Eye wars have started in Florida as optometrists want to perform surgery despite not being medical doctors
On this edition of the Politically Incorrect Podcast I am joined by Richard Miniter, the Chief Executive Officer of American Media Institute. He was the author of a wonderful three part series on Non-doctors in Florida Lobby for OK to Perform Eye Surgery.
The series looks at an attempt by optometrists, to get lawmakers in Florida to pass a bill allow them to perform surgery, despite the fact they are not medical doctors. As you might expect ophthalmologists, who insist that such surgery should be done only by trained and licensed medical doctors.
You can read the entire series right here on NEWS TALK FLORIDA. Starting with part one below.
Non-doctors in Florida Lobby for OK to Perform Eye Surgery
When the legislative session opened in Tallahassee last week, lawmakers and lobbyists were surprised by an epic battle over eye surgery.
A series of bills authorizing optometrists, who are not medical doctors, to perform such surgery have ignited the latest round of what critics call “the eyeball war” in Florida. On one side are optometrists who claim they are capable of performing many common procedures. On the other side are ophthalmologists, who insist that such surgery should be done only by trained and licensed medical doctors. Billions of dollars in fees are at stake in this battle, which echoes similar disputes across the country. There is also a political dimension because one of the top lobbyists for the legislation, Michael Corcoran, is the brother of Florida’s Speaker of the House, Richard Corcoran.
State Senator Jack Latvala (R-Clearwater) introduced the bill in the Senate on February 23. In the House, Manny Diaz, Jr. (R- Hialeah Gardens) introduced a companion bill to allow non-doctors to perform eye surgery on February 24.
State law currently bars non-doctors from performing such eye surgery. Sweeping away such barriers, the new legislation would also allow optometrists to prescribe the same drugs tat doctors can and act like surgeons in caring for patients across Florida, one of the largest markets for eye surgery in the world. The optometrists, if the law passes, would be required to complete some additional but undefined specialized medical training. That additional training will not involve becoming a licensed medical doctor.
The proposed state law could affect almost all of the Sunshine State’s 20 million residents. “If you live long enough, you will get cataracts and eventually need corrective surgery,” said Jaime Membreno, a veteran and ophthalmologist from Kissimmee. “Allowing optometrists to do this kind of surgical procedure is like allowing the mechanic to fly a fighter jet.”
Optometrists see it differently. “The fact is we are the primary care for the optics of the eye,” said Salvatore DeCanio, an optometrist in South Florida. “We know far more about optics and prisms in the eye than ophthalmologists. They have a different specialty.”
DeCanio, who is a fellow of the American Academy of Optometry and has 32 years of experience in optometry, said he and his colleagues already do far more than ask patients to read eye charts.
“I removed something from the cornea today on a patient who was in need of immediate care,” he said. “I am part of a group that is comfortable with some mildly invasive procedures. As an optometrist, the cornea and lens of the eye is not a strange animal for us.”
Both the American Optometric Association and the Florida Optometric Association did not return calls from the American Media Institute. Instead, the American Optometric Association provided a written statement that read in part: Patients trust optometrists “to deliver the highest quality, most advanced and most personalized care as well as the best outcomes.”
Ophthalmologists, who are licensed medical doctors and trained surgeons, are outraged over what they say is heightened risk to patients. Even a small mistake in eye surgery can lead to irreversible blindness, said Dr. William Mallon of Vero Beach, a leading opponent of the legislation.
“It takes a minimum twelve years of schooling and training to perform eye surgery,” said Dr. Mallon. “Medical school. Supervised residency. The night before my surgeries, I go for a run and get a full night’s sleep. I know that if I lose focus for even a single second of surgery, my patient’s life could be permanently changed. Recently I operated successfully on a one-eyed patient, who was terrified to have a cataract removed from her one remaining good eye. I understood her fear. I think about the stakes every time I walk into the operating room.”
