The Eyes Should Have It.

Empowering optometrists to perform simple laser procedures is a common sense reform.

Having access to eyecare hits home for me and I think it is a very important issue. I have had poor eyesight and worn glasses for almost my entire life. I also have high eye pressure and have thus been a heavy consumer of eyecare services.

Let’s start with some background here. There are three different eyecare professionals (all starting with the letters O-P) that provide eyecare to patients. Ophthalmologists are physicians that specialize in eye and vision care. As highly trained physicians, they are the lone provider in the market that can perform more invasive procedures like cataract surgery and LASIK.

Optometrists are also very highly trained and educated eyecare providers. Much like physicians, optometrists complete a four year bachelor’s degree followed by a four year graduate degree in optometry. Many optometrists also complete residencies.

Opticians assist patients with choosing the right eyeglasses and contact lenses. Although their work presents no risk of serious harm to patients, inexplicably they are licensed in 22 states. I won’t touch on opticians any further in this post.

It is very clear that optometrists are not perfect substitutes for ophthalmologists. No optometrist would ever claim that they can do all of the tasks that ophthalmologists are trained to do. But history has shown that optometrists can grow professionally and it doesn’t make much sense to restrain these highly trained medical providers from doing work that they have the training and expertise to perform.

The provision of medical care in the United States is subject to an imbalance between demand and supply. Demand continues to grow as the average age of the population increases and due to expansions in Medicaid across the United States. Supply, on the other hand, is rigid and unresponsive due to a web of state and federal regulations.

There are no easy solutions to addressing this imbalance and it is unlikely that any one policy can serve as the silver bullet. Eyecare seems to be particularly bad given recent projections in the market for ophthalmologists. A recent article in Ophthalmology describes the situation this way: “from 2020 to 2035, the total ophthalmology supply is projected to decrease by 2650 full-time equivalent (FTE) ophthalmologists (12% decline) and total demand is projected to increase by 5150 FTE ophthalmologists (24% increase).” Some back of the envelope calculations suggest that the US has a net loss of about 100 ophthalmologists each year as retirements outpace new licensees.

Are there any viable solutions? Empowering optometrists to work to the full extent of their training can definitely help. Almost 50 years ago, my home state of West Virginia was the first state in the country to allow optometrists to prescribe therapeutic drugs like eye drops to treat high eye pressure. Today, every state in the country allows optometrists to have this privilege.

It cannot be understated how large of a change this was. Patients now had another option for seeking treatment and diagnosis for a large number of eye problems like glaucoma. Almost 40 years ago, Medicare changed its classification of optometrists to “medical doctors” for the purposes of reimbursement.

My published research with Kihwan Bae and Protik Nandy estimates the effects this change had on patients. We find that granting optometrists prescription authority for therapeutic drugs improved public eye health. Vision impairment declined by 12 percent on average over a 15‐​year period after the policy change. We also find evidence that this decline in vision impairment was larger among the nonwhite population.

Today there is a new battleground— should optometrists be permitted to perform simple laser procedures on patients? The map at the top of the post depicts the current landscape. Twelve states have authorized optometrists to perform some laser procedures on patients. The subset of permitted laser procedures varies from state to state. In Mississippi, optometrists are permitted to perform one procedure: a YAG Laser Capsulotomy (YLC). YLCs are performed to make sure that patients who have already received cataract surgery can continue to see clearly.

In Oklahoma, the first state to grant optometrists the authority to perform laser procedures, optometrists have been providing treatment since the 1980s. Oklahoma permits optometrists to perform five different laser treatments.

Optometrists outnumber ophthalmologists by more than 30,000 providers (about 48,000 optometrists to 17,000 ophthalmologists). By default, patients are much more likely to live close to an optometrist than ophthalmologist. It doesn’t make sense to make patients drive a long distance, especially if they have poor eyesight, if they can receive needed treatment from a provider that is nearby.

A recent survey of 146,403 laser procedures performed by optometrists yielded just 2 cases of complaints. My esteemed colleagues Kihwan Bae and Liam Sigaud are working on an empirical study that should be ready for the light of day in the near future. The authors find evidence that patients benefit from authorizing optometrists to perform laser procedures and that the benefits are larger for rural patients.

Given economic realities, it makes sense for states to continue to consider granting optometrists authority to perform some laser procedures. There are more than a dozen states right now that have active legislation. Here in West Virginia, SB565 has passed both the Senate and House. The bill would allow optometrists to perform 3 laser procedures if enacted. Supply side healthcare reforms like authorizing optometrists to perform some laser procedures are a common sense reform.