Regulatory Affairs: Scope-of-Practice Issue or Turf War?

Failed bill would have expanded procedures optometrists can perform.

A proposal in California that would have expanded the scope of practice for optometrists in the state was passed by the state legislature, but Gov. Gavin Newsom effectively vetoed the bill by failing to sign it before it expired on Sept. 30. 

Assembly Bill 2236 was supported by the California Optometric Association (COA), arguing that the measure was safe for patients and would have increased their access to critically needed eye care. Ophthalmologists and the California Medical Association (CMA), on the other hand, characterized the measure as radical and would have endangered patients because the optometrists insufficiently trained to perform invasive procedures.

“I am not convinced that the education and training required is sufficient to prepare optometrists to perform the surgical procedures identified,” says Gov. Newsom in a late-September letter to state lawmakers explaining his decision to not sign the bill. “This bill would allow optometrists to perform advanced surgical procedures with less than one year of training. In comparison, physicians who perform these procedures must complete at least a three-year residency program.”

CMA’s statement after the governor announced his decision says, had the bill passed, many Californians, particularly residents of underserved communities, might have had eye surgery done by an optometrist — without knowledge about the training gap between optometrists and ophthalmologists. 

“CMA is grateful that Gov. Newsom has recognized that the inadequate training stipulated by AB 2236 would expose patients to serious health risks, loss of vision or even life-threatening consequences,” says CMA President Robert E. Wailes, MD. “We thank those physicians who spoke up to let legislators and the governor know that all Californians deserve to have well-trained physicians to provide high-quality care, and they expect the state of California to ensure strict safety standards to protect patients.” 

However, COA President Amanda K. Dexter, OD, FAAO, indicates that the fight on the issue isn’t over. “California optometrists sponsored AB 2236 to address a real and growing concern for our patients, particularly Medi-Cal enrollees, who face long waits for specialty care or go without needed health procedures,” says Dr. Dexter. “While we are deeply disappointed in this veto, we will keep pressing forward on a policy solution because the shortage of health care providers serving Californians with low incomes, rural communities and people of color will only grow worse without action.” 

The issue has been dealt with by several states over the years and could become an issue in other states in the future, according to Safe Eyes America, a nonprofit dedicated to delivering high-quality eye care to patients. The group, which opposed the California bill, notes that 12 states — Oklahoma, Colorado, Wyoming, Kentucky, Alaska, Arkansas, Louisiana, Mississippi, Virginia, Tennessee, New Mexico and Iowa —allow at least some of the procedures that AB 2236 would have authorized that require the use of scalpels, injections or lasers. 

“It’s a terrible thing when the best interests of patients aren’t put first and special interests have the ability to craft legislation putting patients in danger,” says Kenneth Cheng, MD, of Safe Eyes America. 

AB 2236 would have allowed optometrists to use two types of lasers to treat glaucoma and a third to perform YAG capsulotomy to treat secondary cataracts, says COA Executive Director Kristine Shultz. It also would have allowed optometrists to perform corneal crosslinking to treat keratoconus. 

“These are in-office procedures that don’t require sedation, take just a few minutes to perform and have very low complication rates and side effects,” says Ms. Shultz. 

Some who opposed the bill noted that other states that expanded the scope of optometrists’ practice have less dense populations, so patients had to travel long distances for medical and surgical eye care. In California, they maintained that almost all residents were within a half-hour drive from an ophthalmologist. Ms. Shultz says while that might be technically correct, a large number of them don’t accept Medi-Cal, the state’s Medicaid healthcare plan, a reality that results in a very real patient-access issue across the state. 

It’s a terrible thing when the best interests of patients aren’t put first.
Kenneth Cheng, MD

Ms. Shultz also counters CMA’s contention that passing AB 2236 would have been dangerous, noting that optometrists can perform some interventional procedures already, including removing foreign objects such as metal shavings from eyes. In fact, she considers AB 2236 a compromise bill that included adequate training requirements for optometrists and would have required notification to state regulators within three weeks of a bad outcome. 

The American Society of Retina Specialists and the American Association for Pediatric Ophthalmology and Stabismus (AAPOS) joined CMA and Safe Eyes America in successfully opposing the California bill. AAPOS President member Christie Morse, MD, AAPOS, EVP, said she was alarmed that the proposal would have allowed optometrists to perform additional procedures without additional pediatric-specific training. 

“There is nothing more important than helping children successfully see their way into adulthood,” says Dr. Morse. “It is this commitment and dedication to children that drives pediatric ophthalmologists (medical physicians and surgeons) to deliver the highest standard of treatment and surgical care to our pediatric patients. The delivery of such care requires years of medical and surgical training.” OSM