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Effort to keep OD surgery out of VA gains key Senate supporter
Sen. Arlen Specter expressed support for the efforts of the Veterans Eye Treatment Safety Coalition, which is trying to prevent optometrists from performing surgery in the VA health system.
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The chairman of the Senate Veterans Affairs Committee expressed support last month for efforts to keep optometrists from performing surgery in the VA health care system.
Sen. Arlen Specter, R.-Pa., assured members of the Veterans Eye Treatment Safety (VETS) Coalition that he supports only qualified eye care professionals performing ocular surgery within the VA, according to a statement from the American Academy of Ophthalmology.
Sen. Specter said he has been assured by VA undersecretary Robert Roswell, MD, that no optometrists are currently performing surgery in the VA system. According to the AAO, Sen. Specter asked the VETS coalition to let him know if they become aware of any optometric surgery in the VA system.
Meanwhile, in the House, a Veterans Eye Treatment Safety Act, introduced last year by Rep. John Sullivan, R.-Okla., awaits action. The VETS Act would prohibit nonphysicians from performing eye surgery in all VA medical facilities. It would change the way the VA credentials health care professionals.
The VETS Act of 2003 was drafted to prevent VA facilities nationwide from credentialing surgical privileges to optometrists. The act was introduced in November and has been lobbied for by the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery.
Action on this bill could take place in April, according to Patrick Eddington, a lobbyist for the AAO, who added that many members of Congress have shown support for the bill.
The bill was sparked by concerns about credentialing practices in the VA medical system. Optometrists have expanded scopes of practice that differ from state to state, but the VA system allows practitioners to perform throughout the system according to their state license.
In other words, if an optometrist who is licensed to perform laser procedures in Oklahoma — the only state that grants such privileges to optometrists — is transferred to a VA facility in another state, he or she carries those privileges to the new posting, regardless of the other state’s OD licensing limits.
This is exactly what happened at a VA facility in Wichita, Kan. The facility allowed an optometrist who was licensed in Oklahoma to perform laser procedures in Wichita. A House VA Committee investigation subsequently found that other optometrists were also performing laser surgery in the VA system.
“Oklahoma is the only state where optometrists can perform surgery, but the VA credentialing system allows them to practice anywhere,” said Bob Palmer, director of state affairs for the AAO. “The VA system allows healthcare providers to practice with the credentials granted by the state in which they are licensed.”
The VETS Act aims to change the VA credentialing system to prevent this ability to move credentialing privileges from state to state, according to AAO representatives.
For Mr. Eddington, the issue represents the results of a flawed VA credentialing system.
“In Wichita, they were basically misinformed that [the optometrist] could perform these procedures. The people who credentialed her were not qualified to do so,” he told Ocular Surgery News.
Victor J. Connors, OD, president of the American Optometric Association, said the bill is an overreaction to the state-by-state extended scope of practice in optometry and the VA credentialing process. He said optometrists in certain states are trained to perform certain anterior segment procedures.
“We have not been aware of any evidence that patient safety has been or is being compromised by an optometrist to practice within the scope of their licensure. We believe the bill will be and should be rejected by those who understand the appropriate role of the state regulation of scope of practice and federal government licensing issues,” he said.
Allison Weber Shuren, MSN, JD, of Arent Fox in Washington, said the issue is about how a profession’s scope of practice is defined and by whom.
“In this instance, optometry has included laser procedures within its definition of ‘routine care,’ she said. “Others disagree with the characterization of surgery as routine care.”
This leads to a different interpretation of the purpose of the VETS Act by optometry and ophthalmology, she said. Ophthalmology says the aim of the VETS Act is to prevent optometric surgery, but optometrists say its aim is to prevent them from performing “routine care.”
“This distinction is at the center of the discrepancy and raises the critical question as to the scope of care optometrists are prepared to perform safely and effectively,” Ms. Shuren said.
