MINUTES OF MEETING
ASSEMBLY COMMITTEE ON COMMERCE
Sixty-seventh Session
March 29, 1993
The Assembly Committee on Commerce was called to order by Chairman Gene T. Porter at 3:40 p.m., Monday, March 29, 1993, in Room 332 of the Legislative Building, Carson City, Nevada. Exhibit A is the Meeting Agenda, Exhibit B is the Attendance Roster.
COMMITTEE MEMBERS PRESENT:
Mr. Gene T. Porter, Chairman
Mr. Morse Arberry, Jr., Vice Chairman
Ms. Kathy M. Augustine
Mr. Rick C. Bennett
Mr. John Bonaventura
Mr. Val Z. Garner
Ms. Chris Giunchigliani
Mr. Dean A. Heller
Mr. David E. Humke
Ms. Erin Kenny
Mr. Richard Perkins
Mr. Scott Scherer
Ms. Myrna T. Williams
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Paul Mouritsen, Senior Staff Analyst, Legislative Counsel Bureau
OTHERS PRESENT:
Mr. Fred Hillerby, Nevada Optometric Association; Dr. Lesley L. Walls, Dean of the College of Optometry, Pacific University; Dr. Douglas K. Devries; Dr. Jerry D. Reeves, President, Southwest Medical Associates; Dr. Geoffrey Checci; Dr. Marietta Nelson; Dr. Kathleen M. Mahon; Dr. Thomas R. Conklin; Dr. Thomas Komadina; Ms. Marsha Berkbigler, Nevada State Opthamological Society and Nevada State Medical Association; Dr. G. Norman Christensen, former President, Nevada State Medical Association; (See also Exhibit B, attached).
ASSEMBLY BILL 332Authorizes optometrist to administer and prescribe therapeutic pharmaceutical agents.
Mr. Fred Hillerby, Nevada Optometric Association, introduced Dr. Lesley L. Walls, Dean of the College of Optometry, Pacific University.
Dr. Walls testified. He stated he was both an optometrist and a physician, and provided his educational and professional background. He announced he supported AB 332. He compared the curricula of medical school and optometry school with particular regard to the eye. He advised the eye was not emphasized in medical school, but in optometry school, was emphasized during the entire four years of schooling. He asserted the curriculum of an optometry school was as full as the curriculum of a medical school. He stated the admissions requirements of optometry schools were stringent.
Dr. Walls advised over 80 percent of optometry students at Pacific University held bachelor's degrees upon admission, and a bachelor's degree was a prerequisite for graduation. He reported the average grade-point average of the students, upon admission, was 3.3. Dr. Walls advised accreditation for the university's optometry school was parallel to accreditation for the medical school.
Dr. Walls spoke regarding the faculty of Pacific University's College of Optometry. He indicated, in the past, most instructors of optometry were optometrists. He advised over the past 10 to 12 years, many curriculum and faculty changes had occurred at Pacific University. He explained, in addition to doctors of optometry, the faculty now included instructors with PhDs, including PhDs in pharmacology, anatomy, physiology, and other fields. He apprised several physicians taught on the faculty.
Dr. Walls addressed the concern about the clinical experience of optometrists. He said there had been dramatic changes in curriculum over the past ten years, which consisted, mainly, of increased instruction in pharmacology, pathology, and signs of systemic disease, and increased direct clinical experience, designed to enable graduates to safely use the medications AB 332 would permit them to use. He advised optometrists gained direct clinical experience through preceptorship programs in Veterans Administration, military and Public Health Service hospitals. He stated Pacific University operated two county clinics, where many indigent patients, with high pathology, were seen. He stated Pacific University's College of Optometry provided both the patient encounters and experience its students needed in order to have the ability to use the medications specified by AB 332 upon graduation.
Dr. Walls stated he was pleased AB 332 provided no "grandfathering" of privileges. He said, under the provisions of AB 332, optometrists would be required to have 150 hours of continuing education courses. He said most states required optometrists to have 100 to 110 hours of continuing education. He explained, in addition, AB 332 required optometrists to pass a stringent national test on treatment and management of ocular disease. Dr. Walls advised AB 332 would require an optometrist, once certified to use the specified medications, to participate in a minimum of 30 hours of continuing education.
Dr. Walls opined the medications specified in AB 332 were safe to use. He maintained optometrists were not asking they be permitted to use medications which they were not properly educated and trained to use. Dr. Walls advised, in his experience, both as an optometrist and as a physician, use of the specified medications was very safe. He stated patients would be the beneficiaries of the expansion of the law provided by AB 332.
