TPA certification improves relations with ophthalmology on local level

Issue: December 1998

KOKOMO, Ind. - Seven years after adopting legislation that clarified their therapeutic pharmaceutical agent (TPA) privileges, Indiana optometrists say the law has improved their professional relationships with ophthalmology.

"Referral centers and comanagement with ophthalmology have become more prevalent since we adopted TPA privileges," said John E. Fawcett, OD, president of the Indiana Optometric Association.

Indiana's legislators adopted and finalized an updated TPA law on May 13, 1991. Under the law, Indiana ODs can prescribe all topical agents as well as oral antihistamines, antimicrobial agents, antibiotics, decongestants, NSAIDs and glaucoma drugs. They can prescribe topical, but not oral, steroids and cannot prescribe controlled substances.

"Lack of a DEA (Drug Enforcement Administration) number has not prevented me from writing prescriptions or from having a very active therapeutic practice," said Dr. Fawcett, who estimates that 80% or more of the state's 1,050 optometrists are TPA certified. He said the state association has no plans at this time to expand Indiana's TPA legislation.

In solo private practice, Dr. Fawcett practices full-scope optometry for all ages, consults with specialists when needed and actively comanages surgical patients with ophthalmologists.

Indiana optometrists must take 30 hours of approved continuing education every 2 years to maintain their licenses, and 30 additional hours to remain TPA-certified.

While Indiana does not have legislation that specifically addresses hospital privileges, some ODs here have obtained them, Dr. Fawcett said. The state association offers its support and guidance to ODs who seek hospital privileges, he said, and considers its primary goals the development and delivery of quality vision care and eye care services to Indiana residents.

Kentucky ODs seek direct access

With strong prescribing privileges from a 1986 TPA law and an amplification law passed in 1996, optometrists in Kentucky have begun working toward gaining direct access to patients.

Ophthalmologists and optometrists have enjoyed good working relationships on the local level in the state and share concerns over the gatekeeper system that requires patients to go to their primary care physicians to get referrals for eye care, said Jonathan L. Shrewsbury, OD, president of the Kentucky Optometric Association.

The rural setting of much of the state can make it more difficult to secure a referral from a family physician and is unnecessary when the patient knows that pain in the eye or loss of vision requires eye care, he said.

"With other problems where the pa tient might not know whether an orthopedic specialist or a physical therapist would be needed, for example, the family doctor can dictate where to go to start medical care in the right direction," Dr. Shrewsbury said. "When it's an eye problem, patients know it's an eye problem."

During the 1998 legislative session, optometry and ophthalmology joined forces with other medical fields in developing a far-reaching health care reform bill, which precluded addressing the direct access issue. Dr. Shrewsbury expects optometry and ophthalmology to work together again to develop direct access legislation in the next session.

Direct access is one of few significant obstacles for Kentucky optometrists, Dr. Shrewsbury said. ODs here can prescribe all but Schedule I and II drugs, and there is little interest in securing those privileges at the current time, he said. About 87% of the state's 631 licensed optometrists are TPA certified.

Dr. Shrewsbury typically writes 18 to 20 prescriptions per week, mostly antibiotics, antibiotic/steroid combinations and, with his location in the Ohio Valley, allergy medications.

Although glaucoma treatment is not a large part of his practice, it is becoming a more important aspect of practices through out the state, he said. Kentucky optometrists do not need an ophthalmological consultation before beginning glaucoma treatment. Most ODs have been treating glaucoma since 1986.

Another aspect of optometric practice that is becoming more common is acquiring hospital privileges. The association has not pursued the issue of securing privileges at all hospitals, but has assisted individual optometrists in this process.

"The ability to secure hospital privileges is pretty widespread because it's a rural state. I don't think the desire has been there previously," he said.

In the past, many optometrists preferred to allow family doctors or emergency staff personnel to handle hospital cases, then follow up in their own offices the next day, Dr. Shrewsbury said. More optometrists are joining hospital staffs, a privilege that will become more important as managed care continues to develop as a factor in Kentucky, he said.

For Your Information:

John E. Fawcett, OD, may be contacted at P.O. Box 3007, 3415 S. Lafountain, Kokomo, IN 46904; (765) 453-4000; fax: (765) 453-4011.

The Indiana Optometric Association may be contacted at 201 N. Illinois St., #1920, Indianapolis, IN 46204; (765) 237-3560; fax: (765) 237-3564.

Jonathan L. Shrewsbury, OD, may be contacted at 1303 N. Main St., P.O. Box 109, Beaver Dam, KY 42320; (502) 274-3294; fax: (502) 274-4811.

The Kentucky Optometric Association may be contacted at P.O. Box 572, Frankfort, KY 40602; (502) 875-3516; fax: (502) 875-3782.