Optometric surgical privileges improve access to care, ease financial burdens

Although not all states share the same access-to-care needs, rural areas derive a clear benefit from such legislation.
I. Ben Gaddie, OD
I. Ben Gaddie

The issue of whether optometrists should be permitted to perform surgical procedures is one that has generated a great deal of controversy, legislative debate and contention within the eye care profession.

Currently, two states – Oklahoma and Kentucky – permit some degree of laser surgical privileges for optometrists. In 1998, Oklahoma became the first state to allow optometrists to perform some minor surgical procedures, including some procedures using a scalpel and lasers. In early 2011, Kentucky optometrists gained the authority to perform certain types of injections, laser procedures and “lump and bump” procedures around the eyelids.

While many arguments have been articulated both for and against optometric surgical privileges, perhaps the most powerful case for such legislation can be conveyed simply through numbers.

“There are 550 doctors of optometry in 106 of Kentucky’s 120 counties. In contrast, two-thirds of the state’s counties do not have an ophthalmologist,” I. Ben Gaddie, OD, president of the Kentucky Optometric Association and a Primary Care Optometry News Editorial Board member, said in an interview. “And at the same time, patient need is increasing.”

Defining ‘surgery’

David A. Cockrell, OD
David A. Cockrell

According to David A. Cockrell, OD, FAAO, vice president of the Oklahoma Board of Examiners in Optometry and secretary-treasurer of the American Optometric Association, some of the minor procedures categorized legislatively as surgery would not fall into most people’s definitions of surgery.

“We don’t get to define which procedures are listed as surgical procedures,” Dr. Cockrell told PCON. “Many of the procedures optometrists perform – from the simple removal of an eyelash to something much more broad – aren’t considered by the general public to be surgery.”

Bobby J. Christensen, OD, FAAO, a private practitioner in Oklahoma, said most procedures performed by optometrists are minor, such as foreign body removal, draining a stye or epilating lashes.

“It has been my experience over the last 30 years that optometrists will not attempt a procedure they do not feel qualified to perform, even if the law will allow it,” he said in an interview. “If the foreign body is embedded on the visual axis or has penetrated into the posterior stroma, the optometrist is going to refer that patient to the corneal specialist, just like most general ophthalmologists would do.”

Bobby J. Christensen, OD, FAAO
Bobby J. Christensen

Dr. Cockrell pointed out that some newly developed technologies and procedures might be classified as surgeries, which would automatically exclude optometrists from performing them.

“If optometrists don’t have surgical privileges and something new comes out – even if it’s something we’ve already done, but just a new technique – we have to go back each time and legislate for that specific technique,” he said. “No other health care profession has to do that.”

Access issues

In states such as Kentucky and Oklahoma, which encompass many remote areas, the issue of access to care has been a key consideration in seeking optometric surgical privileges. Dr. Gaddie said the legislation is expected to make care more available to Kentuckians.

“This law will enable patients to visit their local eye doctor to undergo these procedures, instead of having to travel to an ophthalmologist – often in another city or county – for the same level of care,” he said. “Patients benefit by having greater and easier access to a wide range of eye care performed by the eye doctor they know and trust.”

Dr. Cockrell added that the issue of access to care is not strictly geographical. He discussed two underemphasized access problems, the first of which is wait times for appointments.

“In many busy surgical practices, it literally could be 1 to 2 months’ wait time for a surgical intervention, even for simple procedures,” he said, “as opposed to a quick appointment within a day or two. So it’s a timeliness issue.”

The second issue Dr. Cockrell cited was access to insurance panels, another potential source of confusion.

“Someone I refer to might not be on that patient’s panel, although I might be,” he said. “It then becomes a panel/provider issue, which can become complicated and expensive for the patient.”

Economic considerations

For patients with limited access to eye care, the option of seeing a nearby optometrist for minor surgery could decrease time away from work, thus reducing financial burdens.

“In some areas, a patient might have to make a 3-hour trip to get a procedure that literally takes 10 to 15 minutes to perform,” Dr. Cockrell said. “They have to take a full day off from work to do this, which significantly increases the cost. If they can see a practitioner in their own community for the same procedure, their time away from work is considerably reduced.”

Dr. Gaddie said optometric surgical privileges also help streamline the Medicaid process and cut costs.

“Medicaid costs will be reduced, because eye care patients will need fewer referrals and fewer multiple office visits, and will incur lower transportation costs,” he said. “This is a much-needed savings for a program running a deficit in the hundreds of millions of dollars.”

For practitioners, surgical privileges might decrease frustrations over billing codes, Dr. Christensen added.

“Many of the minor procedures fall under the surgery codes,” he said. “The optometrist might not get paid for a simple epilation because of the billing code.”

