Surgical comanagement restrictions fail in Florida

Issue: July 2001

TALLAHASSEE, Fla. — Two bills — HB 553 and SB 924 — that had been pushed by some ophthalmologists and the officials of the Florida Medical Association (FMA) as part of a strategy to keep patients in the care of ophthalmologists were never passed before Florida’s legislative session ended.

The Miami Herald reported May 1 that state Republicans tabled the controversial bill that would have required eye surgery patients to get postoperative care only from medical doctors. Contentious debate on the measure prompted the bill’s sponsor, Rep. Mike Haridopolos, R-Melbourne, to declare the bill dead for the session.

Many state representatives said they saw no convincing evidence that there was a problem with the current activity of comanagement between optometrists and ophthalmologists. Among the representatives who were not convinced was Rep. Rob Wallace, R-Tampa, who never allowed the bill to be heard in his budget committee.

A “moral victory”?

The Florida Society of Ophthalmology (FSO) is declaring the dead bill a moral victory for ophthalmology in Florida. In an open letter on its Web site, the society said that optometrists, who for the past 10 years have attempted to expand their scope of practice in a variety of areas, such as surgery, systemic drugs and hospital and ambulatory surgical privileges, this session filed no expansion of scope legislation.

Kenneth L. Franklin, executive director of the Florida Optometric Association, believes that the society’s use of the word “victory” is not entirely appropriate. “We read the press releases that sound like they won, and the truth is that nobody won,” he said. “The criticism that was rendered by that group was that they stopped optometry from doing laser surgery, which was not even asked for. Additionally, they basically regurgitated some items that we were doing 5 or 10 years ago in legislation as though that was the ‘win’ that they had achieved.”

Senate bill was close

State Sen. Daniel Webster, R-Orlando, sponsored the Senate version of the postoperative ocular care bill SB 924. That legislation came close to passing.

Sen. Webster attempted to add the bill onto an extensive health care reform bill (SB 1558) during the last hours of the session. The amendment, which would have allowed delegation of all postoperative ocular care to an ophthalmologist for all procedures except for cataract surgery, where the delegation was required during the first 10 days after surgery, passed 21 to 13.

However, Sen. Don Sullivan, MD, an orthopedic surgeon who was acting as president of the Senate, ruled that it required a two-thirds vote on an amendment to be added to a bill on third reading. Thus, the amendment was not added. SB 1558 later that night passed the legislature.

Originally, SB 924 and HB 553 would have authorized only medical doctors licensed under chapters 458 and 459 of the Florida statutes to provide postoperative ocular care. Those chapters pertain to medical doctors and doctors of osteopathic medicine only.

A “meritless” bill

Mr. Franklin said the bills ultimately failed because they lacked merit. He explained that the Florida sponsors and ophthalmologists in favor of the bill failed to demonstrate the harm that they were trying to correct with legislation.

“This clearly was an economically driven vehicle; it had nothing to do with patient harm or with quality of care. There was no documented evidence of failings on the part of the current system of health care delivery,” he said.

Steve Hull, lobbyist and public relations director of the FSO, said that documented evidence of problems was one of the reasons that the bill was supported by certain groups. “The Florida College of Emergency Physicians endorsed and advocated for the bill because of the high number of postoperative eye problems showing up in the emergency rooms throughout Florida,” he said. “Also the Florida Agency for Health Care Administration released a report citing several confirmed problems of postoperative eye care adverse incidents. The American Academy of Ophthalmology also endorsed the legislation.”

Mr. Franklin said that the support for the optometric position offered by more than half of the state’s ophthalmologists sent a strong message to organized ophthalmology. “There were 235 ophthalmologists who opposed the bill,” he said. “As a consequence of all this, a number of ophthalmologists who were part of organized medicine have tendered their resignations in those organizations, simply because the leadership was off on a tangent from what really needed to be provided to patients in Florida. Rogue leadership issues don’t work well in Florida, and I think this bill proved that.”

Mr. Hull said that part of the reason the bill failed was due to the optometrists’ “strong grassroots organization,” as well as OD pressure on freshman members of the House. “Also, many ophthalmologists who were in engaged in comanagement were pressured by optometrists to send letters to their congressman and then send a copy of the letter to [their comanaging optometrists],” he said. “A lot of ophthalmologists were reluctant to make a stand due to proposed economic boycotts.”

Also, “to our knowledge, we have not had one member drop membership of this society because of the legislation,” he added.

While optometry received a lot of support from ophthalmology, the legislation also had strong backing from the medical and ophthalmological community, said Mr. Hull. “The FSO based its support of the FMA-initiated legislation on a survey of the FSO’s membership, which showed that 90% of survey respondents supported only medical doctors providing postoperative ocular care,” he said.

Mr. Hull said that he believes the FMA will most likely continue to push the issue and ask that the bill be reintroduced into the next session. Committee hearings begin in September and the next session starts in January 2002.

Preserving patient choice

Had the bill passed, it would have set a negative precedent for other states, said Howard J. Braverman, OD, immediate past president of the American Optometric Association (AOA) and a private practitioner from Florida. “If the Florida legislation had passed, it would have restricted patient access and patient choice, inconveniencing patients and reducing the number of doctors available to deliver care, particularly in rural areas and prisons,” Dr. Braverman told Primary Care Optometry News. “It also would have set a terrible precedent for the rest of the country by eliminating a privilege optometrists throughout the United States have exercised well and appropriately for decades. Florida would have become the first state in the union to roll back the standards set by Medicare on a federal level.”

Preserving patient choice is the main reason that TLC Laser Eye Centers lent its support, said TLC President and Chief Operating Officer Thomas G. O’Hare. “We had people in Tallahassee meeting with legislators on the benefits of comanagement as they relate to patient choice — how important it is to preserve patient choice and ensure that patients have the ability to continue their relationship with their primary eye care provider,” he told Primary Care Optometry News. “No legislation should create a barrier in the patient’s ability to continue with that relationship. All patients should have the opportunity to have their surgery performed by a highly experienced and capable surgeon and then to have great follow-up care performed by their optometrist.”

Continued success with comanagement

“People who are trained as highly skilled surgeons want to be surgeons,” said Mr. Franklin. “The system of comanaged care has been working in Florida for 25 years without incident.”

“Not one patient has been harmed in a comanagement situation,” Dr. Braverman said. “Furthermore, no disciplinary action has been brought in Florida either against an optometrist by the state board of optometry or against an ophthalmologist by the state board of medicine as a result of patient harm during comanagement. Testimony by patients showed that there actually is a need for comanagement. Fortunately, the Florida legislature realized that the current system works.”

For Your Information:

Kenneth L. Franklin is the executive director of the Florida Optometric Association. He can be reached at PO Box 13429, Tallahassee, FL 32317; (850) 877-4697; fax: (850) 878-0933; e-mail: Ken@floridaeyes.org.

Steve Hull, is executive director of the Florida Society of Ophthalmology. He can be reached at 4494 Southside Blvd., Suite 201, Jacksonville, FL 32216; (904) 998-0819; fax: (904) 998-0855; e-mail: shull@sunshinenetwork.com; Web site: www.MDeye.org.

Howard J. Braverman, OD, is the immediate past president of the American Optometric Association. He may be reached at 1935 E. Hallandale Beach Blvd., Hallandale, FL 33009-4708; (954) 458-2112; fax: (954) 458-7186; e-mail: AmOptBDHJB@aol.com.

Thomas G. O’Hare is the president and COO of TLC Laser Eye Centers. He may be reached at 5280 Solar Dr., Ste. 300, Mississauga, Ontario L4W 5M8; (905) 602-2020; fax: (905) 602-7956.