BILL ANALYSIS
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|Hearing Date:August 29, 2000 | Bill No:SB 929|
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SENATE COMMITTEE ON BUSINESS AND PROFESSIONS
Senator Liz Figueroa, Chair
Bill No: SB 929Author:Polanco
As Amended:August 24, 2000 Fiscal:Yes
SUBJECT: Optometrists; scope of practice
SUMMARY: Expands 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.
Existing law:
1)Provides for the licensing and regulation of
optometrists by the Board of Optometry (Board), and
specifies the scope of practice that an optometrist
may lawfully perform;
2)Provides that licensed optometrists who meet
additional training requirements can be certified to
use therapeutic pharmaceutical agents (TPA or TPA
certified).
3)Establishes a TPA Advisory Committee within the
Board, and specifies its membership and role.
4)Specifies that a TPA certified optometrist may
lawfully treat a limited range of disorders of the
eye with a limited number of specified medications.
This bill:
1)Revises the definition of the practice of optometry
by specifying that it includes the diagnosis,
treatment, management and prevention of certain
disorders and dysfunctions of the visual system.
2)Expands the conditions that a TPA certified
optometrist is lawfully authorized to diagnose and
treat, and expands the treatments that these
optometrists may use in connection with the expanded
scope of practice. Specifically, the bill allows
optometrists to treat:
- infections of limited portions of the anterior
segment and adnexa, for patients other than those
with AIDS,
- ocular allergies of the anterior segment and adnexa,
- ocular inflammation that is nonsurgical in cause,
and that results from traumatic iritis, peripheral
corneal inflammatory keratitis, episcleritis, and
(for patients over age 18) unilateral nonrecurrent
nongranulomatous ideopathic iritis, provided that if
the latter condition recurs within one year, the
patient shall be referred to an opthalmologist, and
provided that opthalmological consultations occur in
certain cases,
- ocular pain associated with conditions that
optometrists may lawfully treat, other than pain
related to a surgical procedure,
- primary open angle glaucoma in patients over 18
years old, provided that the optometrist is
certified as provided by the bill.
3)Expands the list of medications that TPA certified
optometrists may use, including:
- topical steroid antiallergy agents, subject to
specific requirements governing mandatory
consultation and referral of patients to an
opthalmologist,
- topical steroid antiinflammatories, subject to
disease-specific requirements governing mandatory
consultation and referral to an opthalmologist,
- topical antiglaucoma agents, provided that the
optometrist is certified to treat glaucoma, and
subject to specified limitations,
- nonprescription medications used for the rational
treatment of an ocular disease that is within the
scope of the optometrists practice,
- oral antihistamines, subject to specific
requirements governing mandatory consultation and
referral of patients to an opthalmologist,
- prescription oral nonsteroidal antiinflammatory
agents, subject to a mandatory referral to an
opthalmologist if the condition has not resolved
within 3 days,
- specified oral antibiotics, limited to specified
regions of the eye, disease-specific, and subject to
specific requirements governing mandatory
consultation and referral of patients to an
opthalmologist,
- topical antiviral medication and oral acyclovir for
the treatment of specified diseases, subject to
disease specific requirements governing mandatory
consultation and referral of patients to an
opthalmologist,
- oral analgesics that are not controlled substances,
- codeine and hydrocodone with compounds specified in
the Controlled Substances Act, subject to a
mandatory referral to an opthalmologist if the pain
has not resolved within 3 days.
4)Establishes record-keeping responsibilities for
optometrists in cases that involve consultation and
referral to an opthalmologist, and provides that the
opthalmologist shall have access to those records.
5)Permits TPA certified optometrists to perform
specified diagnostic tests, excluding techniques
that would constitute surgery.
6)Expands the authorization for TPA certified
optometrists to 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.
7)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.
8)Prohibits optometrists from performing injections,
except auto-injectors to counter anaphylaxis.
9)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 opthalmologist.
10)Requires TPA certified optometrists to complete 35
hours of continuing education (out of a total
requirement of 50 hours every 2 years) in specified
disciplines relevant to the certification.
11)Makes conforming changes to the Controlled
Substances Act to reflect the new prescribing
authority established by the bill.
12)Clarifies the scope of practice of assistants who
work for both optometrists and opthalmologists.
13)Expresses the intent of the Legislature that the
expansion of the scope of practice for optometrists
proposed by the bill not be amended prior to January
1, 2009, and that no legislation be introduced to
that end until January 1, 2008.