Dr. Mallon cast the bill as part of a larger push by optometrists, who often make referrals to ophthalmologists, to use political leverage to make money. He gave up his practice in Jacksonville in 1999, in part, because he was told that his patients’ post-surgical care would have to be overseen by optometrists or they wouldn’t refer any patients to him. He believes post-surgical care, as well as eye surgeries themselves, should be directed by doctors.
“Those optometrists totally controlled the market up there,” he said. “They were risking the patients’ well-being for a 20% fee-sharing arrangement.”
Such fee-sharing arrangements, known as “co-management,” are an increasingly common practice in Florida and are legal if done correctly. Critics say the practice is unethical. Usually these arrangements are not disclosed to patients. Mallon and other critics say this arrangement puts money ahead of the best care for patients.
Behind the political battle are patients’ lives and careers. Cases of vision loss and other complications have grown in the handful of states that allow optometrists to prescribe medicine and perform laser eye surgery, studies show. Additionally, trained doctors can spot a range of maladies — everything from lymphoma and heart arrhythmias to sleep apnea and diabetes — that non-medical doctors are not as extensively trained to look for. What everyone can see is the mountain of money at stake, though both sides insist that patient outcomes are the real issue.
Optometrists, who are now legally allowed to call themselves “optometric physicians” in Florida, have long sought to put themselves on an equal footing with traditionally trained doctors. Ambition plays a role, too. Many optometrists have opened small chains—dozens of storefronts selling eye glasses and eye care—that would further prosper with the added business. Ophthalmologists tend to have small practices and directly supervise all patient procedures; their boutique enterprises would suffer from big-chain competition.
The push to give optometrists new powers is driven by a complex web of dark money — contributions filtered through shadowy political organizations to hide their source — that has funded massive lobbying efforts. In the last election cycle, optometrists spent $2.1 million on candidates, according to FloridaPolitics.com. For the 2018 election cycle, optometrists have raised more money for Sunshine State lawmakers than any other health-care lobby.
Optometrists greatly outnumber ophthalmologists in Florida, as they do in most states, and usually outraise their doctor rivals by a large margin. Most of the optometrists’ donations to politicians flow through a non-profit organization called the Florida Optometry Eye Health Fund. Checks written to it are tax-deductible and the lobbying organization is exempt from federal income taxes and state sales taxes.
“The Florida Optometry Eye Health Fund had the highest revenues during the previous tax year among all 501(c)4 nonprofit organizations based in Florida,” said Laura Curlin, the Data Director at MapLight, a non-profit focused on political transparency.
By contrast, ophthalmologists raised less than $200,000 — less than one-tenth of the amount raised by their rivals, public filings show.
Florida is in the forefront since the state has one of the nation’s highest concentrations of retired people, who typically need more eye care than working-age people do. Similar legislative battles, however, are breaking out all over the country.
“Every year when state legislatures open around the country,” said Dan Briceland, a spokesman for American Academy of Ophthalmology, “there are efforts by non-physician practitioners to lobby for expanded scope of practice.”
The long-running lobbying war between optometrists and ophthalmologists – what politicos derisively call the “Eyeball Wars” – is intensifying.
The conflict pits two different sets of eye professionals, with very different educational backgrounds, against one another.
Ophthalmologists must attend four years of college and four years of medical school, followed by internships lasting at least one year, three years of residency and usually at least an additional year fellowship, which includes hundreds of hours of practice supervised by experienced medical doctors.
Optometrists usually complete four years of college and graduate school, but are not required to graduate from medical school. A few optometry schools allow applications from students who didn’t complete an undergraduate degree. In virtually all cases, optometrists do not work in internships at hospitals or supervised residencies at medical facilities.
The proposed Florida legislation would create a new type of medical professional – a “certified optometrist” – who would complete a specialized post-graduate degree, which is not a medical school degree.
States including Oklahoma, Louisiana, and Kentucky that have experimented with surgical powers for optometrists have had mixed results. Oklahoma was the first state to allow optometrists to perform surgical procedures, in 1998.