Chairman Porter inquired whether the bachelor's degree required by Pacific University for graduation from its College of Optometry was one of bachelor of arts or one of bachelor of science. Dr. Walls replied either degree was acceptable, on condition a student had the "core of prerequisites" required by the university, but said most students held a degree as a bachelor of science. Chairman Porter asked what the core curriculum requirements were for admission. Dr. Walls responded "up to calculus", a minimum of 2 semesters of physics, chemistry, and those undergraduate courses which would fulfill requirements for a bachelor's degree. He stated it was highly recommended a student take biochemistry prior to admission. He asserted there was no difference between the prerequisites for admission to the university's college of optometry and those required to study medicine. Chairman Porter asked if one could enter medical school with a bachelor of arts degree. Dr. Walls responded affirmatively. He said, at one time, a bachelor of science degree was required to enter medical school, but there had been a move to more "humanistic" medicine.
Chairman Porter asked Dr. Walls to distinguish between an optometrist and an ophthalmologist. Dr. Walls responded the main difference was optometrists were not surgeons and ophthalmologists were trained surgeons, surgery being their sub-specialty. He said there was a tremendous amount of overlap in the two professions. He advised both optometrists and ophthalmologists were able to diagnose, treat and manage the medical aspect of ocular diseases and disorders.
Chairman Porter inquired how an ophthalmologist obtained a specialty in surgery. Dr. Walls responded, in addition to (graduation from) medical school, a residency in ophthalmology was required. He said the program for ophthalmology was expanding and required much time. Chairman Porter asked how long the program lasted. Dr. Walls explained the program usually consisted of one year of internship followed by an additional three years. Chairman Porter asked what was taught during internship. Dr. Walls replied a rotating internship consisted of three months of general internal medicine, three months of pediatrics, perhaps two months each of surgery and obstetrics and a month or more of electives. Chairman Porter inquired if the four year program required to become an ophthalmologist was in addition to medical school training. Dr. Walls responded it was. Chairman Porter asked the length of a medical school program. Dr. Walls replied four years.
Chairman Porter asked what kinds of medications AB 332 would permit an optometrist to prescribe. Dr. Walls replied optometrists would be permitted to use medications applied topically to treat diseases and disorders of the eye, and some systemic medications, used primarily for infections and disorders of the eyelid. Chairman Porter asked the meaning of "systemic." Dr. Walls indicated systemic medications were those swallowed, such as tablets, capsules or liquids.
Chairman Porter asked the number of potential diseases of the eye. Dr. Walls replied there were many potential diseases of the eye. He said optometrists were conservative, and should an optometrist have any question or concern regarding a diagnosis, he would quickly consult with someone who had greater education and training. Chairman Porter asked with whom an optometrist would consult. Dr. Walls replied if a condition of the eye or eyelid were involved, an optometrist would consult with an ophthalmologist. Chairman Porter inquired if Dr. Walls would consult with an ophthalmologist rather than another optometrist. Dr. Walls responded if he knew an optometrist who had expertise in the area in which he was experiencing a problem, he would not hesitate to consult him, but he would "use, according to the seriousness of the situation, the best and quickest person. "Chairman Porter asked if Dr. Walls intended to imply an ophthalmologist was more qualified than an optometrist. Dr. Walls responded whether an optometrist or an ophthalmologist was more qualified depended on the situation; if a disorder required surgery, the patient would need to see an ophthalmologist.
