BILL ANALYSIS                                                                                                                                                                                                    







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        |Hearing Date:June 28, 2010         |Bill No:AB                         |
        |                                   |2683                               |
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                      SENATE COMMITTEE ON BUSINESS, PROFESSIONS 
                               AND ECONOMIC DEVELOPMENT
                         Senator Gloria Negrete McLeod, Chair

                        Bill No:        AB 2683Author:Hernandez
                        As Amended:June 14, 2010 Fiscal:   Yes

        
        SUBJECT:  Optometry.

        SUMMARY:  Authorizes optometrists to practice in long term care  
        settings such as skilled nursing facilities (nursing homes),  
        psychiatric hospitals, and intermediate care facilities.

        Existing law:
        
       1)Licenses and regulates the practice of optometry by the California  
          Board of Optometry (Board) within the Department of Consumer Affairs  
          (DCA).

       2)Requires an optometrist to notify the Board in writing of the address  
          or addresses where he or she is to engage, or intends to engage, in  
          the practice of optometry.

       3)Exempts an optometrist from notifying the Board if he or she engages  
          in temporary practice which is limited to 7 calendar days during a  
          30-day period and 54 days during the calendar year at any the  
          following settings:

           a)   A facility licensed by the State Department of Public Health.

           b)   A public institution, including, but not limited to, a school,  
             community college, or correctional facility.

           c)    A mobile unit operated by a governmental agency or nonprofit  
             or charitable organization.

           d)   The home of a non-ambulatory patient.






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           e)   The practice location of a licensed optometrist who is absent  
             for a reason approved by the Board.

       4)Authorizes an assistant in the office of a physician and surgeon or  
          optometrist under the direct responsibility and supervision of a  
          physician and surgeon or optometrist to fit prescription lenses.

       5)Specifies additional duties that an assistant may perform in the  
          office of, and under the direct supervision of, an ophthalmologist  
          or optometrist.



        This bill:

       1)Authorizes an optometrist to engage in the practice of optometry at  
          any health facility or residential care facility, provided the  
          optometrist:

           a)   Maintains a primary business office, separate from the health  
             facility or residential care facility, that meets all of the  
             following requirements:

             i)     Is open to the public during normal business hours by  
               telephone and for purposes of billing services or access to  
               patient records.

             ii)         Is licensed to the optometrist or the employer of the  
               optometrist as a local business with the city or county in  
               which it is located.

             iii)        Is registered by the optometrist with the Board.

             iv)         Is owned or leased by the optometrist or by the  
               employer of the optometrist.

             v)     Is not a residential dwelling.

           b)   Maintains or discloses patient records in the following  
             manner:

             i)     Records are maintained and made available to the patient  
               in such a way that the type and extent of services provided to  
               the patient are conspicuously disclosed.  The disclosure of  
               records shall be made at or near the time services are rendered  
               and shall be maintained at the primary business office;





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             ii)         The optometrist complies with all federal and state  
               laws and regulations regarding the maintenance and protection  
               of medical records, including, but not limited to, the federal  
               Health Insurance Portability and Accountability (HIPA) Act of  
               1996;

             iii)        The optometrist keeps all necessary records for a  
               minimum of seven years from the date of service.  Any  
               information shall be certified by the optometrist as being  
               true, accurate, and complete;

             iv)         Records shall be maintained for each prescription as  
               part of the patient's chart, including the optometrist's name  
               and license number, the place of practice or primary business  
               office, and the description of the goods and services for which  
               the patient is charged and the amount charged;

             v)     A copy of any referral or order requesting optometric  
               services for a patient from the health facility's or  
               residential care facility's administrator, director of social  
               services, the attending physician and surgeon, the patient, or  
               a family member shall be kept in the patient's medical record.

           c)   Possesses and appropriately uses the instruments and equipment  
             required for all optometric services and procedures performed  
             within the health facility or residential care facility.

       2)Exempts an optometrist from providing notification to the Board of  
          each health facility or residential care facility, provided all  
          requirements are met.

       3)Defines certain terms for purposes of the above provisions,  
          including:

           a)   Health facility as specified in the Health and Safety Code,  
             exclusive of a hospital, as defined.

           b)   Residential care facility as any facility licensed by the  
             State Department of Social Services caring for persons who cannot  
             live alone but who do not need extensive services. 

