BILL ANALYSIS                                                                                                                                                                                                    Ó


          |SENATE RULES COMMITTEE            |                        SB 492|
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                                    THIRD READING

          Bill No:  SB 492
          Author:   Hernandez (D)
          Amended:  5/8/13
          Vote:     21

           SENATE BUSINESS, PROF. & ECON. DEVELOP. COMM.  :  8-0, 4/29/13
          AYES:  Price, Block, Corbett, Galgiani, Hernandez, Hill,  
            Padilla, Yee
          NO VOTE RECORDED:  Emmerson, Wyland

           SENATE APPROPRIATIONS COMMITTEE  :  7-0, 5/23/13
          AYES:  De León, Walters, Gaines, Hill, Lara, Padilla, Steinberg

           SUBJECT  :    Optometrists:  practice:  licensure

           SOURCE  :     Author

           DIGEST  :    This bill permits an optometrist to diagnose, treat  
          and manage additional conditions with ocular manifestations;  
          directs the California Board of Optometry to establish  
          educational and examination requirements; and permits  
          optometrists to perform vaccinations and surgical and  
          non-surgical primary care procedures.

           ANALYSIS  :    Existing law defines the practice of optometry; and  
          specifies that an optometrist who is certified to use  
          therapeutic pharmaceutical agents (TPAs) may also diagnose and  
          treat specified conditions, use TPAs, and order specified  
          diagnostic tests.



                                                                     SB 492

          This bill: 

          1. Adds the provision of habilitative optometric services to the  
             definition of the practice of optometry. 

          2. Allows an optometrist who is TPA certified to treat the  
             lacrimal gland, lacrimal drainage system and the sclera in  
             patients under 12 years of age. 

          3. Allows an optometrist to treat ocular inflammation and pain,  
             nonsurgical in cause except when comanaged with the patient's  
             treating physician and surgeon. 

          4. Permits optometrists to treat eye lid disorders, including  
             hypotrichosis and blepharitis.

          5. Allows an optometrist to use all TPAs approved by the Food  
             and Drug Administration (FDA) for use in treating eye  
             conditions including codeine with compounds and hydrocodone  
             with compounds as listed in the California Uniform Controlled  
             Substances Act and the U.S. Controlled Substances Act.   
             Limits the use of these agents to three days. 

          6. Requires, in any case that an optometrist consults with a  
             physician and surgeon, the optometrist and the physician and  
             surgeon to both maintain a written record in the patient's  
             file of the information provided to the physician and  
             surgeon, the physician and surgeon's response, and any other  
             relevant information.  Upon the request of the optometrist or  
             physician and surgeon and with the patient's consent, a copy  
             of the record shall be furnished to the requesting party.

          7. Removes the requirement for optometrists to only utilize  
             specific TPAs. 

          8. Allows TPA-certified optometrists to remove sutures, upon  
             notification of the treating physician and surgeon. 

          9. Removes the restriction that optometrists can only administer  
             oral fluorescein to patients suspected as having diabetic  

          10.Deletes the list of specific tests optometrists are permitted  
             to order and permits optometrists to order any laboratory and  



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             diagnostic imaging tests for conditions authorized to be  
             treated pursuant to this bill.

          11.Authorizes an optometrist to perform a clinical laboratory  
             test or exam classified as waived under CLIA (Clinical  
             Laboratory Improvement Amendments) and designated as waived  
             in #10 above necessary for the diagnosis of conditions and  
             diseases of the eye or adnexa, or if otherwise specifically  

          12.Adds the provision that optometrists can administer  
             immunizations for influenza, Herpes Zoster Virus, and  
             additional immunizations that may be necessary to protect  
             public health during a declared disaster or public health  

          13.Permits optometrists to test for and diagnose diabetes  
             mellitus, hypertension and hypercholesterolemia.

          14.Specifies that an optometrist diagnosing or treating eye  
             disease or diagnosing other diseases shall be held to the  
             same standard of care to which physicians and surgeons and  
             osteopathic physicians and surgeons are held. 

          15.Requires an optometrist to consult with and refer to a  
             physician and surgeon or other appropriate health care  
             provider if a situation/condition occurs that is beyond the  
             optometrist's scope of practice.

