BILL ANALYSIS �
SB 492
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Date of Hearing: August 6, 2014
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Mike Gatto, Chair
SB 492 (Hernandez) - As Amended: August 4, 2014
Policy Committee: Business and
Professions Vote: 8-1
Urgency: No State Mandated Local Program:
Yes Reimbursable: No
SUMMARY
This bill expands and amends the scope of practice for
optometrists by creating advanced practice certificates for
additional procedures and immunizations, and by expanding an
optometrist's professional discretion in several areas.
Specifically, this bill:
1)Allows optometrists who are certified to use therapeutic
pharmaceutical agents (TPAs) to use all TPAs approved by the
United States Food and Drug Administration and indicated for
use in diagnosing and treating eye conditions.
2)Expands and modifies the list of conditions an optometrist can
diagnose and treat.
3)Requires the Board of Optometry (board) to grant a certificate
to an optometrist for the use of advanced procedures,
including removal of lesions, laser treatment, wound closure,
and injections (excluding injections for cosmetic effect), if
the optometrist meets specified educational and certification
requirements.
4)Specifies the minimum number of procedures required to
demonstrate competency, including 20 to 35 clinical eyelid or
adnexa surgical training procedures, 18 to 25 laser training
procedures, and six to 12 injection training procedures.
Requires the board to convene an advisory committee to
establish the exact number of training procedures required.
5)Requires the board to grant an advanced procedures certificate
to licensees who submit proof of completion of a satisfactory
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curriculum on advanced procedures, as determined by the board,
for licensees graduating after May 1, 2016. For licensees
graduating prior to May 1, 2016, specifies the exact
instruction required to satisfy the educational requirements.
6)Requires the board to grant a certificate to an optometrist
for immunizations, which include influenza, pertussis, Herpes
zoster (shingles), or other immunizations necessary to protect
public health, if the optometrist meets specified educational
and certification requirements.
7)Authorizes the board to allow optometrists to use any
noninvasive technology to treat specified conditions.
8)Requires an optometrist to consult with, and if necessary,
refer a patient to a physician or other appropriate health
care provider if a situation or condition occurs that is
beyond the optometrist's scope of practice.
9)States that it is the intent of the Legislature that the
Office of Statewide Health Planning and Development (OSHPD),
under the Health Workforce Pilot Projects Program (HWPPP),
designate a pilot project intended to test, demonstrate, and
evaluate expanded roles for optometrists in the performance of
management and treatment of diabetes mellitus, hypertension,
and hypercholesterolemia.
FISCAL EFFECT
1)This scope expansion and the creation of two new
certifications will result in the following fiscal impacts to
the Board of Optometry (State Optometry Fund):
a) One-time costs of approximately $400,000 per year for
the first two years for exam development, Information
Technology changes, regulations, licensing, enforcement and
program oversight.
b) Ongoing costs for enforcement and program oversight are
likely in the range of $250,000 or more annually.
c) Potential increased revenues of $50,000 associated with
an increase in certification fees currently authorized for
treatment of glaucoma, as this certification is necessary
to pursue the advanced certification created by this bill.
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Fees are not authorized for the new certificates created
by this bill.
1)Minor cost pressure to the Office of Statewide Health Planning
and Development (Health Data and Planning Fund) to oversee a
pilot project, as specified by legislative intent language.
COMMENTS
1)Purpose . The purpose of this bill is to expand the list of
procedures optometrists are allowed to perform. The author
contends this bill encourages timely access to high-quality
health care, given there is a robust network of optometric
providers that are well-trained, evenly distributed throughout
the state, and regulated by the Department of Consumer
Affairs. The author states this bill is a limited expansion of
scope for optometrists that is consistent with their education
and training, and is a logical advancement of the profession
that has been proven safe in other states. The author also
argues the educational requirements contained in this bill are
substantially greater than those required of optometrists in
other states.
2)Background . An optometrist (Doctor of Optometry or O.D.) is an
independent primary health care professional for the eye.
