The Affordable Care Act, also known as ObamaCare, has transformed the healthcare landscape across America. Though not yet fully implemented, it is already changing the way we buy and access healthcare, mostly in negative ways. Premiums keep going up. Doctors are speeding up their retirements to avoid having to deal with the law. Its push to digitize our medical records may expose Americans to violations of our privacy, and even to misdiagnoses as doctors and nurses are forced to use templates rather than handwritten notes to describe the ailments patients present them.
ObamaCare is also creating chaos in how states deal with which medical personnel are allowed to perform different tasks. The Department of Health and Human Services essentially writes much of the law on the fly, and state legislatures and health departments find themselves regulating between the voluminous law’s many gaps. Chaos presents opportunities, and into those opportunities, some say, consortia of health practitioners are stepping, to take advantage.
Specifically, two groups — nurse practitioners and optometrists — are moving to increase their medical taskings to include many typically done by MDs, without obtaining the years of training that MDs obtain.
Taking the second group first, though most Americans don’t realize it, there is a vast difference in training between optometrists and ophthalmologists. Optometrists typically undergo four years of training to become certified. Some optometry schools do not even require a college degree. Ophthalmologists, on the other hand, must finish college, must finish medical school, and must finish additional internships, residency, and specialization study that can all add up to 12 to 15 years of training.
But optometry groups are moving in California and other states to take on the duties now performed by ophthalmologists and other medical doctors. Kentucky and Oklahoma are among the states that are set to conflate optometrists as if they are equally trained. Optometrist groups are even lobbying, which means donating to politicians, to enable themselves to become primary healthcare providers, monitoring blood pressure and many other conditions far afield of vision. This can and has led to problems for patients.
I spoke with a surgeon who teaches at a major southern university this week on the subject of how ObamaCare is enabling the blurring of lines between eye doctors.
“It is bringing massive, sweeping changes in how health care is delivered and paid for. Optometrists want to be equal to medical doctors. They are positioning themselves to expand their scope” into primary care delivery and even surgery.
“You do not want people who are not trained” in medical procedures to perform them, the surgeon told me. “But optometry schools are positioning themselves to be on a par with medical doctors. To be primary care physicians. Optometrists are positioning themselves to be able to charge as much for services as a medical doctor.”
The fees charged are key to the story. If optometrists and nurse practitioners can get states to see them on a par with MDs, they can charge fees on a par with MDs, and they can expand their practices to take on revenue-generating services that most states do not currently allow them to perform.
“They just don’t know what they don’t know,” the surgeon told me. “They have less training, which will end up costing us more” in health care. How? More highly trained medical doctors with more experience will tend to order less lab testing than less-trained and experienced people will. More testing means more cost. And along with that increased cost, less training will lead to more errors.
Dr. [David] Parke’s experience included treating a man whose “skin tag” was excised by an optometrist. Nine months later the patient came to the university medical center with an invasive, substantive squamous cell carcinoma that required a massive reconstructive surgery. “We asked the patient, ‘Why’d you let him do that?’ He replied, ‘Well he’s a doctor, he had on a white coat and he said he could.'”
In another case, an elderly patient with severe end-stage glaucoma could only be controlled surgically through a technique called filtering blebs. “She went to an optometrist who said to the patient, ‘Mrs. Jones, you have cysts on your eyes, I should take care of those now,’ and he proceeded to excise them, completely undoing the surgery.”
“In the end it scares me, quite frankly,” says Dr. Parke.
The surgeon I spoke with added: “They want to cut on eyelids and they want to use needles to inject in and around the eye. They want to manage complex disorders of the eye. They want to prescribe systemic medications like anti-viral oral medications for viruses, specifically for shingles, which people can get in their eye and can require corneal specialists. But once again, they haven’t seen those kind of patients, they haven’t managed those kinds of patients. You can’t do a refresher course when you haven’t had the basic course.” The surgeon added that less-trained doctors and nurse practitioners can end up removing objects that should be biopsied for cancer, but due to a lack of training, no biopsy is done.
Case in point: young Victoria Patterson of South Carolina, who suffered a misdiagnosis from her optometrist in 2006 that could have killed her. A second opinion from a pediatric ophthalmologist corrected the misdiagnosis, enabling her to get the treatment that she needed.
Another case in point: the California veterans who went blind under the care of optometrists rather than MDs.
A Veterans Administration probe that found eight veterans suffered potentially preventable vision loss while under the care of optometrists at a Northern California VA facility is prompting medical groups to call for a state investigation.
The groups sent a petition Wednesday to the California Department of Consumer Affairs seeking an evaluation of the care received by the veterans at VA Palo Alto. The patients had glaucoma, a class of eye diseases that can lead to blindness.
The California Medical Association, California Academy of Eye Physicians & Surgeons and American Glaucoma Society want the state to suspend a new state law set to take effect in January that would expand optometrists’ ability to care for glaucoma patients.
It’s the latest salvo in an ongoing dispute between optometrists, who have four years of training, and ophthalmologists, who are medical doctors, over who should be allowed to treat the disease.
“This illustrates what can happen when people who aren’t qualified treat glaucoma,” said James Ruben, a pediatric ophthalmologist who is president of the Academy of Eye Physicians & Surgeons.
That was in 2009, before ObamaCare. The president’s signature law has only made the situation worse.
In an ironic twist, ObamaCare’s chaos is helping foster the charge to increase roles for less-trained medical personnel. Over time, if more states allow optometrists and nurse practitioners to deliver MD level training, costs to patients will increase, not decrease, as the president and his Democratic Party promised the law would do.
My surgeon source is not surprised.
“We knew this when ObamaCare was passed, and we watched it unfold.”
We’re still watching it all unfold, finding out what was in that law long after it was passed — over the objections of a majority of Americans.