The right to perform surgery
The controversy over the right of optometrists to perform laser surgery is not new. The AAO’s Mr. Palmer said the issue began in the 1990s, when the Board of Optometry in Oklahoma first tried to grant laser privileges to optometrists. The action was challenged in court, which found that the board did not have the authority to grant that privilege, he said.
“From that point, 1999, the optometry lobby in Oklahoma then went to the state legislature, and they enacted a bill that basically gave optometrists there the right to perform anterior laser surgery, including PRK, but with the exception of LASIK,” he said.
Mr. Palmer said the Oklahoma decision has led numerous state boards of optometry nationwide to seek similar surgical privileges for optometrists, but so far without the same success as Oklahoma. The AAO’s Surgical Scope Fund was created to fight such legislation around the country, he said.
Mr. Eddington noted that nowhere else but in Oklahoma do optometrists perform surgery.
Ronda Edens, a public relations director at the Wichita VA facility, said the optometrist in question arrived at the facility in 2001 and performed a handful of laser procedures before she was stopped by the ensuing controversy. Ms. Edens said the undersecretary of health for the VA, Dr. Roswell, then imposed a system-wide ban.
Patient safety issue
Mr. Eddington said the AAO has proposed a number of solutions to the VA, citing concerns about patient safety.
“This is a real public policy issue and an issue about state rights. Undersecretary Roswell repeatedly asked us for ideas. … In every case, he has rejected our proposals for dealing with this, even in some circumstances where we cited VA precedent, some of which he has himself signed off on,” Mr. Eddington said.
He said the AAO’s disappointing interactions with Dr. Roswell led them to pursue the federal legislation. Mr. Eddington said they were concerned over the possible misuse of the VA credentialing process by optometrists to obtain surgical privileges. In the past, he said, the VA has cited a federal supremacy argument, which allows them grant additional practicing privileges to a nonphysician’s license, he said.
Dr. Roswell was unavailable for comment.
Regarding the VA’s ability to grant additional practicing privileges, Ms. Shuren said, “The VA can take away rights, but practitioners still have to stay within a realm of their state licensure.
“My experience with the VA is that, in an effort to have consistency across the delivery system, it more often will follow more restrictive standards rather than giving broader rights,” she said.
Optometry speaks
Dr. Connors, of the AOA, countered that legislation such as the VETS Act is unnecessary and bred from misconceptions. He said such a bill could impede what has become routine care for optometrists. It could prevent optometrists from using punctal plugs and performing other less complicated anterior segment procedures.
Dr. Connors said optometry is an autonomous profession that should have the ability to expand its practice along with technology.
“As a learned healthcare profession, [we] should have the ability to prove [ourselves] through a credentialing or education process to take care of those patients, and that [we] are causing no harm to the patient,” Dr. Connors said.
He added that optometrists in Oklahoma have performed more than 12,000 laser procedures, and there have been no complaints regarding patient safety.
“They say it’s for protection of the vets, and I question that. It goes far beyond that. It is an intrusion of how the country regulates and why it credentials,” he said. “It’s lack of respect for nonphysician-based health care professions.”
