vacuum. The question is not simply, "Do we want board certification?" The second question is, "Do we have the tools to be a player in the future of healthcare delivery without board certification?" The answer to the first question is easy. "NO, we don't want board certification." The answer to the second question is more complicated.

There is little dissention regarding the need for change in healthcare delivery on the part of entities including the federal government, state governments, public advocacy groups like the Association of Retired People (AARP) and employer groups and, of course, third-party payers. Healthcare reform is a given. The question is, "How will we reform healthcare delivery in the United States?"

Reform and value-driven health care

The topics involved in reform are many, including increasing access to health care, universal insurance, quality of care, quality of providers and, certainly, development of metrics for quality of care and quality of provider. And, within this context of healthcare reform, the notion of "value-driven health care" has emerged. Newly operating government programs, such as the Physician Quality Reporting Initiative (PQRI) and pay-for-performance (P4P), are the initial pieces of the implementation of the value-driven healthcare model. This model is not new. Changes in healthcare delivery have been in the works since the mid 1990s. The difference today is that healthcare reform is now imminent. These reform initiatives make it imperative that optometry look to the future and design policies and programs that will keep us the viable, important healthcare providers we have become.

What is value-driven health care? As used by policymakers and concerned parties, it is simply a model to enhance quality of care and cost containment, or cost efficacy. It is based upon the premise that all procedures, all treatment and all providers do not necessarily provide the same quality outcomes. And a critical component in "quality of care" regarding the provider is known as "continued competence." In virtually all other healthcare professions, continued competence is measured by a process known as "maintenance of certification" (MOC). Policymakers are developing outcome measurements to determine cost containment models. Recently, the American Board of Medical Specialties (ABMS) has advocated to the Centers for Medicare & Medicaid Services (CMS) for MOC to become a reportable measure for PQRI. In April 2009, this request was granted and will be added to the PQRI measures.

The AOA response, both past and present

What is the AOA doing to prepare optometry for the value-driven healthcare model? The Association, working with other optometric organizations, believes now is the time to take the next steps to engage the profession in an effort to enable our colleagues to demonstrate continued competence throughout their careers in clinical practice in a manner consistent with all of the other healthcare professions — and in a manner recognizable to healthcare policy makers.

The AOA has been a participant in a multi-year effort (the JBCPT) to develop a program of board certification in optometry accompanied by periodic confirmation of competence through a MOC program. This is not the first time optometry has studied the certification issue. An AOA committee first studied this issue in 1968, and our profession has studied it in every decade since. The other participating groups in this project team: the AAO, AOSA, ARBO, ASCO and NBEO.

The JBCPT has spent the past 18 months reviewing both the reasons for board certification, as well as developing a model for discussion at the upcoming AOA Optometry's Meeting this month.

As we reviewed the information available on how to design a board certification model, it became apparent that there were many reasons for the "why to study the need for a board certification" process.

Why board certification?

Let's take a look at a few of the reasons why our profession needs to move forward with a board certification process.

It is clear that reform will involve improving the quality of care provided and increasing the efficiency of care delivered. One of the first programs intended to do this is the inception and implementation of the PQRI. This program has been in the planning stages for several years, with implementation begun in the past few years. We also have seen a great deal written about the concept of P4P through the past few years in the Medicare arena, as well as other third-party payer discussions. Both of these programs are certainly the beginning of the implementation phase of value-driven healthcare delivery. The newly specified requirements for E-prescribing, which occurred with passage of the recently passed Federal Stimulus plan, moves healthcare another step down this road. The stated goal of these programs: to improve quality by reducing errors, decreasing redundancies, improving outcomes of care and, of course, containing the rate of growth of total healthcare expenditures.

A new program requires board certification

During this period, we have seen the passage of the H.R. 6111 Tax Relief and the Health Care Act of 2006. This Act created a new Medicare program called the Medical Home Demonstration Project. This trial project is a three-year trial that was implemented in the spring of 2008. The goal of the Medical Home Demonstration Project is two-fold: cost containment and improved quality of care. For the first time in a Medicare program, this Act requires that a specific provider must be board certified. While we can speculate as to why this occurred, it really doesn't matter. The fact is, board certification is a requirement for a specific provider in a Medicare program for the first time since the inception of Medicare. Optometry does not have a board certification process, should it become required. Also, there is no requirement for optometry to be included in this new program.

In January 2009, we saw the release of the document, "Call To Action: Health Reform" authored by Max Baucus (D-Mont.). Baucus is the chairman of the U.S. Senate Finance Committee. Throughout this document, he makes significant references to both the Medicare Medical Home Project and to the PQRI program. He references the fact that if the Medical Home trial is successful in controlling cost and improving quality, it should be expanded to include private payers and Medicaid.

The public advocacy group AARP is on record as saying "…a new regulatory model is needed. A new regulatory model must go beyond imposing mandatory continuing education (CE) to require some form of the five-step model that includes periodic assessment of knowledge, skills, and clinical performance; development, execution, and documentation of an improvement plan based on the assessment and periodic demonstration of current competence."

