Introduction
An optometrist has the technical ability to detect the early signs of potential ocular and systemic diseases. This is because the eyes, because of their rich blood supply, provide opportunities for inspection of the cardiovascular system. The fundus region in the eye can be observed non-invasively and directly, providing vital clues on the systemic status. Retinopathy may be caused by several factors like diabetes, hypercholesterolemia, hypertension and HIV positive status (Rughani, 2013). Cardiovascular disease (CVD) is the biggest contributor to mortality in the Western world. It accounts for approximately 80% premature mortality in diabetes. The optometrist plays the important role of not only preventing sight loss due to ocular manifestations of disease but also in diagnosing cardiovascular diseases (and recommending treatment) through these manifestations. Besides CVD, hypertension is also a disease that manifests itself in an ocular fashion (Rughani, 2013). It is important to note that hypertension is a significant risk factor for stroke, arterial aneurisms and heart failure as well as various eye conditions. The retina is a target organ for hypertension. This explains the ocular manifestation; which may be diagnosed through proper optometry. Hypertension, diabetes mellitus and CVD may be manifested through Retina Vein Occlusion (RVO) which may be diagnosed through optometry (Rughani, 2013). RVO leads to painless vision loss. Against this background is a shortage of physicians in the state of California. As a result of all these issues and health problems as well as the shortage of physicians in California, Senator Ed Hernandez introduced several bills, including the Senate Bill 492, to address the doctor shortage. He states that the problem of doctor shortages can be overcome thy allowing optometrists to perform some of the procedures performed by doctors such as diagnosis, treatment, prescriptions as well as surgeries. The argument is that this will relieve the pressure on doctors. This paper examines Senate Bill 492, the severity of the problem it is addressing and the arguments made for and against it.
Senator Ed Hernandez of California believes that it is critical that California citizens are provided with increased access to quality healthcare. With an expected 4.5 to 5 million increases in the number of Californians with access to insurance (as the Affordable care Act comes into play) the system will be extensively strained. California has 30,000 physicians for primary care while there are more than 38 million residents in the state. This makes California 26th in the rankings of doctor-resident ratios according to the Association of American Medical Colleges (AAMC). Only 16 out of the state of California’s 58 counties have adequate supply of physicians as recommended by Federal government. Moreover, according to the AAMC, more than 30% of the doctors in California are close to their retirement age. At the same time, the state is making preparations to expand the Medi-cal and has stated that most residents should have health insurance as stipulated in the Affordable Care Act. This will increase the strain of doctors and drastically affect the doctor-patient and doctor-resident ratios. Although Lin (2013) believes that the issue is more of a distribution issue than a shortage issue, something needs to be done. Lin (2013) estimates that there will be a shortage of approximately 17,000 physicians in California by the year 2015. The SB 492 recommends the provision of the addition of the services that an optometrist can offer (so long as they are TPA certified). It permits the optometrist to treat the lacrimal gland as well as the sclera and the lacrimal drainage systems in 12 years-and-under patients as well as other detailed specifications. If passed, the Senate Bill 492 would permit the prescription of US, FDA-approved drugs to be used for treatment of the eyes and delivery of drugs in the manner the drug is approved for delivery in including through injection. This would take the load off the doctors and counter the shortage.
However, there are opponents to the passage of this bill. These include the California Medical Association (CMA), who asserts that they prefer the state focusing on developing more medical training institutions; adding the number of residency slots and widening the programs which help medical students pay-off their student loans. The opponents to this bill see it as an instrument for the dilution of physician practices, which may lead to various undoing.
The bill is known as the Senate Bill number 492 and its author is Ed Hernandez of D-West Covina. The Optometry practice bill licenses optometrists while regulating their practice. According to the existing law, optometry is the prevention and the examination of human eyes, the determination of the range of sight for human vision and the prescription of spectacle lenses and contact lenses. The existing law holds that educational and examination requirements must be met for licensure to ensure that optometrists who are in practice are competent. The significance of this bill in legal terms is that it effectively deletes the existing definition of optometry. The law would provide licensed optometrists with the authority to conduct certain health related services such as examining, diagnosing as well as treating diseases, disorders or conditions of visual systems. The following list of duties is permitted under the bill:
- Examination, prevention, diagnosis and treatment of any condition, disorder or disease pertaining to the visuals system, the eye and adjacent structures.
- Prescribing appropriate drugs, such as narcotic substances apart from those listed under schedule 1.
- Performing both surgical as well as non-surgical primary care processes that require no more than local or topical anesthetic.
