BILL ANALYSIS
----------------------------------------------------------
|Hearing Date:April 14, 2008 |Bill No:SB |
| |1406 |
----------------------------------------------------------
SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC
DEVELOPMENT
Senator Mark Ridley-Thomas, Chair
Bill No: SB 1406Author:Correa
As Introduced: February 21, 2008 Fiscal: Yes
SUBJECT: Optometry.
SUMMARY: Revises and recasts the scope of practice for
optometrists to provide that an optometrist who is
certified to use therapeutic pharmaceutical agents may
diagnose and treat the eye, or any part of the visual
system, for any of the conditions that he or she is trained
and authorized by the Board of Optometry to diagnose and
treat.
Existing law:
1)Regulates the practice of optometry through the licensure
and regulation of some 6,500 optometrists by the State
Board of Optometry (Board), within the Department of
Consumer Affairs (DCA).
2)Defines the practice of optometry as including the
prevention and diagnosis of disorders and dysfunctions of
the visual system, and the treatment and management of
certain disorders and dysfunctions of the visual system,
as well as the provision of rehabilitative optometric
services, and includes specified practices, including:
a) Examination of the eye or its appendages, and
analysis of the vision system.
b) Determination of the powers or range of vision and
the accommodative and refractive states of the eye.
c) Prescribing or directing the use of optical
devices.
d) Prescribing of contact and spectacle lenses for, or
SB 1406
Page 2
their fitting.
e) The use of topical pharmaceutical agents (TPAs) for
the sole purpose of the examination of the human eye
or eyes for any disease or pathological condition.
1)Prescribes certain eye or eye appendage conditions for
which an optometrist who is certified to use TPAs may
diagnose and treat, as specified.
2)Describes the specific TPAs that a optometrist may use in
diagnosing or treating eye or eye appendage conditions as
indicated above.
3)Requires an optometrist to consult with an
ophthalmologist in diagnosing or treating specified
conditions, and establishes record-keeping
responsibilities, and provides that the opthalmologist
shall have access to those records.
4)Permits TPA certified optometrists to carry out specific
activities, including:
a) Perform specified diagnostic tests, excluding
techniques that would constitute surgery.
b) Remove foreign bodies from the cornea, provided
that the foreign bodies are nonperforating, no deeper
than the anterior stroma, and the removal does not
involve surgical techniques.
5)Authorizes the Board to certify a TPA certified
optometrist to perform lacrimal irrigation and dilation
of patients over age 12, subject to specified
limitations, only after the optometrist has completed at
least 10 of these procedures under the direct supervision
of an opthalmologist.
6)Prohibits optometrists from performing injections, except
auto-injectors to counter anaphylaxis.
7)Authorizes the Board to certify TPA certified
optometrists to treat primary open angle glaucoma in
patients over 18 years old, provided the optometrist has
successfully completed specified educational requirements
and has provided treatment for at least 2 years to at
least 50 patients in a collaborative relationship with an
SB 1406
Page 3
opthalmologist.
This bill:
1)Revises and recasts those provisions to instead provide
that an optometrist who is certified to use therapeutic
pharmaceutical agents may:
a) Diagnose and treat the eye, or any part of the
visual system, for any of the conditions that he or
she is trained and authorized by the Board to diagnose
and treat.
b) Use any TPA he or she determines to be necessary.
c) Perform minor surgical procedures not requiring
general anesthesia
any test or procedure necessary for diagnosis of the
visual system.
d) Perform lacrimal irrigation and dilatation
necessary for diagnosis of the visual system.
e) Injections necessary for diagnosis and treatment.
2)Requires the board, in establishing certification
standards for those optometrists, to consult with the
clinical faculty of approved California schools of
optometry and other interested parties.
3)Revises and recasts provisions related to licensees who
graduated from a California accredited school of
optometry prior to January 1, 1996,
4)Makes other related and conforming changes.
FISCAL EFFECT: Unknown. This bill has been keyed "fiscal"
by Legislative Counsel.
COMMENTS:
1.Purpose. This bill is sponsored by the California
Optometric Association (Sponsor) to amend the Optometric
Practice Act to remove existing statutory restrictions
SB 1406
Page 4
that operate as barriers to efficient, effective primary
care; redefine the regulatory model for optometry in a
manner consistent with medicine and dentistry in
California, and optometry as practiced in most other
states; and delegate responsibility for licensing,
setting qualifications, and enforcement to the State
Board of Optometry and properly-accredited professional
entities. The bill also makes conforming amendments to
other provisions of the Business and Professions Code.
