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California TPA usage: 1 year later
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California's bill passed in February 1996 amid a swirl of controversy. The bill allowed optometrists to prescribe topical drugs, but not steroids or glaucoma medications. It required a 65-hour preceptorship with an ophthalmologist, and a compromise agreement restricts ODs from seeking amplification until 2000.
Supporters said the bill gave California optometrists a much needed beachhead for TPA usage. Opponents said the bill and compromise were too weak to be of value, so ODs should have held out for a better law.
Now, however, both supporters and detractors have rolled up their sleeves and gotten down to the business of getting certified and prescribing TPAs, a matter of no small import considering there are 5,800 active optometric licenses in the state.
Rifts are healing
California Optometric Association (COA) president David Benkle, OD, a solo practitioner in Stockton, Calif., concedes the bill was not the best, but said it was the only option. "The bottom line is something is better than nothing. The legislature did us a huge favor."
Things have been "going better than expected," he added, saying courses for the Treatment and Management of Ocular Diseases (TMOD) examination have been filling up beyond expectations. The California State Board of Optometry said more than 1,129 optometrists have been TPA certified.
Philip B. Smith, OD, immediate past president of the COA, said he thinks rifts in the association have largely been healed: "Most optometrists are pleased and happy to be in the loop."
Stanley Postar, OD, a Los Angeles practitioner who was an outspoken bill opponent, said the bill "only has to do with turf and money. It has nothing to do with patient care." However, he said, "I hold no ill feelings. I didn't drop out of the COA."
Richard K. Simonds, OD, who has two offices in the San Diego area, said most ODs are pursuing certification because they are enthusiastic about TPA use or fear being locked out of insurance plans.
However, he said, some older optometrists are not bothering to get certified, and some ODs are still refusing because the law is watered down.
He thinks all ODs who "plan on practicing more than 5 years should pursue their therapeutic credentials," because there will be "strength in numbers" when they go for amplification. Dr. Simonds received his certification in Feb. 1997.
J. Clifford Wright, OD, a private practitioner from Berkeley, Calif., acknowledged that the bill was disappointing, but said, "I'm grateful to have something. We can live with what we have until we get the others." He said refusing to work with the new law is "cutting off your nose to spite your face."
The long preceptorship was a major point of controversy. Dr. Benkle, who was certified in December, conceded that "it's kind of a slow process." But he said he learned a lot in the preceptorship: "I'm a better doctor for it."
Although it took him more than 3 months to complete his preceptorship with Glenn Cook, MD, Dr. Smith said it offered him "a hands-on opportunity to see what these medications do."
Dr. Wright said the preceptorship was "pretty onerous" and expensive, but he learned practice management tips in addition to clinical information from Stephen Turner, MD. Dr. Simonds said his work with Forrest P. Murphy, MD, helped forge "a greater mutual respect for both professions." However the hours out of the office affected his cash flow: "It was tight there for a while."
"I still think the bill is incredibly weak and certainly an insult to optometry," Dr. Postar said. However, he got certified, and completed what he called his "65 hours of slavery to ophthalmology.
"There's no sense moaning about it and not doing it," he continued. "I wish the thing had never passed, because my profession is better than what we got. The bill keeps us right under the thumb where the MDs want us."
Dr. Benkle said 65 hours are probably too many, but wondered if the rules could change because of the time demand on MDs: "I wouldn't be surprised if next year ophthalmology gets flack from its members who are saying, 'This many hours isn't necessary.'"
Much of the acrimony over the bill was because the COA did not communicate with its members about the compromises, Dr. Benkle added. "In the final draft, everybody was taken aback that so much wasn't included, like steroids and glaucoma. We vowed that won't happen again. When we seek amplification, we'll see where our members think optometry should be not in the next 3 to 4 years but in the next 15 to 20 years."
The bill has enabled optometrists to broaden their treatment repertoire. Dr. Wright, who comanages refractive and cataract surgery, said the effect on his practice has been positive. He now treats abrasions, corneal infiltrates and ocular allergies and keeps more cases.
"I refer fewer patients to my ophthalmologist," Dr. Wright said. "That makes me happy, makes patients happy, and I think makes the MD happy, because that keeps him or her doing surgery." Dr. Benkle said he can now more fully manage conjunctivitis, contact lens problems, pain and allergies.
Dr. Simonds writes up to 10 prescriptions a day for a variety of conditions. Now, he said, instead of referring patients with conjunctivitis, he tries to determine its cause so he can begin a treatment regimen.
Dr. Postar said he writes about four prescriptions a week, mostly for antibiotics and nonsteroidal anti-inflammatories. But he said ODs "desperately needed a more general oral antibiotic and steroids." To illustrate this, he said he was comanaging a patient who lost his steroids, and Dr. Postar could not prescribe new ones. "I have to go to the MD, but I'm supposed to be responsible for this patient?"
Problem with DEA numbers
One of the problems TPA use has brought, and not just in California, is the inability to get Drug Enforcement Administration (DEA) numbers. Dr. Wright said it is a big issue because many patients have health insurance through HMOs, which often use software that will not fill prescriptions without the number: "It makes us look like second class doctors, and it makes the patient waste money."
Dr. Benkle said the COA approached Blue Cross, the state's biggest insurer, and the company created a way for ODs to enter a "dummy" DEA number that runs the programs. The COA has asked all insurers to adopt this policy.
Dr. Smith said despite its shortcomings, the bill enables optometrists to "get in and solve problems."
For Your Information:
- David Benkle, OD, president of the California Optometric Association, can be reached at (209) 951-2020; fax: (209) 951-2016.
- Philip B. Smith, OD, immediate past president of the California Optometric Association, can be reached at 3636 Fourth Ave., San Diego, CA 92103; (619) 297-4339; fax: (619) 297-6572.
- Richard K. Simonds, OD, can be reached at 6755 Mira Mesa Blvd., Suite 141, San Diego, CA 92121; (619) 535-8282; fax: (619) 535-0537.
- J. Clifford Wright, OD, can be contacted at 15251 East 14th Street, Suite B, San Leandro, CA 94578; (510) 481-2121; e-mail: jcwod@earthlink.net. Dr. Wright is not a paid consultant for any companies mentioned in this article, nor does he have financial interest in any products mentioned above.
- Stanley Postar, OD, can be reached at 13637 Ventura Blvd., Sherman Oaks, CA 91423; (818) 784-3526; fax: (818) 784-2894. Dr. Postar is not a paid consultant for any companies mentioned in this article, nor does he have financial interest in any products mentioned above.