Friday, February 25, 2011
Tuesday, February 22, 2011
[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.
Monday, February 21, 2011
The Left has labeled the legislation as an assault upon the working class. The term "working class" properly includes anyone that works, people such as doctors and lawyers and hedge fund managers, but for the sake of argument we will go with the Left's twisted definition of the term which means only folks who work for someone else for moderate to low wages.
Most of the working class in this country does not work for the government, although they do pay the taxes that pay the salaries of government workers. The non-government working class should consider the protests against the proposed Wisconsin legislation as an assault upon THEM. Unusually favorable benefits for union government workers is an assault upon working class taxpayers.
Part of the proposed legislation in Wisconsin is to require that state workers increase their contributions for health insurance premiums to 12.6%, which is still far below the amount most non-governmental working class people pay. 12.6%! Wow. let us play our fiddles for these poor, beleaguered people. The non-governmental working class should be angry!
There is an assault upon the working class going on in Wisconsin. The non-governmental working class should be thankful there is.
Saturday, February 19, 2011
Friday, February 18, 2011
Tuesday, February 15, 2011
Monday, February 14, 2011
“The President's budget is the clearest sign yet he simply does not take our fiscal problems seriously,” McConnell said. “It is a patronizing plan that says to the American people that their concerns are not his concerns. It’s a plan that says fulfilling the President’s vision of a future of trains and windmills is more important than a balanced checkbook.”
“The President’s budget comes in at close to a thousand pages. The people who voted for a new direction in November have a five-word response: We don’t have the money. We don’t have the money.”
. . .
“The White House wants us to engage in a debate this week about percentage cuts at this or that agency, about multi-year projections and CBO scores. It all misses the point. The real point is this: We're broke. We don't have the money.”
“This budget was an opportunity for the President to lead. He punted,” McConnell said. “It only pretends to do the things people want. And the reaction we’ve seen from across the political spectrum so far today suggests that nobody’s buying it.”
“This is a status quo budget at a time when serious action is needed. This is business as usual at a time when bold, creative solutions are needed. This is not an I-got-the-message budget. It’s unserious, and it’s irresponsible. We need to look for ways to preserve what’s good that does not put us on path to bankruptcy. That was the challenge of this budget. The administration failed the test.”
Sunday, February 13, 2011
So what I’m going to tell you next you may not want to hear, but it’s true. The House Republican proposal will freeze this much of the budget at 2008 levels and will add $3 trillion to the debt over five years. It’s too little. It’s not enough. It’s too timid, and we must be more bold.
They’re talking about cutting $35 billion. We spend $35 billion in five days. We add $35 billion to the debt in nine days. It’s not enough, and we will not ruin in our country unless we think more boldly. We must cut more spending. We must cut out the unconstitutional programs we never intended to have here. We used to say as Republicans that we thought education was for the states and the localities and now we have a Department of Education that is consuming $100 billion and it’s time we go back to the Republican roots that says, we believe in abolishing the Department of Education.
There is, though, one compromise we will have to make as conservatives. Those of you who know me know I don’t like to compromise, but there is one compromise you have to make. And this is the compromise, and you have to think this through.
We have always been, as conservatives against the domestic welfare, the abuses of domestic spending, for making domestic spending smaller, but you have to understand that that’s this much of the budget. If you cut out all discretionary non-military spending you don’t balance the budget. You can’t get there unless you look at the whole budget. That means we will have to have entitlement reform. But here’s the compromise that also conservatives will have to make. We will have to look long and hard at the military budget – I knew there was going to be – I knew there had to be some dissension somewhere.
The thing is, is that the most important thing that our government does, the one primary and most important constitutional thing our government does is our national defense. Absolutely. But you cannot – you cannot say that the doubling of the military budget in the last 10 years has been done wisely and there’s not any waste in it. If you do – if you refuse to acknowledge that there’s any waste can be culled from the military budget, you are a big-government conservative and can you not lay claim to balancing the budget.
With regard to entitlement reform, it has to happen. There isn’t any question that it will happen. It’s whether we do it gradually in a rational manner, or whether we wait until there’s a collapse of the country and we have to do it dramatically. Everybody knows the answer. I said it in my campaign. The Republicans attacked me for it and so did the Democrats. The age of Social Security will have to gradually rise.
Saturday, February 12, 2011
Friday, February 11, 2011
The most significant difference from conservative talk radio hosts that I noticed, beyond the obvious difference in political perspectives, was their mean-spiritedness. The lefty hosts were unrelenting in their negative and derogatory comments about their political foes. Sarah Palin and Michele Bachmann were particular targets while I was listening.
Now conservative talk show hosts are not innocent when it comes to negative and derogatory comments, but their comments are usually quick and short. When Rush or Sean Hannity say something mean-spirited about Obama or Pelosi or Reid, they usually quickly move on to a substantive discourse on the issue at hand. The lefty hosts I heard just went on and on and on with personal putdowns. It was ad hominem ad nauseam!
Are these lefty commentators just naturally nasty and mean? Or is it that they lack the ability to rationally and clearly articulate their opposition to another person's particular policy or decision? Or is it that their positions are so weak that ad hominem attacks are their only refuge?
I do not have the answers, just the questions. Think I'll stick with Reggae next road trip!
Thursday, February 10, 2011
"When we started this debate, the president's vision of reform had the support of about 70 percent of the American people," McConnell said. "But here's the problem: We didn't swear an oath to uphold whatever's popular. We swore an oath to uphold the Constitution."
Wednesday, February 2, 2011
The compromise must be conservatives acknowledging that we can cut military spending and liberals acknowledging that we can cut domestic spending. Freezing domestic spending at 2010 levels does not significantly delay the coming debt crisis and is at best a diversion from the real budgetary cuts that are necessary.
I am honored by the privilege of serving in the United States Senate. I am honored and humbled by the responsibility of defending our Constitution and our individual freedoms.
Tuesday, February 1, 2011
urges Congress to repeal the individual health insurance mandate of the Patient Protection and Affordable Care Act, more commonly known as the Federal health care reform bill. It also asks Congress to cease and desist enacting mandates that are beyond the scope of its powers as spelled out by the U.S. Constitution.
The second resolution, House Concurrent Resolution 46, is undoubtedly well-intentioned yet nonetheless ill-advised. That resolution
The second resolution, House Concurrent Resolution 46, is undoubtedly well-intentioned yet nonetheless ill-advised. That resolution
urges the calling of a convention to proposing an amendment to the Constitution that seeks to limit the Federal government from spending more money that the revenue it generates, impose limits on Federal debt, expenditures, revenue and taxes; require a waiting period on all bills to give time for all members of Congress and the public to review; and to limit the power of Congress to employ its spending power outside its authorities and prohibit mandates on Kentucky and other states.
"A major part of our current economy crisis is that Congress continues to place unfunded mandates on states, while adopting borrow, spend and tax plans to carry out needless programs at the Federal level,” Rep. DeCesare added. “It’s time we cut up the Federal government’s credit cards and stop Washington for placing the burden of the cost on taxpayers.”
I do not object to any of the specific issues mentioned with respect to a proposed constitutional convention, but I would prefer to see each addressed separately as its own constitutional amendment, if necessary, or as legislation if possible. The thought of a new constitutional convention terrifies me; there is too great a risk that in attempting a wholesale revision of the constitution, we will lose a structure of limited government that has served us well for more than two centuries. Even though the individual initiatives seem conservative, the method proposed -- a constitutional convention -- is not conservative. To the contrary, it is radical and needlessly risky. House members therefore should oppose Resolution 46.