The scope of success

Excerpted from page 36 of the July/August 2021 edition of AOA Focus.

Don Harris is the kind of gentleman who “everyone just knows.”

The 70-year-old is a staple of Blytheville, Arkansas, walking around town and happily taking up the occasional odds-and-ends jobs for local businesses. With diabetes and glaucoma to boot, Harris was one of the very first patients Matthew Jones, O.D., treated when he began practicing in the rural Arkansas Delta over a decade ago. And without fail all these years, Harris walked to every single appointment for regular pressure checks and drops.

That is, until suddenly he didn’t.

“Several months went by and we hadn’t seen Don, so we reached out to him and learned he had a debilitating stroke,” Dr. Jones recalls. “He was in a wheelchair and in the process of rehabilitation in a care facility.”

It took months for Harris to return home and resume mobility, albeit with a walker. Hence, Harris’ days of walking to and from appointments—not to mention the pharmacy—were limited. Consequently, when Dr. Jones and practice staff took to picking up Harris for his appointments, it wasn’t all that surprising to find Harris’ eye pressure was “through the roof.” He simply could not make it the couple of miles to refill his drops prescription.

“He’d been going without his glaucoma drops for who knows how long and his pressure was uncontrolled,” Dr. Jones says. “Here’s a gentleman of sound mind but not of sound body and just really has no help. Those months of delayed treatment were certainly detrimental to his health.”

As it happened, Harris’ health paralleled a fight unfolding in the state capitol for the exact optometric scope of practice expansion that would benefit him. When not in the exam lane, Dr. Jones was alongside his Arkansas Optometric Association (ArOA) colleagues as they advocated for Act 579, an advanced procedures bill that included selective laser trabeculoplasty (SLT), YAG laser capsulotomy, specific injections, and lumps and bumps removal. Patients such as Harris were the reason why such scope expansions were not only necessary but also ultimately life changing.

“This is the type of patient Act 579 is meant to help,” Dr. Jones recalls. “Literally, the reason we did this—not for us but for our patients.”

Legislators agreed and Act 579 was signed into law in March 2019. But that’s hardly where Arkansas’ saga ends nor that of Harris and Dr. Jones. Far from it.

Optometry’s accessibility, education reinforce scope expansion

As a profession, optometry delivers more than two-thirds of the primary eye health care in America, with doctors practicing in more than 10,176 communities. But that’s not even the most astonishing argument for expanding scope commensurate to the level of education and expertise that optometry receives: it’s the fact that 99% of the U.S. population has access to a doctor of optometry.

Such sheer accessibility is why the AOA and affiliates affirm that optometry is not only well-positioned geographically but also clinically adept to provide a range of advanced procedures. Yet, as a regulated profession, optometry is bound by restrictive laws based on outdated misrepresentations of doctors’ education and capabilities that create unnecessary barriers to care.

Optometry’s advocates are changing that.

“More and more states are moving toward full recognition of optometry and our essential and expanding role in health care,” noted William T. Reynolds, O.D., then president of the AOA, when Arkansas initially approved Act 579. “Together, our AOA and state associations are a nationwide force working to expand patient access to the full range of care that highly trained doctors of optometry are ready, willing and able to provide.”

Launched in 2018, the AOA Future Practice Initiative (FPI) is that close, operational partnership with affiliates that identifies and eliminates outdated barriers and fully recognizes contemporary optometric practice. The initiative leverages the advocacy strength and communications tools of the AOA to boost affiliates’ efforts and help produce legislative wins.

Chris Wolfe, O.D., AOA State Government Relations Committee (SGRC) chair, says the FPI ha accomplished two immediate goals. The first: establishing a centralized information hub able to quickly mobilize and combat the falsehoods that ophthalmology peddles. The second: establishing close and timely relationships with affiliates and their members as states’ grow their grassroots advocacy.