The Colorado standard

Colorado's Department of Regulatory Agencies (DORA) recently announced a plan to develop a continued competency program. The only licensed group to which this program does not apply is allopathic medicine. In its announcement, DORA states, "Any system must take into account existing professional development programs administered by voluntary credentialing and specialty boards or by hospitals or other employers, when the private programs meet Board-established standards."

The message is clear and consistent. The assumption of policymakers is that a more highly qualified provider will also provide higher quality care (better outcomes) as well as more cost-effective care; and, this theory is being tested today with the push for continued competency. The method endorsed by the ABMS is MOC. One recommendation during a forum held March 17, 2009 is that MOC be used as a method for increasing physician accountability; that MOC be included in healthcare reform legislation as a way for patients, health insurers and policymakers to know that providers are delivering effective, quality care. One suggestion for including MOC in healthcare reform would be to count it as a PQRI measure. And by the way, we now know that PQRI measurements affect reimbursements.

We can't wait until we are excluded

Some demand that the profession delay developing a board certification process at this time and continue to seek more input as to the need for a board certification/maintenance of certification/continued competence mechanism for optometry. I believe we have ample evidence to suggest that it is the intention of policymakers to insist upon and require the establishment of measures to improve quality. And this is not a future plan; these plans are being developed today. I urge that we do not delay our decision-making process. The opposite of action now is to wait and see whether we are excluded from a program because we do not have a way to prove continued competence and then try to "fix" it after the fact. I point out the fact that optometry was left out the last time the United States experienced a major healthcare reform. That was the inception of Medicare. We were excluded for 21 years.

This is the environment in which optometry finds itself. The healthcare world is looking for measurements of transparency and quality that translate to professional accountability in healthcare providers. Virtually all independent, prescribing, doctoral-level providers can demonstrate continued competence should they voluntarily choose to do so, through a widely accepted process known as "board certification;" with a notable exception. Us.

Addressing the opposition

Opposition to this process has raised several objections that I will address very briefly. One objection is the term "board certification." We have been asked to call it something else. We have been down that path, attempting to be different. This is not the time to set ourselves apart from the other healthcare professions; this is a time to be included. Optometry did not invent the term "board certification." It is the standard terminology used to describe clinical competence beyond that which is required for initial licensure. We also did not invent the MOC terminology. MOC is becoming the standard mechanism to demonstrate "continued competence" or "physician accountability."

There are voices within our profession who recommend that any continued competency process for optometry be tied to licensure. We would be the only healthcare profession to do that. I cannot imagine why we would wish to trade a voluntary process for a mandatory process tied to licensure or re-licensure. I cannot imagine advocating for a process that threatens the very license of optometrists while still falling short of the standardized methods already established by other professions. It neither helps the public nor improves the quality of our process by making our process different than every other healthcare profession.

Some suggest that our process will not be credible because all O.D.s have not completed mandatory residency programs. We are by no means the only profession to begin a board certification process in this manner. I believe that each of the board certification processes began without required residency training. All five of the last five specialty boards to develop a board certification process began without residency programs developed and in place. They then worked to develop residency requirements for future practitioners. Why would we choose to make optometry different than the others by requiring residency completion a requirement at the time of the inception of board certification?

Opportunity to participate

We did not develop the demand for continued competence or quality measures, and certainly not healthcare reform.

But they are developing rapidly from many positions, including federal and state government initiatives, as well as third-party payers and, most importantly, the public. Fortunately, we are participants in this process as a viable, stand-alone profession. We have the opportunity to choose how we want to participate. Do we want the opportunity to develop our own process, or do we wait and see what is developed for us?

A call for support

I believe that the JBCPT did develop a process that achieves our mission statement adopted in our first meeting January 2007: "Develop and propose an attainable, credible and defensible model for Board Certification in Optometry and maintenance of certification for adoption by the profession. This model will establish standards for voluntary board certification and maintenance of certification in the practice of optometry. This model will communicate information about these standards to support the public's quest for high quality health care." OM

ELLIOT M. KIRSTEIN, O.D., F.A.A.O.
Cincinnati, Ohio

NO, at this time, certification is a poor way to fight a battle we do not yet understand.

■ LIKE MANY THINGS IN LIFE, the notion of optometric board certification has gray and unclear margins. While it is clear that optometrists need to continually strive for greater self-empowerment and a more secure role in our healthcare delivery system, I am concerned that, while Optometric Board Certification is eventually going to be part of our futures, it is an inappropriate priority for optometry at this time. It is a good battle, but not the right battle.

Since the time of my training at The Massachusetts College of Optometry (now the New England College of Optometry) in the early 1970s, I have seen the amazing empowerment of optometry. This started with Rhode Islands' diagnostic pharmaceutical legislation, the inclusion of optometry in the Veterans Health Administration system, Medicare parity and the therapeutic legislation which occurred in all 50 states. Proudly looking back on this long journey, one cannot resist the temptation to ask what our next step should be.