Chairman Porter asked the worst thing which could happen to the public if optometrists were allowed the right to prescribe therapeutic medication. Dr. Walls responded an allergic reaction to a medication was the worst thing which could happen, but indicated an allergic reaction would be very uncommon. Chairman Porter asked if an allergic reaction to medication could result in loss of sight. Dr. Walls replied, normally, an allergic reaction did not result in loss of sight, and he would not worry about that happening. Chairman Porter asked what Dr. Walls would worry about. Dr. Walls answered, normally, an allergic reaction was a minor thing. He said the worst scenario involved a systemic allergic reaction, which could result in anaphylactic shock. Chairman Porter inquired what was meant by anaphylactic shock. Dr. Walls explained a patient's blood pressure might fall, which would necessitate administration of C.P.R., which optometrists were trained to administer. He said it would be necessary to get the patient quickly to a hospital, where, normally, the patient would see an internist. Chairman Porter indicated Dr. Walls was assuming an allergic reaction occurred while a patient was still in his doctor's office. Dr. Walls responded most allergic reactions occurred within minutes. Chairman Porter asked if the same would be true if a patient took a systemic medication. Dr. Walls answered, if a patient ingested a systemic medication, reaction could be delayed, but the reaction would occur regardless of who prescribed the medication. Chairman Porter asked where the safety to the public existed if a patient, who had an allergic reaction to medication prescribed by an optometrist, could obtain counteracting medication only by seeing an ophthalmologist. Dr. Walls replied he knew no ophthalmologists who were happy to treat anaphylactic reactions, and an ophthalmologist would quickly place a patient who had such a reaction under the care of an internist. Chairman Porter asked Dr. Walls to assume there were ophthalmologists willing to treat a patient with a systemic allergic reaction, and asked whether such an ophthalmologist would have the ability to prescribe counteractive or additional medication or the patient would be required to go to another medical doctor to obtain such medication. Dr. Walls replied an ophthalmologist was a physician and, as such, had an unrestricted license and could legally write any prescription he chose. Chairman Porter asked if, under the provisions of AB 332, an optometrist would have the ability to prescribe medication to counteract a patient's allergic reaction. Dr. Walls answered his opinion was an optometrist would not have that ability because injectable medications would be required.
Mrs. Williams asked the science prerequisites for admission to optometry school. Dr. Walls answered the science prerequisites were the same as those required to enter medical school, and consisted of math, chemistry, physics and some physiology, in addition to those science courses required to obtain an undergraduate degree. Mrs. Williams asked if a student could enter optometry school without an undergraduate degree, how it was ascertained the student had the required foundational courses. Dr. Walls replied if a student entered Pacific University's optometry school without an undergraduate degree, he would have to meet the requirements of Pacific University's undergraduate institution to acquire a bachelor's degree.
Mrs. Williams asked if Pacific University's undergraduate program was nationally accredited. Dr. Walls responded affirmatively.
Ms. Giunchigliani requested confirmation that the provisions of AB 332 did not involve surgery but pertained only to the prescription and dispensation of therapeutic pharmaceuticals. Dr. Walls confirmed such was true.
Mr. Fred Hillerby, Nevada Optometric Association, testified. He explained the scope and practice of optometry was defined by statute. He said the legislature last dealt with optometry in 1979, when it passed legislation allowing optometrists to use drugs in diagnosing diseases of the eye. Mr. Hillerby read a definition of optometry. He stated he wished to reaffirm that optometry is a primary care practice.
Dr. Douglas K. Devries testified, paraphrasing and expanding slightly on prepared text (Exhibit C).
Chairman Porter asked Dr. Devries' charge for an office visit and an ophthalmologist's charge. Dr. Devries replied his charge for a comprehensive medical examination was $67. He said he did not know all the rates charged by ophthalmologists, but speculated those rates were similar to those he charged and, perhaps, slightly greater.
Chairman Porter asked what services an ophthalmologist provided which an optometrist did not provide. Dr. Devries replied, in terms of a basic medical examination, an ophthalmologist provided no services not provided by an optometrist. He said a basic medical examination included examination of the entire retina through a dilated pupil. Chairman Porter asked where the "efficiency" existed if an optometrist charged the same as an ophthalmologist for providing the same service. Dr. Devries submitted, if an optometrist was able to use therapeutic medications, he would not have to refer a patient with an ocular disorder to another doctor, whom the patient would also have to pay for an examination. Chairman Porter asked whether Dr. Devries would charge a patient his fee of $67 if he referred the patient to an ophthalmologist for treatment. Dr. Devries replied, if he conducted a comprehensive examination of the patient, the fee for that examination would be the same whether he was or was not able to treat the patient.
Chairman Porter asked if Dr. Devries could treat a patient during a period in which the patient required therapeutic medication. Dr. Devries replied he could. Chairman Porter asked if a patient could visit an ophthalmologist to obtain medication, and then return to an optometrist to have lenses fitted. Dr. Devries replied, "yes." Chairman Porter inquired if such had been Dr. Devries experience. Dr. Devries said it depended on the disease entity. He indicated often, if he referred a patient to another doctor for treatment of a simple disease entity, such as conjunctivitis, the patient would return.