Patients there who had eye surgeries performed by optometrists were, after accounting for confounding variables, 189 percent more likely to need a follow-up procedure than when the same operation was performed by an ophthalmologist, according to a University of Michigan study published in the Journal of American Medical Association of Ophthalmology.
Veterans hospitals have also experimented with using optometrists to perform surgeries and subsequently backed away from the practice.
“After what happened here, we made a change in policy to ensure that anyone receiving surgical care for cataracts saw an ophthalmologist as part of their treatment for the condition” says Michael Hill-Jackson, a public affairs officer with the Veterans Affairs Hospital in Palo Alto, CA.
When a veteran unexpectedly lost his eyesight after treatment for glaucoma by an optometrist in 2009, the veterans hospital launched a full-scale investigation. It found 381 patients who had been treated by optometrists and were at risk of progressive vision loss. A further review of these cases revealed that 87 patients were “high risk for further vision loss and 23 were suffering from progressive vision loss.” Seven veterans had been blinded in one or both eyes or had their vision reduced.
Each side sees these two studies differently. For the ophthalmologists, they offer proof that allowing non-doctors to perform surgery is risky and dangerous. For optometrists, these studies are just snapshots of bad luck. They do not point to other studies that make a positive case for optometrists cutting out cataracts or cancer; instead, they say, the record is still open. Indeed, the record is sparse because so few jurisdictions have allowed optometrists to operate on eyes.
One Indian River country optometrist spoke off-the-record with the American Media Institute because she fears her colleagues at the Florida Optometric Association would harm her business if she publicly questioned their agenda. While she favors permitting optometrists to carry out laser eye surgeries, she opposes opening all eye surgeries to her fellow optometrists. “I think there is a whole subset of very good optometrists who are wannabe ophthalmologists,” she said. “That’s fine but those people should go to medical school before they perform operations.”
Part 2
Record Sums Pour In, As Optometrists Ready For Big Fight in State Capital
By Richard Miniter and Joseph Hammond, American Media Institute
Optometrists are now among the largest donors to political causes in Florida, according to state tax filings.
The eye-care specialists, who are not medical doctors, have amassed a war chest of more than $2.1 million and hired the brother of Florida’s Speaker of the House Richard Corcoran, and other legendary lobbyists, to spearhead their efforts. Often using a collection of interlocking groups to move money from anonymous sources, the optometrists are boosting candidates who favor their cause while winning the ire of their rivals, the ophthalmologists, and transparency activists who decry their use of “dark money.”
Their opponents, medical doctors known as ophthalmologists, have raised a comparative pittance. Since 2013, FOCUS, one of the ophthalmologist’s PACs, has taken in $143,064. Another PAC, FOCUS EYEMED, raised $97,764, according to government reports. These PACs together raised less than one-tenth of the money raised by optometrists.
“A lot of ophthalmologists in the state won’t join the Florida Society of Ophthalmology because they worry about losing their referrals from optometrists,” said Dr. William Mallon of Vero Beach. “We are having to go hat-in-hand to our national organization to get some money, but we can’t possibly catch up.”
For optometrists, the pace of fundraising is constant. In a promotional video on the website of the Florida Optometric Association, April Jasper, looks directly into the camera and asks for money for the optometrists’ political-action committee.
“Not only do we need you to be a member of the Florida Optometric Association, but there is another way we need you to be involved, and that is by donating to our PAC,” said Jasper, “It is important to us to have that separate piece always active and always being contributed to.”
Florida’s war between optometrists and ophthalmologists has raged for decades. The optometrists have increasingly sought the prerogative to perform surgical tasks, for which 47 states (including Florida) require a medical degree.
Then-Senate President Don Gaetz (R-Niceville) declared “the eyeball wars have ended,” after optometrists won the right to prescribe seven different prescription drugs in 2013. In fact, it was only a lull between rounds. After a few years of quiet but determined fundraising the optometrists are back.
Now their new push is a series of bills in the Florida legislature that would allow optometrists to expand their scope of care to perform new procedures such as laser eye surgeries.
