Legislature(1997 - 1998)
04/22/1997 03:03 PM House HES
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* first hearing in first committee of referral
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HB 195 - LICENSURE OF OPTOMETRISTS Number 1629 CHAIRMAN BUNDE announced the next item on the agenda was HB 195, "An Act relating to licensure of optometrists; and providing for an effective date." Number 1634 JEFFREY A. GONNASON, O.D., stated that he has been licensed as a optometrist since 1976. He has been in an Anchorage practice for over 20 years. On behalf of Alaska Optometric Association he wanted to thank the committee for hearing HB 195. The association represents approximately 80 Alaskan doctors of optometry. He said 150 years ago dentistry progressed out of the barber shop and optometry progressed out of the jewelry store. Both professions have expanded their scope of practice over the years in accordance with technological advances. Today optometry is a primary health care profession that examines, diagnoses and treats disorders of the human eye. It utilizes medications and procedures in accordance with professional training and competency. DR. GONNASON explained that, historically, medical doctors have enjoyed unlimited legislative trust in their scope of practice. Alaska's optometrists have had their scope of practice unduly restricted by old state statutes which do not account for modern advancements in education and training. This bill, HB 195, was carefully drafted to give the board the authority to authorize the use of advanced methods and procedures for those optometrists who meet additional board qualifications. Currently optometry school graduates, trained in modern technology, cannot fully utilize their training in Alaska. DR. GONNASON said the bill will allow the board to determine the scope of practice through regulation within limited guidelines. This is currently done for dentistry and nurse practitioners. The limited use of lasers and other modern technology and limited non- evasive surgical procedures may be allowed through the board under this bill. Dentists and podiatrists perform surgery and do not attend medical school. He questioned why optometry should be subject to discrimination. DR. GONNASON stated a laser is a tool used in many different facets in health care as well as industry. This legislature trusted optometry in 1988 and in 1992, passing diagnostic and therapeutic medication legislation. Optometrists have shown themselves to be reasonable, competent and trustworthy under the expanded privileges. Previous testimony on the 1988 and 1992 legislation described the great harm that would occur to patients, including death and blindness, if optometrists were allowed to expand their scope. As of now, there have been no complaints of harm to the Division of Occupational Licensing in regard to the expansion of optometrists' privileges. Malpractice insurance rates have remained the same in states where the scope of optometric practice has been expanded. DR. GONNASON referred to the state audit report of the Board of Examiners in Optometry which concluded that, "the 1992 Optometry legislation benefited the public and furthered the public interest health and welfare and that the board does provide assurance that licensees are qualified and act in a competent manner." Optometrists are held to the same standards of care as medical doctors and other health care professionals. DR. GONNASON stated that HB 195 would provide better access to quality, affordable and cost effective health care. This is especially true for many of the smaller towns and villages which are only served by an optometrist. Optometrists are reasonable, educated and caring professionals. They are licensed by the state with strict standards. They are regulated by the state board, by legal liability concerns, community opinion, by medicine and by the legislature looking carefully over their shoulders. The state Board of Optometry should be allowed to determine the scope of practice through regulations, as is done by other health professions in Alaska, to keep current with advances in health care. No optometrist would attempt to perform a procedure or treatment that he or she was not trained or comfortable with doing. Optometrists should be treated as the trusted, learned professionals that they are. Number 1859 REPRESENTATIVE DYSON received letters from people in the medical community which informed him that no other state currently allows the expansion of responsibilities as would occur with the passage of HB 195. He stated that 47 states currently prohibit optometric surgery, 30 of these states have passed this legislation since 1991. Number 1886 DR. GONNASON said 37 states say that optometrists cannot use lasers. The reason why the Alaskan law says that optometrists cannot use lasers is because, in order to get the 1988 legislation passed, optometrists had to accept language prohibiting this procedure. Lasers are used by optometrists in four or five states. Optometrists do not use lasers because there is specific language stating that they can use them, but because they are not prohibited in their state. The use of lasers is currently taught in optometry school. Dr. Maynard Falconer, a recent retiree, has