Fighting for veterans, fighting for optometry

Excerpted from page 28 of the November/December 2022 edition of AOA Focus.

Erin Mozingo, O.D., is determined to become the “best comprehensive eye doctor” she can be.

It’s why the Southern College of Optometry graduate sought further clinical training “heavy” in ocular disease—and she found it, like so many doctors of optometry before her, in a Department of Veterans Affairs (VA) residency.

“Here is an opportunity for exposure in primary care, ocular disease, ophthalmology co-management, specialty contact lens, low vision and traumatic brain injury,” Dr. Mozingo says. “You can gain exposure to many areas of optometry in a multidisciplinary way.”

Now in private practice in southern Georgia, Dr. Mozingo was just one of 215 VA residents acquiring invaluable experience in the largest optometric clinical training program in the nation. Each VA residency program offers a different opportunity, and at Lake City VA Medical Center, Dr. Mozingo is getting the clinical experience she desired.

The VA has the largest clinical education program for optometrists in the U.S. There are currently 220 VA residents training in VA sites across the country. Additionally, 1,300-1,400 students will be trained annually at a VA site during their fourth-year externships. These residencies and externships serve as an introduction to the interdisciplinary health care system utilized by the VA. As a result of their experience, many of those doctors of optometry choose to pursue a career in serving our veterans in the VA.

One month into the program, Dr. Mozingo had seen veterans and their families from across northern Florida and southern Georgia with conditions ranging from cataracts and age-related macular degeneration to glaucoma and diabetes. But already, Dr. Mozingo’s residency has taught her something more: the importance of advocating for those who have sacrificed so much of their lives and health for our nation.

“Optometry plays a vital role in managing the overall health of veterans, and it is imperative that we maintain a high standard of care for such complex patients,” she says. “We can provide many services that veterans otherwise would not have access to, such as low vision and contact lens, which allow our patients to maximize their remaining vision and gain independence they otherwise may not have.

“It is important to preserve and further those opportunities for these patients.”

Optometry’s biggest scope battle

As the largest integrated health care network in the U.S., with 1,298 facilities serving 9 million enrolled veterans annually, the Veterans Health Administration (VHA) is monolithic.

And optometry’s contribution is no less monumental.

More than 1,000 VA doctors of optometry currently practice at 95% of VA sites where eye care is offered, while often being the only licensed independent eye care practitioner at that location. Put another way, VA optometry provides care for nearly 70% of the total visits for eye care annually, with more than 3.1 million overall patient visits.

But the sheer scope of the VHA’s mission in providing exceptional health care for all veterans is not without its challenges. Driven by concerns over accessibility, the VHA launched a program in 2020 with goals to develop innovative solutions, practices and products, as well as advance clinical training and develop new payment and service delivery models. This direction to innovate in such a broad network has turned everyone’s attention—from states to private insurers and Medicare—on VA policies.

Such is the case, the AOA and the Armed Forces Optometric Society (AFOS) have doubled down on their own VA work, knowing what happens at the federal level could come to bear on other optometric practice settings. Licensure reciprocity, third party reimbursements and states’ scope of practice advocacy have threads connecting them to the veterans’ program.

Bob Theaker, O.D., AOA Federal Advocacy Committee chair, scored it thusly at the joint AOA on Capitol Hill and AOA Payer Advocacy Summit in Washington, D.C., in April 2022: When optometry’s opponents realize they cannot stymy scope advancement efforts at the state level, they look to the VHA to force changes that could trickle down.

“The biggest scope battle isn’t necessarily going to be in the states. The biggest scope battle is at the VA system,” Dr. Theaker said.

Two words too far

A year to be remembered for VA optometry was 2020. That year, a pair of VA-issued directives would set into motion a pathway for full recognition of the care that doctors of optometry have been educated and licensed to provide for decades. And it began with scrutiny of the VA’s guiding policy for furnishing eye health and vision care, particularly around therapeutic laser procedures.

In 2004, the VHA briefly trialed permitting doctors of optometry with the appropriate training and licensure—only Oklahoma doctors had laser scope at the time—to provide therapeutic laser care under the supervision of an ophthalmologist. However, in a reversal months later, the VHA withdrew that decision and codified within its eye and vision care policy that such procedures could “only be performed by ophthalmologists.”

While the AOA and AFOS spoke out vehemently against the decision, noting it wasn’t based on any evidence of poor quality and that the VA’s own medical inspector deemed such optometric laser cases as meeting VA standards of care, the VHA would repeatedly uphold the ban every five years. That is, until 2019.

Lindsay Wright, O.D., AFOS executive director, explains that on third review, the insertion of language that such procedures were limited to ophthalmologists due to “safety concerns” ceded grounds for direct appeal. After all, that simply wasn’t the case.

“Ophthalmology added this inflammatory language that made it sound like this ban was in place due to wrongdoings that weren’t founded—that has never been the case,” Dr. Wright says.

