Gaining access: A win for veterans and doctors of optometry

Since 1998, when the state of Oklahoma extended to doctors of optometry the authority to perform a fuller range of eye procedures, David Cockrell, O.D., has been licensed to provide that service to patients—except among military veterans and their families using Veterans Affairs (VA) benefits. But, due to the recent shelving of a counterproductive guideline of the U.S. Department of Veterans Affairs, Dr. Cockrell now can.

On Sept. 30, the VA revised its guidelines to open up greater access to veterans seeking the care of doctors of optometry whose state scope laws allow them to perform invasive eye procedures.

“This removes the barrier,” says Dr. Cockrell, who practices in Stillwater, Oklahoma, and is a past AOA president. “It really opens access to veterans.”

It opens access to doctors of optometry, too, who are eligible to participate in the VA’s Community Care Program and their state law allows. The program provides health care to eligible veterans through local, in-network providers outside of VA medical centers, making the care of doctors of optometry more accessible to veterans.

Game-changing win

The restrictive language within two of the VA’s Eye Comprehensive Standardized Episode of Care (SEOC) guidelines had previously prevented veterans from accessing care from doctors of optometry for so-called “invasive” eye procedures. The 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.”

The change comes amid opposition from ophthalmology and as a result of persistent advocacy over nearly 20 years by the AOA, the Armed Forces Optometric Society (AFOS), the Mississippi Optometric Association (MOA) and members of Congress that urged the VA to recognize 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.

“This opens opportunities to provide contemporary care to veterans in a more timely and easily accessible manner,” AOA President Robert C. Layman, O.D., says. “My practice is close to a VA center with eye care services, so I rarely see patients through Community Care programs. It won’t be a game changer for my practice, but it will make a big difference for many.

“It is always nice to see policy validate the value optometry brings to the health care system, especially when it means making contemporary technology and procedures available to those who served our country,” Dr. Layman adds. “As our field advances, giving greater access to patients to experience the best optometry offers is quite gratifying. We will continue to represent the profession and the patients we serve no matter what opposition is encountered.”

Beyond the big advance in care for veterans, optometry leaders are cautiously optimistic that it bodes well for future advocacy, specifically when it comes to the anticipated release of the VA’s National Standards of Practice. Currently, the VA is developing new national standards of practice (NSP) for doctors of optometry and other health care practitioners within the VA system. Triggered by a coordinated effort by the VA and Department of Defense to implement a unified electronic health record platform, such NSP will outline the list of services that veterans may seek from VA doctors of optometry and could have a significant impact on veterans’ access to care. These NSP for optometry are expected to be released in the coming months.

“Our safety record with contemporary procedures speaks for itself and delivers the care the public needs,” Dr. Layman says.

AOA President-elect Ronald L. Benner, O.D., called the change in veterans’ care guidelines an important “acknowledgement” of the skills and training doctors of optometry deliver to their patients, and significantly, another jumping-off point for optometry’s advocacy.

“This language change is a major victory for the profession,” Dr. Benner says. “Those pioneering states that expanded scope with this VA barrier in place—while continuing to fight from the state legislature into the federal arena—deserve recognition for their years of hard work.

“Doctors of optometry can now practice at the highest level allowed by their state license,” Dr. Benner says. “Patients will be able to have their continuum of care provided by their optometrists and not have to be needlessly referred back into the VA system for delayed care. Recognizing doctors of optometry for their skill and training is a game changer within the VA system as it elevates the profession across the board, from the VA members seeking care to those who look to the VA as setting standards of care. The VA standards have long been thrust, by our opponents, into legislative battles for scope expansion as a reason to not allow procedures we are educated and trained for. Those days are gone. We will now be able to use those same arguments in our case to advocate for those skills and procedures that have long been denied.”

At the VA, eye and vision care are the third-most requested service by veterans.

Timely access to care

The VA’s standard for veterans’ wait times for appointments is 20 or 28 days, depending on the service being sought. However, for years, the VA has had to battle long wait times for veterans seeking services at VA medical facilities. Despite congressional efforts at reform in 2014 and 2018, a study in JAMA Network Open in August 2022 found that long wait times persist whether at VA facilities or a non-VA community-based facility.

The AOA looked at access for veterans in 10 U.S. states, finding access to care by optometrists greater than by ophthalmologists:

Arizona: Ophthalmologists are present in two VA facilities across the state. Doctors of optometry are available in five different facilities.

Arkansas: Ophthalmologists are present in four VA facilities, but there are no appointments available to new patients at two of these facilities. Doctors of optometry are available in five different facilities.

Kentucky: Ophthalmologists are present in two VA facilities across the state. Doctors of optometry are available in five different facilities.

Maine: Ophthalmologists are present in one VA facility across the state. Optometrists are available in four different facilities.

Michigan: Ophthalmologists are present in four VA facilities across the state. Optometrists are available in seven different facilities in the state.

North Carolina: Ophthalmologists are present in seven VA facilities, but there are no appointments available to new patients in two of these facilities. Optometrists are available in 13 different facilities.

Texas: Ophthalmologists are present in 12 VA facilities across the state. Optometrists are available in 25 different facilities, but there are no appointments available to new patients in two of these facilities.

Washington: Ophthalmologists are present in three VA facilities in the state. Optometrists are available in six different facilities, but there are no appointments available to new patients in one of these facilities.