a daughter who just graduated from college and is trained in lasers. He emphasized that there are types of laser procedures that optometrists are not trained in such as retina treatment. There are also laser procedures which are straightforward and simple to use. Lasers are tools. DR. GONNASON referred to a study done by John Hopkins University which shows an Alaskan Native woman in the "slit lamp" laser. The article states that paraprofessionals and technicians, can learn to perform this sight saving procedure in a matter of minutes with no complications. This bill would specifically say that optometrists could use lasers as determined by the board based on the proper credentials and qualifications. Some older optometrists are not trained in the more modern procedures and would not be allowed to perform these additional procedures. Number 1985 REPRESENTATIVE DYSON stated that this bill allowed optometrists to prescribe more prescription drugs and asked if this was done in other states. DR. GONNASON answered that there are 33 or 34 states which allow optometrists to go beyond topical medications and prescribe systemic medications. The department was concerned whether or not the board would need to ask for more credentials. Currently those optometrists who use medications need to have an endorsement on their license. The board designed this endorsement to include the ability to prescribe systemic medications. In 1992, the oral portion of the bill was compromised in order to pass the bill. This left the ability to administer topical medications in the endorsement. The bill, HB 195, specifically excludes controlled substances, schedules I and II. Those drugs are considered dangerous. TAPE 97-33, SIDE A Number 0000 DR. SAM McCONKEY, M.D., testified next via teleconference from Fairbanks. He said he has been a board certified ophthalmologist with the eye clinic in Fairbanks since 1975. As a physician he is morally and ethically obligated to advocate for the patient. There are two important issues to identify in this discussion. The first issue is patient care and who is qualified to deliver it. He said a physician has a college degree followed by four years of medical school and three or more years of specialty training in medical and surgical diseases of the eye. This adds up to at least 12 years of school after high school. An optometrist has, in most cases, a college degree and four years of optometric school. Clinical training and experience is the path to competency, not legislation. It is difficult for the lay public to understand that even the drops used to treat eye problems can cause strokes, cardiac arrest, high blood pressure, depression, suicide and shock. DR. McCONKEY stated that the committee was being deceived by organized optometry. This bill by request is all about money. It has nothing to do with patient care. It has to do with the medical care dollar and how it is divided. For the last 25 to 30 years, organized optometry has realized that there are too many optometrists in the United States and cannot make a decent living fitting glasses and contact lenses. Optometric school administrators do not want their students to realize that there are too many optometrists because their schools would not remain full. DR. McCONKEY explained that practicing optometrists are not to be blamed for this, they are only the pawns in the larger scenario. This is an ingenious, well thought out, well financed, political strategy. It has been successful. Unsuspecting state assemblies have legislated optometrists into positions of medical care givers. Passage of these bills convinces state and federal agencies that optometrists should be included in the split of the health care dollar. He referred to the 1988 and 1992 bills, the legislature asked the two separate components to resolve this issue outside of the legislative process. Optometrists were given a few low risk drops to treat minor eye problems. The quid pro quo for this agreement was that optometrists would not initiate legislative initiatives until they received proper education, training and medical testing by someone other than their board. DR. McCONKEY said HB 195 would allow (indisc.) medical prescription drugs except narcotics, cataract surgery, eye muscle surgery on children, surgery for injuries and laser procedures. He said these items have to do with training and experience. The citizens of the state of Alaska do not deserve to be confused further about who is qualified and who has the responsibility for the medical and surgical care of their eyes. Number 0386 DR. PETER CANNAVA testified next via teleconference from Kenai. He presented a scenario where he was a flight attendant who has decided that he wanted to fly the airplane because he was no longer content with being a flight attendant. If someone asked him why he wanted to be a flight attendant pilot, he could answer that his flight attendant school gave a course in piloting and that they will tell him when he is qualified to pilot and will regulate him. He would redefine what a pilot is. His definition says that a pilot is going to be someone who only flies above 20,000 feet so it will be non-dangerous or non-invasive flying. There is a precedent for this shown by helicopters, jet