AOA, AFOS ensuring optometry well represented in formation of national practice standards by VA

Due to a Department of Veterans Affairs (VA) initiative to create national practice standards for the professions that operate under its auspices, the AOA and the Armed Forces Optometric Society (AFOS) are working double time to ensure that the education and abilities of doctors of optometry are reflected and respected to the fullest scope of the care they deliver.

Overall, the practice standards would specify exactly what services various professions—such as optometry, nursing, physical therapy—are recognized by the VA to provide across the enterprise, says Margaret “Marrie” Read, O.D., a member of the AOA Federal Relations Committee and former AFOS president. The standards are being prompted by the VA’s decision to modernize its electronic health record (EHR) to promote interoperability and data sharing in conjunction with the EHR being rolled out by the Department of Defense.

“To have these systems be universal across all facilities, regardless of location, the VA is proposing to have each profession set up in its electronic medical record a set of standardized procedures, skills, scope and codes,” says Dr. Read, who briefed AOA members at the virtual AOA on Capitol Hill in May. “Currently, each VA facility has different rules for each profession (besides medical doctors). A set of national practice standards for each health care profession would allow doctors of optometry to carry out the same responsibilities and tasks irrespective of state or facility requirements.”

“The VA is currently collecting input from stakeholders to develop and create these new, national standards of practice,” Dr. Read says. “AFOS and AOA have expressed their support for developing these new standards. Furthermore, we both have communicated our concern for limiting scope and the detrimental impact it could have on caring for our nation’s veterans.”

VA: National health system

Historically, the VA has operated as a national health system. As long as doctors were licensed in one state, they were able to practice in any VA facility no matter the location. This was reiterated according to the Federal Register November 2020 final rule on the authority of VA professionals to provide health care and not to be “unduly burdened” by individual state requirements for doctors’ licensing, registration and certification.

The COVID-19 pandemic underscored the VA’s practice of moving its health care professionals around the country, quickly, without hindrance of state requirements. The final rule continues to provide flexibility within the VA health care system. During the pandemic, the VA has deployed personnel to VA medical facilities as well as nursing homes and communities hard hit by COVID-19.

“Put simply, it is crucial for VA to be able to determine the location and practice of its VA health care professionals to carry out its mission without any unduly burdensome restrictions imposed by state licensure, registration, certification, or other requirements,” the final rule reads. “This rulemaking will support VA's authority to do so and will provide an increased level of protection against any adverse state action being proposed or taken against VA health care professionals who practice within the scope of their VA employment.”

In addition, to facilitate its EHR modernization efforts, the VA is seeking to establish national standards of practice—described as the “tasks and duties that a VA health care professional practicing in the health care profession may perform and may be permitted to undertake” regardless of the VA facility they are located in.

“The reason why this is important is because each health care profession is designated a role in the EHR system that sets forth specific privileges within the EHR that dictate allowed tasks for such profession. These tasks include, but are not limited to, dispensing and administrating medications; prescriptive practices; ordering of procedures and diagnostic imaging; and required level of oversight.”

AFOS and the AOA are working to ensure these concepts are not at odds with each other. Just as the “final rule” provides authority to the VA in order to limit undue burden by an individual state, so should the practice standards be developed in such a way they remain expansive and flexible.

Allies onboard

In May, Reps. Anthony Brown (D-Md.)  and Susie Lee (D-Nev.) wrote the secretary of veterans affairs on the matter. While applauding the VA’s pursuit of improvements to the quality of health care and access to care for veterans, they expressed the concerns of providers that veterans may experience a  “VA-induced shortage of available practitioners if the VA adopts overly restrictive standards, limiting access to needed treatments.

“Ensuring improved veteran access to care is an ongoing priority for Congress,” they write in their letter. “Veteran access to care could be significantly impacted by the level of care VA includes or fails to include in national practice standards for various practitioner types with differing states’ scopes of practice. It is critical that as new standards are aligned, VA considers the potential for delayed care and consequently decreased access and level of health care for VA beneficiaries due to impacts from increasing restrictions on the scope of practice for each provider type.”

In June, the 250,000-member American Veterans’ (AMVETS) Executive Director Joseph Chenelly testified at a budget hearing of the House Committee on Veterans Affairs.

“AMVETS supports the creation of these new, national practice standards to aid in the implementation of the new joint VA-DOD EHR system,” Chenelly testified. “AMVETS agrees with VA that basing these practice standards on the most restrictive state scope of practice for its health care professionals is not a viable option, as it would lead to decreased access to needed care and reduced health outcomes for our nation’s veterans.

“AMVETS urges VA to continue working toward utilizing its health care professionals to the full scope of their license, registration or certification,” he continued. “As such, AMVETS believes these new national practice standards must be inclusive of all health care services that its health care professionals are authorized to provide in any state. Anything short of fully comprehensive practice standards will unnecessarily limit veteran access to care and negatively impact veteran access and health outcomes.”

The VA’s intentions have drawn fire from several medical organizations. Over 100 medical doctor groups signed on to a letter to the former veterans affairs secretary in the Trump administration.

“If there must be uniform privileging in the VA,” the groups’ letter reads, “then, instead of setting practice privileges to align with the least restrictive scope provisions, the VA should ensure that veterans are provided with the best care and adhere to the most conservative state scope requirements.”

Providing feedback

Nearly 1,000 VA doctors of optometry and more than 200 residents each year provide the lion’s share—at nearly 70%—of all veterans’ eye and vision care.

The VA has always been at the forefront of delivering care to patients. Doctors of optometry have a longstanding history of being leaders in educating students and residents and providing the highest standard of care to our veterans, Dr. Read says. And, AOA and AFOS have worked together to advance the recognition of optometry’s contribution to the nation’s health care system.

Given the doctors’ out-sized role in providing optometry services to veterans, “the hope and goal is to make sure these new, national standards of practice are set at the fullest and highest scope of the profession of optometry in any state, so that veterans have unrestricted access to the full range of services, including advanced procedures that doctors of optometry are now trained, educated and licensed to provide,” Dr. Read says.

“Anything short of comprehensive practice standards would restrict access to care veterans need and deserve,” she says. “Additionally, the VA must include ‘as taught’ language to the scope of optometric practice standards to ensure that our optometric colleagues remain current and do not have barriers in caring for our veterans.”

The AOA expects the practice standards to be finalized in the coming months. To learn more and to find out how you can help, including by connecting with your members of Congress and urging that they join the AOA, other leading members of Congress, national veterans advocacy groups, and their state’s veterans in this fight, please contact advocacy@aoa.org. Learn more on how you can help expand access to needed care.