Impact on optometric education

As optometrists in some states expand their practice scopes into surgical procedures, this expansion is likely to broaden the parameters of optometric education. According to Dr. Gaddie, most optometry students are already exposed to some extent of surgical training.

“Most of the schools and colleges of optometry teach and train laser and minor surgical procedures already,” he said. “Any substantive scope-of-practice change in the profession of optometry has implications for optometric education.”

‘Providing the latest and best’

Dr. Cockrell said he believes optometry – and health care overall – is likely to benefit from the profession gaining surgical privileges.

“I think this will have a positive effect on health care,” he said. “Health care is continually changing, and optometry still encompasses a broad range of services, from routine eye examinations to specialized vision therapy, to traumatic brain injury therapy. This enables our profession to spread out and do more.”

Dr. Gaddie said the acquisition of surgical privileges is also likely to improve the eye care experience for patients.

“We already comanage and treat a variety of complex conditions, as well as provide pre- and postoperative care for glaucoma, cataracts, complications from diabetes and other issues,” he said. “Now, doctors of optometry will be able to provide the latest and best technology to treat their patients in their office, rather than forcing them to make a second appointment to travel to another doctor.”

He added that in light of health care reform, the need for such efficiency is likely to become greater than ever in his state.

“Health care reform is expected to create an additional 600,000 newly insured Kentuckians who will need convenient access to quality eye care,” he said. – by Jennifer Byrne

Editor’s Note: Primary Care Optometry News attempted to interview several representatives from optometry schools regarding the curriculum as it relates to surgical privileges, but we were unable to obtain any comments. We welcome your feedback on the optometric education aspect of this issue.

  • Bobby J. Christensen, OD, FAAO, is senior vice president of strategic planning for Vision Source, a network of private practice optometrists. He can be reached at 6912 East Reno #1, Midwest City, OK 73110; (405) 732-2277; fax (405) 737-4776; vsourcebc@cox.net.
  • David A. Cockrell, OD, can be reached at 1711 W. Sixth St., Stillwater, OK 74076; (405) 372-1715; fax: (405) 372-3350; dacockrell@cockrelleyecare.com.
  • I. Ben Gaddie, OD, is a Primary Care Optometry News Editorial Board member. He can be reached at Gaddie Eye Centers, 7635 Shelbyville Rd., Ste. 101, Louisville, KY 40222; (502) 423-8500; fax: (502) 339-0571; ibgaddie@bellsouth.net.
I. Ben Gaddie, OD
I. Ben Gaddie

The issue of whether optometrists should be permitted to perform surgical procedures is one that has generated a great deal of controversy, legislative debate and contention within the eye care profession.

Currently, two states – Oklahoma and Kentucky – permit some degree of laser surgical privileges for optometrists. In 1998, Oklahoma became the first state to allow optometrists to perform some minor surgical procedures, including some procedures using a scalpel and lasers. In early 2011, Kentucky optometrists gained the authority to perform certain types of injections, laser procedures and “lump and bump” procedures around the eyelids.

While many arguments have been articulated both for and against optometric surgical privileges, perhaps the most powerful case for such legislation can be conveyed simply through numbers.

“There are 550 doctors of optometry in 106 of Kentucky’s 120 counties. In contrast, two-thirds of the state’s counties do not have an ophthalmologist,” I. Ben Gaddie, OD, president of the Kentucky Optometric Association and a Primary Care Optometry News Editorial Board member, said in an interview. “And at the same time, patient need is increasing.”

Defining ‘surgery’

David A. Cockrell, OD
David A. Cockrell

According to David A. Cockrell, OD, FAAO, vice president of the Oklahoma Board of Examiners in Optometry and secretary-treasurer of the American Optometric Association, some of the minor procedures categorized legislatively as surgery would not fall into most people’s definitions of surgery.

“We don’t get to define which procedures are listed as surgical procedures,” Dr. Cockrell told PCON. “Many of the procedures optometrists perform – from the simple removal of an eyelash to something much more broad – aren’t considered by the general public to be surgery.”

Bobby J. Christensen, OD, FAAO, a private practitioner in Oklahoma, said most procedures performed by optometrists are minor, such as foreign body removal, draining a stye or epilating lashes.

“It has been my experience over the last 30 years that optometrists will not attempt a procedure they do not feel qualified to perform, even if the law will allow it,” he said in an interview. “If the foreign body is embedded on the visual axis or has penetrated into the posterior stroma, the optometrist is going to refer that patient to the corneal specialist, just like most general ophthalmologists would do.”

Bobby J. Christensen, OD, FAAO
Bobby J. Christensen

Dr. Cockrell pointed out that some newly developed technologies and procedures might be classified as surgeries, which would automatically exclude optometrists from performing them.