       4)Authorizes an assistant to fit prescription lenses and perform those  
          additional duties in any setting where optometry or ophthalmology is  
          practiced, under the direct responsibility and supervision of a  
          physician and surgeon, optometrist, or ophthalmologist,  





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          respectively.

       5)Defines "setting" for purposes of Item # 4 above, to include, but not  
          be limited to, any facility licensed by the State Department of  
          Public Health or the State Department of Social Services. 

       6)Makes technical, clarifying and conforming changes.


        FISCAL EFFECT:  The Assembly Appropriations Committee analysis, dated  
        May 5, 2010 indicates absorbable fee-supported special fund costs to  
        the California Board of Optometry to increase oversight of a small  
        group of professionals addressed by the bill

        COMMENTS:
        
        1.Purpose.  This bill is sponsored by  Board of Optometry  (Board) in  
          order to authorize optometrists to practice optometry at a health  
          facility or residential care facility, upon meeting specified  
          requirements.  

        According to the Author, "California laws are vague and do not  
          adequately address notification, standard of practice and record  
          keeping requirements for optometrists who practice in health  
          facilities.  A definition of optometric care in non-traditional  
          settings is needed in order to allow optometrists to provide this  
          type of care in a way that will protect the public and increase  
          access to care.  Furthermore, due to low overhead costs and  
          potentially high profit margins, increasing numbers of optometrists  
          are providing this type of care either part-time or as a sole mode  
          of practice.

        "Additionally, over the next several years and decades, Californian's  
          and the nations' baby boom generation are reaching age 65 and  
          represent among the fastest growing population in the state and in  
          the nation.  It is projected that the number of elderly patients who  
          live in assisted living facilities, traditional nursing homes, and  
          various tiers of intermediate care is expected to double by year  
          2030.  The concomitant expectation is that a great number of  
          professional services, such as optometric services will be rendered  
          for a non-ambulatory, or relatively immobile, percentage of the  
          population.  The Board wants to ensure that optometric services  
          rendered to patients in these settings are provided in a manner as  
          consistent as possible with the level of care that would be provided  
          by the practitioner in his/her regular practice location."






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        2.Background.  Optometrists diagnose and treat vision problems and eye  
          diseases and write prescriptions for eyeglasses, contact lenses, and  
          medications.  Optometrists are required to complete at least three  
          years of study at an accredited college or university before  
          beginning specialized optometry training.  The specialized training  
          is four years in duration and the optometry student must then pass  
          written and clinical state board examinations prior to licensure.   
          Currently, more than 6,500 optometrists practice in California.

        In 2007, AB 986 authorized optometrists to practice at temporary  
          locations in a similar fashion to statutes that authorize dentists  
          to work at temporary practice locations, such as nursing homes,  
          schools, and other public institutions.  However, those provisions  
          only authorized a limited term timeframe for the practice of  
          optometry at these temporary locations; 7 calendar days during a  
          30-day period and 54 days during the calendar year.  

        According to the Author and Sponsor, current law provides inadequate  
          regulatory safeguards for optometrists who practice in long-term  
          care facilities.  This bill increases those safeguards.  The Author  
          indicates the number of professionals practicing in these patient  
          settings will increase as the proportion of elderly Californians  
          continues to increase.

        3.Use of Assistants.  This bill was amended on May 17, at the request  
          of the California Medical Association to clarify that assistants  
          under the direct oversight of an ophthalmologist or optometrist may  
          carry out certain tasks and functions in any setting where  
          ophthalmology or optometry is practiced.  Formerly, the law  
          specified that these assistants may carry out these functions in the  
          office of a physician and surgeon or optometrist.  

        Writing in support of these amendments, the Chairman of the UC Davis  
          Eye Center states that ophthalmology practices have traditionally  
          employed specialized ophthalmic technicians who are not usually  
          formally trained as medical assistants, but have training that is  
          specifically relevant to eye care.  In order to provide efficient  
          and affordable health care, amendments were made by SB 929 in 2000,  
          which authorized assistants to administer medications under the  
          direct supervision of a physician and surgeon or optometrist.  Since  
          that time, however, the Department of Public Health has interpreted  
          that amendment as not applying to practice operating in  
          hospital-based clinics, which are under its licensing jurisdiction.   
          Prohibiting supervised technicians from administering drops under  
          direct supervision "greatly impairs our ability to render care in an  
          efficient and cost-effective manner.  Moreover, the nature of the  





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          practice in academic health centers which often care for larger  
          numbers of patients with more serious health problems seriously  
          impairs out ability to care effectively."