The road to reform

Because our current political environment is focused on bringing reform to our healthcare delivery system, we must not allow ourselves to get caught in the middle of the road, staring at the oncoming headlights. We must think on our feet and arm ourselves with the best possible tools to compete and thrive in this quickly changing environment.

Ironically, we are being forced to make these decisions without reliable and complete knowledge of what challenges might lie ahead. To prepare for this ill-defined adversary, it will be best to gain strength as individuals and as a profession. The strength that I am talking about is defined in terms of our educational backgrounds, clinical aptitude, continuing education, state legislation and our day-to-day performance in our local healthcare communities. So, is the effort required to achieve board certification really going to give us enough bang for our energy buck? Is it wise to spend this energy at a time when we must be very careful about how we squander our finite resources? Is it our right priority?

Remembering the past

The sense of urgency touted by proponents of certification seems reminiscent of the 1990s when physicians were warned that they must all join large groups, measure "outcomes" and meet the standards of the new age of "managed care." We were warned that private practices would disappear. "If you're alone," they said, "you'll be out." What happened to all of those "outcomes?"

What happened was that many of us reacted in fear and responded poorly to a mindless ill-defined trend. We did not apply common sense. Objectively speaking, we are only speculating about upcoming healthcare changes, and it seems that many feel some misguided comfort in going after certification as the single most reasonable means to confront these changes. Board certification is a poor way to fight a battle that we do not have the necessary information to understand. Just "doing something" in the face of an un-defined challenge is a weak and squanderous tactic.

We have other opportunities

I argue that before we take on certification as a priority, common sense dictates that we need to do some mandatory housekeeping. This is housekeeping that, irrefutably, will empower us so that we can meet the upcoming needs of our profession and, most importantly, our patients.

1. Let's make optometric residency our standard. As O.D.s have enjoyed a stellar growth in privileges through the past 35 years, we have not made enough changes to our standard educational curriculum. Our four-year programs are busting at the seams. There is not enough time to properly address the expanding body of knowledge that students must assimilate. This will be hard work, yet I believe that it is necessary to make these changes so that our graduates will have the right ammunition for the fight ahead.

2. We must take better care of our neonates. Approximately 70% of optometry graduates directly enter commercial optometric settings after graduation. I am not stating this as a criticism. I respect their economic realities, but what tools do we give them to develop academically and professionally beyond that point? My observation is that we abandon them at a time that is critical in their growth as optometric professionals. These bright young people need better post graduate educational opportunities and mentoring that will help them to fortuitously expand on their four-year educational foundation. Our schools, professional organizations and our local professional communities must provide this help.

3. Let's make optometric licenses portable. This is 2009. Working couples seem to be the standard. Spouses get transferred, people choose to live elsewhere. The days of moving back home, opening an office and settling down died with Norman Rockwell. Fixing this old mess will require work. It may not appear as sexy as board certification plaques on our walls, but it will give O.D.s the needed security that they can move with their spouse, be near their grandchildren or just seek a better opportunity. Any worthy businessperson who understands the benefits of the free market system would laugh at our current archaic laws. Think about how ironic it would be if a "board certified" O.D. couldn't work after moving to another state with his or her spouse.

4. Let's fix our state laws so that optometry can be practiced at a consistently high level in all fifty states. I continue to be disappointed that states, such as Massachusetts, have highly restrictive optometric glaucoma laws. Righting this wrong will require an increased commitment from O.D.s in those states. Through the years, I have heard countless stories and excuses about how powerful organized ophthalmology resides in those states. I cannot resist thinking that optometry is weak in those states. I prefer to reflect on the lesson given to us by Gloria Steinem: "Power can be taken, but not given." If Massachusetts legislation is going to be changed, it will happen because of impassioned and committed Massachusetts O.D.s This is a right battle, and it is time that we fight it the right way.

A reasonable goal…in the long-term

Though I am against board certification at this time, I do not consider it an unreasonable long-term goal. I specialize in treating glaucoma, and I admit that I like the idea of being able to call myself a board certified glaucoma specialist. My understanding is that, as written, the plan for certification would not allow me to do this. Indeed, it seems that most of the possible merits cited by proponents of certification are illusive and just not supported by facts.

Optometry has some hard work to do before making certification a priority. The work will be less glamorous but will yield real and meaningful rewards. Most of us have learned that doing the right thing is not necessarily the easiest thing. Engaging in the issues I've outlined above will be difficult and require that hands get dirty. But, these efforts will give us the tools to tackle our upcoming challenges.

Fix real problems

Let's not get swept away with the illusion that certification will fix our real problems. Certification now is a mere short cut that would prove to be an unfortunate, naive and foolish example of putting the cart before the horse. OM