Chairman Porter referred to Dr. Devries earlier testimony, that there were no differences in premiums charged for malpractice insurance in states which permitted optometrists to dispense therapeutic agents and states which did not, and asked if Dr. Devries had ascertained how much his malpractice insurance premiums would be if he was permitted to prescribe such medications. Dr. Devries replied he had. He referred to a letter from a national underwriter of optometric insurance coverage, contained in a booklet distributed to the committee members (Exhibit D, available in the research library), and stated there was no difference in the premiums. Chairman Porter asked Dr. Devries if his insurance carrier held the opinion Dr. Devries had no greater exposure to liability if permitted to prescribe therapeutic agents than if not permitted. Dr. Devries responded affirmatively.
Chairman Porter asked, "If we give you this power, are you capable of blinding somebody?" Dr. Devries responded he did not believe so. He said, at this time, an ophthalmologist could blind an individual in the process of diagnosis. Chairman Porter reiterated his question. Dr. Devries said the capability to blind an individual might exist, but he did not perceive it.
Chairman Porter asked Dr. Devries to argue the position of opponents to AB 332, and state the reasons, if any, why optometrists should not have the right to dispense therapeutic agents. Dr. Devries said the opposition would state optometrists had neither the appropriate education nor sufficient experience to enable them to dispense therapeutic agents.
Mr. Fred Hillerby provided further testimony. Mr. Hillerby discussed various sections of AB 332. He said section 2 provided an optometrist who was granted the privilege of administering therapeutic agents must have a separate certification. He stated section 3 pertained to requirements for certification, and he cited the provision requiring 150 hours of education. Mr. Hillerby held the most important requirement pertaining to the "grandfathering" clause was the requirement an optometrist pass one of the specified board examinations within two years of applying for certification. Mr. Hillerby explained section 4 set forth the actual certification process and provided the state board of pharmacy be notified of the licensing of an individual to use therapeutic agents. He said section 5, on line 19, defined a therapeutic pharmaceutical agent as "an oral or topical medication approved by the Food and Drug Administration for the treatment of abnormalities of the eye or ocular adnexae." He advised section 6, in subsections 8 and 9, added two provisions to NRS 636.025. He advised section 7 pertained to continuing education and pointed out optometrists certified to use therapeutic agents would be required to have no less than 30 nor more than 50 hours of continuing education each year to maintain their certification. He said sections 8 and 10 corrected the current practice act, and under section 10, one diagnostic drug, no longer available on the market, would be deleted. He advised sections 11, 12, 13, and 14 addressed the pharmacy statutes and the corrections needed should the legislature pass AB 332.
Mr. Hillerby advised the legislatures of 32 states had passed bills allowing optometrists to use therapeutic drugs and said that fact weighed heavily in support of AB 332. He stated the Public Health Service, Veterans Administration and military services had, for years, allowed optometrists to use therapeutic drugs.
Mr. Hillerby said the theme of opposition to AB 332 was a desire to see no expansion in the scope of practice of any health care provider. He said that theme ignored changes in education, technology and the needs of the citizens of Nevada and of the United States and was unrealistic.
Mr. Hillerby referred to various letters in Exhibit D expressing support for AB 332 and read a portion of a letter from Dr. John Beeston.
Mr. Hillerby proposed the question before the committee was whether well-trained, primary eye care providers were ready for the next step in the natural evolution of their profession. He stated 32 states had answered "yes" to the question. He advised nine states, including Nevada, had legislation pending which involved the same consideration. He urged support of AB 332.
Chairman Porter stated he was unpersuaded by the argument "everybody else is doing it." He expressed concern for the safety of the citizens of Nevada should the legislature pass AB 332, and asked if anyone could address that concern. Mr. Hillerby responded something could go awry, and things did go awry whether an optometrist, a physician, a physician's assistant or a trained surgeon was involved, and said he could only advise it had not happened. He stated West Virginia, in 1976, was the first state to pass a bill like AB 332, and the experience in West Virginia had not demonstrated "things went awry." Mr. Hillerby cited a study, done by the National Association of Insurance Commissioners, concerning malpractice. He said malpractice occurred; the issue was what to do about it. He said the state board was very concerned about complaints it received and about ascertaining the source of a problem when it perceived a pattern.
Mr. Hillerby referred to Dr. Walls' testimony regarding optometrists' training and experience. He recalled Dr. Walls said the diagnostic drugs currently being used had as much potential to cause blindness as any therapeutic drug an optometrist would be permitted to use by the provision of AB 332. Mr. Hillerby said he was aware of only one case of malpractice involving an optometrist which had gone to court in the state of Nevada. He cited certain states which had laws similar to AB 332 in effect since the middle 1980's and the lack of negative experiences in those states. He referred to a letter, in Exhibit D, from the Optometric Protector Plan, which discussed the experiences of 7,000 optometrists. He advised the incidence of malpractice in the optometry profession was, and always had been, very low.