          16.Allows an optometrist to consult with and refer to a  
             physician and surgeon or appropriate health care provider if  
             a situation or condition occurs that is beyond the  
             optometrist's education and training. 

           Shortage of optometrists  .  According to a report prepared by the  
          Center for the Health Professions at the University of  
          California San Francisco, the number of optometrist licenses in  
          California has declined, but the number of licensees with a  
          secondary practice location has increased.  According to the  
          California Board of Optometry, there are approximately 9,000  
          optometrists in California, the largest population of  
          optometrists in the United States.  These optometrists are  



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          generally concentrated in coastal counties, the Bay Area and  
          counties in the Sacramento region.  Several counties have no  
          licensed optometrists with an address of record in those  
          counties, and a number of other counties have ratios that  
          indicate there is approximately one optometrist for every 10,000  

           Optometrists' education, training and scope  .  After completion  
          of an undergraduate degree, optometrists complete four years of  
          an accredited optometry college after which they are awarded the  
          Doctor of Optometry degree.  Some optometrists also undertake an  
          optional one year non-surgical residency program to enhance  
          their experience in a particular area.  Students graduate with  
          2,500-3,000 patient encounters; these include a mix of  
          post-surgical, medical and routine visits. 

          Optometrists are trained to diagnose mild to severe eye problems  
          such as serious eye infections, inflammations of the eye,  
          trauma, foreign bodies and glaucoma.  They also examine the eye  
          for vision prescription and corrective lenses.  Optometrists may  
          apply for certification to administer TPA; to perform lacrimal  
          irrigation and dilation; and to diagnose and treat primary open  
          angle glaucoma.

           Ophthalmologists' education, training and scope  .  After  
          obtaining an undergraduate degree, ophthalmologists complete  
          four years at an accredited medical school and earn a Medical  
          Degree.  This is followed by a one year internship and a three  
          or four year surgical residency.  Many ophthalmologists pursue  
          additional fellowship training in specialized areas such as  
          retina, glaucoma or cornea.  Ophthalmologists may become  
          certified by the American Board of Ophthalmology, which  
          requires, serving as primary surgeon or first assistant to the  
          primary surgeon on a minimum of 364 eye surgeries. 

          The central focus of ophthalmology is surgery and management of  
          complex eye diseases.  An ophthalmologist specializes in the  
          refractive, medical and surgical care of the eyes and visual  
          system and in the prevention of disease and injury. 

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  Yes

          According to the Senate Appropriations Committee:



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             One-time costs of about $950,000 over two years to revise  
             regulations and certify additional optometrists to use  
             therapeutic pharmaceutical agents by the California Board of  
             Optometry (State Optometry Fund).

             Ongoing costs of about $350,000 for certifications and  
             enforcement activities (State Optometry Fund).

             Increased fee revenues of about $80,000 over the first two  
             years and about $10,000 per year thereafter for additional  
             certifications (State Optometry Fund).

             Indeterminate impact on state health care programs, such as  
             the California Public Employees' Retirement System and  

           SUPPORT  :   (Verified  5/24/13)

          Bay Area Council
          Blue Shield of California
          California Hospital Association
          California Optometric Association
          California Pharmacists Association/California Society of  
          Health-System Pharmacists
          Californians for Patient Care
          United Nurses Associations of California/Union of Health Care  
          Vision Service Plan
          Western University of Health Sciences

           OPPOSITION  :    (Verified  5/24/13)

          American College of Emergency Physicians- California Chapter
          Blind Children's Center
          California Academy of Eye Physicians & Surgeons
          California Academy of Family Physicians
          California Association for Medical Laboratory Technology
          California Medical Association
          California Society of Anesthesiologists
          California Society of Plastic Surgeons
          Canvasback Missions Inc.
          Lighthouse for Christ Mission Eye Center



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          Osteopathic Physicians & Surgeons of California
          Union of American Physicians and Dentists

           ARGUMENTS IN SUPPORT  :    According to the author's office, this  
          bill is intended to allow optometrists to practice to the full  
          extent of their education and training in order to expand access  
          to the health care delivery system for the millions of  
          Californians who will have new access to coverage through the  
          implementation of the federal Patient Protection and Affordable  
          Care Act (ACA).  This bill allows optometrists to diagnose,  
          treat and manage specific eye disorders and common diseases such  
          as diabetes, hypertension and hyperlipidemia; expands the drugs  
          optometrists can prescribe; and permits optometrists to  
          administer immunizations and to perform surgical and  
          non-surgical procedures.

