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The bitter scope of practice battle between ophthalmologists and optometrists (ODs) has moved to the Veterans Affairs system, as the VA tries to develop national standards of practice for 51 health care occupations at VA facilities, regardless of state scope of practice laws.
At issue within eye care is whether ODs should be allowed to do laser procedures such as YAG capsulotomy and selective laser trabeculoplasty on patients within the VA system in states where scope of practice laws prohibit it.
The Veterans Health Administration (VHA), which implements the VA health care program, has more than 1,300 health care facilities—172 medical centers and 1,138 outpatient sites—serving 9 million enrolled veterans each year.
A US House subcommittee listened to arguments for and against scope expansion for ODs at a hearing Sept. 19, while also evaluating whether to allow certified registered nurse anesthetists to administer anesthesia without a supervising physician.
The hearing was held by the House Committee on Veterans’ Affairs Subcommittee on Health.
Committee Chair Mariannette Miller-Meeks, MD—an ophthalmologist and veteran who served in the US Army for 24 years—oversaw the hearing.
The American Medical Association outlined in prepared remarks what was at stake: “Since the VHA is such a large health care system, the actions it takes, especially in terms of the scope of practice of its non-physician providers, could have an immense impact on health care in its entirety.”
Hearing participants seemed to agree that health care for veterans needed improvement.
One participant said ODs took care of most eye care visits for veterans and provided details of that treatment.
No one provided figures for how many ophthalmologists currently worked within the VA, but many studies suggest a shortage of ophthalmologists in the US in the future.
A research article published Sept. 20 in Ophthalmology, the journal of the American Academy of Ophthalmology, said total ophthalmology supply in the US through 2035 is projected to decrease by 2,650 full-time equivalent ophthalmologists (from a total of about 22 thousand), a 12 percent decline, and total demand projected to increase by 5,150 full-time equivalent ophthalmologists, a 24 percent increase, representing a supply and demand mismatch of 30 percent workforce inadequacy.
AOA’s Arguments
Representing the American Optometric Association at the hearing was Paul Barney, OD, of Anchorage, Alaska, who has served as center director for the Pacific Cataract and Laser Institute for 25 years.
Barney said he is a practicing OD who routinely provides laser and other surgical care to patients. He also is an adjunct professor at two US optometry schools. He said he did part of his training at a US Army hospital and VA outpatient clinic.
He noted that 10 states already have authorized ODs to use lasers for ocular conditions, with Oklahoma allowing laser use for 30 years. In addition, all federal health care programs cover the full range of services provided by ODs under state scope of practice laws, including laser procedures, as do all major private payers.
In his prepared remarks, Barney said eye and vision care ranks as the third-most requested service by veterans, with VA optometrists caring for more than 70 percent of veteran visits involving eye care services, including 73 percent of 2.5 million ophthalmic procedures and nearly 99 percent of services in low vision clinics and blind rehabilitation centers. ODs practice at 95 percent of the VA sites where eye care is offered, and they are the only licensed independent eye care practitioner available in many facilities, he said.
AAO’s Arguments
Speaking on behalf of the AAO was its CEO, Stephen McLeod, MD, former chairman of the Department of Ophthalmology at UC San Francisco for 17 years while also a staff ophthalmologist at the San Francisco VA medical center.
McLeod said the AAO had “deep concern that veterans will be put at risk if the VA adopts national standards that allow optometrists to perform surgery.”
He said eye surgery was among the most challenging of procedures, and damage is impossible to repair in some cases.
In response to a question from Miller-Meeks, McLeod said the idea that it is “the norm” for ODs to do laser surgery is wrong. The 33 thousand ODs in the US account for about half of 1 percent of YAG laser capsulotomy procedures, while they account for 0.1 percent of total laser procedures, he said.
“Bringing optometric surgery into the VA with any degree of scale is a far outlier from what happens in the community,” McLeod said.
McLeod noted that the ophthalmic industry does not have a good system for reporting bad outcomes unless volunteered by the physician. Malpractice suits are not a good gauge, as physicians can smooth over situations where patients are unhappy, he said.
VA Clarifies Plan
In the second half of the hearing, Erica Scavella, MD, assistant undersecretary for health for clinical services and chief medical officer of the VHA, tried to temper concerns when she clarified that the VA would allow laser surgery to be performed only by ODs from the 10 states where laser surgery was part of their scope, though the ODs might be transported to perform the surgery in states that don’t have the same scope.
Her comments raised more questions from House members on how such a two-tiered system related to use of ODs would work.
Scavella said ODs would be evaluated by the VA facility needing the surgery based on their skills, experience, and past clinical outcomes. She added that all of this remained under review.
History of VA Scope Expansion Plan
The VA’s scope expansion plan was unveiled in November 2020 when the agency published an interim final rule titled “Authority of VA Professionals to Practice Health Care” under its Federal Supremacy Project.
The interim rule laid out how the VA was using the Supremacy Clause of the Constitution to preempt state laws as it developed national standards of practice.
The VA’s timeline for implementing these standards indicates that the agency is in Phase II—seeking professional and public input—of three phases.
Participants at the hearing provided no deadline for wrapping up this phase or publishing the standards, which must be re-evaluated every five years at a minimum.
What Led to the Process?
Several participants asked why national standards of practice were needed within the VA, complaining that the agency’s reasoning has been poor and has changed over time.
Ethan Kalett, executive director of the Office of Regulations Appeals in Policy at Veterans Affairs, said at the hearing that the goal was to remove barriers. Kalett gave the example that someone needing physical therapy in a profession where a referral was needed would not need that referral within the VA.
Kalett said most health care would not see any changes.