VA Optometric Surgery Campaign
http://www.crstoday.com/PDF Articles/1004/Brennan.html
A timeline of events demonstrates optometrists efforts
to perform laser eye surgery.
By Michael Brennan, MD
This article describes the course of optometric scope-of-practice expansion related to the Veterans Health Administration (VHA) during the last 7 years. This piece is not intended to challenge surgery by nonsurgeons. The three salient events that frame this discussion of surgical intervention by nonsurgeons are featured, in addition to strategic and tactical outcomes. The strategies of nonphysician providers to shuttle between state legislative and federal regulatory authorities to enhance their licensing and privileging capabilities are illustrated, with a focus on the use of the Department of Veterans Affairs (VA) educational platform for optometric surgery. A critical assessment of the detriment to patient safety from nonphysician ophthalmic surgery is reserved for other authors.
1997 VHA OPTOMETRY
SERVICE GUIDELINES
The Optometry Service Guidelines for VHA Facilities, Handbook 1121.1, was released on October 23, 1997. The guidelines enabled optometrists to gain privileges for a vast range of invasive ophthalmic procedures, including both anterior and posterior segment laser surgery. Without federal legislative entitlement, established federal healthcare policy, or discussion in an open, multidisciplinary, professional forum, these guidelines formally allowed nonsurgeons the privilege of performing ophthalmic surgery. Because surgical education was not authorized in any optometry school due to the limits of state statutes, optometrists entry into a nationwide VA educational system still required a single state breakthrough coupled with existent VA privileging policy that promoted federal jurisdiction over state restrictions.
Ophthalmology and a National Medical Coalition forced the VA Under Secretary for Health Affairs to rescind this handbook by March 31, 1998. Under questioning during a Senate VA Committee Hearing, the Under Secretary stated that optometrists would not be permitted to perform laser surgery in a VA facility. The subsequent Veterans Administration Eye Care Guide restored the credentialing and privileging capacity for optometrists to standard, nonphysician VA guidelines, summarized as follows. In the absence of overriding Veterans Administrating Central Office directives, local facility commanders are charged to consider the needs of the institution, as well as the issued state license capacity and competency of the nonphysician provider, to determine the limits of local VA facility privileging.
The leadership of the AAO and AMA substantially increased national attention on federal medical policy as dictated by the Veterans Administration Central Office. Within the domain of ophthalmology, Veterans Integrated Service Networks were upgraded to include an ophthalmology consultant, the Association of Veterans Administration Ophthalmologists became more actively engaged, and veteran service organizations, such as the VFW and American Legion, were challenged to speak for quality eye care.
Nonphysicians countered in state legislatures by markedly increasing the number of scope-of-practice initiatives for laser surgery and pharmaceutical privileges.
Indian Health Service and Military Service venues were pursued by limited-license providers, including optometrists and psychology, for national educational and practice opportunities that would be unrestricted by local (state) statute. Through aggressive state advocacy by ophthalmology and the medical community, laser surgical initiatives at the state level were resisted with one exceptionOklahoma.
OPTOMETRIC SURGERY IN OKLAHOMA
(November 1998)
In stark contrast to the VA scene where the optometric strike was silent, sudden, and almost subtle, the Oklahoma encounter lasted a decade and featured legislative and legal face-offs. Optometrists who had attended a laser surgery session at the annual AAO meeting began performing PRK and YAG capsulotomies at the Northeastern State University College of Optometry (Tahlequah, OK) in the mid-1990s, based on the assumption that a clause in the scope-of-practice statute permitted optometric laser surgery. Years later, the Optometric Board of Examiners finally certified optometrists to perform anterior segment laser surgery. Legislative attempts to either sanction or disallow optometric laser surgery led to several legal encounters between the Oklahoma Board of Licensure (Medical Board) and the Oklahoma Board of Examiners in Optometry. In July 1997, the court issued a ruling prohibiting optometric laser surgery. Optometry redirected its efforts to political persuasion, and Senate Bill 11-92 was enacted, permitting laser surgery excluding retinal laser, LASIK, and cosmetic lid surgery. Noteworthy was the optometric campaign slogan, if its good enough for veterans, its good enough for Oklahomans, which referred to the VA Optometry Service Guide mentioned earlier. In Oklahoma, relatively few optometrists were performing laser procedures and these in small numbers. Out-of-state optometrists, including several VA practitioners, became licensed in Oklahoma via weekend courses and board examinations. Included in the Northeastern State University College of Optometrys advertisements were weekend courses for other opportunities, such as Botox injection (Allergan, Inc., Irvine, CA), advanced suturing, and excision of lid lesions.