FISCAL EFFECT: Minor absorbable costs to the Board of
Optometry.
COMMENTS:
1.Purpose. According to the author, this bill is
sponsored by the California Optometric Association
(COA) to expand the scope of optometric practice to
include additional conditions and additional means
of treatment. The language in the bill is 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 (which is neutral on
the bill), was to resolve medical/scientific issues
via discussions between practicing and academic
professionals. In many ways, this proposal is a
product of leaving science to the scientists (and
then codifying the results).
2.California's Optometric Scope Of Practice Is Now,
And Will Remain Under The Terms Of The Bill, One Of
The Narrowest In The Country. According to the
sponsors, current California law limits what
optometrists can do more than any other state. U.C.
Berkeley's optometry school, one of the pre-eminent
optometry schools in the country, trains its
graduates to perform far broader services than they
can perform in California so that these graduates
will be qualified to practice in other states. In
fact, many graduates who would prefer to remain in
California opt to establish their practice elsewhere
precisely because of the limitations of California
law.
The California Academy of Opthalmologists has
acknowledged that the bill, while expanding
optometric scope of practice in significant ways,
keeps California's law among the narrowest. For
example, 45 other states allow optometrists to treat
glaucoma to some extent, and every one of those 45
states allows a broader scope than is being proposed
by SB 929 . 50 other states/territories already
allow use of topical steroids; 39 allow use of oral
steroids. SB 929 proposes to make California the
51st to authorize topical steroids; it continues to
prohibit use of oral steroids by optometrists.
Similar comparisons can be made as to other
expansions proposed by the bill.
3.Optometrists Argue That Safe And Effective Practice
In Other States Proves the Bill's Expansion Is
Reasonable. Sponsors argue that there is nothing in
the bill that optometrists are not presently being
adequately trained to perform. They argue that
optometrists are proving in the laboratory of the
real world that they can safely perform everything
authorized by this bill. Because optometrists have
successfully practiced everything proposed by the
bill in other states for some time, and because
there is no evidence that even hints at risk or harm
to patients, they argue that opposition arguments
suggesting patient risk are misplaced. Vision
Service Plan (VSP), which also supports the bill,
states that its national experience establishes that
optometrists can provide safe, effective service to
patients under the terms of the bill. VSP believes
that its 9 million California members will have "a
greater array of treatment options and reduce
unnecessary referrals and duplicative office
visits."
4.Late Assembly Amendments Narrow The Bill. In the
Assembly Appropriations Committee, the bill was
amended to eliminate the establishment of a
Multi-Disciplinary Committee. This Committee would
have been authorized to expand the treatment and
diagnostic options available to optometrists without
amending the statute. As a result of opposition by
certain physicians and the California Medical
Association (CMA), the provision was removed, and
therefore the Legislature would retain authority
over the diseases and conditions, as well as the
treatments, that are within optometrists scope of
practice.
5.Patient Advocates And Consumer Groups Support The
Bill. A range of patient advocate groups and
consumer organizations (listed at the end of this
analysis) argue that the bill will provide better
access to necessary health care services for
underserved populations, especially low-income and
uninsured patients.
6.CMA Objects To Expanding Prescribing Authority For
Antibiotics. The CMA is concerned about the
over-prescription of many drugs, especially
antibiotics. It fears that the bill will only
exacerbate an existing problem of bacterial
resistance to antibiotics. It also is concerned
that a patient's optometrist and physician may both
be prescribing antibiotics unaware that the other is
also prescribing antibiotics.
7.CMA Fears Liability Issues. The bill provides for
detailed co-management of many of the diseases that
optometrists would be authorized to treat.
Depending on the disease, there are specific
mandatory consultation and referral requirements.
The CMA suggests that physicians may be saddled with
liability where a "bad result" is referred to them,
and has requested some sort of exemption from
liability.
SUPPORT AND OPPOSITION:
Support:California Optometric Association (sponsor)
Vision Service Plan (VSP)
Congress of California Seniors
State Board of Optometry
Advisory Council to Area 1 Agency on Aging
(Humboldt and Del Norte Counties)
Consumer Federation of California
California Primary Care Association
American Public Health Association
Southern California Public Health Association
Engineers and Scientists of California, Local
20
Consumers First
Western Center on Law and Poverty
Community Blind Center
Numerous individual opthalmologists
Numerous individual optometrists
Numerous individuals
Opposition:California Medical Association
Numerous individual opthalmologists
Consultant:Mark Rakich
SB 929
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