Ms. Kenny referred to page 3, line 9, of AB 332 and asked if removing a superficial, foreign body from the eye was considered surgery. Dr. Devries answered, and said the procedure was not surgery. Ms. Kenny asked if an optometrist, legally, could remove a visible foreign body from a patient's eye. Dr. Devries responded the optometrist could attempt to flush the foreign body from the eye but could not remove something embedded in the ocular tissue. Ms. Kenny asked the procedure to remove something embedded in the eye. Dr. Devries explained a drop of anaesthetic, the same used when checking the pressure of the eye, would be used to numb the eye, after which an instrument, such as a pair of jeweler's forceps, would be used to remove the foreign body. He indicated there were various instruments which could be used. Ms. Kenny asked if optometrists, legally, could use such tools at the present time. Dr. Devries replied optometrists could not. Ms. Kenny asked if an ophthalmologist would utilize the same procedure Dr. Devries had described to remove a foreign body from the eye. Dr. Devries responded affirmatively. Ms. Kenny inquired if an optometrist was trained in optometry school to perform such a procedure. Dr. Devries replied affirmatively, and said optometrists performed procedures to remove foreign bodies from the eye during preceptorship science training.
Dr. Jerry D. Reeves, President, Southwest Medical Associates, read from prepared text (Exhibit E) in support of AB 332.
Dr. Geoffrey Checci testified. Dr. Checci advised he had trained as an optometrist prior to attending medical school. He spoke regarding the comparative educations of optometrists and ophthalmologists. He explained the education of an ophthalmologist or other medical practitioner was divided into three sections. He said in medical school a student learned the basic interactions of the various parts of the body, as they related to the field of study the student would later pursue. He advised following medical school, a doctor would take one year of internship, during which he would do the same things he had done in medical school, but would have a greater degree of responsibility. He stated the third stage of a medical practitioner's education was a residency. He advised it was at the resident level a doctor would specialize in ophthalmology, dermatology or some other field. He indicated one could take additional training beyond a residency, in the form of a fellowship, in order to subspecialize. Dr. Checci explained the kinds of medical activities in which a student engaged while attending medical school. He said it was absolutely necessary to have the background provided by medical school prior to training in a specialty. He advised an optometrist's education was divided into two sections, consisting of attendance first at college and then at optometry school. He said one went to optometry school to learn to do a specific technical task. He stated the training given at an optometry school provided some background in medical matters but did not train one as a physician.
Dr. Checci said in order for a doctor to do nonsurgical ophthalmology, he first needed to be trained as a physician. Dr. Checci advised he decided to become an ophthalmologist after he had practiced for two years as a licensed optometrist. He stated he then spent an additional nine years acquiring education: four in medical school, one in internship, three in residency and one in a fellowship to subspecialize in retinal disease and surgery. He said to suggest one could accomplish the same thing in 150 hours of education was patently ridiculous. Dr. Checci proposed even if an optometric education was expanded to teach an individual to do everything a doctor did as a resident, that individual still would not have attended medical school.
Dr. Checci advised there were dangers in using either topical or systemic medications. He said individuals completely trained in the medical profession worked very hard to minimize injury to people, and even those individuals experienced problems. He stated if an individual did not receive maximum training, there would be additional dangers.
Chairman Porter asked why it was not safe to permit optometrists to use therapeutic medications. Dr. Checci responded if one had not attended medical school, one could not understand how some of the medications optometrists wished to use interacted with the body. Chairman Porter asked what course in medical school taught one about drug interactions. Dr. Checci replied no specific course but, rather, numerous courses. He said the first two years of medical school were primarily didactic, consisting of classroom instruction, during which many courses prepared a student with regard to drug interaction, not only pharmacology, but also pathology, biochemistry, and others. He advised the second two years of medical school were spent, primarily, in on-the-job training in a hospital, under the supervision of interns, residents and staff members, during which time a student physically cared for patients. Chairman Porter asked if Dr. Checci's argument was if one suffered an allergic reaction to a medication, not only one's eyes but also other parts of one's body might suffer the allergic reaction, and a physician's medical school training equipped him to determine reactions by those other parts of the body, while an optometrist lacked such training. Dr. Checci responded, "Precisely."
