An Ophthalmic Activist in Oklahoma

TCRSToday: Could you give us a brief overview of the events that have led to the existing situation in Oklahoma between ophthalmology and optometry?
Dr. Bradford: In 1998, Oklahoma passed an unprecedented law allowing optometrists to perform laser surgery. They are trained in Oklahoma's optometry school. This was the first huge step in an aggressive optometric lobbying effort in Oklahoma. In April of this year, Oklahoma passed a law that determined that the practice of optometry included nonlaser surgery, to be defined by rules promulgated by the Board of Optometry. The rules were declared by the board on October 4, 2004, and negotiations are ongoing. Oklahoma ophthalmologists are appealing to Governor Henry, who has promised not to allow the rules to expand optometry's scope of practice. Oklahoma ophthalmologists are looking forward to Governor Henry's keeping the rules on the straight and narrow.

Despite the recent legislation, the current state of affairs between ophthalmologists and optometrists in the state can hardly be described as static. Negotiations and organized activities are still taking place, and I do not consider the new optometric scope-of-practice expansion a done deal.

CRSToday: What is the Department of Veteran Affair's role in optometric scope of practice?
Dr. Bradford: Physicians, nurses, dentists, as well as optometrists who are employed by the VA system have a different licensing requirement than those outside of that system. Within the VA, a physician's state of licensure is independent of the facility and state. The VA system is structured to be able to move its employees from state to state. As a result, its nurses, dentists, and physicians all carry one license because, from an administrative and a logistical standpoint, it is too expensive and time-consuming to relicense these providers every time the VA moves them to another state. An optometrist who is licensed in Oklahoma to perform laser surgery could work for the VA in another state and perform laser surgery in that state under his Oklahoma license. The VA held a moratorium on this topic and subsequently issued a directive1 that has been updated several times. Its wording has been altered slightly, but the directive basically states that an optometrist can perform laser surgery within the VA system if his state of licensure allows it and if he has been both trained and credentialed. Additionally, the optometrist must perform the laser surgery under the supervision of an ophthalmologist. This supervision required of ophthalmologists is not defined, which creates a very awkward situation for ophthalmologists who are licensed in a state where optometrists are not legally permitted to perform surgical procedures. There is a whole host of questions that arise from this directive. One example is, what is the physician supposed to do if he feels as though the procedure is not going well?

CRSToday: How did optometrists in Oklahoma gain surgical privileges in the first place?
Dr. Bradford: The 1998 laser bill that passed in Oklahoma read that optometrists were allowed to perform laser surgery, excluding retinal laser surgery, LASIK, and cosmetic lid surgery. In 2001, ophthalmologists in Oklahoma became aware that the state's optometric school was teaching minor lid surgery, which entails cutting the eyelid with a blade. Attorneys who carefully reviewed the optometric statutes did not believe that optometrists had any statutory right to cut eyelids and remove lesions. Instructors at the optometric school were also teaching students pterygium management and how to deliver Botox (Allergan, Inc., Irvine, CA) injections. These factors contributed to a growing concern among the medical community that some optometrists in Oklahoma appeared to be overstepping their statutory rights.

CRSToday: What was Ophthalmology's next move to address its concerns?
Dr. Bradford: At this point, activists within ophthalmology had to determine whether any optometrists were actually performing the procedures that they learned in the Oklahoma optometric school. Medicare billing records revealed that some optometrists were indeed billing for lid lesion removals, Botox injections, and quite a few other surgical codes. With evidence that the Oklahoma optometric school was teaching these procedures and that some optometrists were billing for them, ophthalmic activists asked Attorney General Drew Edmondson's opinion about optometrists' explicit statutory rights and whether the Oklahoma State Board of Optometry were independent. They wanted to know whether the independence of the optometry board, which was established by law in 1999, simply allowed that board to set its own scope-of-practice standards.

Ophthalmic activists also verified that the Oklahoma Board of Optometry was not credentialing optometrists to perform lid surgery. Rather, they were credentialing their students to perform anterior segment surgery. They maintained two different categories of lasers: (1) optometrists credentialed to perform anterior segment surgery and (2) those credentialed to perform refractive surgery, who formed a smaller group. Absolutely no optometrists, however, were credentialed to perform eyelid surgery, interestingly. The Attorney General stated his opinion in March 2004 that (1) optometrists did not have the statutory right to cut eyelids, and (2) the Oklahoma State Optometric Board did not have the independence to decide scope of practice.

The optometrists believed the State Attorney General's opinion on this issue interfered with their ability to practice because the CPT book of surgical codes included punctal occlusion, superficial corneal foreign body removal, and eyelash removal. Optometric activists' complaints to the Oklahoma state Attorney General about this issue resulted in an updated opinion2 on April 6, 2004, that clarified that the CPT codebook did not define surgery according to Oklahoma law. This statement transferred the issue of whether punctal plugs, lash removal, and corneal foreign body removal were surgery and would have allowed medical directors to deny optometrists those codes. These codes were never the issue, and it is likely that medical directors would not have denied these codes. The optometric activists did not resolve the issue with the medical directors, however. Because of their political clout, they simply went straight to the legislature and pushed for an overnight addition to pharmacy bill HB 2321 that gave them power over their own scope of practice, merely requiring the Oklahoma State Optometric Board to promulgate rules. In promoting the legislation, optometrists told the legislators that the attorney general's opinion had unintended consquences that inhibited their practice and that they simply wanted the right to practice punctal plug insertion and removal, lash removal, and superficial corneal foreign body removal. They had the political power to do that because they have spent 30 years with grassroots politics.