Washington, D.C. (50-mile radius): Ophthalmologists are present in two VA facilities across the region. Doctors of optometry are available in six different facilities.

West Virginia: Ophthalmologists are present in four VA facilities across the state, but there are no appointments available to new patients in one of these facilities. Doctors of optometry are available in five different facilities.

The above information, collected Nov. 30, 2022, is available at the VA site Access to Care.

Nationwide, optometry is in the U.S., serving patients in 6,500 communities, in over half of which they are the only eye care providers. They provide over three quarters of first-time eye care visits and two-thirds of all eye care in the U.S. on an enduring basis.

“AFOS and AOA worked to ensure that language in the SEOC allowed for veterans to receive the best access to care in the community,” says Lindsay Wright, O.D., executive director of AFOS.

Recognizing Mississippi’s scope of practice

The change in the SEOC was triggered by a patient encounter with a Mississippi doctor of optometry last year.

Mississippi lawmakers expanded the state’s scope of practice for doctors of optometry in 2021 to include injectable authority; excision and removal of non-cancerous lid lesions, as well as chalazion; improved pharmaceutical authority; and the ability for doctors to perform YAG laser capsulotomy. Yet, in March 2022, a Mississippi doctor of optometry providing routine care to a veteran in the community was denied coverage by the local VA system to diagnose and treat trichiasis with entropion due to the former language in the SEOC. The VA reportedly suggested that the doctor refer the veteran to an ophthalmologist nearly 60 miles away for needed epilation.

In collaboration with the AOA’s Third Party Center and AFOS, the MOA determined the issue was unique to Mississippi’s VA and initiated immediate outreach to not only the VA but also Mississippi’s members of Congress. State Sen. David Parker, O.D., R-Dist. 2, one of the MOA’s federal keypersons, successfully discussed the issue with U.S. Rep. Michael Guest, R-Miss., who agreed to champion the issue.

“We were alerted by one of our members in spring 2022,” Sarah Link, MOA executive director, says. “We began efforts to contact the Mississippi VA, and finally connected with the Mississippi VA chief of staff in early July. That is when we found out it was a national SEOC language issue and not a state restriction. We alerted the AOA immediately, and they began working with the national VA on the SEOC language.”

Rep. Guest and other members of Congress reached out to the VA and raised concerns that veterans were being negatively impacted by the SEOC language and urged removal of the restrictive SEOC language, especially given that Medicare, Medicaid, the Indian Health Service and all major private payers already cover and reimburse doctors of optometry for these services.

“As Mississippi’s existing scope of practice laws allow optometrists to perform these procedures, I am concerned about the impact of this policy on the ability for Veterans to receive needed care in our state,” Rep. Guest wrote in a letter to VA Secretary Denis McDonough.

In responding to legislators’ outreach, the VA confirmed to one Capitol Hill office that the Office of Integrated Veteran Care had reviewed the issue and changed the specific 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.”

The change in VA guidance will make a real difference to Mississippi’s veterans needing eye care, says Stacie Moore, O.D., MOA president.

“It now aligns with the current scope of practice of Mississippi doctors of optometry,” Dr. Moore says. “Veterans now have an expanded list of licensed optometrists for services allowing for time-efficient, quality eye care.”

Adds Kris May, O.D., MOA legislative chair: “Our state is a rural one and many patients do not have access to care. The ability to provide high-quality, full-scope care to all residents of Mississippi allows us to focus on the best patient outcomes possible, without getting bogged down in referral and transportation difficulties. For the patient, it means easier access to care and procedures. For the practice, it means utilizing our efforts to provide efficient and excellent care rather than exerting efforts coordinating visits for procedures we can provide.

“Ultimately, the most important factor is assuring our veterans access to high-quality care,” Dr. May says. “Many states have expanded their scope of practice for optometrists, recognizing their training and abilities can provide expanded access and excellent care for their residents. It is encouraging to see the VA decide to do the same. My hope is that this model carries forward into the VA's national standards of practice guidelines and nationally expanded scope of practice for VA optometrists, so our veterans continue to have access to the care they deserve.”

Moving forward, MOA’s Link says, the affiliate will work with the VA Medical Center in Jackson to ensure it is now providing authorizations for doctors of optometry, according to their license credentials.

Deserving care

Not long after the VA added doctors of optometry to the SEOC language, Dr. Cockrell saw a veteran in his office. The man had recently moved to Oklahoma from Colorado.

“I was the first provider he had seen who he could actually access in our community outside of direct VA care,” Dr. Cockrell says. “He was thrilled to be able to do that. If you think about it, there are some veterans who can make a 160-mile round trip. But there’s a whole lot of them, like this gentleman who was 78, where these trips become a significant burden for either them or their family members to take them or have to go through some of the wait times at the VA centers. We’re in virtually every community in America.

“This is exactly what we trained for,” adds Dr. Cockrell, noting there are six doctors in his practice. “We enjoy providing care to all of our patients. But this is a group of people who have done a great deal for America and to be able to provide that care and ease the burden of travel, it is a pleasure and a privilege. The AOA on a national basis, along with working with our state affiliates, is going to continue to help every state move forward to take advantage of this opportunity.”

Download the AOA’s fact sheet for more information about the VA’s NSP for optometry or contact the AOA’s advocacy staff for more information about how you can help advocate for the profession.