Florida optometrists battle comanagement in legislature

Issue: May 2001

TALLAHASSEE, Fla. – In what many hope is not becoming an unfortunate trend across the country, Florida optometrists are battling a bill in the state House committee that threatens to keep ODs from comanaging refractive and cataract surgery patients in the postsurgical phase. On April 20, the Senate bill passed 28-10.

Rather than targeting optometrists specifically, Senate Bill 924c1 and House Bill 553 edge ODs out of the comanagement picture by precluding any person who is not a licensed physician or osteopathic physician from performing any ocular postoperative duties. According to the bills, doing so would constitute grounds for disciplinary action and may carry penalties.

The bills were originally proposed by the Florida Society of Ophthalmology and first appeared in the legislative session that began in early March. According to the statement of substantial changes in the committee substitute for the Senate bill, “The bill revises disciplinary violations applicable to a Florida-licensed allopathic or osteopathic physician proscribing the delegation of ocular postoperative responsibilities to a person not licensed as a Florida-licensed allopathic or osteopathic physician.”

The bills have passed three committees they have gone to thus far, said Ronald Foreman, OD, president of the Florida Optometric Association (FOA). “The Senate bill passed both Senate committees, and that clears it to go to the Senate floor,” he said. “The House bill has cleared only one House committee and it has two more to go through before it reaches the floor. Then it will be placed on the agenda.”

The bills also received the support of the American Medical Association, the Florida Medical Association (FMA), the Florida College of Emergency Physicians, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS), whose support has since been withdrawn.

Penalties for violation

Both HB553 and SB924 state that a violation of the bill as proposed could incur one or more of the following penalties: a) refusal to certify, or certification with restrictions, to the department an application for licensure, certification, or registration; b) revocation or suspension of a license; c) restriction of practice; d) imposition of an administrative fine not to exceed $10,000 for each count or separate offense; e) issuance of a reprimand; f) placement of the physician on probation for a period of time and subject to such conditions as the board may specify, including, but not limited to, requiring the physician to submit to treatment, to attend continuing education courses, to submit to re-examination, or to work under the supervision of another physician; g) issuance of a letter of concern; h) corrected action; i) refund of fees billed to and collected from the patient; j) imposition of an administrative fine in accordance with s. 381.0261 for violations regarding patient rights.

FMA Issue Paper

The FMA has written an Issue Paper to advise MDs about the legislation.

“In all surgical specialties, with the exception of ophthalmology, the surgeon has full responsibility for the patient. In recent years non-medical doctors have been increasingly engaged in comanaging ocular surgical care,” the paper states.

The FMA’s paper states that legislation is needed to protect the public from untrained health providers. According to the FMA, “It is important that when surgery on the eye is required, the most highly trained specialists are available. In many cases optometrists are providing postoperative ocular care. Optometrists have no surgical training, are prohibited from doing any type of surgery and are only allowed to prescribe eye drops. Optometrists are not allowed, because they do not have the training, to prescribe systemic drugs or diagnose diseases of the body, all requirements to oversee patients after surgery.”

The FMA also states that most complications occur after surgery. This legislation would allow only MDs to provide postoperative ocular care. According to the FMA, it is exceedingly rare for vision threatening complications to transpire intraoperatively. Greater than 90% of all complications from eye surgery that blind an eye or significantly reduce vision occur 2 to 10 days after the surgery is completed, therefore, speed of diagnosing complications and/or initiating surgical remedy is vital, the FMA states.

“The shorter the duration of a patient’s onset of signs/symptoms to surgical intervention, the higher percent the chance of favorable outcome. Disaster results when a carpetbagger surgeon hundreds of miles away, and an optometrist, cannot accurately diagnosis or treat this emergency,” states the issue paper.

ODs advertising surgery

The position paper also claims ODs are advertising for surgeries they are not allowed to perform. “Optometrists aggressively advertise to non-patients to come in for free LASIK evaluation or free cataract evaluation, even though they cannot perform the surgery. Commonly large outdoor billboards advertise the free evaluations despite numerous ophthalmology practices in the neighborhood. Optometrists lure interested potential patients so that they can then act as bounty hunters referring the newly captured patients to the highest bidder ($600 per eye for LASIK),” the position paper states.

As with most position papers and recent legislation, the FMA also points to the inappropriate practice of using postoperative care as an inducement for referral fees. The FMA cites the February 2000 AAO/ASCRS paper, which states, “If the reason for sharing postoperative care with another provider is economic, specifically as an inducement for surgical referrals, or the result of coercion by the referring practitioner, it is patently unethical and, in many jurisdictions, illegal.”

Dr. Foreman stated that this practice is already illegal in Florida and that “the FOA doesn’t endorse this type of practice.”

Unclear motives

The motivation behind the bills has optometrists in Florida perplexed, said Dr. Foreman. “They keep looking for a problem,” he told Primary Care Optometry News. “There is no problem, but now we have a ‘solution.’ It’s a direct assault on optometry, despite what they may say. They can couch it as abandoning patients in the emergency room, itinerant eye surgeons who don’t care for their patients, quality of care or kickbacks – that was an issue until they realized it’s illegal to do that. All of these issues have not been held to the standard of producing evidence to substantiate these claims, but they were adequate enough to give these bills momentum.”

In the meantime, said Dr. Foreman, the constantly changing bills are simply causing unnecessary problems. “These bills have cost the optometry community hundreds of thousands of dollars, and there’s no documented problem,” he said. “But we’re still having to defend ourselves. The true problem lies within the ophthalmological community. If they had followed regulatory guidelines and had the fortitude to discipline themselves, the very problem they raise in this issue would cease to exist.”

For Your Information:

Ronald Foreman, OD, is president of the Florida Optometric Association. He may be reached at 1387 South First St., Lake City, FL 32055; (904) 752-1714; fax: (904) 755-1858.