Optometrists in Australia have been embracing therapeutic prescribing rights and going back to school to add another dimension to their qualifications. In the face of our ageing population, these optoms are expected to relieve the pressure on our overloaded public health system – where waiting lists in some instances for eye surgery are three or four years long.
With this mind mivision and students from UNSW decided to look at the American system, which introduced similar rights to optometrists a number of decades ago, to paint the picture of how this significant development may impact the future of eye care in Australia.
The introduction of drug laws to the United States of America, which allow optometrists the right to prescribe various Therapeutic Pharmaceutical Agents (TPAs), have been integral in the expansion of the scope of optometric practice in the States. However, it was no easy task – with the practice of optometry individually regulated by all 50 states, it took almost 21 years to have the laws passed! See Table 1 for the detailed TPA passage by state.
The industry remains complex. Each state certifies its optometrists to prescribe at a different level. This means some states restrict optometrists to prescribing only topical pharmaceutical agents, while other states allow optometrists to prescribe oral medications, administer injections and even perform minor surgeries. 2 Currently all 50 states allow their optometrists to prescribe topical drugs, 47 states allow their optometrists to prescribe oral medications and over half of the states have injectable drug prescribing authority.1
Optometrists want to perform surgical procedures, inject drugs and Botox and broaden the medications that they are able to prescribe
Why Therapeutics Was Introduced
One of the main arguments presented when lobbying first began was the need for qualified professionals to provide eye care in rural areas.3 Optometrists were the only eye care practitioners available in many rural areas and small towns. This meant that optometrists were forced to refer patients with pathology to either the local General Practitioner (GP) or to an ophthalmologist, who may have been many hours away. It was reasoned that optometrists were the most qualified to treat minor eye disease in these situations.
Another argument was the potential to increase the collegiality, communication and cooperation of the GP and other health care professions with optometrists. GPs, who may not be comfortable treating eye disease or lack the essential instruments for accurate diagnosis, would be more likely to refer patients to an optometrist if they were able to prescribe TPAs.2
Furthermore, by allowing optometrists to prescribe therapeutics, primary and secondary eye care would be delivered more quickly, effectively and successfully.7
The insurance industry also influenced the move. It was believed that, without the ability of optometrists to handle drugs, insurance companies would view ophthalmology as the primary eye care provider. Therefore, it would not be logical for an insurance company to pay an optometrist’s fee when the patient might be referred to an ophthalmologist, who would also require payment.6
Other motives for breaking the drug barrier and expanding the scope of optometric practice include the potential to retain patients. During this period in the U.S.A., many ophthalmologists included refraction as a part of their examination. Once a patient was referred to the ophthalmologist for suspected pathology, they were unlikely to return to their optometrist. In addition, they often directed family and friends straight to the ophthalmologist for primary eye care, including refraction.6 Finally, it was believed that therapeutic prescribing would translate into greater prestige for the optometrist’s practice.2
It is important to note that some optometrists saw the movement towards TPA prescribing in optometry as a distraction from the distinctively optometric concepts of enhancing vision.6
Optometry Entry and Education
In the U.S.A., there are a total of 17 colleges offering the Doctor of Optometry degree. Unlike the Australian undergraduate optometry entry program where students immediately study optometry following their high school education, prospective optometry students in the U.S.A. must complete an undergraduate degree, which takes at least three years. Students must then sit the Optometry Admissions Test9, which measures both academic ability and scientific comprehension. Their performance is graded for entry into the four year postgraduate Doctor of Optometry program.
The content of the U.S.A. based optometry degree is comparable to the modules offered in the Australian based optometry program. Students gain knowledge in vision science, optics, biochemistry, pharmacology, anatomy and an overview of systemic diseases.9 Clinical training in the diagnosis, treatment and management of ocular dysfunctions and diseases is also emphasised. Graduate optometrists interested in refining and developing skills in a specialty area, take a one year post-graduate clinical residency program.9
Applicants must satisfactorily pass their Doctor of Optometry degree to attain a licence to practice optometry. They must also pass a national examination administered by the National Board of Examiners in Optometry which measures knowledge and skills in three areas: basic science, clinical science and patient care. Additionally, students must sit a national, regional or state clinical examination.11 Many states also require completion of an exam on relevant state laws relating to the practice of optometry.9 Once a licence is obtained, it needs to be renewed every one to three years, depending on state regulations. Licences can only be renewed once adequate continuing education credit points have been accumulated, which is similar to Australia’s new Continuing Professional Development (CPD) points system.
Impact on the Profession
Therapeutics has impacted on the patient, the optometry profession, the relationships between optometrists and other health professionals and specialists, as well as the health and insurance systems.
Patients can now present to an optometrist instead of visiting a GP or an Accident and Emergency Department. This eases the burden on health providers and decreases the strain on hospital facilities and staff. Patients benefit from the convenience of visiting just one practitioner and they save money. GPs and hospitals are freed up to help other patients, thus improving the health of the broader population.12
Another impact is a reduction in the number of referrals from the optometrist to the ophthalmologist.12 Furthermore, the number of referrals to the ophthalmologist via the GP from the optometrist is also reduced.
Additionally, there is a greater number of intra-professional referrals from non-therapeutic optometrists to therapeutically endorsed optometrists. This allows the patient to access the necessary specialty care for a given condition or problem in a convenient and efficient manner in order to enhance their ocular experience and contact.
Therapeutic prescribing has also provided a considerable advantage to the optometric practitioner, who can now treat patients without passing on the business.
