You're Only In Up To Your KneesEven after two decades of TPAs, optometrists remain in the shallow end of the therapeutic treatment pool.
What are you prescribing for?
It's almost 2001, about 25 years since West Virginia became the first state to institute an optometric TPA act. Since then, every state has approved some form of therapeutic prescribing authority. In 45 of 50 states now, optometrists can prescribe glaucoma drugs.
Gaining the rights to prescribe drugs has been a hard-fought battle in almost every state. Before you go on to fight for further privileges, take a minute to determine where you stand now. Here's a look at the state of therapeutics for optometrists-how many of your colleagues are TPA-certified, which drugs they prescribe most, how much they're earning by providing this treatment and how many 'scripts they are writing.
Therapeutic agents are useful for the optometrist only if he or she is certified to prescribe them. The good news is that almost all optometrists in the United States are DPA certified (about 95%). The rest of the story-encouraging news rather than bad news-is that about three-quarters are also TPA certified. This information comes from the Results of the First National Census of Optometrists, submitted to the AOA by Project HOPE Center for Health Affairs, and is the most recent information available that analyzes TPA certification, albeit from 1998.
Randall Thomas, O.D., of Concord, N.C., a frequent lecturer on pharmaceuticals and co-author of Review of Optometry's Clinical Guide to Ophthalmic Drugs, says that in terms of prescribing therapeutics, many optometrists are still getting their feet wet. As a group, he says, O.D.s are "probably up to their kneecaps." Yet they could be qualified enough to be in up to their eyeballs. "We're doing so much better, but we have so far yet to go."
Parts of the country are in deeper than others. By region, the Midwest leads the pack in TPA certification; 87% of O.D.s there have it, says the National Census report. The South is similar, with 86% of O.D.s certified. Then comes the West, with 65%, and the Northeast, with 45%. Of course, one must consider the scope of the TPA laws within each region (see "Optometric Therapeutic Authority, State by State."). For example, in Pennsylvania where the TPA law is just four years old and is more limited than in most other states, only 15% of docs are certified. In Oklahoma on the other hand, 91% are.
These data do support the notion that O.D.s in rural areas-where it's not so easy for patients to get to an ophthalmologist-assume greater patient care. In general, more optometrists in non-metropolitan counties are TPA-certified vs. their city-dwelling colleagues.
Interestingly, the fewer ophthalmologists in town, the more certified O.D.s there are. For example, when the ratio of optometrists to ophthalmologists in an area is 1-1 or fewer, only 70% of those optometrists are TPA certified. But in areas with no ophthalmologists, 87% of O.D.s are TPA certified. "Clearly, the ability to prescribe drugs for therapeutic purposes is an important part of an O.D.'s practice in markets with relatively fewer ophthalmologists," says the National Census report.
Also interesting, optometrists younger than 35 are more inclined to be TPA-certified (85%) than any other optometric age group.
Over the past 20 years, optometrists have lobbied aggressively for TPA privileges. But the fruits of that labor appear to be professional satisfaction rather than personal gain. In February 1998, Review of Optometry's National Panel, Doctors of Optometry survey reported that 7 in 10 doctors earn less than 10% of their practice gross from treating disease, and more than half earn less than 5%.
No data are available to pinpoint more recent numbers for therapeutic-based revenue, concedes Richard Edlow, O.D., chair of the AOA's Information Data Committee. But when pressed, Dr. Edlow came up with a "very ballpark" figure of about 8.25% of the average optometrist's gross practice revenue coming from therapeutic treatment. That's about $35,000 of gross.
It's more of a guess than science, he says, and only partially based on the statistics he's seen. Here's how he came up with it: Average gross income for O.D.s was $420,077 in 2000, reports Review of Optometry's National Panel, Doctors of Optometry income survey (see page 44).
Dr. Edlow estimates that about one-third of average gross practice income comes from professional services. Of that number, he says, probably about 25% is medically-oriented income. (Thus, $420,077 x 33.3% x 25% = $35,006.) Dr. Edlow says that the Information Data Committee is planning on expanding its surveys to track optometrists' thera- peutic usage, and maybe will derive income information from that. Thus, optometrists will be able to benchmark their prescription writing (and therapeutically-derived income) to help determine where their practice stands, and where it should be headed.
The areas of growth for optometric prescriptions are allergies, glaucoma and dry eye treatment, predicts Bobby Christensen, O.D., a lecturer on therapeutics and a private practitioner in Midwest City, Okla. "We'll witness growth [in prescriptions] with these conditions ... because these ailments are chronic problems, and quite frankly you don't really ever fix them."
(Unless otherwise indicated, the prescription data below come from NDC Health Information Services.)
The average O.D. writes about nine or so 'scripts a week, our OPR survey shows. "We're getting new and better ophthalmic pharmaceuticals almost each quarter, and there seems to be a flurry of drugs coming to market to really enhance our care," Dr. Thomas says. Perhaps that's one reason why optometrists have increased their prescription writing by 20% in the past year, NDC data show.
But even these bigger numbers are probably under-reported, Dr. Mann says. There are a few reasons why. For one, the agencies that track who's writing prescriptions use DEA numbers, but optometrists in some states cannot get these numbers. Also, in some ophthalmologist-owned practices, the prescription is credited to the ophthal- mologist owner, not the optometrist employee who writes it. Lastly, optometrists are giving out sample bottles for some conditions instead of writing prescriptions.
Bottom line, "these are exciting times, and optometry's just beginning to really immerse itself in these newer therapeutic modalities," Dr. Thomas says. So if you're not yet in up to your knees (or even if you are), start wading in further, he encourages.
North and Down UnderTPAs at a Glance
Other countries look to the United States for leadership in TPA legislation. Here's a look at what's happening at two opposite points on the globe:
Australia. The Aussies haven't been busy just with the Olympics. The first Australian optometrists (those in the state of Victoria) should be prescribing drugs in a month or so, the Optometrists Association of Australia reports. Optometrists in Victoria had passed a TPA act in 1996. Since then, the state board drew up qualifications and has just administered the first TPA course. The TPA act in Victoria permits essentially all topicals, but no oral or injectible drugs. Tasmania has also passed a similar TPA act earlier this year, and the states of Queensland and New South Wales are pushing legislation. Other states are taking a "wait-and-see" approach based on what happens in Victoria.
Canada. Optometrists in Quebec were able to amend their act in June to prescribe therapeutics. The specific medications and treatments are still being discussed, the Canadian Association of Optometrists says. Elsewhere, optometrists in Alberta, New Brunswick and the Yukon are able to prescribe topicals, remove foreign bodies and comanage glaucoma. Saskatchewan optometrists can use topicals except those for glaucoma, posterior uveitis and in some cases anterior uveitis. Optometrists in Nova Scotia can use topicals except steroids and glaucoma drugs. The remaining provinces have no TPAs. "Optometrists really provide the bulk of primary eye care," says Glenn Campbell, executive director of CAO. "In parts of Canada, access to ophthalmology is just very difficult in terms of distance and waiting time ... It just makes sense for optometrists to be prescribing and treating."
© Review of Optometry OnLine
November 15, 2000
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