          Blue Shield of California states, "Expanding the range of  
          services that these practitioners are able to provide will  
          improve access and quality of care as they are well trained and  
          highly educated professionals that are already providing  
          integral health services."

          Californians for Patient Care note, "It is widely noted that  
          there are not enough trained medical professionals to  
          appropriately care for the influx of new patients.  We believe  
          it is important that qualified, educated and trained  
          optometrists be allowed to practice to the extent of their  
          licenses to best serve California's patient population  
          throughout the state."

          The California Optometric Association believes that this bill,  
          "addresses the health care provider gap by expanding the scope  
          of practice of optometry.  Optometrists are positioned and  
          prepared to be part of the solution to meeting the additional  
          health care needs upon enactment of the ACA in 2014."

          The United Nurses Associations of California/ Union of Health  
          Care Professionals indicate, "SB 492 would allow optometrists to  
          practice to the full extent of their education and training in  
          order to expand access to the health care delivery system for  
          the millions of Californians who will have new access to  
          coverage through implementation of the federal ACA."

           ARGUMENTS IN OPPOSITION  :    The California Medical Association  



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          (CMA) outline several concerns.  Included is the provision of  
          primary care services that optometrists would be permitted to do  
          if the bill passed.  CMA believes that this is "?beyond the  
          existing scope of practice related to visual disorders and could  
          result in serious harm to patients."  They also note that  
          optometrists "?do not have the training and experience necessary  
          to provide comprehensive primary care.  In addition, SB 492  
          would allow optometrists to practice medicine without being  
          subject to the Medical Practice Act.  Currently, optometrists  
          are licensed by the Board of Optometry.  Under SB 492, the scope  
          of practice for optometrists would be expanded to the point  
          where they would be practicing as ophthalmologists, who are  
          required to have a medical license, without being subject to the  
          controls and oversight of the Medical Practice Act."

          The California Association for Medical Laboratory Technology  
          notes, "While we recognize the ability of optometrists to  
          perform certain waived tests limited to their scope of practice,  
          we have concerns about the broad range of testing contained in  
          this bill.  Of greater concern is whether or not optometrists  
          receive the proper education and training to perform as a  
          laboratory director." 

          The California Academy of Eye Physicians & Surgeons is concerned  
          about the expanded scope of practice for optometrists permitted  
          by this bill.  Specifically, they are concerned about the  
          provisions that would allow optometrists to conduct eye  
          surgeries and prescribe medications by all routes with no  
          additional training.

          The Union of American Physicians and Dentists states that "SB  
          492 rolls out an uncertain health care delivery system with  
          patients subject to unintended consequences of the bill.   
          Medical supervision over optometrists is critical to safe  
          patient outcomes.  SB 492 raises serious patient safety concerns  
          in allowing optometrists to prescribe medication and perform  
          surgical procedures without and medical supervision." 

          The Lighthouse for Christ Mission Eye Center and the Canvasback  
          Missions, Inc. states, "The bill would give optometrists greatly  
          increased privileges, including the ability to treat any disease  
          that might have a "manifestation" in the eye without additional  
          specific training requirements.  The Board of Optometry, whose  
          members have no experience doing surgery or treating the added  



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          diseases would be allowed to decide those training  

          The California Society of Anesthesiologists argues, "SB 492  
          would allow the diagnosis and initiation of treatment of any  
          condition with ocular manifestation.  This is a broad and  
          unclear authorization that has not attained scientific  
          consensus.  It is not a sufficient basis to authorize  
          comprehensive primary care.  Also, by granting full drug  
          prescribing authority to optometrists, the bill would add a new  
          category of authorized controlled substance prescribers at a  
          time when more controls are being sought over excessive  

          MW:d  5/24/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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