- Using prescription of visual therapy, habilitation and rehabilitation of sight.
- Performing or ordering the necessary laboratory as well as diagnostic imaging tests.
In addition to this, an optometrist is permitted to administer immunizations as well as diagnosing conditions that may be manifested in an ocular fashion. This bill is bound to benefit optometrists. This is because they will get more patients in their practice and earn more money. While Californians are going to benefit largely from this bill if passed, optometrists are viewed as the main beneficiaries. It is interesting that Ed Hernandez, the author of the bill is an optometrist by profession. His scope of work is bound to expand significantly if this bill is passed into law. There are 9,000 optometrists in California who will venture into their new widened spheres of practice and benefit financially. Physicians, on the other hand, are bound to lose some grip on their fellow Californians. Granted, their workload will be reduced to more manageable levels. However, they will not get as many patients looking for their services as before. This implies that doctors in private practice in affected branches of medicine will see their incomes reduce markedly. The main stakeholders of this bill are doctors and optometrists.
The proponents of the Senate Bill 492 include the Bay area council, California Blue Shield, the California Optometric Association, Health-System Pharmacists, Californians Patient care, California Hospital Association, Vision Service Plan and the Western University of Health Sciences. The first argument in support of the bill is that it enables optometrists to practice the profession to the complete extent of their training and education to expand accessibility of healthcare to the millions of California citizens. These citizens will be provided with access to coverage when the patient protection and Care Act (ACA) is implemented. The second argument in favor of the bill is that optometrists will be accorded with the permission for diagnosis, treatment and management of specific eye disorders as well as major diseases like diabetes, hyperlipidemia and hypertension. In addition, the optometrists will be permitted to administer immunizations and conduct surgical procedures. The Blue Shield of California and the Californians for Patient Care assert that the expected influx of patients with the passage of the Affordable Care Act is bound to bring in an overwhelming influx of patients. They believe that this calls for educated, qualified and trained optometrists to be allowed to extend the bounds of their practice. According to the Optometric Association of California, this bill addresses the gap in health care provision. They believe that optometrists are best suited to expand their practice.
The groups in favor of this bill also stand to obtain financial gains if it is passed. Some may argue that this may be the real motivation behind their rallying call for the bill to proceed for enactment. The fact that Ed Hernandez has authored a bill that would personally benefit from is a major point of discourse among political analysts. Optometrists are going to benefit from a windfall of clientele and this will reflect financially in their practice. According to Hrabe (2013), the Senate Bill 492 has underlying benefits which its proponents are hiding beneath the claim that the bill will overcome doctor shortages. Opponents are quick to point this out but one may also argue that opponents to the bill stand to gain if it is rejected.
The opposition of the bill includes members of the: American Emergency Physicians College, California Medical Association, Canvasback Missions Inc., Academy of Eye Physicians & Surgeons and the Society of Plastic Surgeons (California). There are several arguments presented in opposition of this bill. These concerns are outlined by the CMA. The CMA believes that the increased services for primary case which the bill is going to provide optometrists with if passed are beyond the existing capacity of practice that is linked to visual disorders. They believe that optometrists could lead to serious harm to patients if allowed to practice. Moreover, SB 492 permits optometrists to practice medicine even though they are not under the Medical Practice Act. This is because optometrists are currently under the Board of Optometry. Under the scope of practice stipulated under the SB 492, optometrists would be elevated to the status of ophthalmologists. Ophthalmologists are required to operate while in possession of a medical license. These feelings are echoed by the Union of American Physicians and Dentists and other stakeholders. For example, they argue that while they recognize the capacity of optometrists to perform some waived tests which are limited to their scope of medical practice, they have major concerns regarding the wide range of testing that is permitted by this bill. They are even more concerned with the fact that optometrists may not have received the proper training and education required to perform as a lab director. The eye physicians are more concerned about provisions that permit optometrists to carry out eye surgeries and prescriptions via all routes without having additional training. The Union of American Physicians and Dentists argue that the bill (SB 492) provides for an uncertain healthcare delivery system where patients are subject to unintended penalties of the bill. Optometrists need to be supervised so that safe patient outcomes can be achieved. There are grave patient concerns involved in this bill because optometrists are accorded the permission to prescribe drugs and operate on patients with no medical supervision. The Society of Anesthesiologists in California asserts that SB 492 allows diagnosis as well as initiation of treatments for conditions which have ocular manifestation. This authorization is unfounded because it is not merited through scientific consensus.