| University of Chicago discussing surgery center |
| Controversy has revolved around the development of a surgery center at the Illinois College of Optometry. According to the college, the center was proposed by the University of Chicago. Arol Augsburger, OD, president of the Illinois College of Optometry, said the concept is based on the relationship the two schools have had. For 6 years, he said, the two schools have been affiliated and have provided training in a joint environment. The idea was that a surgery center at the college of optometry would be more cost-effective than one at the University of Chicago’s hospital, he said. “At the college, we have property adjacent to our existing facilities. This is an issue that was brought to our attention by the University of Chicago, and from a business perspective it made good sense,” said Leonard Mesner, OD, vice president for patient care services at the college. Dr. Augsburger said having a surgery center at the optometry school would allow students to understand aspects of surgery that will be valuable if they are to provide primary eye care to patients. “We think it’s vitally important that two disciplines like this, that have related missions, work together in the training and patient care programs. It’s important that the optometrist understand the surgery … while recognizing the role the ophthalmologist plays. … That can only be done by setting up a model like this arrangement,” Dr. Augsburger said. Rich Paul, executive director of the Illinois Association of Ophthalmology, questioned the need for the optometric surgery center. “Why would they need [the center] except that they’re introducing their students to surgery?” he asked. Allen Putterman, MD, an oculoplastic surgeon in Chicago, Ill., said many ophthalmologists in the state are concerned the center could lead to surgical training of optometrists. In the past, he said, optometrists have used aspects of their training, such as classes in pharmacology, to obtain privileges from state legislatures. He said that although may be is valuable for optometrists to know about surgery, optometrists’ attempts to obtain surgical rights in various states are an overriding concern to ophthalmologists. “Obviously, [optometrists] wouldn’t be involved initially in surgery. There is just a concern that it could happen, and that they could use that as a method for getting privileges,” Dr. Putterman said. He said plans for the center are on hold until a new chairman assumes head of the department of ophthalmology at the University of Chicago. Outgoing department of ophthalmology chairman J. Terry Ernest, MD, PhD, declined to comment for this article, as did his successor, William Mieler, MD. For Your Information: |
Surgery a broad term
Defining surgery by reimbursement classifications could limit the ability of optometrists to perform routine procedures, said Arol Augsburger, OD, president of the Illinois College of Optometry.
“Regular procedures – epilation of eye lashes, punctal plugs — are defined by the reimbursement rules as ‘surgery.’ I don’t think anybody confuses those procedures with operating on the retina, but technically they are classified that way and are part of routine surgery. They shouldn’t be confused with major surgery,” Dr. Augsburger said.
He said the VA follows guidelines from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), by which hospitals abide.
“It seems unrealistic to expect that if those credentials exist and competency is demonstrated, that by crossing a state line that person would not have the same kind of competency, because it’s based on the reviews that JCAHO has long used to provide privileges,” Dr. Augsburger said.
Michael W. Brennan, MD, secretariat for the AAO, agreed that the definition of surgery in some cases may be vague, but he said the VETS act is aimed to prevent optometrists from performing invasive procedures.
As an example, he said, administering an ophthalmic needle might not be considered surgery but is invasive.
“What we’re trying to do is draw some limits and state that invasive procedures carry critical patient risk and that optometric education and training doesn’t give them the background in handling the judgment, the performance and/or the complications of invasive procedures,” Dr. Brennan said.
Regardless of the state and federal regulatory process, Mr. Palmer said optometry is trying to obtain surgical rights by forgoing medical training.
“It ends up being a shortcut to try and obtain medical privileges without going to medical school. The shortcut is you seek legislative enactment,” Mr. Palmer said.
For Your Information:
- Victor J. Connors, OD, can be 6602 University Ave., Middleton, WI 53562; 608-836-0678; fax: 608-831-8470.
- Patrick Eddington and Bob Palmer can be reached at 1101 Vermont Ave., NW, Suite 700, Washington, DC 20005-3570; 202-737-6662; fax: 202-737-7061; e-mail: peddington@aaodc.org; rpalmer@aaodc.org.
- Michael W. Brennan, MD, can be reached at 1214 Vaughn Road, Burlington, NC 27215; 336-228-0254; fax: 336-222-7511.
- Arol Augsburger, OD, can be reached at the Illinois College of Optometry, 3241 South Michigan Ave., Chicago, IL 60616; 312-949-7070; fax: 312-949-7070.
- Ronda Edens, can be reached at the Robert J. Dole Dept of VA Medical and Regional Office Center, 5500 E. Kellogg, Wichita, KS 67218; 316-685-2221; fax: 316-651-3666.
- Allison Weber Shuren, MSN, JD, can be reached at Arent Fox Kintner Plotkin & Kahn, PLLC; 1050 Connecticut Ave NW, Washington, DC 20036-5339; 202-775-5712; 202-857-6395; e-mail: shuren.allison@arentfox.com.