The number of politically active non-profits in Florida has doubled from 67 to 155 since the U.S. Supreme Court handed down its decision in Citizens United vs. FEC in 2010, according to research by MapLight, a non-profit that promotes political transparency.
“The Florida Optometry Eye Health Fund had the highest revenues during the previous tax year among 501(c)(4) nonprofit organizations based in Florida,” said Laura Curlin, the Data Director at MapLight.
The fund raised $799,162 in 2016, which includes money for political activities, tax records show. Money collected by the Florida Optometry Eye Heath Fund Inc. is often later transferred to the Florida Optometric CCE, another lobbying group for optometrists.
In addition to hiring Michael Corcoran, the brother of Florida’s current Speaker of the House Richard Corcoran, the optometrist lobby has hedged its bets. The political action committee of Rep. Jose Oliva, who is set to be Speaker in the 2018-2020 legislative session, has already received $50,000 from a PAC associated with optometrists, according to the Tampa Bay Times.
The ties between the Florida Board of Optometry and its PAC are intertwined. Stephen Kepley, a Vero Beach optometrist, is a member of the Florida Board of Optometry. Tax records also list Stephen Kepley as a director of the Florida Optometry Eye Health Fund Inc., the optometrists’ non-profit arm.
The optometrists’ political-action committee, OD-EYEPAC, collects money from both the optometrists’ trade association and its non-profit arm. The Florida Optometric Association donated $535,000 to OD-EYEPAC while the Florida Optometric Eye Health Care Fund gave them $260,000 in 2016, according to FloridaPolitics.com. Slightly more than half of the $2.1 million total that optometrists gave to candidates in the past election came through OD-EYEPAC.
The efforts don’t stop at the ballot box. Lobbyists are raking in money from optometrists, fourth-quarter 2016 financial disclosures from prominent lobbyists show.
Bill Rubin of the Rubin Group received between $20,000 and $29,000 from Florida Optometry Eye Care Fund in the fourth quarter of 2016. The Florida Optometric Association also paid as much as $9,999 to that group.
The Florida Optometry Eye Care Fund paid Corcoran & Johnston, the lobbying and advocacy firm which employs Michael Corcoran some $56,000 and David Ramba’s company, the Ramba Consulting Group, between $30,000-$39,000, according to fourth-quarter 2016 disclosures required by state law.
Lobbyist David Ramba cuts a large figure in the state capital. Ramba attended a dinner at Shula’s 347 Grill, one of Tallahassee’s most expensive steakhouses in 2013. The dinner was organized by six Republican state senators and the head of the Florida Optometry Association to thank Ramba for his work on optometry legislation. When a reporter from the Tampa Bay Times questioned if the meeting violated state ethics rules, the senators denied discussing politics.
One of the attendees was former State Senator Garrett Richter, a Republican, who was then a frequent passenger on Capital Air, a private plane company owned by Ramba, who is both a lawyer and a licensed pilot. Often the lobbyist would take the controls as he flew distant lawmakers to and from the state capital, which one lawmaker jokingly referred to the operation as “Ramba Air.”
The close ties between lobbyists and elected officials is worrisome, say opponents of the optometrist’s legislative agenda.
“When Kentucky passed similar legislation in 2014, it was because there were similar close ties between legislators and lobbyists,” said Dan Briceland, a spokesperson for the American Academy for Ophthalmology. “The legislation was passed in just 11 days without much debate and what limited debate there was occurred because [U.S. Senator] Rand Paul (a licensed ophthalmologist) got involved.”
The ophthalmologists said they are being outspent and out-dazzled by major lobbyists like Ramba, just as the state capital readies for the biggest fight between optometrists and ophthalmologists that it has ever seen.
“We are outgunned up there in Tallahassee when it comes to lobbying,” said Jamie Membreno, a Kissimmee ophthalmologist. “Both in terms of money and the special relationships that optometry lobby has developed with well-placed politicians. There are more optometrists and they raise more money.”