That patent misrepresentation opened the door for optometry’s advocates. As of early 2020, four states had passed optometric laser procedures, with more in the wings. Damning ophthalmology’s argument was the fact that optometry has enjoyed a clean record of top-level patient care for over 20 years with the procedures in question, as evidenced by the overall lack of malpractice claims filed and low rates for malpractice insurance. Additionally, the ban did not correlate with other federal health care—the Indian Health Service, Medicare and Medicaid—as well as all major private insurers, which recognized optometry’s authority in such states and reimbursed for such procedures.

What’s more, percolating in the background was a mixture of events that would further prove the ban unfounded. A perennial issue of veterans’ access was intensified by the surging COVID-19 virus that threatened to tax already stretched health systems nationwide. Such is the case that these events would hasten the VA’s work toward a groundbreaking new policy to be issued in late 2020: license portability.

But in the spring of 2020, optometry’s advocates were in the thick of conversations with the VA over the policy language. Denise Roddy, O.D., AOA Federal Advocacy Committee member, saw a critical opportunity to connect with her congressman on the issue. Rep. Kevin Hern, formerly a small-business owner in Oklahoma for whom Dr. Roddy had become optometry’s trusted keyperson, was receptive to optometry’s desire to provide full-scope care for veterans.

In May, Rep. Hern penned a bipartisan letter to the VA urging an immediate update to the policy that would permit licensed doctors of optometry the ability to provide such care in states where authorized. It would be a watershed moment. In August, the VHA issued an amended eye and vision care policy that removed the “safety concerns” language, as well as wording that limited therapeutic laser procedures “only” to ophthalmologists. In effect, the 15-year ban was rescinded.

“The VA laser ban repeal represented a bipartisan effort led by a very conservative Rep. Hern to do what was best for veterans, as well as overturn an imposed restriction by appointed government officials,” Dr. Roddy notes.

But it wasn’t only optometry celebrating the change. Veterans Service Organizations (VSOs) applauded the decision to remove the barrier to care. Commenting on the laser ban reversal, AMVETS National Director Joe Chenelly chalked it up as a significant victory for America’s veterans and their families.

“AMVETS is proud of and applauds the VA for its recent and decisive move toward ensuring that more of our veterans have access to the full range of eye care services, including laser eye procedures, that doctors of optometry are ready, willing and fully able to provide,” Chenelly remarked in fall of 2020. “AMVETS is committed to ensuring that our veterans have access to the care they need, where and when they need it—and we’re happy that the VA is increasingly joining us in that mission.”

But 2020 held more in store for VA optometry.

Defining national standards of practice

In November, the VA issued a directive to create ubiquitous scope of practice standards for its health care providers notwithstanding any state requirements that “unduly interfere with their practice,” such as licensing or credentialing. The directive set the agency on a path toward creating national standards of practice for its health providers concurrent to the VA’s efforts to replace its EHR system with one already deployed by the Department of Defense.

Called the VA Supremacy Project, the initiative triggered an administration-wide effort to develop standards of practice for 50 health care occupations, including optometry. From an operational standpoint, the standards of practice inform the specific privileges available to each provider type within the EHR system, such as prescribing, ordering of procedures or imaging, and required oversight levels.

Marrie S. Read, O.D., AOA trustee and AFOS past president who served on the AOA’s Federal Relations Committee, as well as within the U.S. Navy for more than 25 years, says the standardization process has similar ramifications to that of optometry’s laser ban fight.

“We do expect this decision to occur imminently, possibly in the upcoming months, and just as the laser ban stood for nearly 15 years, this decision will have long-term implications,” Dr. Read says.

Unsurprisingly, the national practice standards whipped up strong opposition among medical organizations, including ophthalmology, which contended such scope of practice expansions could threaten patient safety and diminish the standard of care within the VA. These groups called on the VA to align the new practice standards with the most restrictive state scope for optometry and others. But, for its part, the VA has countered that basing such standards on the most restrictive state would harm veterans’ access to care in every other state.

As in the laser ban fight, many in Congress and VSOs are on optometry’s side. In the subsequent months after the VA’s directive, Reps. Anthony Brown, D-Md., and Susie Lee, D-Nev., wrote to express concerns that overly restrictive standards could induce a shortage of practitioners, while AMVETS’ Chenelly testified before the House Committee on Veterans Affairs in support of authorizing VA providers to practice full-scope care.

Nearly a year after the VA Supremacy Project launched, then-AOA President Robert C. Layman, O.D., attended a nonpartisan veterans’ advocacy breakfast, hosted by HillVets, where he spoke to the importance of veterans’ access to full-scope optometric care. His remarks earned an enthusiastic fist bump from VA Secretary Denis McDonough in attendance. Only a month later, a bipartisan group of 17 members of Congress, led by Reps. Hern and Troy Carter, D-La., sent a letter to McDonough that furthered the gravity of this moment.

