[The following is a guest post.]
Last week a bill (SB 110) was passed by the Kentucky House and Senate dramatically expanding the scope of practice of optometry in our state to include certain surgical procedures. Since 1997 there have been 46 attempts in 21 states by optometry organizations to legislate surgery privileges. All but one of these attempts was blocked. Optometry has been largely unsuccessful in these endeavors because it is not in the public’s interest. What’s wrong with this bill and why did it pass in Kentucky?
The United States system of medical education is the world’s best and is based on a system of training that hinges on a foundation of common conceptual and technical skills that are necessary for the practice of all specialties. It was a great optometric coup to convince legislators that these skills could be instilled without the rigors of medical school. What the lay public and legislators failed to comprehend was that exposure to family medicine, cardiology, neurology, general surgery, and other specialties in the standard medical school curriculum is necessary for learning the art and science of diagnosis and the basics of patient management. Specialty training, such as ophthalmology, is undertaken only after this foundation is developed.
It takes at least 8 years beyond undergraduate training to become an ophthalmologist: 4 years of medical school, an internship, and a 3 year residency. Ophthalmology, like other medical specialties such as cardiology, gastroenterology, internal medicine, etc., is overseen by a board through which certification is obtained. The American Board of Ophthalmology requires, in addition to the aforementioned schooling, serving as primary surgeon or first assistant to the primary surgeon on a minimum of 364 eye surgeries and performing well on the state licensing examinations, both written and oral. Some ophthalmologists complete additional training beyond residency in one or two year fellowships devoted to “subspecialties” such as cornea, glaucoma, and retina. As such, subspecialization involves 9-10 years beyond undergraduate school. All post-MD medical training programs within the United States, including ophthalmology residency programs must maintain accreditation through the Accreditation Council for Graduate Medical Education. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines. Ophthalmology residency programs include both supervised medical and surgical experience. This must include adequate exposure to the various ophthalmic subspecialties and include experience where the resident assumes primary responsibility for patient care.
Optometry differs on several accounts. The practice of optometry commonly includes examining the eye for vision prescription and corrective lenses and examining, diagnosing, treating, and managing disorders of the eye and visual system but optometrists’ education does not include medical school. After undergraduate education, optometrists must complete 4 years of an accredited optometry college, after which they are awarded the Doctor of Optometry degree. Some optometrists also undertake an optional 1-year residency program to enhance their experience in a particular area. The process takes 4-5 years beyond undergraduate school. Optometry students, in contrast to ophthalmology residents, care for relatively healthy patients, have no hands-on surgical experience, and lack fundamental knowledge and exposure to the care and treatment of more serious eye conditions. Furthermore, they do not receive training and clinical experience, comparable to that of ophthalmology residents, to diagnose and manage non-ophthalmic medical conditions, some of which may be relevant to the patients’ ophthalmic care. For many optometrists, their only exposure to patients with serious eye disorders such as advanced macular degeneration, diabetic retinopathy, and retinal detachment is during externships at optometric-friendly ophthalmology practices. In these externships, they are primarily observers without significant patient care responsibility. Furthermore, there is no significant oversight or accreditation of these programs. This is in stark contrast to the typical ophthalmology resident’s clinical experience.
Optometrists are licensed by their states to provide primary vision care and nonsurgical management of certain eye diseases and must pass the licensing exam of the National Board of Examiners in Optometry. In some states, optometrists have unsuccessfully attempted to expand their scope of practice to include the performance of laser and nonlaser eye surgery but, to date; Oklahoma has been the only state to authorize this. As is presently the case in Oklahoma, a worrisome provision of SB 110 is the creation of an independent optometric board; no other board or state agency would have the authority to question what constitutes the practice of optometry. The optometric board could expand optometric scope of practice as it solely determines, without any legislative or regulatory oversight.
Considering the difference in training why would anyone want to have their surgery performed by an optometrist instead of an ophthalmologist? Would our legislators, the governor, or you choose an optometrist as their surgeon, when there is no shortage of well-trained ophthalmologists?