ROBERT J. DOLE VA MEDICAL CENTER, WICHITA, KANSAS
(Spring 2003)
Armed with an Oklahoma license and certified for laser surgery, optometry approached the privileging systems of the VA. The Wichita VA Professional Standards Board granted privileges to an optometrist to perform laser and lid surgery, as compatible with VA nonphysician policy. Allowing nonphysicians to practice to the limit of their issued license, the VA vaulted the statutory authority of one state as an accepted practice for the entire nation.
The AAOs response, fortified by a coalition including the AMA, the American College of Surgeons, the ASCRS, The American Academy of Family Physicians, and the American Osteopathic Association prompted the VA Under Secretary to enact a moratorium that suspended national optometry laser surgery privileges. The coalition later introduced House and Senate Bills defining ophthalmic surgery and restricting this practice to licensed MDs and DOs. The AAOs Surgery by Surgeons campaign spread to veteran service organizations and national regulatory and licensure boards. The Veterans Administration Central Office reacted with the following directive.
VHA DIRECTIVE 2004-045
(August 24, 2004)
It is Veterans Healthcare Administration (VHA) policy that optometrists are not to be granted clinical privileges to perform therapeutic laser eye procedures independently; they may be granted clinical privileges to perform such procedures under the supervision of an ophthalmologist, provided the optometrists state license statutes allow the performance of laser procedures, the optometrist has been fully trained, and the optometrists competency has been confirmed.
As of press time, ophthalmology and optometry representatives were deliberating the issues of surgical supervision concerning obligation, proximity, liability, and informed consent. The House and Senate bills remain actively sponsored, awaiting VHA Central Office resolution.
CONCLUSION
Well stated by many of their political enthusiasts, optometrys goal is a parallel profession rivaling ophthalmology. The optometry lobby felt it could force federal and state regulators and legislators to accept its arguments of access and affordability and capture surgical privileges. The lobby realized that optometric schools could not offer the essential surgical experience due to restrictive state statutes. This limitation forced the biphasic approach of seeking statutory and regulatory power, through isolated state and widespread federal venues, to expand scope of practice before requiring education and training that is comparable to what is required of ophthalmologists. This goal was accomplished via political persuasion both in Oklahoma and within the VHA Central Office. Opportunities for the advancement of optometrys educational level exist in private ophthalmology practices, academic ophthalmology, and the Federal Health System. Many nonstandard, nonguaranteed ophthalmology relationships are currently accredited by the American Council on Optometric Education, but the Federal Health System offers the best solution for secondary optometric education. The VA, in contrast to the Military and Indian Health Services, offers the advantages of widespread national distribution, aggressive advancement of nonphysicians, and a well-recognized educational mission and environment.
By design and an extremely potent political presence, the Federal Medical System has become optometrys surgical training venue. Two huge issues are before the Veterans Administration Central Office leadership: (1) must the Optometric Accreditation System for surgical education and training follow the same standards as the Accreditation Council for Graduate Medical Education; and (2) as the August 24, 2004, surgical supervision directive becomes a reality, will ophthalmology be required to educate and certify optometry in the art and science of surgery?
The AAO and its coalition partners from the family of medicine will maintain a very close and continuous dialogue with the VA leadership. n
Michael Brennan, MD, is Secretariat for the AAO. He may be reached at (336) 228-0254;
[email protected]