Part 3
Eye Specialists Are Secretly Selling Patients, Critics Say
By Richard Miniter and Joseph Hammond, America Media Institute
As the sun sank, 63-year-old Pat Raynor found it hard to focus on the road. The red and white tail-lights of the cars ahead were swimming in a haze. Raynor, a diabetic who lives in Hampton, Va., had long feared that the disease would harm her vision. As her night vision decreased she went to see a local optometrist and was startled by the procedures the optometrist was suggesting. As someone who deals with health policy through her position with the state’s health department, Raynor knew the shared care the doctor was suggesting was unusual.
Her care provided an eye-opening experience of how some optometrists and ophthalmologists collude in a way that, critics charge, can ignore the best interests of patients.
“The optometrist told me I would need cataract surgery,” Raynor said. “She dilated my eyes and then explained to me that she would refer to an ophthalmologist and I would return to her for post-operative care. I would end up paying both her and the surgeon for my care. I had trouble reading the documents but I signed them.”
It bothered her though that she was unable to read the documents clearly while her eyes were dilated. Staff at the eye clinic she said told her the documents were normal. “Everyone signed these, I was told.”
In some ways, she welcomed the surgery. By then she was having trouble seeing even in broad daylight. After having often paid $600 annually for a special kind of eye glasses, she looked forward to having good vision again. It was only the next day she began to wonder about the documents.
“I called and asked my optometrist to see the documents I’d signed. The office assured me that these were normal papers that ‘everybody signs.’ I knew what they were saying, however, it just wasn’t right.”
Still not satisfied with the papers that she was shown; Raynor contacted her diabetes specialist who suggested she still see an optometrist and provided a referral to a recommended ophthalmologist. “I didn’t realize it until I pulled up that day in the parking lot but, it was still the Virginia Eye Care Center, just I was referred to a different doctor. I was told there this time by the ophthalmologist that my optometrist would do the post-operative care if I did the surgery with them. They also suggested I take out a credit card so I could pay for the procedure.”
Raynor’s experience is emblematic of the dark side of patient co-management or share-care, which some of the ophthalmologists and optometrists who spoke to the American Media Institute describe as dangerously inadequate. Rather than just the practice of an optometrist referring a patient to an ophthalmologist for care, co-management is a fee-sharing arrangement where ophthalmologists perform surgeries and optometrists provide post-surgical care.
Co-management means big money for optometrists, who are not medical doctors. “In most places in the U.S, cataract surgery is the most common surgical procedure,” says Jaime Membreno, a Kissimmee-based ophthalmologist. “If you say out of 100,000 cataract surgeries (which cost can cost between $600-$2000), that 20% are co-managed, that’s generating something like $50 million dollars per year.”
The co-management of patients was kickstarted in 1999, through a regulation issued by the U.S Department of Health and Human Services’ Office of Inspector General sanctioning the practice. At the time, regulators warned that if the practice if misused, serious anti-trust issues could emerge.
Proponents of the measure argue that it allows eye patients in rural areas to receive more rapid access to medical care. Since patients often see their optometrists more regularly, this can lead to an increased level of comfort. Critics charge that co-management has degenerated into fee-splitting, a practice which is illegal according to the Stark Laws at the federal level and Florida laws regarding patient self-brokering. The Stark Laws prevent a physician from referring a Medicare or Medicaid patient to another medical professional if a financial arrangement exists between the two parties.
A joint position paper between the American Academy of Ophthalmology (AAO) and American Society of Cataract and Refractive Surgery is supposed to guide management. While the version of these guidelines published in 2000 stressed that co-management should not be done for financial gain, the version released a year ago had more vague language. An article on the American Optometric Association website called the new policy “a momentous reversal of long-held policy.”
“There are many areas in the state of Florida where there isn’t an ophthalmologist,” says Salvatore DeCanio, a South Florida optometrist who has 32 years of experience in his field and thinks the case for co-management is often under-stated, “And even if there is I think many people would be willing to travel an extra mile to see a premiere ophthalmologist.”