pilots and test pilots who are only regulated by their boards. The legislature might retort that all the people mentioned are pilots by training, from the beginning of their school, whereas a flight attendant has no historical basis or schooling. The legislature might say that it is not the function of the legislature to give sanctions to born again professions and that to be a real pilot, he should go to the proper schools, pass the proper tests and be regulated by the proper authorities and stop trying to short circuit the system. DR. CANNAVA mentioned that the committee would hear some testimony by a physician who claims that optometrists are well trained. He encouraged them to ask this physician how much of his income is generated by optometric referrals and how much he has just invested in a clinic solely dedicated to take care of optometric referrals. DR. CANNAVA stated that if HB 195 was as innocuous as Dr. Gonnason explained, they would not have redefined non-invasive surgery as surgery done without a general anesthetic. Physicians and surgeons are currently doing everything under local anesthetic including neural surgery, knees, hips, hysterectomies, gall bladders and appendectomies. For optometry to be so naive as to classify all of these things as non-invasive, simply because they are done under local anesthetic, indicates the paucity of their training. DR. CANNAVA commented that the other part of HB 195 that should be questioned is where optometrists claim they need to use systemic or oral antibiotics and pain killers. Part of his responsibilities include plastic surgery, repairing broken sinuses and treating infections of the face and paranasal sinuses. It is only in treating sinuses, skin infections and things like that where he uses systemic antibiotics. The eye rarely needs antibiotics, other than by drop form. When antibiotics are needed it involves an injection into the eye. DR CANNAVA said optometrists claim they need oral pain killers. He probably writes three prescriptions for pain killers by mouth a year. There are topical medications which adequately take care of pain. Number 0739 DR. RONALD ZAMBER, M.D., testified next via teleconference from Fairbanks. He described his education and background. He spent no less than 20,000 hours of intense medical and surgical training to develop the competency to administer and prescribe appropriate medical therapeutics and surgical remedies. Despite this training, he could assure the committee that he was not overtrained. There are no groups in this nation qualified to provide complete medical and surgical management of eye diseases other than ophthalmologists. Neurosurgeons are not qualified to provide complete medical and surgical management of eye diseases. DR. ZAMBER said this bill addresses more than vision, it addresses general medical well being. During those 20,000 hours of training as an intern and surgical resident, he saw dozens and dozens of patients who had been prescribed medication which appeared benign but ultimately wound up causing multi-system failures. The issue is one of competency and qualifications. This bill talks about lasers, about instruments that can in a microsecond blind a patient. Number 0959 DR. ROBERT FORD, M.D., said he is an ophthalmologist and the founder of Pacific Cataract and Laser Institute which has 11 sites in the Northwest including one in Anchorage. He is licensed in Alaska. When he finished his ophthalmology training he came out with the same bias that other witnesses have presented. Shortly after he went into private practice, he started to indirectly work with optometrists. He began to work more closely with a particular optometrist who won his respect. He began to make the gradual transition to respecting optometrists. Ophthalmologists do have more training and are going to need to do the more complicated procedures, but optometrists are legitimately going to be the ones in the future of health care who will do the primary eye care. He has chosen to work cooperatively with optometry. Optometrists do the primary care and they refer patients to him to do surgery and then patients are referred back to do post operative care. DR. FORD mentioned the two previous pieces of legislation. He said these bills involved risk, but the risk was balanced by the reward. Time has proven that the risk was worth the reward. Now is the next phase of expansion of the optometric practice. The decision to expand optometric practice has not been an easy one for him. This bill would allow optometrists to use a YAG laser which accounts for a significant portion of the revenue that the company gets. It is harder and harder to make the books balance in medicine. A cataract surgeon's fee is about half what it used to be. He questioned whether or not the company could float financially if the YAG laser procedure was used by optometrists. He decided to maintain his commitment to principle that by giving to another profession, he would feel good about himself. DR. FORD stated that an honest reading of the Idaho law suggested that optometrists could do these laser treatments, so optometrists did these laser procedures. Over a hundred of these procedures were done, without any problems. A number of years ago it was felt this