House Panel Re-Opens Eyeball Wars

Mar 15, 2017

Credit Staff Sgt. Darlene Seltmann / US Air Force

House lawmakers are wrangling over whether to allow optometrists to perform procedures traditionally reserved for ophthalmologists.  The long-standing fight is tied up in questions of access and professional scope. 

Optometrists and ophthalmologists both work on eyes, but they have a different scope of practice.  Generally speaking, an optometrist does eye exams and prescribes glasses or contacts.  Dr. Ryan Smith explains an ophthalmologist is an medical doctor—which means four years of medical school, a year of internship and then three years of residency.

“That’s the first time that you can perform these procedures on your own as an ophthalmologist after eight years of schooling after college—after undergraduate,” Smith says.  “Some of us, again, do a fellowship which is another year or two this is extensive training afterward.” 

“Optometry school is four years after undergraduate,” Smith continues.  “At that point they can begin seeing patients on their own.”

But there are three states—Kentucky, Oklahoma and Louisiana—where optometrists can perform surgical procedures.  Optometrist Carl Spear practices in Pensacola, but he has licenses in Kentucky and Oklahoma. 

“To the knowledge of any of the board members in those three states that I spoke with—to date—there has not been a medical malpractice claim brought against an optometrist for any of the procedures that are asked for in this bill,” Spear says.

Viewed one way, the fight is about money—a turf battle that’s been playing out for years, and Bruce May with the Florida Society for Ophthalmology thought both sides came to an agreement in 2013.

“There were many protracted hearings back in 2013, and during that process the speaker and the president of the Senate at the time made it clear they were going to put an end to what they referred to as the eyeball wars,” May says.  “Those leaders actually demanded that the parties sign a compromise.”

That deal gave optometrists the ability to prescribe about a dozen oral medications, but reserved all surgeries for ophthalmologists. 

But now Spear argues Florida’s patient pool is growing too fast.

“Taking Florida out of the equation, you look at general demographics across the US, in the year 2000 there’s 19,000 ophthalmologists—19,000 to 20,000,” he says, “In the year 2025 there’s going to be roughly 19,000.” 

“Residency training is not increasing,” Spear goes on. “During that time period the growth in glaucoma macular degeneration, cataracts and diabetic retinopathy will have increased about 3x so somebody has got to be available to take care of those patients.”

Rep. Pigman (left) with House Speaker Richard Corcoran.
Credit Florida House of Representatives

The question of access, with demand outpacing supply, is key for the measure’s supporters.

“I’m a rural physician,” Rep. Cary Pigman (R-Sebring) says, “so access to care issues are real for me.  And I’ve seen over the years the gradual de-credentialing, or leaving the hospital, so that when the person comes in with an eyelid injury, worse than the ophthalmologist or the optometrist you have me fixing it.”

Pigman chairs the committee that took up and passed the measure Wednesday.  He worries lack of access is hurting low income Floridians as more ophthalmologists refuse to accept patients whose Medicaid coverage offers lower reimbursements. 

And in pressing one of the measure’s opponents he alludes to the problem.

“If there is an access to care issue, and it’s low Medicaid participation of the ophthalmologists,” he says, “is there a way to fix that short of just increasing reimbursement?”

“Because realistically looking at the budget—I don’t think that’s going to happen.”

Medical advances and competition are driving down the cost of optical procedures—House Speaker Richard Corcoran recently highlighted the field as an example of markets leading to greater choice and lower bills. 

But the stress of that market may be driving ophthalmologists away from less lucrative patients.  Adding optometrists to the mix would likely increase the competition.  But whether that will lower costs and expand access enough to support Florida’s neediest is far from certain.