There are several unintended consequences that may arise from passage of the Senate Bill 492. Essentially, the bill extends the coverage of the practice of optometrists into methods, practices and procedures that are relatively new to them and that are not part of what they have been purposed for as optometrists. The three most worrying issues about permitting optometrists to perform physician duties include: First, the bill enables them to perform diagnosis. Granted, they have the capacity to conduct this without making mistakes, however, diagnosis is a practice that will take time before they can fully master it. In the process of learning, patients may get the wrong diagnosis. This may adversely hamper their medical well-being. The second issue is that optometrists will be enabled to provide prescriptions. Prescriptions are usually a major undoing for physicians who are not keen on their work. Due to their relative inexperience in handling prescriptions, there is no telling whether there will be mistakes in prescriptions. These kinds of mistakes may lead to life-threatening scenarios. Thirdly, unsupervised performance of surgery by optometrists poses serious medical risks. Qualitycareaccess.org (2013) lists the opinions of several senators and other professionals regarding the Senate Bill 492. According to Senator Hannah Jackson of Santa Barbara, she opposes the bill because optometric training and experience differs from that of physicians. Senator Jim Nelson of R-Gerber has serious concerns regarding the medical practice in California, saying that the current trend will lead to rationed care as well as diminished care. Optometrists and nurses do not have the relevant training and experience. Enactment of this bill is a dangerous and slippery slope. An unnamed reporter of the Sun Newspaper has fears that allowing optometrists, nurses and pharmacists to perform diagnosis, disease management, prescriptions and surgery and with no prior training or supervision will place patients in great risk and will raise health care costs significantly. Penny Wood, a contributor to this discussion asserts her belief that there is no need to have individuals providing generalized instead of specialized care. This is because as a team, physicians, optometrists, pharmacists and nurses provide remarkable health care. Enabling all these professionals to provide a wide scope of services may end up lowering the quality of healthcare and may have serious negative impacts on medical practice.
I have several recommendations regarding this bill. Granted, there is a shortage of physicians in California. However, the widening of optometric practice should be done in a step-wise manner. The state should develop criteria for selecting the most qualified optometrists for the first stage of integrating them into wider medical practice. In addition, there should be stringent measures to ensure that optometrists are supervised when undertaking serious medical procedures such as surgery and treatment. This is because there are serious risks posed by unsupervised surgery. Specific practices like diagnosis may be left entirely to optometrists for the measure to make an impact. The underlying benefits at stake with the bill should be done away with and should not be the main motivating factor for the discourse. Another recommendation for the passage of this bill is that optometric studies should be revamped to include the more rigorous demands for the new job descriptions. This would not only lead to better patient outcomes and risk reduction but also it can put to rest the many grievances surrounding the Senate Bill 492. Patients would also be at relatively more ease with optometrists.
Conclusion
The Senate Bill 492 allows an optometrist to diagnose, manage and treat the additional conditions with ocular manifestations. It directs that the California Board of Optometry should establish examination and educational requirements. It allows optometrists to conduct vaccinations as well as surgical and non-surgical procedures for primary care. In short, the bill would permit optometrists to diagnose all eye-related ailments including for conditions like diabetes. This is aimed at reducing the shortage of doctors by expanding the tasks that are legally permitted for optometrists. Proponents of this bill argue that it will reduce the problem brought about by shortage of physicians. They underpin this argument by stating that since citizens will be provided with access to coverage when the patient protection and Care Act (ACA) is implemented, the number of people needing specialized care will increase. Opponents to this bill see it as a plan by optometrists to increase their practice and ultimately, their incomes. They also claim that optometrists are not trained well enough and would require supervision. Another opposing argument is that optometrists would not be able to carry out proper diagnosis and surgery, leading to great risks.
References
Hrabe, J. (2013). Sen. Hernandez authors bills to benefit his optometry business | Cal Watchdog. Cal Watchdog. Retrieved December 1, 2013, from http://calwatchdog.com/2013/06/17/sen-hernandez-authors-bills-to-benefit-his-optometry-business/
Lin, J. (2013). Calif. bills would let optometrists, nurses do more. Insurance news & sales ideas for life & health insurance professionals. Retrieved December 1, 2013, from http://www.lifehealthpro.com/2013/03/14/calif-bills-would-let-optometrists-nurses-do-more
Rughani, S. (2013). The vital role of optometry in disease detection. Ophthalmic Public Health Part 3 C, 4(3), 1-4.
Qualitycareaccess.org. (2013). What People Are Saying. Coalition for Patient Access and Quality Care. Retrieved December 1, 2013, from http://www.qualitycareaccess.org/What_People_Are_Saying.html