        "The care delivery activities involved in practicing ophthalmology and  
          optometry are no different when performed in a hospital-based clinic  
          compared with a private office.  Given that technicians have been  
          administering these medications for decades in private offices (and  
          indeed in hospital-based clinics for nearly that long until the  
          recent DPH challenge) without known issue, this clarification in law  
          only serves to restore what had reasonably been intended in the  
          first place."
        
        4.Prior Legislation.   AB 986  (Eng, Chapter 276, Statutes of 2007)  
          allowed the practice of optometry at temporary locations under  
          certain conditions, established a retention period for optometrists  
          to maintain patient records, and increased licensing fees.

         SB 929  (Polanco, Chapter 676, Statutes of 2000), among other things,  
          authorized assistants working in the office of an optometrist or  
          ophthalmologist, and under the direct supervision of an optometrist  
          or ophthalmologist, to perform a number of optometric tests and  
          procedures.
        
        5.Arguments in Support.  The  Board of Optometry  in sponsoring the bill  
          states that optometrists who practice in a variety of  
          non-traditional settings, such as long-term health care facilities,  
          skilled nursing facilities, psychiatric facilities, and intermediate  
          care facilities, have asked the Board to set minimum standards and  
          clarify what is required for optometrists who work in these  
          settings.  Additionally, due to low overhead costs and high profit  
          margins, increasing numbers of optometrists are providing this type  
          of care either part-time or as a sole mode of practice.  According  
          to the Board, California laws are vague and do not adequately  
          address notification, standard of practice and record keeping  
          requirements for optometrists who practice in health facilities.  As  
          a consumer protection agency, the Board feels it is necessary to  
          establish guidelines in order to prevent any possible abuse by  
          licensees regarding billing and services provided.

         Advanced Eyecare, Inc  . argues that many residents of health care  
          facilities have health or behavioral issues making them not readily  
          transportable to a doctor's office, "in house" care is often the  
          only way these patients may receive vision services.  However, under  
          existing law, providing "in-house" optometric vision services the  
          residents of a care facility is at best cumbersome and at worst a  





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          crime.  "In fact, the State's largest vision insurance company,  
          which also administers some Medi-Cal vision benefits is preventing  
          its panel doctors from providing "in-house" care to nursing home  
          residents.  This bill would allow optometrists to care for these  
          facility residents while requiring certain criteria prior to  
          providing in house services.

         Vision Service Plan  believes that the proper vision health care is  
          extremely important to enhance the quality of life for all persons,  
          and supports the ability for qualified optometrists to provide  
          on-site vision care to his or her geriatric patients residing in  
          health and residential care facilities.

        6.Clarifying Amendments.  Committee staff has worked with the Sponsors  
          to clarify and focus certain provisions of the bill.  The following  
          clarifying amendments will be offered as Author's amendments in  
          Committee:
        
           a)   Clarify the definition of "residential care facility."

           Revise page 4, line 36 through page 5, line 3 to read:
              (2) "Residential care facility" means any facility licensed by  
             the State Department of Social Services  caring for persons who  
             cannot live alone but who do not need extensive medical services.  
              The services provided in these facilities vary according to the  
             needs of the individual, but typically include help with  
             medications and assistance with personal hygiene, dressing, and  
             grooming. Residential care facilities include,   as defined in  
             subsection (1) of paragraph (a) of Section 1502 of the Health and  
             Safety Code (a) (1), including  but  are  not limited to, the  
             following:





           b)   Clarify the requirements of a primary business office.

           Revise page 5, line 26 to read:  "Is not  located in or connected  
             with  a residential dwelling."

           c)   Specify that both the place of practice and the primary  
             business office must be included in the information maintained by  
             an optometrist.

             Revise page 6, line 12 to read:  "The place of practice  or   and  





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             the  primary business office."


        SUPPORT AND OPPOSITION:
        
         Support: 

        Board of Optometry (Sponsor)
        Advanced Eyecare, Inc.
        Chairman, UC Davis Eye Center
        Vision Service Plan

         Opposition:  

        None received as of June 21, 2010.



        Consultant:G. V. Ayers