“If optometrists don’t have surgical privileges and something new comes out – even if it’s something we’ve already done, but just a new technique – we have to go back each time and legislate for that specific technique,” he said. “No other health care profession has to do that.”

Access issues

In states such as Kentucky and Oklahoma, which encompass many remote areas, the issue of access to care has been a key consideration in seeking optometric surgical privileges. Dr. Gaddie said the legislation is expected to make care more available to Kentuckians.

“This law will enable patients to visit their local eye doctor to undergo these procedures, instead of having to travel to an ophthalmologist – often in another city or county – for the same level of care,” he said. “Patients benefit by having greater and easier access to a wide range of eye care performed by the eye doctor they know and trust.”

Dr. Cockrell added that the issue of access to care is not strictly geographical. He discussed two underemphasized access problems, the first of which is wait times for appointments.

“In many busy surgical practices, it literally could be 1 to 2 months’ wait time for a surgical intervention, even for simple procedures,” he said, “as opposed to a quick appointment within a day or two. So it’s a timeliness issue.”

The second issue Dr. Cockrell cited was access to insurance panels, another potential source of confusion.

“Someone I refer to might not be on that patient’s panel, although I might be,” he said. “It then becomes a panel/provider issue, which can become complicated and expensive for the patient.”

Economic considerations

For patients with limited access to eye care, the option of seeing a nearby optometrist for minor surgery could decrease time away from work, thus reducing financial burdens.

“In some areas, a patient might have to make a 3-hour trip to get a procedure that literally takes 10 to 15 minutes to perform,” Dr. Cockrell said. “They have to take a full day off from work to do this, which significantly increases the cost. If they can see a practitioner in their own community for the same procedure, their time away from work is considerably reduced.”

Dr. Gaddie said optometric surgical privileges also help streamline the Medicaid process and cut costs.

“Medicaid costs will be reduced, because eye care patients will need fewer referrals and fewer multiple office visits, and will incur lower transportation costs,” he said. “This is a much-needed savings for a program running a deficit in the hundreds of millions of dollars.”

For practitioners, surgical privileges might decrease frustrations over billing codes, Dr. Christensen added.

“Many of the minor procedures fall under the surgery codes,” he said. “The optometrist might not get paid for a simple epilation because of the billing code.”

Impact on optometric education

As optometrists in some states expand their practice scopes into surgical procedures, this expansion is likely to broaden the parameters of optometric education. According to Dr. Gaddie, most optometry students are already exposed to some extent of surgical training.

“Most of the schools and colleges of optometry teach and train laser and minor surgical procedures already,” he said. “Any substantive scope-of-practice change in the profession of optometry has implications for optometric education.”

‘Providing the latest and best’

Dr. Cockrell said he believes optometry – and health care overall – is likely to benefit from the profession gaining surgical privileges.

“I think this will have a positive effect on health care,” he said. “Health care is continually changing, and optometry still encompasses a broad range of services, from routine eye examinations to specialized vision therapy, to traumatic brain injury therapy. This enables our profession to spread out and do more.”

Dr. Gaddie said the acquisition of surgical privileges is also likely to improve the eye care experience for patients.

“We already comanage and treat a variety of complex conditions, as well as provide pre- and postoperative care for glaucoma, cataracts, complications from diabetes and other issues,” he said. “Now, doctors of optometry will be able to provide the latest and best technology to treat their patients in their office, rather than forcing them to make a second appointment to travel to another doctor.”

He added that in light of health care reform, the need for such efficiency is likely to become greater than ever in his state.

“Health care reform is expected to create an additional 600,000 newly insured Kentuckians who will need convenient access to quality eye care,” he said. – by Jennifer Byrne

Editor’s Note: Primary Care Optometry News attempted to interview several representatives from optometry schools regarding the curriculum as it relates to surgical privileges, but we were unable to obtain any comments. We welcome your feedback on the optometric education aspect of this issue.

  • Bobby J. Christensen, OD, FAAO, is senior vice president of strategic planning for Vision Source, a network of private practice optometrists. He can be reached at 6912 East Reno #1, Midwest City, OK 73110; (405) 732-2277; fax (405) 737-4776; vsourcebc@cox.net.
  • David A. Cockrell, OD, can be reached at 1711 W. Sixth St., Stillwater, OK 74076; (405) 372-1715; fax: (405) 372-3350; dacockrell@cockrelleyecare.com.
  • I. Ben Gaddie, OD, is a Primary Care Optometry News Editorial Board member. He can be reached at Gaddie Eye Centers, 7635 Shelbyville Rd., Ste. 101, Louisville, KY 40222; (502) 423-8500; fax: (502) 339-0571; ibgaddie@bellsouth.net.