procedure could legally be done by a physician's assistant. In summary, he felt it was the American way to allow professions to grow. Optometry has grown a lot in the last ten years, it is a different profession than it used to be and he would like to see them continue to grow. We should allow them to further expand their practice. Number 1213 HANS KELL, O.D., cited his education and clinical background. Optometry is a profession which has grown progressively more sophisticated and capable. Currently, doctors of optometry complete eight to nine years of professional training; four years of undergraduate and four years of graduate training in optometry and a residency program. The training in optometry includes basic sciences, preclinical education and clinical experience. Admission requirements and tests are similar to those for dental and medical schools. Biomedical science taught in the first two years of optometry and medical schools are comparable and often share the same textbooks and instructors. In some universities the optometry, dental and medical students attend these classes together. Optometry schools are accredited by the same national agencies that accredit medical schools. Clinical training for optometry occurs in various clinics, Health Maintenance Organizations, Public Health, and Veterans' Administration hospitals. DR. KELL said this training prepares doctors of optometry to provide primary eye care similar to the family dentist providing general dental care or the family medical doctor providing primary health care. To establish perspective, there is value in comparing the education of optometry with that of medicine. In 1980, Dr. Rushmer conducted a review which observed that the professions of optometry, dentistry, podiatry and medicine all have similar state and national board requirements. These professionals attend accredited educational institutions. He further stated that, "the basic educational experience of these professions is remarkably similar and cannot account for consistent underutilization of non- medical health professionals." Number 1347 DR. KELL stated that optometry training in pharmacology, the use of lasers and other methods for the diagnosis and treatment of the eye are of the same quality as those methods taught to ophthalmologists. While the clinical application of these tools is relatively straightforward, their justification for use and providing follow up care is the most difficult component of treatment. Optometrists have safely and effectively used their clinical judgement to evaluate, recommend treatment and perform follow up care for many years. Number 1396 REPRESENTATIVE DYSON asked if this was a turf war. He referred to the similar chiropractic issue. Number 1432 DR. GONNASON agreed, on the national level, optometrists are paid to do Medicare procedures and there is competition for those patients. In managed care plans there is competition as to who gets to be the gate keeper. If the optometrist is the gate keeper, then there are a lot less surgeries done. Number 1456 REPRESENTATIVE DYSON did not want to imply that the medical doctors were only looking after their vested interest. Number 1472 DR. KELL agreed that we are all honorable people. Ophthalmologists as well as optometrists are patient advocates. He thanked the legislature for the bill that passed in 1992 which has given optometrists the privilege of following patients after surgery. Currently, optometrists examine the patient and, if necessary, the patient is referred for surgery. After surgery, those patients are followed up with medications. He stated that there are many types of lasers and their applications. Some procedures are much more straightforward than others. He felt the most important thing was the justification for the procedure and the correct follow-up of potential complications which could occur and what to do. The money really lies in the procedure itself. Number 1532 REPRESENTATIVE GREEN asked for a definition of non-invasive. Number 1547 DR. GONNASON answered that a non-invasive procedure is one which does not open the globe. A pimple on the eyelid might be drained under surgical conditions. He said clipping your fingernails is surgery. There are procedures currently being done that were authorized in the 1992 legislation, one of which is the removal of foreign bodies. In this procedure the eye is numbed with a medication, the metal is picked out and then a battery powered drill is used to grind out the rust. If that metal had penetrated the eye ball, then it would be under the realm of the specialty ophthalmologist. Number 1620 REPRESENTATIVE GREEN asked how the laser would be used. Number 1626 DR. GONNASON explained that the best example is one is called a Peripheral Iridotomy. Alaska Eskimos have the highest percentage of Acute Angle Closure Glaucoma. As compared with other forms of glaucoma where pressure slowly goes up, this glaucoma is an attack. The pressure of your eye builds as if the eyeball is going to burst. The eye will go blind if it is not treated within 24 or 48 hours. This is a definite medical emergency. The treatment is to poke a hole in the iris so that fluid can go from the front to the back. A laser focused inside the cornea burns a tiny hole which