For four years, the eyecare practitioners of Florida coexisted in peace.
Then, everything changed when the optometrists attacked.
At least, that’s been the reaction of some who opposed a bill in the Florida legislature that would allow optometrists to expand their services to include minor surgical procedures.
A measure by state Rep. Manny Diaz Jr., R-Hialeah, prompted more than two hours of debate and testimony Wednesday, culminating in an 8-7 vote by the House Health and Human Services Health Quality Subcommittee.
“House Bill 1037 recommends changes to the scope of practice in the field of optometry,” Diaz told the committee. He said that the Board of Optometry would be given authority to define a new prescription formulary for drugs that certified optometrists could prescribe.
In addition, Diaz said that optometrists would be permitted to perform minor external procedures, which could include procedures like removal of benign growths on the eyelid and the use of lasers to treat glaucoma that has not responded to eye drops. “Again, no operating room or hospital-based care is required for this kind of treatment,” said Diaz.
Any optometrist looking to expand his practice to include prescribing approved drugs or performing those minor surgeries would need to complete additional training. The list of approved surgeries would be contingent on the approval of the Florida Surgeon General, and upon creation of a certification course.
Diaz told the committee that this was an issue of expanding access to care. He said that of the approximately 1,400 ophthalmologists in the state of Florida, only 400 accept Medicaid.
“I’m a rural physician, so access to care issues are real to me,” said Subcommittee Chair Cary Pigman, R-Avon Park. “I’ve seen over the years the gradual de-credentialing, or leaving the hospital,” adding that sometimes a physician like himself would have to deal with an eyelid injury, despite being less qualified than either an ophthalmologist or an optometrist to treat it.
The greater good
Similar access v. expertise debates on the expansion of dental therapy, which would allow credentialed dental therapists to join dentists in performing some minor procedures, have occurred in North Dakota, Arizona and other states.
Dr. Ken Lawson, legislative chair of the Florida Optometric Association and a practicing optometrist in Manatee County, told the committee that this was not an effort to “elevate” optometrists to the level of ophthalmologists.
“The number one issue in this state is not bad care, it’s no care,” Lawson said. “I’ve had patients that I’ve seen that I felt needed the procedures that I’m asking you to do, and I could not get an ophthalmologist to take their insurance or take them as an indigent patient.”
“If they all took it, maybe I wouldn’t be standing here in front of you today putting up this bill,” he said.
Dr. Carl Spear told the committee that he first trained and practiced in Oklahoma, where optometrists have been allowed to expand their services pursuant to additional training.
Spear told the panel that after his optometry residency, he stayed on at Northeastern State University in Oklahoma as a professor, teaching optometry courses in laser therapy, minor surgical procedures and oral medications.
“It really and truly is an access to care issue,” said Spear, who currently practices in the panhandle. He added that, nationwide, the number of ophthalmology residents is not keeping up with population growth. According to Spear, there were approximately 19,000 ophthalmologists nationwide in the year 2000 — the same number of ophthalmologists projected for the year 2025.
Ophthalmologists that came to testify at the hearing sharply disagreed that increasing the scope of optometry would benefit patients.
“There is no such thing as a minor surgery,” said Dr. Ryan Smith, an ophthalmology resident in Gainesville who is about to begin a one-year fellowship to become a glaucoma surgical specialist.
Smith said that all of the laser surgeries being discussed “are certainly ablative [surgical removal of body tissue] and certainly invasive. Even the most minor things that they’re asking for are extremely dangerous, and especially in the wrong hands.”
Smith, who told the committee that his wife is a dentist, rejected the comparisons between optometry and dentistry.
“Blindness is blindness. It doesn’t come back. Surgical procedures on a tooth … you have 32 of them. And you have two eyes, they don’t come back,” he said.
Dr. Jason Goldman, a Coral Springs internist and governor of the Florida Medical Association, told the subcommittee that the bill endangered patient safety and would not solve the access to care problem.
“The issue is not that we don’t have the trained ophthalmologists, it’s an issue of Medicaid reform, which is beyond the scope of this bill,” Goldman said.
“To say that we don’t have access, so we need optometrists to perform these procedure is like saying we don’t have enough airline pilots, so we need the flight attendants to fly the plane,” he said.
Refighting the fight
Bruce May, a lobbyist for the Florida Society of Ophthalmology, said that optometrists had made a similar request of the legislature for expanded scope back in 2013.
The vociferous nature of debate led to the then-speaker of the House and Senate president having all parties sign a compromise agreement ending the “eyeball wars.” Under that deal, May said that optometrists settled for being able to prescribe 14 oral drugs, and agreed that surgery would be prohibited.
“I don’t know why the optometrists are walking back from the agreement they made just four years ago,” said May. “I do know that nothing has changed since 2013 that would make it safe for optometrists to perform surgeries and prescribe all oral medications.”
Diaz told the committee that one of the problems with the existing situation is that any set of drugs — such as the list of 14 that the 2013 bill specified — quickly becomes outdated as technology improves.
Some lawmakers expressed concern about the potential for error from less-trained hands performing surgeries. State Rep. Robert Asencio, D-Miami, told the subcommittee that as a glaucoma patient, he didn’t have the luxury of starting with a less-experienced professional and working his way up to treatment by a specialist.
Diaz addressed that concern, along with the suggestion that any reforms should wait for an overhaul of Medicaid.
“If we have the choice between choosing an ophthalmologist for surgery on a complicated matter over an optometrist, clearly those of us that have the resources and the opportunity will make that choice,” said Diaz.
“I know we talk about fixing it somewhere else, and we always have those conversations, but the truth is that you have an opportunity with a bill here in front of you to address some of that,” he said.
Diaz added that some of the structural issues with the bill could still be addressed in the full committee and on the House floor.