Optometrists argue that in many rural areas of Kentucky patients have immediate access to optometrists but not to ophthalmologists. An expanded scope of optometric practice would help to fill the void. In reality, virtually everyone in Kentucky lives within an hour or so to a qualified ophthalmologist. The same arguments were used to pass legislation in Oklahoma where in reality optometrists that perform laser procedures are concentrated almost entirely in metropolitan population centers. It’s not about patient access it’s about money.
There are hundreds of optometrists in the state of Kentucky. They are well organized and politically active. As was printed last week in the Courrier Journal last week:
Kentucky optometrists and their political action committee have
Given campaign money to 137 of the 138 members of the state legislature and Gov. Steve Beshear, contributing more than $400,000 as they push for a bill to expand their practices. Members of the Kentucky Optometric Association and its PAC have given at least $327,650 to legislative candidates in the last two years alone and have hired 18 lobbyists to help them make their case. They also gave a total of at least $74,000 more to Beshear’s re-election campaign, the Republican gubernatorial campaign of Senate President David Williams and the House and Senate political caucuses. A review of records filed with the Kentucky Registry of Election Finance shows that the PAC or its members made the contributions to the lawmakers either in their most recent election campaign or the one that will take place next year.
They spent years lining the pockets of legislators and made certain that the bill would be introduced and ramrodded through both house bypassing the Health and Welfare committees in the two chambers without time for debate or for the medical community to react. In essence it was a legislative ambush.
Optometry has also been able to enlist the help of some ophthalmologists and stifle the voices of other ophthalmologists that oppose their goal of expanded scope of practice. Government-sanctioned optometric-ophthalmic comanagement permits the splitting of the fee for performing cataract surgery. Ophthalmologists retain 80 percent of the government approved fee, and optometrists receive 20 percent. The result is that whenever the optometrist refers a patient for cataract surgery, the optometrist receives the equivalent of a kickback from the ophthalmologist for postoperative management. Government has rationalized this arrangement on the grounds that optometrists are qualified to provide postoperative care and merit 20 percent of the surgeon’s fee for doing so. However, the reality is quite different. Optometrists are paid 20 percent of the surgeon’s fee for referring a
Patient to a relatively small group of ophthalmologists willing to participate in the kickback scheme. This represents a generous government-provided stipend to optometrists for making a telephone call and prescribing a pair of glasses. Not all optometrists expect such a kickback, but many do participate very willingly in this arrangement (RP Gervais. Journal of American Physicians and Surgeons Volume 11 Number 4 Winter 2006). This came about because optometrists with the help of a few business-savy ophthalmologists convinced legislators that optometrists could be trained in ophthalmology practices to provide appropriate postoperative care. What legislators did not consider is that this training was intended to attract referrals to ophthalmologists willing to fee-split. Participating ophthalmologists benefit from higher surgical volumes and perceived status as superior surgeons. Talented and ethical surgeons who don’t participate in the kickback scheme do not receive referrals. There is also a strong incentive to overlook misdiagnosis and perform surgery, even if it is premature. Ophthalmologists that contradict referring optometrists and cancel surgery, deprive them of their 20 percent kickback fee, may soon find that patients are being sent to a less ethical ophthalmologist so as to ensure the optometrist’s revenue stream. Also, patients are routinely sent great distances, bypassing local ophthalmologists, so that they can see fee-splitting ophthalmologists. So much for access of care.
The control of optometry even extends to ophthalmology political action committee contributions (PAC). Their refusal to refer patients to ophthalmologists that contribute further strengthens their position. Ironically, money from comanagement probably supports the optometric PAC. No wonder the ophthalmological community has been relatively quiet during this legislative battle.
Hopefully, Governor Beshear, will have the fortitude to veto this bill and protect the public. We have the world’s greatest medical system. Those who desire to practice medicine should be trained in this system that has stood the test of time. The training and experience to practice medicine cannot be legislated, bought, or obtained in a brief weekend course.
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