Dr. Marietta Nelson introduced Dr. Kathleen M. Mahon.
Dr. Mahon advised she was a pediatric ophthalmologist and was board certified in medical quality assurance and utilization review. She said she was also trained as a pharmacist. Dr. Mahon stated she opposed AB 332. She advised pharmacology was a branch of science dealing with drugs and all their relationships. She stated she spent 400 classroom hours in the study of pharmacology while in pharmacy school. She advised pharmacists were very well trained in risk analysis and risk perception in the use of drugs but were not trained in prescribing and "hands-on use" of drugs, while physicians were so trained. Dr. Mahon said after all her pharmacology training in pharmacy school, and additional training in pharmacology in medical school, she was still unready to prescribe all oral and topical medications. She said it was 18,000 hours of training, under direct supervision of other physicians and during many years following medical school, which gave her the experience needed to prescribe powerful, dangerous drugs. She indicated at least 1/4 of those 18,000 hours was spent performing medical treatments of the eye, not limited to surgery.
Dr. Mahon said she discussed AB 332 with internists, pediatricians, family practitioners and emergency room doctors, and received a consensus of opinion it was ludicrous to expect any individual to be knowledgeable enough to prescribe oral and topical medications without "hands-on" medical training and supervised residency training in his youth. She said classroom, book training was not the only requisite to being able to prescribe such drugs. She cited examples of doctors using drugs for purposes other than eye drops, and by doing so, gaining knowledge of what to expect should those drugs be used as eye drops. Dr. Mahon stated the eye was not an organ isolated from the rest of the body, and topical eye drops were absorbed into the body and could cause many side effects. She said 32 deaths were attributed to one drug which optometrists desired to use to treat glaucoma. She advised the most serious, possible effect of use of drugs was not blindness, but death. Chairman Porter asked where the 32 deaths of which Dr. Mahon spoke occurred. She replied they occurred all over the United States and were reported to the National Registry of Drug Induced Ocular Side Effects. She referred to the first page of the section entitled "Risk" in a booklet provided to the committee (Exhibit F, available in the research library). Dr. Mahon said the rest of the body was not protected from the effects of medications administered in the eye, and medications taken by mouth influenced the entire bodily system, often before reaching the eye.
Dr. Mahon said she wished the committee to carefully consider and analyze the risks of allowing individuals, who had not attended medical school and had not participated in supervised residencies, to have use of powerful and dangerous drugs. She asserted it was not reasonable to expect a 150 hour course to qualify an individual to use those drugs. She contended a 150 hour course could not substitute for 18,000 hours of post medical school training. She said the 18 pediatricians, family practitioners, and internists with whom she talked each had an average of 15,000 to 18,000 hours of training following medical school.
Dr. Mahon discussed removal of foreign bodies from the cornea of the eye. She stated she had done this often and had never used small, sharp forceps to do so.
She said, in summary, she was opposed to AB 332.
Mr. Scherer asked if there were any side effects from the use of cromolyn sodium. Dr. Mahon replied cromolyn sodium was a fairly safe drug, but some people were allergic to it and could have bad reactions.
Mr. Scherer asked if a distinction could be drawn between medications routinely used in treatment of the eye and proven to be relatively safe, and medications which involved greater risk and required much greater skill and expertise in their use. Dr. Mahon contended she would not know where to draw the line in distinguishing those drugs. She said sulpha drugs, theoretically quite safe, could cause a Stevens-Johnson reaction, which she had observed in children and which could result in blindness. Mr. Scherer asked the response to a Stevens-Johnson reaction. Dr. Mahon replied the reaction was sometimes very difficult to treat and required use of high dosage steroids, lubricants and artificial tears. Mr. Scherer asked if the speed with which an allergic reaction was treated would make a difference. Dr. Mahon replied it would, but the condition must be recognized early to provide early treatment.
Mr. Scherer observed physicians assistants and advanced practitioners of nursing had the ability, limited by the Board of Pharmacy, to prescribe certain medications. He queried, "So are you telling me it's not possible to draw a similar line for optometrists?" Dr. Mahon responded she was not on the Board of Pharmacy and, being adamantly opposed to AB 332, had not seriously considered where to draw such a line.