DeCanio thinks it is the best interests of the patient and all health care providers that ophthalmologists don’t focus on surgery.
“If you’re a good surgeon and you want to continue to be a good surgeon you should spend your time doing operations. You shouldn’t be dealing with a general eye exam. The busy surgeons work with good sharp optometrists on post-operative care. Sharecare is a team effort where professionals are operating at their highest skill level.”
Actually, only 22,660 people out of Florida’s 20 million residents live more than 40 miles from an ophthalmologist, according to FloridaPolitics.com.
“Physicians should engage in co-management arrangements only to assure the highest quality of care,” says an official policy of the American Medical Association. “those who participate in surgical co-management arrangements must avoid such financial arrangements as fee splitting, which are both unethical and illegal.”
While referrals are commonplace across medicine, giving a fee to a professional making a referral (co-management) is not common outside of eye care. The practice is largely confined to post-operative cataract care, where optometrists refer patients to eye surgeons in return for getting a fee for supervising the patient’s recovery. The problem is that non-doctors, such as optometrists, often cannot treat surgical complications as doctors can.
Optometrists and ophthalmologists who spoke to the American Media Institute said that due to Florida’s large elderly population co-management is rampant — and the fee-splitting is usually not disclosed to patients.
Brad Oren was a young ophthalmologist, happy to be practicing after eight years of medical school and residency. Just three weeks into his practice, he was told about co-management. “I walked into my waiting room in West Palm Beach, and there was a stranger who turned out to be an optometrist. He was friendly at first, and he wanted to speak to me about co-management; he wanted to talk about percentages,” he said. “I soon realized that this was a practice not in the best interest of the patients.”
The optometrist made what Dr. Oren now knows is a very common pitch for co-management: If I refer patients to you, you will send them back to me for post-surgical care and I will collect 20% of the overall surgical fee. If you don’t agree, no optometrist will refer any patients to you. Since most patients come through optometrists, they have real leverage over licensed surgeons. These arrangements can be bad for patients.
“In my former practice area, patients would come from hours away to see a surgeon when there was already was one, as good or often better, in their hometown,” Oren said. Why were patients with poor eyesight driving hours out of their way? He said it was because the distant doctor had agreed to share his fee with the referring optometrist.
Other problems with co-management include the inability of non-doctors, such as optometrists, to correctly diagnose and treat surgical complications or spot emerging diseases. A missed or wrong diagnosis could lead to permanent blindness.
A Florida native, Oren now practices in New England. “I left Florida and moved to the Northeast to get away from co-management. I was tired of being pressured to get into these commercial relationships, which don’t benefit patients.”
Chip Richardson has struggles with co-management at his ophthalmology practice in Eastern Kentucky. “In rural areas of Kentucky, seniors are being traded around like commodities and ophthalmologist in the countryside won’t survive unless he goes along with it.”
Richardson was so troubled that he traveled to Washington D.C. in 2013 to explain to Federal Trade Commission officials that co-management violated the anti-trust laws. Having prepared for months for the meeting, he was shocked by the cold reception he received.
“The FTC told me what the optometrists are doing is just good businesses sense,”he said, “but the collusion is leading to over-diagnosis of cataract surgery and we are seeing people getting this surgery earlier than they should.”
Alone and on the long trip back to coal country, he kept turning over the meeting in his mind. “From the federal government’s standpoint, there is cost-benefit to [people being treated before it is medically necessary]. If an individual gets the surgery done on private insurance before they are Medicaid or Medicare eligible, that is one less individual for whom the U.S. government has to foot the bill down the road.”
How many optometrists are using co-management is unclear — no law requires the practice to be disclosed and no state or federal agencies track to practice.
But Pat Raynor thinks even one is too many. She eventually traveled to Florida for cataract surgery from a specialist and stayed an extra week to receive post-surgical care from the surgeon who operated on her. She now drives at night without fear.
“I hope that other people don’t go through what I had to go through,” she said, “just because some people are trying to line their pocket instead of helping people.”