2.Background. According to the Sponsor, California's laws
licensing three classes of independent health care
practitioners with at least four years of accredited,
post-graduate education (physicians and surgeons,
dentists; doctors of podiatric) define in general what
they are permitted to do, consistent with their education
and training, in fairly simple, straightforward terms. A
single license covers all subspecialties, which are
credentialed not by the state but by private, national or
state professional bodies. Their respective regulators
(the Medical Board of California, the Dental Board of
California, and the California Board of Podiatric
Medicine) define the Legislature's general grant of
authority through regulation and protect the public
through enforcement.
By contrast, the Sponsor indicates that the legislative
scope of practice of optometrists, spells out in detail
what they are not permitted do, in relation to physicians
and surgeons generally and specifically those who
practice the subspecialty of ophthalmology. The Sponsor
states that the State Board of Optometry has little
discretion to interpret those requirements.
3.Prior Legislation. There has been a long, protracted,
and often contentious struggle between optometrists and
physicians and surgeons, particularly ophthalmologists
regarding the optometry scope of practice.
SB 929 (Polanco, Chapter. 676, Statutes of 2000) expanded
the scope of lawful practice for optometrists by
specifying additional diseases and conditions that
optometrists may treat (in particular certain types of
glaucoma) with specified medications, and by specifying
the extent of physician involvement that is required
under various circumstances. The language in the bill
SB 1406
Page 5
was the product of extensive and detailed negotiations
with the California Academy of Opthalmology (CAO). The
goal of these negotiations, which resulted in an
agreement between COA and CAO, was to resolve medical and
scientific issues via discussions between practicing and
academic professionals.
SB 668 (Polanco, Chapter 13, Statutes of 1996) was an
initial expansion of the optometrist scope of practice.
Prior to SB 668, the practice of optometry was basically
limited to the examination of the eye and its appendages,
and the determination of the powers or range of vision.
Optometrists were permitted to use topical pharmaceutical
agents only for the purpose of examining the eye for any
disease or condition. Optometrists were not authorized
to treat eye diseases, with or without medication. SB
668 expanded optometrist's scope of practice by providing
for TPA-certification to enable optometrists to diagnose
and treat a limited number of conditions of the eye, and
to use limited and specified pharmaceutical agents.
TPA-certified optometrists were permitted by this
legislation to prescribe and dispense drugs under the
Pharmacy Law. SB 668 also stated the intent of the
Legislature that the scope of practice of optometrists
not be expanded again prior to January 1, 2000,
reflecting an agreement by COA and the California Academy
of Ophthalmology.
4.Arguments in Support. In sponsoring the bill, the
California Optometric Association (COA) states that taken
as a whole, the statutory restrictions on the practice of
optometry have worked to keep doctors of optometry from
becoming a fully-utilized asset in California's primary
care health system, particularly as the state of diseases
in the population and eye care technology continue to
change. Like ophthalmologists, optometrists receive
specialized, intensive education and clinical training in
all aspects of the visual system, according to COA.
Unlike ophthalmologists, optometrists specialize in
primary eye care over surgery; besides vision correction
through lenses and therapy, they are qualified and
trained to diagnose all eye disease and unrelated
diseases that reveal themselves through the eye.
COA argues that currently, there are nearly three times
more licensed optometrists than ophthalmologists,
SB 1406
Page 6
practicing in over 100 cities and towns in 54 of
California's 58 counties. More than 2,600 optometrists
accept and treat Medi-Cal patients, as opposed to about
1,200 ophthalmologists. Because of their numbers,
dispersion throughout the state, and greater availability
to working families, optometrists are more available to
potential patients than any other systemic specialist.
Seven of ten eye care patients see optometrists first; for
many of them, it is their first visit to a health care
professional on their own initiative. These
restrictions, according to COA, prevent optometrists from
utilizing the diagnostic, therapeutic, and operative
tools available to their colleagues in 42 other states.
Full access to these tools would enable optometrists to
treat a wider range of eye problems on diagnosis,
eliminating unnecessary and expensive referrals, and
result in getting those patients to appropriate specialty
eye care sooner.
The Congress of California Seniors writes in support that
there are more than twice as many optometrists statewide
serving Medi-Cal patients as ophthalmologists, and in
many rural and urban communities an optometrist is the
only eye care professional whose services are within
reach of many patients. The bill would increase access
to affordable primary care for California residents.