Ms. Augustine remarked Dr. Devries had raised the point patients were forced to wait, unnecessarily, to arrange appointments with physicians when conditions were discovered. She asked if Dr. Mahon, when she received a referral from an optometrist, made the patient wait an unusually long time or tried to see the patient as soon as possible. Dr. Mahon replied she tried to see such a patient right away. She advised she, as a pediatric ophthalmologist, had never turned away a child. She stated in an emergency, she would sometimes see an adult, and other times would refer them to the ophthalmologist on call. She asserted, in Clark County, an ophthalmologist was always on call and was required to see a patient within 24 hours. She maintained she was not aware of any individual's having to wait an inordinate amount of time to be seen.
Ms. Augustine asked if optometrists were now serving the needs of patients needing glasses and basic eye examinations, leaving ophthalmologists free to provide other services. Dr. Nelson responded and said many ophthalmologists were primary eye care doctors, which meant they would try to treat everything they could treat.
Dr. Nelson referred to Chairman Porter's earlier question, whether a patient referred by an optometrist to an ophthalmologist for a specific problem would return to the optometrist, and said she knew of no ophthalmologist who would not return such a patient to the optometrist. She stated, "We think that the optometrists do a great job of doing what they do. We just don't want them to be doing things that they're not trained to do."
Dr. Nelson indicated she wished to supplement an earlier statement of Dr. Mahon, and said, in Las Vegas, on-call ophthalmologists tried to see patients as soon as possible, and she was not aware of any problem cases which had been delayed.
Dr. Nelson advised Nevada was well supplied with ophthalmologists. She said only a tiny percentage of Nevadans were not within a one hour drive of an ophthalmologist, and more and more ophthalmologists were attempting to service the rural areas of Nevada, at least on a part-time basis.
Ms. Augustine stated she understood an optometrist charged a $67 fee for a basic eye examination, and inquired what fee Dr. Nelson would charge. Dr. Nelson replied her fee for a medical examination of the eye was $55. She said if, in addition, she performed a refraction, she would charge an additional $12. Dr. Nelson posed the question, "Are they getting the same thing for the same price?" and contended, in many cases, a patient paid more to see an optometrist than to see an ophthalmologist and did not receive services identical to those an ophthalmologist would provide. She said optometric literature indicated only a small percentage of optometrists routinely dilated the eye.
Mr. Perkins asked Dr. Nelson to review the list of drugs contained in Section 10, subsection 3, of AB 332 and advise if any had the potential to create problems and sideeffects. Dr. Nelson replied the medications listed, through line 39, were dilating drops which optometrists in all 50 states could use. Dr. Nelson advised when a bill allowing optometrists to use those medications was passed in the state in which she took her residency, there was little organized opposition, because the bill was viewed as providing a means for optometrists to do a better job of diagnosis. She declared, although optometrists had gained the right to use such drugs in all 50 states, only a small percentage of optometrists used them. She asserted, although the medicines under discussion could cause harm, the risk of harm from their use was small and the benefit great. She indicated the same was not true of use of therapeutic medicines, from which the benefit was debatable and the risk of harm far greater.
Dr. Thomas R. Conklin testified. He mentioned Dr. Devries testimony regarding removal of foreign bodies from the cornea using jewelers forceps, and declared no ophthalmologist would remove a corneal foreign body with a jeweler's forceps. He stated it would be very dangerous to do so.
Dr. Conklin said only one of the 32 states which had passed a bill similar to AB 332 could be regarded as having a law as liberal as proposed by AB 332; he said the remaining 31 states were much more restrictive.
Dr. Conklin read from prepared text (Exhibit G).
Mr. Heller asked if Dr. Conklin was familiar with the changes in the laws of those 32 states of which he spoke earlier. Dr. Conklin answered he could not advise the specifics of the laws of each of those states. Mr. Heller inquired if Dr. Conklin was comfortable with the law passed in any of the 32 states. Dr. Conklin replied he was not.
Mr. Heller asked Dr. Conklin what he believed was the ultimate goal of the optometrists. Dr. Conklin responded their goal was to expand the practice base of optometry.