The strengthening of inter-professional relationships is also profound,12 as there is a greater clarity of the roles and responsibilities of each profession. The relationship between optometrists and ophthalmologists in particular is better in terms of co-management, as optometrists play more of a role in disease management and drug prescription, and need only refer to ophthalmologists in more severe or advanced stage disease.
One potential challenge which arose from therapeutic licence introduction is the increased costs associated with optometrists’ extra responsibilities. These include prescribing costs, training costs and administrative costs. There is also either increased paperwork or computerised information in the practice. However reimbursement schemes for prescribing pharmaceutical agents provide financial assistance to optometrists.
Since the introduction of therapeutics to optometry, optometrists have become important sources of medical eye care across the USA. This increase in responsibility means that it is imperative that optometrists stay up-to-date with the latest developments in eye care pharmaceuticals and are able to assess a patient’s insurance coverage for treatment. In doing so, they can prescribe drugs covered under the patient’s insurance plan, thus decreasing the cost, without sacrificing the quality of care.13
The tiered insurance coverage refers to the level of monetary reimbursement of pharmaceutical items which insurance companies are willing to provide on a selected prescribed drug. The majority of existing insurance plans work on a three tier system,13 where the patient elects the tier they would like to be insured under and the coverage of items specific to the chosen tier are set out in a drug formulary. The three tiers are detailed in Table 2. The coverage of medications varies between health insurance companies and is subject to change at any time.
Patients are more likely to be compliant with medications if they are sufficiently insured. Conversely, if the patient is inadequately insured and full payment of medication is required, there may be decreased compliance of medication. Overall, most patients are expected to benefit from insurance payments as 79.6 per cent13 of the American population is affiliated with an insurance plan.
Expanding the Practice
The major battle optometry is facing in the U.S.A. currently is the further expansion of their scope of practice. Optometrists want to perform surgical procedures, inject drugs and Botox and broaden the medications that they are able to prescribe. Most recently, layered drug-dispensing soft contact lenses have been developed which are able to release a constant, steady and substantial amount of drug. These contact lenses have been classed as drugs and therefore many optometrists are unable to prescribe them.4
Currently Oklahoma is the only state in which optometrists are able to perform laser surgery on the anterior eye, including Nd:YAG capsulotomies, iridotomies, Argon Laser Trabeculoplasties (ALT) and Photorefractive Keratectomy (PRK), however, they are unable to perform LASIK. This has been a topic of major conflict between optometrists and ophthalmologists. Currently a number of states, including West Virginia, have proposed bills allowing optometrists to perform similar minor surgeries, with no states succeeding as of yet.4
Early last year the FDA approved Latisse by Allergan. Latisse is a 0.03 per cent bimatoprost ophthalmic solution with the specific indication to treat hypotrichosis of the eyelashes. The product increases eyelash growth by thickening, lengthening and darkening the lashes. Lumigan by Allergan, is a glaucoma medication from the same formulation. In a curious example of the way TPA law has effected optometrists in the United States, optometrists in certain states may be able to prescribe Lumigan for glaucoma, but unable to prescribe Latisse for cosmetic indication.18
For those optometrists who are able to prescribe Latisse, this development presents not only a new treatment modality, but a new patient base that will allow practices to expand the cosmetic side of optometry. Studies have shown it is extremely safe, with the only adverse effects noted being ocular irritation, itching, conjunctival hyperaemia and eyelid skin hyperpigmentation. The fact that these side effects are all ocular in origin reinforces that optometrists are best qualified to prescribe these products.18,19
The evolution of optometry in the United States of America from its origins in the pre-therapeutic era to the introduction and present growth of therapeutics in this industry emphasises that the optometric profession is dynamic. The passing of the TPA law in 1976 has had numerous benefits and some limitations between optometrists and other allied health professionals, has improved the experience for the patient, and is heading towards the establishment of uniformity across the entire country through the electronic prescribing system. There has also been a further repercussion in the development of the tiered insurance system to boost the advantages for the patient by providing a subsidy for their drug costs.
The potential for optometrists to increase their scope of practice to encompass greater therapeutic intervention for their patients remains an exciting arena of development. However it is vitally important, that with the lateral shift of scope from refractive expertise towards the area of diagnosis and treatment of disease, optometrists do not leave a vacuum in the leadership role in refractive care.6 After all, patient care is of the utmost importance – the best continued service should be provided for patients in all facets of practice.
Ms. Debbie Narunsky and Ms. Britt Fang are final year optometry students studying their Bachelor of Optometry and Vision Science at the University of New South Wales. This is their first published work.
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Table 1: TPA Passage by State
North Carolina, Indiana
New Mexico, Iowa, Rhode Island
Kentucky, South Dakota, Nebraska, Missouri, Florida
Wyoming, Arkansas, Idaho, North Dakota, Kansas, Tennessee, Montana, Maine
Georgia, Virginia, Colorado
Utah, Texas, Oregon
New Jersey, Ohio, Connecticut, Alaska
Arizona, Minnesota, South Carolina, Louisiana, New Hampshire
Mississippi, Vermont, Delaware, Michigan
Guam, Maryland, Alabama, Nevada, Illinois, New York
California, Hawaii, Pennsylvania
Table 2: Three-tiered System
Generic drugs covered only, with a minimal patient co-payment
Insurer preferred drug brands covered, with a higher patient co-payment or lower co-insurance payment than tier 1
insured non-preferred drug brands covered, with an even higher patient copayment or even lower co-insurance payment than tiers 1 and 2