CRSToday: What, in your opinion, is optometry's motivation for pursuing these laws?
Dr. Bradford: I cannot say what motivates anybody other than myself. Before HB 2321 was passed, however, I talked directly with the optometric activists and told them, if punctal plugs, lash epilation with forceps, and superficial corneal foreign body were the problem, that they could first address it directly with the medical directors. I was certain that medical directors would be willing to pay for those codes because they had historically done so. I suspect that all state ophthalmologists would agree that punctal plugs, lash removal, and foreign body removal are appropriate for optometrists to perform. The activists' response was that they did not trust ophthalmology and that they wanted to have a law. I thought that a law would be fine and proposed replacing the ambiguous wording with language that specifically listed punctal plugs, lash removal, and superficial corneal foreign bodies. I saw this compromise as in the best interest of both patients and providers. My proposal, however, was unacceptable to the optometrists. Why would a group turn down what it stated it needed? That is the current state of affairs, and I think that most people can draw their own conclusions.

CRSToday: Is the gray area encompassed within the term invasive surgery helping to blur the line in terms of optometric scope of practice?
Dr. Bradford: Is an injection invasive surgery? I feel that it is. As a general ophthalmologist, I see plenty of patients with retinal problems. Although I have access to photography in my building, I refer these patients to my retinal colleagues, as do most of the ophthalmologists I have encountered. The reason is that retinal treatments are much more sophisticated than they used to be. I personally do not think there is any reason for optometrists to perform fluorescein angiography. In another example, certain treatments for macular degeneration involve injecting medication into and around the eye. I feel that it is very dangerous to have laws on the book that allow nonphysicians to perform these injections. Similarly, I think Botox injections should be performed by a medical doctor.

CRSToday: What are your views on the argument of physician scarcity in certain states?
Dr. Bradford: Physician scarcity is not a problem in Oklahoma. The state is not huge, although it is rural. It is simply impossible to have an ophthalmologist in every small town, and patients who live in a rural setting understand that they must drive to the city for specialized care. They make this accommodation for a number of services. Complex ocular problems and surgery require care from a qualified medical professional. Simply legislating the privilege to perform certain procedures does not give less educated professionals the knowledge and ability to deliver that level of care. Access to a lower quality of care is not a reason to expand optometric scope of practice.

CRSToday: Is the percentage of practicing ODs who would like to gain surgical privileges higher than what optometric activists would have people believe?
Dr. Bradford: Optometrists generally say that they do not know any optometrists who want to perform these procedures. This may or may not be true, but there certainly is a small minority who want this right. I am sure that there are plenty of optometrists who never plan on performing laser surgery, but I have heard optometrists say that theirs is a legislated profession. They try to push the legislation so that the next generation has a greater scope of practice.

CRSToday: Some say that as many as 99.9% of optometrists in the US are not interested in pursuing surgical rights.
Dr. Bradford: Then you have to ask why they are so politically active. The requirements that ophthalmologists must fulfill to be board-certified have been so carefully outlined that it should not be questioned whether the entire length of training is necessary. It is not possible to shortcut the educational process and deliver the same quality of care. The public is not asking for lower standards of training. Our state's youth are being told that they can bypass medical school, become certified in optometry in less time, and perform many of the same procedures that ophthalmologists do.

CRSToday: Why did ophthalmology's efforts fall short in Oklahoma?
Dr. Bradford: Optometrists are very politically active, and especially so in Oklahoma. When you talk about optometry's political power in Oklahoma, it is always remembered that a prior Speaker of the House taught optometrists to lobby and they learned well.

CRSToday: Are you pleased with the number of ophthalmologists who have become involved or are participating in fighting optometrists' attempts to broaden their scope of practice?
Dr. Bradford: No, I think ophthalmic participation should be 100% in Oklahoma, and, although it is much higher than in the past, it is not 100%. Optometrists could gain further privileges. It is very frustrating to try to educate legislators. Some have said to me that, although they know the right choice on the issue, they must still vote in favor of optometry. My only encouragement is that the legislature will be changing in Oklahoma soon as a result of term limits. I should note, however, that some very good legislators know the score and are willing to do what they think is right for patients.

CRSToday: What are the direct ramifications of the Oklahoma ruling on the rest of the country?
Dr. Bradford: What happened in Wisconsin in 2000 is a good example. Oklahoma optometrists visited optometrists in Wisconsin to teach them eyelid and laser surgery after the Board of Optometry in Wisconsin declared a ruling that optometrists could perform laser surgery. The Wisconsin optometric board received backlash from the legislature and the public and ultimately retracted that declaration.

CRSToday: What additional efforts have been made or are underway to broaden optometry's scope of practice elsewhere?
Dr. Bradford: In North Carolina, the Board of Optometry has sued the Board of Medicine over injections. Similar legislation was introduced in New Jersey last year but failed. In some states, such as New York and Illinois, optometrists are trying to build ASCs at optometry schools. They want their students to perform all pre- and postoperative care, an effort I view as a foray into surgery. n

Cynthia Bradford, MD, currently serves as Secretary for State Affairs on the AAO's Committee of Secretaries. She is Associate Professor of Ophthalmology at the Department of Ophthalmology at the University of Oklahoma Health Sciences Center/Dean A. McGee Eye Institute in Oklahoma City. Dr. Bradford may be reached at (405) 271-1819; cynthia-bradford@dmei.org.

1. Therapeutic Laser Eye Procedures. VHA Directive 2004-045 (2004). PDF file available at: http://www1.va.gov/vhapublications/ ViewPublication.asp?pub_ID=1148. Accessed: September 29, 2004.
2. Attorney General Opinion 04-9. PDF file available at: http://www.oklegal.onenet.net/oklegal-cgi/ifetch?okag+1270240066208+F. Accessed: September 29, 2004.