Mr. Garner asked how most cases of glaucoma were discovered. Dr. Conklin responded, in most cases of glaucoma, its discovery resulted from a routine eye examination. Mr. Garner inquired who performed routine eye examinations. Dr. Conklin replied, primarily, ophthalmologists and optometrists performed those examinations. Mr. Garner asked if Dr. Conklin had statistics which would indicate whether glaucoma was discovered most frequently by optometrists or by ophthalmologists. Dr. Conklin indicated he could give no statistics, but could state that, in general, optometrists dealt with younger individuals and glaucoma was a rare condition in young, healthy adults. He advised most cases of glaucoma were found in the geriatric population, which was primarily cared for by ophthalmologists. Mr. Garner suggested Dr. Conklin had said as many optometrists as ophthalmologists discovered glaucoma. Dr. Conklin asserted he had not said that. Mr. Garner asked how many optometrists there were and how many ophthalmologists. Dr. Conklin answered there were approximately 12,000 to 15,000 ophthalmologists in the United States and approximately 20,000 optometrists. Mr. Garner said, "So, it would just follow that they probably discover quite a number of glaucoma cases." Dr. Conklin responded he was sure they (optometrists) did, and optometrists had referred patients to him for treatment of glaucoma.
Mr. Scherer asked if the Federal Food and Drug Administration, when it approved a medication, specified its use. Dr. Conklin replied the administration did and was very specific.
Dr. Thomas Komadina testified. Dr. Komadina said he would attempt to express his opinion regarding some of the earlier testimony of the proponents of AB 332. He referred to Dr. Devries testimony regarding use of a jeweler's forceps to remove corneal foreign bodies, and stated every ophthalmologist would agree such a procedure would not be appropriate therapy. He said testimony was given that AB 332 had nothing to do with surgery. He explained "surgery" was defined by the Current Procedural Terminology (CPT) book, a government publication used by all insurers, including Medicare and Medicaid. He stated removal of corneal foreign bodies was a surgical procedure. He advised AB 332 would permit optometrists to perform surgery on the eye.
Dr. Komadina said Dr. Devries mentioned he could not get an ophthalmologist to see his patients and had to send them to emergency rooms for treatment. Dr. Komadina related two weeks earlier, a patient was referred to him by one of Dr. Devries office colleagues, and he saw the patient in his office.
Dr. Komadina alleged Dr. Devries testimony, that he could not foresee any complications from use of either topical or oral therapeutic medications, offered one of the most convincing and cogent reasons for not allowing optometrists to use such medications. He said every ophthalmologist knew the complications which could arise from use of topical and oral therapeutic medications.
Dr. Komadina said the average cost of malpractice insurance to an ophthalmologist in Nevada was $9,000 to $10,000, while the cost to an optometrist was $300. He advised the reason for the difference in cost was the difference in the risk involved in caring for a patient. He apprised a study was commissioned by the American Optometric Association to determine how co-management of care occurred in patients who had cataract surgery. He said the results of the study showed: optometrists required more post-operative visits to care for such patients; optometrists missed 40 percent of serious eye problems which occurred after surgery; and the final vision obtained by patients cared for by an ophthalmologist was better than that obtained by patients cared for by an optometrist.
Ms. Marsha Berkbigler, Nevada State Ophthalmological Society and Nevada State Medical Association, testified. She said in addition to the study by the American Optometric Association, the Congressional Office of Technology Assessment, in 1988, issued a warning to Congress which said allowing optometrists the expanded role in providing post-operative care for cataract patients, in settings separate from an ophthalmologist's office, was not advised.
Dr. G. Norman Christensen, former President, Nevada State Medical Association, read from prepared text (Exhibit H).
Ms. Marsha Berkbigler submitted a document entitled "Position Statement on Assembly Bill 332" from the Nevada State Medical Association (Exhibit I).
Dr. Devries gave further testimony. He stated an optometrist's education was not isolated to the eye, but included training on how the eye related systemically and on ocular manifestations of systemic disease.
Mr. Hillerby testified. He maintained Dr. Devries, in his earlier testimony, said nothing about removing a corneal foreign body but spoke only of removing a foreign body. He referred to the study conducted by the Congressional Office of Technology Assessment and advised the result of the study was Medicare's approval of comanagement by optometrists. Mr. Hillerby referred to prior testimony regarding an additional study and advised optometrists reported major complications in post-management care of surgical patients to ophthalmologists, as they should. He said both studies confirmed the appropriate role of an optometrist in post-management of surgical patients. He contended state optometrists were asking permission to do the same things which nurse practitioners, physician's assistants, family practitioners and others with limited training were permitted to do.
Chairman Porter closed the hearing on AB 332.
There being no further business to come before the committee, Chairman Porter adjourned the meeting.
RESPECTFULLY SUBMITTED,
________________________
SARA J. KAUFMAN
Committee Secretary
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Assembly Committee on Commerce
March 29, 1993
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