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To the Editor
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The recent Ocular Surgery News cover story, “Optometric integration and scope of practice still disputed,” in the May 25, 2019, issue leads only to the conclusion that organized ophthalmology’s unbecoming opposition to the rapidly advancing, patient-centered wave of optometric scope expansion is now a defining obsession for the profession. Although it’s understandable when those most fearful of change try to cling to the past for their own sense of comfort and security, optometry and the American Optometric Association are focused on the future of health care and our essential and expanding role in it, and we are succeeding in our nationwide effort to expand access to the highest quality and most advanced care.
We have more than 16 million Americans struggling with undiagnosed or untreated vision impairments. Furthermore, eye diseases, vision loss and eye disorders alone account for an estimated $139 billion economic impact. It’s clear that access to high-value care is a challenge in America, and doctors of optometry, as part of the patient-centered care team, are a critical part of the solution.
We must address the gaps in the value and efficiency of care that have led to higher costs and poor health outcomes for millions of patients. That includes improving safe patient access to an efficient health system that maximizes resources and care. Scope enhancement does not prohibit the public from obtaining procedures from an ophthalmologist. It gives them the choice to go to the appropriate provider for their needs, making their health care more efficient.
Unfortunately, instead of highlighting states with existing expanded scope of practice laws, the article focused on unfounded concerns over patient safety. If the article had looked into states with expanded scope, it would have revealed that high-quality patient care has prevailed, without an increase in complication rates for these procedures. In fact, there is no evidence of an increase in malpractice cases for the doctors performing expanded procedures, and there has not been a single reported judgment or settlement against a doctor of optometry related to scope expansion. Multiple stakeholders are beginning to recognize the importance of changing the status quo to improve health care.
Legislators are becoming immune to the same old fear rhetoric and “anecdotes” that are pumped into the public discourse, supported by the AAO Surgical Scope Fund. Signs of growing support of optometry’s accessibility and clinical skills as primary eye health care providers are clear in recent legislative changes in states such as Arkansas. They understand that fixing outdated laws will ultimately provide greater access for patients, providing an option of having their care done locally, without needing a referral, without a duplicate exam, without a day off from work to travel and without associated travel costs.
The federal government also recognizes that the status quo is flawed in the 2018 U.S. Health and Human Services report. In it, HHS outlined recommended reforms the government should take to deliver optimal care to Americans and specifically noted that doctors of optometry can provide the same services as other physicians. The report emphasized that “states should consider changes to their scope-of-practice statutes to allow all healthcare providers to practice to the top of their license, utilizing their full skill set.” Such high-level validation only further solidifies the need to bring scope of practice laws into the 21st century.
Instead of trying to placate optometry with platitudes while maintaining a guerilla war to ensure hegemony, ophthalmology should consider investing resources and time in ensuring their profession continues to grow, thrive and truly collaborate with fellow doctors of optometry to advance patient care.
Samuel D. Pierce, OD
President of the American Optometric Association
Kenneth P. Cheng, MD, responds:
I appreciate Dr. Pierce’s interest in my comments published in the OSN cover story. I believe that the article presented the scope of practice in eye care situation factually and highlighted avenues for the professions of ophthalmology and optometry to work together in a model of collaborative care for the benefit of patients.
Dr. Pierce has quite correctly pointed out that there are gaps in the delivery of eye care in this country. Those gaps in care are, however, not in the availability of eye surgery. Even in states where legislation has been passed granting optometrists expanded scope of practice, presumably with access to care as a motivating factor, it has been demonstrated that patients have reasonable access to ophthalmologists. In a study examining access to ophthalmologists in Kentucky, Oklahoma and New Mexico, where optometrists have expanded scope of practice, more than 75% of the residents were within 30 minutes of an ophthalmologist’s practice. There do exist extremely remote areas of the country where access to ophthalmologists is difficult; however, access to optometrists in these areas is also limited. Optometrists, just like ophthalmologists, locate their practices where they can be supported by the availability of patients, and significant numbers of patients do not live in extremely remote areas of the country.
In facing the need to efficiently deliver high-quality care to meet the growing demand in our country and to address the “undiagnosed or untreated vision impairments” that Dr. Pierce points out, I would ask that he and the American Optometric Association embrace, rather than oppose, the tremendous advancements in eye care that technology is making possible. An excellent example of the availability of technology to address this problem is the Technology-based Eye Care Services (TECS) model being introduced in the Veterans Administration system. Utilizing telemedicine, patients in primary care settings are screened for eye disease and appropriately referred for comprehensive examination when necessary, but they can also be prescribed glasses without travel when that is all that is needed. Physicians review all of the information remotely and develop the appropriate assessments and plans. Patient satisfaction and quality assessment measures of the program have been excellent, and the patient convenience and cost savings produced are tremendous. This is an example of the “safe patient access to an efficient health system that maximizes resources and care” that Dr. Pierce has called for.
I agree with Dr. Pierce that doctors of optometry should, and in fact must, be a part of the patient-centered eye care teams that are needed to deliver high-quality care in America. All of the players on the team should have the appropriate education and training for their roles on the team. As Dr. Lindstrom said in the closing paragraph of the article, “There is no substitute for proper education, training and experience to be able to execute a complex, invasive eye surgery. It is in every patient’s best interest regardless of the field, be it eye care, orthopedics or cardiac care, to have someone who has the training and experience to complete surgery in an outstanding fashion perform it.” The AAO’s Surgical Scope Fund supports education of the public in this regard.
- References:
- Maa AY, et al. Ophthalmology. 2017;doi:10.1016/j.ophtha.2016.11.037.
- Stein JD, et al. JAMA Ophthalmol. 2018;doi:10.1001/jamaophthalmol.2017.5081.