relieves that pressure and the patient is cured. He cited an example of the time and inconvenience caused when an optometrist could not do this procedure in Anchorage. He questioned what would have happened if this situation had occurred in Kotzebue or Barrow. Number 1711 REPRESENTATIVE PORTER asked if a neutral party could testify on this bill; someone outside of optometry and ophthalmology. He assumed giving optometrists the ability to perform these things would lower health care costs. Number 1759 REPRESENTATIVE GREEN asked what sort of things an optometrist might want to treat rather than submitting it to an ophthalmologist. Number 1786 DR. KELL answered that the most common procedure is a laser procedure called a YAG Capsulotomy. After cataract surgery a thin membrane of the patient's lens is removed. He clarified that the lens is removed during cataract surgery with the skin or the back of that lens left behind with an implant inserted in front of that. In approximately 33 percent of the eyes that membrane becomes opacified or cloudy. Years ago this was treated by having an ophthalmologist go inside the eye to make a hole in the eye. A laser is able to make a hole in the center which opens it up and allows the patient to see. Currently, optometrists evaluate these patients often and refer these patients for this procedure. The procedure itself takes a minute, then patients are referred back to the optometrists for potential complications like retina detachment. He said this is one procedure that optometrists feel that they could treat. Number 1851 REPRESENTATIVE GREEN asked about the other types of illnesses. Number 1859 DR. KELL mentioned Acne Rosacea which affects the lipid or fat producing glands around the eyelid. The glands and the vessels surrounding them become infected affecting either the make-up or atrophy of these glands so they don't produce the oil layer which helps keep tears from evaporating. This produces dry, scratchy eyes. One of the best treatments for this condition, besides the use of artificial tear lubrication, is to take tetracycline. Tetracycline is a simple, oral medication with minimal complications. Number 1900 REPRESENTATIVE GREEN mentioned the amount of study for both professions and asked what the differences were once you got past the basic courses. Number 1928 DR. KELL answered that ophthalmologists, after four years of medical school, have a year of internship which usually occurs in a hospital setting. Currently ophthalmology residency programs are three years, followed by a voluntary sub-specialty training. At the Bascom Palmer Eye Institute, the first year ophthalmology residents are not trained in surgery except for some of these limited, minor surgical procedures discussed. The ophthalmologists see the indigent patients. During the second year, an observational clinic occurs where the residents observe different sub-specialists. Ophthalmologists that have gone into sub- specialty training might focus only on the retina, pediatrics or neuro-ophthalmology. Those residents observe as well as begin to learn the procedures of their sub-specialties. The third year is when the residents hone their surgical skills. Ophthalmologists have a wonderful training, it is more extensive and more specialized. DR. KELL said that HB 195 proposes that optometrists not perform these specialized procedures, but to perform the more non-invasive, simple procedures. Number 2008 DR. ZAMBER said ophthalmology training varies a little from Dr. Kell's description in that the internship is a surgical, medical or rotating internship. Residents are often involved in emergency care settings, intensive care unit settings and clinical oncology cancer treatment settings. These settings expose the residents to the management of patients with various medical conditions. The purpose of that training is to develop a respect and competency for this process. He was appalled at the lack of respect for this issue. There are no shortcuts, those 20,000 hours were hours well served. Those are 20,000 hours beyond what an optometrist gets in training, treating the patients as a whole. DR. ZAMBER explained that the oral medications which would be allowed to be administered by HB 195 can kill patients. He has seen dozens of patients who have experienced Steven's Johnson Syndrome, a severe allergic reaction which is often life threatening and results in a scalded skin type syndrome and creates a ventilatory dependent state. This syndrome is the result of medications which would be allowed under this bill. Sulfa is the primary offending agent in these types of reactions. Many of the oral therapeutics used to treat glaucoma have a sulfa moiety. DR. ZAMBER explained that he is a published expert on complications related to topical and systemic beta blockers including the promotion and induction of beta blocker induced lupus, a life threatening condition. He emphasized that he is not overtrained. This is not a turf war, it is about patient care. He suggested having an O.D.M.D. testify. Those are optometrists who then went on to receive full medical and surgical training, with most training to be ophthalmologists. TAPE 97-33, SIDE B Number 0000 GORDON PREECS, M.D., said he trained eight years ago with three