Efforts ongoing to change state law and allow optometrists to treat glaucoma
By Elaine Thompson
Telegram & Gazette Staff
Posted Feb 20, 2019 at 7:40 PM
When she lived in Pennsylvania, Aimee McLean went to her regular optometrist for treatment for ocular pressure, which could cause glaucoma, a neurological disorder that leads to vision impairment or blindness, if not treated early.
She was surprised when she moved to Massachusetts and learned that the optometrist she entrusted all her other eye care to, and whose office was within walking distance of her Billerica apartment, could not treat her for ocular pressure. Instead, she would have to take additional time off from work to drive to an ophthalmologist she was referred to in Boston after getting an appointment, then pay to park and pay an additional and higher co-pay.
Massachusetts is the only state that does not allow optometrists to write prescriptions for treatment of glaucoma and ocular diseases. Optometrists usually detect the disease. But they are not allowed to care for it, even though glaucoma is one of the areas that optometrists are educated in because they need to be prepared to practice it in any of the other 49 states.
"It was very inconvenient. It just added unnecessary expenses and time that could have been avoided. I just don't understand the reasons except to collect extra co-pays," Ms. McLean said recently.
The Massachusetts Society of Optometrists and the Massachusetts College of Pharmacy and Health Sciences have been trying to bring Massachusetts in line with what all the other states, the District of Columbia, and the Veterans Administration have been doing for years, beginning in the 1970s. Vermont was the last state, in 2004, to allow optometrists the expanded scope of care.
The statute, which inhibits access to eye care, costs the state's health-care system, including commercial, Medicare and Medicaid, more than $50 million, according to an MSO-commissioned budget analysis.
Jay Gardiner, executive director of the MSO, said the current "outdated statute" causes redundant referrals to ophthalmologists when glaucoma could be treated by the optometrist who detects it.
"It's a forced referral. If you live in Western Massachusetts and you're diagnosed with glaucoma, you might have to travel a great distance. That becomes a barrier to care," Mr. Gardiner said, adding that in two counties - Nantucket and Dukes - optometrists are the only eye-care providers.
Mr. Gardiner said legislators have been filing bills to change the statute for about 18 years.
State Sen. Michael Moore, D-Millbury, has filed bills since 2017 to try to allow optometrists, with additional training prescribed by the state Board of Registration in Optometry and passage of a subsequent exam, to be able to treat glaucoma. The legislation has usually received approval by the Senate, but subsequently no action has been taken after the measure is referred to the House Committee on Ways and Means, according to the senator's office.
In the 2017-2018 session, Mr. Moore's bill was eventually filed as an amendment to the Health Care Financing Omnibus legislation. The amendment was adopted by a voice vote without objection. But ultimately, the final omnibus bill did not survive conference committee negotiations last year.
"We became almost collateral damage," Mr. Gardiner said, noting optimism for passage of Mr. Moore's refiled SD. 74, "An Act ensuring consumer choice and equal access to eye care," for the current legislative session. "We feel it's a positive step when both sides agreed upon the optometry portion. We feel that we've made progress in educating and meeting one-on-one with legislators so they understand the cost benefit to the patient."
State Sen. Sal DiDomenico, D-Everett, and state Rep. Patricia Haddad, D-Somerset, have refiled similar bills in the current session. House Minority Leader Bradley Jones, R-North Reading, a longtime advocate, has filed two bills on the matter: HD2185, An Act modernizing optometric patient care, and HD2197, An Act studying the impacts of the diagnosis restrictions on optometrists.
The bills are expected to be referred to legislative committees for review in the coming weeks.
Mr. Moore and other advocates attribute past failures to misunderstanding as to what proposed legislation would allow optometrists to do.
The bill, he said, is actually part of a larger concern, which is to improve access to quality health care without increasing cost. Optometrists significantly outnumber ophthalmologists in the state. There are approximately 1,600 optometrists and about 600 ophthalmologists, according to the MSO and the Massachusetts Society of Eye Physicians and Surgeons. There are optometrists practicing in all 14 counties in the state, and ophthalmologists in all but Dukes county on Martha's Vineyard and Nantucket County, according to the American Optometric Association.
Mr. Moore pointed out that his bill would give licensed optometrists the authority only to treat glaucoma and ocular abnormalities of the human eye, including prescribing antiviral medications and eye drops to treat such ailments. It does not authorize laser or surgical practices that ophthalmologists commonly perform.
But that is what some have been led to believe, said Dr. Matthew S. Forgues, president of the Massachusetts Society of Optometrists, who operates Forgues Eyecare in Worcester and Shrewsbury, with his father, Dr. Mark Forgues.
He said the Massachusetts Society of Eye Physicians and Surgeons (MSEPS) has in the past said the legislation would expand the scope of service for optometrists to include laser and other types of surgery. He said this is simply not true.
"The legislation we are asking for simply would allow us to use eye drops to treat glaucoma and use oral antibiotics to treat eye infections only, the same quality of care patients have access to in all other 49 states," Dr. Forgues said. "We live in a state with such advanced health care, and we are the only one in the United States who can't do this standard of care."
Dr. Jeremy Kievel, president-elect of the MSEPS, said he has a problem with legislators "getting involved with businesses they don't understand so much." He said his organization is concerned with patient care and don't see a reason to make a change to be in line with the rest of the country. He pointed out that laws in other states vary, including some that allow optometrists to perform surgery.
"I know people look at us (Massachusetts) as the outlier. Maybe we should look at us as the leader," Dr. Kievel suggested, pointing to the state, under then-governor Mitt Romney as being the first to propose universal health care.
Or "maybe we should be the outlier." He said an additional 60 hours of training is not sufficient for an optometrist to treat glaucoma.
Optometrists hold a four-year undergraduate degree, and then attend a four-year optometry school, where they are specifically trained in eye health and eye vision. Some also attend additional residency programs for certain specialties. Ophthalmologists also graduate from a four-year school, but then attend medical school for four years, and complete a residency in ophthalmology. They additionally spend another three years of specialized resident training in eye disease and eye surgery.
Dr. Forgues said all optometry schools, including the ones in Massachusetts, teach to the highest standard, including treatment of glaucoma care because they need to be prepared to practice it in all 49 other states. Also, continuing education requirements for optometrists are very heavy on ocular diseases, including glaucoma care, because it is within the scope of practice in all the other states, Dr. Forgues said.
Charles F. Monahan Jr., president of the Massachusetts College of Pharmacy and Health Services University, said the school, which has campuses in Boston and Worcester, trains students to treat glaucoma. But the law prevents them from using this training to the fullest.
"In our research, we have found that some of our graduates leave the state because of the law and, until (the law is) changed, the commonwealth will be at a severe competitive disadvantage," Mr. Monahan said via email.
Lauren Thamel, 23, of Worcester, a second-year student at New England College of Optometry in Boston, said she is also concerned about the best and brightest graduating optometrists leaving the state because of the law. Even she would have considered it, except for the fact that her parents - Drs. Brian S. Thamel and Valerie A. Riccardi - have a longtime successful practice, Vision Source at 335 Park Ave. in Worcester.
Ms. Thamel is on the school's admissions council and interviews prospective students. She said she's concerned that students who don't have ties to Massachusetts will have no reason to stay here if they're not allowed to treat patients to the highest care they have learned.
"You go to Connecticut, New Hampshire, Rhode Island, any of the other 49 states and you can," she said.