“Our intent with the FPI was to be able to help those states who were already close to passage to get over the hump, so to speak, and that’s still a central component, but there’s also this reinvigoration of the state association members,” Dr. Wolfe says. “It’s not just the state association fighting this battle but the AOA working hand in hand with them on this, helping us along.”

Don’t get him wrong: States are in the driver seat, but the AOA is available in a more active and comprehensive supporting role. That backing includes the knowledge and experience of those advocates who have gone before. In other words, “it keeps you off an island,” Dr. Wolfe says.

The FPI was put to work early and often, especially in the case of Arkansas. Not long after Act 579 was approved, opposition coalesced in the form of a well-funded, ophthalmology-backed group, Safe Surgery Arkansas, that challenged the law and began collecting signatures to force a ballot question. Over the course of a protracted legal battle over the validity of collected signatures, the opposition amassed $2 million in contributions to fight Arkansans for Healthy Eyes, the coalition supporting the scope law.

In addition to Arkansas’ grassroots advocacy, and leveraging FPI support and optometry’s nearly $1 million in contributions nationwide, Arkansans for Healthy Eyes successfully challenged the opposition through to the state’s highest court—and won. The Supreme Court ruling in September 2020 paved the way for the state board to begin rule-making and eventual credentialing for their new procedures.

“With this issue taking national attention, we all knew how important success in Arkansas would be—we knew we needed a win here to set the stage for future passage of scope expansion in other states,” says Belinda Starkey, O.D., ArOA immediate past president. “Grassroots advocacy was key to our success. We are thankful to the SGRC and the AOA for the assistance provided throughout the process, and we’re also very thankful to the many doctors across the country who supported the effort here in Arkansas.”

But concurrent to Arkansas’ fight, other affiliates eyed their own scope battles.

Mississippi’s access solidifies scope expansion

The argument over accessibility especially rang true in Mississippi. There, momentum swelled behind the affiliate’s scope efforts when advocates could point to neighboring states’ scope laws—not only Arkansas but also Tennessee.

On March 17, Gov. Tate Reeves signed a scope expansion that includes injectable authority; excision and removal of non-cancerous lid lesions, as well as chalazion; improved pharmaceutical authority, including Schedules 2-5 and oral steroids; and the ability for credentialed doctors to perform laser capsulotomy. This scope expansion granted qualified doctors of optometry the authority to deliver a level of primary eye health care that rural communities have deserved, without necessitating hours of travel for referrals. In a state such as Mississippi, proximity is a big deal considering 54% of residents live in rural areas and most counties are deemed “medically underserved.” In fact, Mississippi State University estimates over half of the state’s doctors (all disciplines) practice in just four urban areas.

Dax Eckard, O.D., MOA president, notes that scope expansion made sense from an access standpoint, and for the most part, legislators and other stakeholders agreed. Still, advocates faced their fair share of “fierce opposition” that, ultimately, they were able to dissuade.

“I am incredibly pleased not only with our successful, grassroots efforts over the past several years, but also this time we garnered the help of several ophthalmologists in working toward a bill that would be acceptable to both sides,” Dr. Eckard says.

Adds Ryan Wally, O.D., MOA legislative chair: “This scope expansion improves access to care for Mississippians across the state by allowing optometrists to practice closer to the level of their training. Updating our state law also allows us to continue to recruit the brightest and best optometry graduates back to our state.”

Wyoming scope win makes for historic year

Successful advocacy is a combination of hard work and essential relationships that take years to foster. Wyoming’s last scope push took place in the mid-’90s, when they secured therapeutic treatments, so the state’s doctors knew they had work to do with the current group of legislators to be able to successfully enact major legislation. So, to best prepare Wyoming Optometric Association (WOA) members and actively engage with state legislators, doctors there focused on smaller but no less important issues, e.g., telehealth and patient safety measures, in the run-up to 2018.