Vison Service Plan (VSP) provides eye care coverage to more
than 12.6 million Californians states, "We are confident
in the care provided by Doctors of Optometry because
recent California research into eye care provided by both
classes of vision care specialist shows conclusively that
the quality of eye care from doctors of optometry and
ophthalmologists is virtually identical for comparable
services."
5.Arguments in Opposition. The California Academy of Eye
Physicians & Surgeons (CAEPS) opposes the bill arguing
that the bill would severely jeopardize patient safety by
inappropriately allowing optometrists to independently
diagnose and treat patients suffering from such chronic
eye diseases as glaucoma, eye infections associated with
AIDS and diseased eyes in children. Also terribly
troubling to CAEPS is the authority for optometrists to
order any laboratory test or procedure and perform any
SB 1406
Page 7
minor surgical procedure not requiring general anesthesia
in order to diagnose and treat any condition of the eye
or visual system, which includes major portions of the
brain. Furthermore, the bill allows optometrists to use
any drugs he or she determines to be necessary in
diagnosing and treating any medical conditions of the eye
or visual system. Lastly, the bill requires the
California State Board of Optometry and not the Medical
Board of California to determine the appropriate
education, training and certification criteria for
optometrists to essentially practice medicine.
CAEPS argues that the bill would greatly increase the
potential for patient harm and delayed diagnosis of
serious blinding and life threatening diseases. CAEPS
agrees that optometrists perform an appropriate treatment
role in collaboration with eye physicians and surgeons
(i.e. ophthalmologists) under existing optometric scope
of practice. Furthermore, most optometrists and eye
physicians and surgeons currently work well together to
achieve safe, efficacious and appropriate patient care.
CAEPS point out that eye physicians and surgeons have
obtained nearly a decade of appropriate medical education
and training in the overall physical, clinical, imaging
and laboratory manifestations to evaluate, diagnose and
treat all eye diseases of the patient; optometrists on
the other hand, may only have four years of optometric
school and, in some cases, an additional year of
residency.
California Society of Health System Pharmacists (CSHP)
argues that while there is an increasing demand for
ophthalmologists in California, increasing the scope of
practice and prescriptive authority of optometrists will
not safely address the issue.
The American Psychiatric Association (APA) argues that the
bill allows optometrists to diagnose and treat any
portion of the visual system, which also includes the
brain. In addition the bill would authorize the majority
of surgical procedures, including tumor removals and all
forms of laser surgery, and remove the requirement to
refer to an ophthalmologist if the patient's condition
fails to improve. APA indicates that from a medical
perspective, such an expansion of practice authority,
accompanied by a removal of medical oversight and patient
SB 1406
Page 8
safety protections is alarming.
The American College of Surgeons states that as the largest
surgical organization in the world, it is concerned that
it allows optometrists to perform minor surgery as long
as general anesthesia is not required. "There is really
no such thing as a 'minor' surgical procedure; any
incision made into the human body, whether by a scalpel,
a laser, or other device is a 'major' concern for the
patient.
SUPPORT AND OPPOSITION:
Support:
California Optometric Association (Sponsor)
Congress of California Seniors
Engineers & Scientists of California
Operation for Clear Vision
Vision Service Plan (VSP)
Numerous Individuals
Opposition:
African American Eye Physician and Surgeon Alliance
American Academy of Ophthalmology
American College of Obstetricians and Gynecologists
American College of Surgeons
American Osteopathic Association
American Psychiatric Association
American Psychiatric Association (APA)
American Society for Dermatologic Surgery Association
(ASDSA)
American Society of Ophthalmic Plastic and Reconstructive
Surgery
American Society of Retina Specialists
Asian Pacific Islander Eye Physician Coalition
Association of University Professors of Ophthalmology
Blindness Foundation
California Academy of Eye Physicians and Surgeons (CAEPS)
California Educators of Ophthalmology for Quality Care
California Medical Association
California Pacific Medical Center
California Society of Anesthesiologists
California Society of Health System Pharmacists (CSHP)
SB 1406
Page 9
California Society of Plastic Surgeons (CSPS)
Cornea Society
Latino Physicicians for Safe Eye Care
North American Neuro-Ophthalmology Society (NANOS)
Retina Society
Stanford University School of Medicine
University of Southern California, Keek School of Medicine
Numerous Individuals
Consultant:G. V. Ayers