other people in his residency level. One of whom was a doctor of osteopathy, another form of allopathic medicine. This type of doctor has full licensure and authority to practice medicine in Alaska and most of the states. This person was the son of an optometrist and was an optometrist himself. He went back to medical school and received ophthalmologic training. DR. PREECS stated that during the first year of residency they did the dirty work; the injuries, the irritations and red eyes. Their main task, in part, was to screen the people who came through to determine what was serious and what wasn't. The osteopathy resident used to say that he saw more in one day working in the walk-in clinic, than he saw in his whole senior year of optometric school. His goal in optometric school was to learn how to fit contacts and work in a complimentary role to the process of vision care and refractive services. Eye disease was directed to medical care. He felt that if there had been a revolution in what is going on in the course and the exposure of realistic activities in optometric school, it simply escaped him. Number 0191 DR. PREECS addressed Section 7 (6), invasive surgery, which showed a remarkable lack of understanding of the process. He felt invasive surgery was anything that removed, damaged or intruded the tissue. Non-invasive procedures are those which allow you to visualize, allow you to inspect but do not allow you to change the tissue. Invasive surgery is changing tissue, cutting holes, drilling passage ways, making new affects. The fact that a knife is not use does not mean that it is non-evasive. YAG Capsulotomy is a rather simple procedure, but he did not think that allowing optometrists to do this procedure would reduce the cost. The goal would be to acquire access to that well-paid process. He felt that American medicine was over-equipped. There are competing hospitals duplicating services and trying to impress the provider and client communities that they have the best facilities. A ton of money is spent duplicating these processes. DR. PREECS felt discouraged by this subject. He commented that it seemed the medical community would be pecked to death as the state de-professionalizes the process of rendering care at every level, from every source. Every managed health care plan which wants to reduce the access to care by pushing decision-making power farther down stream in a gate keeper mode. Telephone nurses rather than on-site physicians, screening telephone technicians who will understand whether their care will be authorized. He felt this was a part of the process which says we will save money by trying to eliminate the expensive provider, ensure that we have enough cheap providers to go around and hope we don't make many mistakes. He shared in his colleague's concern that ophthalmologists were going to be slowly but surely, biannually by biannually, nickeled with these opportunities to expand and exchange the nature of medical practice. Number 0389 REPRESENTATIVE GREEN explained that he only has one eye and as a result he is nervous about allowing anyone, without the best possible training working, to treat his other eye. He agreed that there were procedures which both professions could learn to do. He refer to his wife's experience, who is a dental hygienist, and their expansion of care. She stated that she preferred to have a doctor available in case of a medical emergency. REPRESENTATIVE GREEN stated that there were some procedures which could be done by both professions; dentists and dental hygienists, chiropractors and medical doctors, and optometrists and ophthalmologists. He felt there had to be a limit put on those procedures because of the possible side effects. He asked if there was a concern among professions that a condition, which isn't obvious, might be overlooked. Number 0559 DR. PREECS referred to some of his first year textbooks which contained something of a warning poised in the image of a cartoon. It was titled, "A patient seen by the ophthalmologist". It depicted a person in a nice two piece suit with a fedora and an eyeball over his shoulders. The warning to the ophthalmologists, as physicians, was not to hone in on the eyeball and forget that they were operating on an entire human process. Optometrists learn about the human system components. How hormones result in life stage changes in the eyes in which neurologic and physiologic changes involve the eye, but are not limited to the eye. Medical practice in the United States is based on the principle that we will start with a profound base of training, a large body of experience and that we all have to do it no matter what we want to do when we finish. DR. PREECS referred to a personal experience when his father-in-law finally addressed his cataract which covered up a devastating retinal detachment. This condition was not able to be treated. He felt that he understood how critical this situation is for his patients and said it is imperative that we understand that we need to have concern the entire patient in the training. Number 0750 CHAIRMAN BUNDE stated that, as is usual, this is the first time the bill is heard and so the committee will not take action on it today.
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