“With doctors of optometry now providing nearly three-quarters of all VA eye and vision care, the services that the Department decides to include or exclude in the optometry practice standard will have a significant impact on veteran access to essential eye care services for years to come,” the representatives noted.

The unrelenting advocacy continued into 2022, where nearly 600 doctors of optometry and students championed the issue on Capitol Hill, equipped with not only the Hern-Carter letter but also a letter from AMVETS and the Veterans of Foreign Wars that spoke fervently in support of the position that VHA providers practice at the top of their license.

As of Congress’ August 2022 recess, optometry’s practice standards were expected imminently—with the wait apparently as carefully watched by ophthalmology groups. A July opinion piece that year in the American Academy of Ophthalmology’s EyeNet magazine noted, “In the history of scope battles, the Federal Supremacy Project potentially raises the most significant issue for ophthalmologists yet.”

Likewise, Dr. Read notes the VA’s decision will reverberate across all facets of optometric practice.

“If the new standards allow doctors of optometry to practice to the fullest extent of one’s license, training and certification, they could be used to support expansion of scope at the state level and advance our profession,” she says. “However, if the VA is constrained to the most restrictive scope, as our opposition has suggested, it could stifle our efforts.”

The trickle down

In affirmation of utilizing the full extent of care provided by doctors of optometry, the VA only recently removed restrictive language for veterans seeking care within their communities. The VA dropped language within two Eye Comprehensive Standardized Episode of Care (SEOC) guidelines that had prevented veterans from accessing community care doctors of optometry for so-called “invasive” eye procedures. The change comes as a result of persistent advocacy on the part of the AOA, AFOS, the Mississippi Optometric Association (MOA) and members of Congress that encouraged the VA’s recognition of the current scope of practice, which allows doctors to provide a wide range of comprehensive medical eye care services, including injections, foreign body removals and therapeutic laser eye care.

The Eye Comprehensive SEOCs, which outline the scope of approved services a community provider may offer to a veteran, previously included language that stated, “only ophthalmologists can perform invasive procedures, including injections, lasers and eye surgery.” However, after hearing from concerned veterans, lawmakers and other stakeholders, the VA changed its language to allow these services to be provided by “an ophthalmologist or optometrist based on the state licensure of the provider.”

In responding to legislators’ outreach, the VA confirmed to one Capitol Hill office that the Office of Integrated Veterans Care had reviewed the issue and changed the SEOC language to allow a doctor of optometry to provide full care authorized by their state license.

“We believe that providing quality care in a timely manner is of utmost importance. Utilizing community care providers to their full extent is part of the process,” the VA wrote to the office of Congressman Trent Kelly, R-Miss. “This change will improve access by allowing providers to render services for which they are legally licensed, reduce the need for multiple Community Care encounters and allow Veterans to choose their preferred provider within the care network.”

While this recent VA decision is a win for veterans seeking full-scope optometric care within their communities, it also emboldens the AOA’s and AFOS’s advocacy for doctors within VA Optometry.

Today, optometry is again at a crossroads. Doctors of optometry in at least 11 states now perform office-based laser procedures, which are taught routinely in schools and colleges of optometry.

VA residencies continue to serve as an important steppingstone for doctors of optometry. Nationwide, there are over 220 accredited post-graduate residencies and more than 1,500 externship positions available for clinical training annually. Dr. Wright emphasizes the educational aspect to the VA’s scope considerations as well.

“The VA is one of the top educational opportunities for most optometrists,” she notes. “These issues really do impact the training our doctors receive because we want them to be able to practice to the highest level of what they’re trained and schooled to provide.”

Dr. Read adds: “Rescinding that ban was the first step in the VA regaining its place as a leader in providing full access to optometric care and a top choice for residency and student training.”

But VA policy isn’t only about education, training and scope. In the same way such policies can be used for or against optometry in statehouse battles, the trickle-down effect of federal policy comes to influence legislation, regulation and the private market, Dr. Read says.

“I would argue that the VA’s effect of private practice optometry is more than ‘trickle down,’” Dr. Read says. “The VA is the largest health care organization in the country and is seen as a model for health care delivery and education.

“Optometry continues to be one of the most requested medical services and is an integral part of the health care team, with VA optometrists demonstrating the need for eye care services within hospitals and clinics nationwide. The AOA and AFOS have been able to leverage this experience and expertise in fighting for parity within Medicare and other insurance payers, as well as our ongoing scope battles.”

This September, a contingent of 20 doctors of optometry from across the country showed up, on short notice, to support AOA Trustee Paul M. Barney, O.D., who appeared at a congressional hearing in Washington D.C., by the House Veterans’ Affairs Committee Subcommittee on Health. Dr. Barney and the AOA’s position is that the new national standards of practice should confer greater authority to optometrists to provide care based on their education, training and licensure, a win-win proposition for veterans now facing wait times and delays in VA care and doctors who would be able to practice at their highest levels.