Optometrists examine, diagnose, treat, and manage diseases,
injuries, and disorders of the visual system, the eye, and
associated structures, as well as identify related systemic
conditions affecting the eye. ODs may prescribe medications,
low vision rehabilitation, vision therapy, spectacle lenses,
contact lenses, and perform certain surgical procedures. An
O.D. degree requires an undergraduate education in a college
or university and four years of professional education at a
college of optometry. Additional optional training can be
pursued, and an optometrist can pursue optional
certifications. The TPA certification allows optometrists to
use certain specified pharmaceutical agents and treat certain
conditions of the human eye, or any of its appendages, with
therapeutic pharmaceutical agents. The optometrist may also
perform certain procedures on the eye.
An ophthalmologist is a physician and surgeon with specialty
training in the anatomy, function and diseases of the eye. The
central focus of ophthalmology is surgery and management of
complex eye diseases. To become an ophthalmologist, an
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individual must obtain an undergraduate degree, complete four
years of graduate education at an accredited medical school
and earn a Medical Degree, complete a one year internship, and
a three or four year residency. Additional optional training
can be pursued.
3)2013-14 negotiations between optometry and ophthalmology . Over
the past year, formal meetings and numerous discussions have
been held between this bill's supporters and opposition.
These discussions significantly reduced the range of open
issues, but ultimately failed to achieve consensus. The
primary issue appears to be the amount of training required to
perform procedures safely. The bill's current form generally
reflects the preferences of the author and the sponsor, the
California Optometric Association. There is a
counter-proposal for an optometric advanced practice
certificate offered by the California Academy of Eye
Physicians and Surgeons, described in detail in the Assembly
Committee on Business and Professions June 24th analysis of
this bill.
4)Recent amendments . This bill was amended on August 4, 2014
with the following substantive changes (changes (b) and (c)
were made in order to honor verbal commitments taken in the
June 24th Assembly Business and Professions committee hearing
on the bill):
a) Reverts back to existing law language related to
ordering laboratory tests.
b) Specifies required clinical experiences are on live
human patients.
c) Specifies the advanced procedures allowed by the bill do
not include "performing blepharoplasty or other cosmetic
surgery procedures that reshape normal structures of the
body in order to improve appearance and self-esteem."
5)Support . The California Optometric Association is the sponsor
and primary supporter of this bill. Other supporters include
Californians for Patient Care, a non-profit patient advocacy
organization; the Bay Area Council; some hospitals and health
facilities; pharmacists; organizations representing nurses,
including United Nurses of California and California
Association for Nurse Practitioners; and Blue Shield of
California. The California Hospital Association and the State
Board of Optometry would support this bill with minor
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amendments.
6)Opposition . Opposition includes a number of medical
associations, including the California Medical Association and
those representing eye physicians and surgeons, emergency
physicians, plastic surgeons, anesthesiologists, and others;
a number of department chairs of ophthalmology, including
those at UC hospitals; the Medical Board of California;
clinical laboratory scientists; a number of individuals,
individual health facilities, and other non-profit
organizations, groups representing patients with diabetes, the
Union of American Physicians and Dentists and the Engineers
and Scientists of California; and the Right to Life Committee.
The medical professionals and groups opposing this bill
believe the training required by the bill is inadequate to
allow optometrists to practice surgery. The California
Academy of Eye Physicians and Surgeons contends the bill's
training requirements cannot credibly prepare someone for
independent practice. They also note issues with the
administration of additional medications, on which they say
optometrists may not be trained in a practical sense; allowing
immunizations to be performed outside the medical home; and
other issues specific to laser surgery, injections, and lid
lesion removal. Finally, they cite a public poll they
commissioned to gauge public opinion about the number of
required surgeries one should be expected to perform before
being allowed to perform surgeries independently, stating the
poll results bolster their case that the training level
required by this bill is far too low.
7)Staff Comments . This bill makes no provisions for the
Optometry Board to recoup costs associated with the two new
certificates. The Optometry Fund currently has a healthy fund
balance in light of annual expenditures. However, annual
expenditures are slightly above annual revenues currently,
resulting in a small annual shortfall. With the increased
workload, and without new revenues to support it, the
Optometry Board would likely experience significant shortfalls
within 2-3 years. In general, licensed or certificated
individuals are responsible for funding the workload costs
associated with oversight of the license or certificate.
Staff suggests fees be established for the new certificates at
levels commensurate with the increased workload.
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Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081