These attempts not only helped put optometry back on legislators’ radar but also began seeding the grassroots activation necessary for a scope fight, explains Jeremy Nett, O.D., WOA president-elect. Doctors needed to get involved, become a familiar face and establish those trusting relationships with legislators. Then when the time came, WOA approached its membership about scope.

“The overwhelming response was that the state’s doctors wanted to push for legislation that would take Wyoming back to the top of the list in regard to patient care,” Dr. Nett says. “As a legislative group, we examined other states’ statute language, legislative approaches and collaborated with the AOA to draft a few versions of our bill.”

Then in 2018, the WOA introduced a bill into the Labor, Health and Social Services committee, where legislators could vet the bill’s merits through hearings. Concurrently, the WOA coordinated with Northeastern State University College of Optometry to schedule laser and procedures courses to show legislators optometry’s level of education and training. Wyoming doctors jumped at the opportunity to complete the course, and by fall of 2019, WOA Executive Director Kari Cline and the lobbying team took a YAG laser statewide on a “Laser Roadshow.” Local doctors invited their representatives to see the procedures firsthand, helping eliminate any stigma about the procedure itself.

“We literally visited every legislative district, and I believe that was a key piece of our grassroots effort,” Cline says. “The combined effort of our doctors educating the legislators who attended on the issue and the legislators getting to see and use the laser made the opposition’s assertions that this was beyond the education and ability of an optometrist fall very flat.”

The WOA’s persistence paid off in the 2021 legislative cycle when the WOA reintroduced the measure with bipartisan support. Again, it was not only optometry’s demonstrated proficiencies with the procedures but also a bigger picture of Wyoming’s patient access landscape that resonated. Like Mississippi and Arkansas, Wyoming’s rural nature meant optometry practices are available in 22 of 23 counties statewide, yet often enough patients would need to drive considerable distances to receive care from a specialist.

If anything, that argument gained strength with COVID-19 lockdowns exacerbating travel issues and optometry stepping up to deliver essential primary eye health care, says WOA Legislative Chair Dana Day, O.D. Because of firm arguments and the grassroots advocacy planted in the years prior, when it came time to introduce the bill to the full legislative body, the WOA was able to remain firm and deliver the scope expansion they sought.

“The success of Wyoming’s legislative efforts resides squarely on the incredible involvement of the WOA members,” Dr. Day says. “Wyoming has always boasted a high membership percentage, which resulted in a more unified approach to scope expansion.

“The volunteer time and personal relationships with legislators were key to this legislative win. The ability to communicate with a personal text to our legislators during committee hearings or floor debate was paramount.”

On April 2, the Wyoming governor signed H.B. 39 into law, officially recognizing doctors of optometry and their ability to perform advanced procedures safely and effectively in the state—the first time in optometry’s history that two states approved such expansion in a calendar year.

‘This is why we do it’

Scope wins are patient wins. Scope wins mean greater accessibility and more patient choice, especially when it comes to primary eye care. But such an argument was lost on naysayers in Arkansas who suggested many patients live within an hour’s drive of an ophthalmologist.

“It’s short-sided. ‘Within an hour’ isn’t close for most patients,” Dr. Jones says. “Sure, it’s closer for maybe you or I, but that’s not easy for a majority of my patients in the Arkansas Delta.”

That’s why when Arkansas’ board promulgated rules, Dr. Jones wasted no time becoming licensed and credentialed with his first patient already in mind. Harris, without reliable access to his pressure-relieving medications, heartily agreed to an SLT after consultation with Dr. Jones. He just didn’t have a ride.

“Well, I’ll come pick you up, I said,” and in just a few minutes, Dr. Jones had completed the procedure—a resounding success.

“Afterward, we went by and picked him up a 12-pack of hot wings and took him back home,” Dr. Jones adds with a laugh. “But that’s the wonderful thing about our profession: It’s a different level of care, because we know our patients and we know their unique circumstances. This is optometry; this is why we do it.”