HBA-MPM C.S.H.B. 1051 76(R)BILL ANALYSIS Office of House Bill AnalysisC.S.H.B. 1051 By: Brimer Public Health 4/18/1999 Committee Report (Substituted) BACKGROUND AND PURPOSE More than 200,000 Texans have untreated glaucoma. If this disease is left untreated, it will lead to blindness. There are 73 counties in Texas with resident ophthalmologists and 142 counties with optometrists. Forty-two states, excluding Texas, have authorized these certified therapeutic optometrists to treat patients with glaucoma. Therapeutic optometrists must pass a nationally certified exam that tests their knowledge of the diagnosis and treatment of glaucoma. Attorney General Opinion DM-152 states that the use of certain drug classifications to regulate practice by therapeutic optometrists is appropriate. C.S.H.B. 1051 allows therapeutic optometrists to treat certain diseases and conditions with specific classes of pharmaceuticals and sets forth conditions under and protocol for which a therapeutic optometrist may treat glaucoma. Furthermore, this bill creates the Optometric Health Care Advisory Committee, which makes rules and recommendations with respect to the practice of optometric glaucoma specialists. RULEMAKING AUTHORITY It is the opinion of the Office of House Bill Analysis that rulemaking authority previously delegated to the Texas Department of Health is modified in SECTION 2 (Section 1.03, Article 4552-1.03, V.T.C.S.) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Section 1.02, Texas Optometry Act (Article 4552-1.02, V.T.C.S.), by amending Subdivision (7) and adding Subdivision (11), as follows: (7) Includes treating the visual system, including the eye and adnexa, under the definition of the "practice of therapeutic optometry." Specifies that the practice of therapeutic optometry does not include the use of surgery or laser surgery except as specifically authorized by this Act. Makes a conforming change. (11) Defines "surgery." SECTION 2. Amends Section 1.03, Texas Optometry Act (Article 4552-1.03, V.T.C.S.), by amending Subsections (b) and (d)-(g) and adding Subsections (h)-(r), as follows: (b) Authorizes a therapeutic optometrist to perform, as well as administer or prescribe, ophthalmic procedures and appropriate medications. Deletes over-the-counter oral medications and ocular pharmaceutical agents other than antiviral agents and antiglaucoma agents from a list of medications a therapeutic optometrist is allowed to prescribe. Authorizes a therapeutic optometrist to administer such devices, procedures, and appropriate medications by oral or parenteral means, in accordance with this section, in addition to topical means, for the purpose of diagnosing and treating visual defects, abnormal conditions, and diseases of the human vision system. Prohibits a therapeutic optometrist from performing surgery or laser surgery. Deletes existing language authorizing a therapeutic optometrist to remove superficial foreign matter and eyelashes from the external eye or adnexa. Deletes existing language relating to the conditions of use of a topical steroid. Makes a conforming change. (d) Requires the Texas Board of Health (board) to adopt rules or the recommendations submitted under Section 1.03A of this Act setting forth additional classifications of pharmaceutical agents, rather than the specific pharmaceutical agents, that may be used in the practice of therapeutic optometry. Makes a nonsubstantive change. (e) Redesignated from Subsection (g). Makes an optometric glaucoma specialist subject to the same standard of professional care and judgment as a person practicing as an ophthalmologist. Deletes existing text regarding the creation of a five-member advisory committee created to assist the board in determining the specific pharmaceutical agents which may be used by therapeutic optometrists, as well as matters regarding committee appointments. Deletes existing text regarding the specific composition of the advisory committee. (f) Authorizes a therapeutic optometrist to prescribe oral medications in certain classifications of oral pharmaceuticals. Sets forth a list of these pharmaceuticals. (g) Authorizes a therapeutic optometrist to independently administer oral carbonic anhydrase inhibitors for emergency purposes only and requires the optometrist to refer a patient to an ophthalmologist. (h) Authorizes a therapeutic optometrist to inject appropriate medication for a patient who has an anaphylactic reaction to counteract the anaphylaxis. Requires the optometrist to immediately refer the patient to physician. (i) Requires a therapeutic optometrist to engage in consultation with an ophthalmologist to develop an individual treatment plan approved by both caretakers no later than the 30th day after the initial diagnosis of glaucoma. Requires the parameters of the consultation to be at the discretion of the ophthalmologist, but must at least include confirmation of the diagnosis and a plan for comanagement of the patient, including periodic review of the patient's progress. (j) Requires a therapeutic optometrist required to engage in the comanagement consultation with an ophthalmologist to inform the patient diagnosed with glaucoma that the therapeutic optometrist is required to have the diagnosis confirmed and comanaged with an ophthalmologist or the patient's choosing, or if the patient does not choose an ophthalmologist, an ophthalmologist practicing in the geographic area in which the therapeutic optometrist practices. (k) Requires a therapeutic optometrist to refer a patient to an ophthalmologist based under certain conditions with respect to the patient and the patient's diagnosis. (l) Requires a therapeutic optometrist who refers a patient to a physician or specialist to inform the patient that the patient may go to any physician or specialist the patient chooses. Provides that this subsection does not prevent a therapeutic optometrist from recommending a physician or specialist. (m) Requires a therapeutic optometrist, upon diagnosing glaucoma, to set a target pressure that is no more than 80 percent of the initial intraocular pressure. Provides that the patient's glaucoma is considered to not be appropriately responding to treatment if the patient fails to achieve the target pressure within an appropriate time. (n) Provides that before a therapeutic optometrist prescribes a beta blocker, the optometrist must take a complete case history of the patient and determine whether the patient has had a physical examination within the 180 days preceding the date of taking the history. Requires the therapeutic optometrist to refer the patient to a physician for a physical examination prior to initiating beta blocker therapy, if the patient has not had a physical examination or if the patient has had a history of congestive heart failure, bradycardia, heart block, asthma, or chronic obstructive pulmonary disease. (o) Authorizes a therapeutic optometrist who diagnoses acute closed angle glaucoma to initiate appropriate emergency treatment for a patient, but requires the optometrist to refer the patient to a physician in a timely manner. (p) Authorizes a physician to charge a reasonable consultation fee for a consultation given as provided by this section. (q) Requires a physician to whom a patient is referred under this section to forward to the referring therapeutic optometrist, no later than the 30th day after seeing the patient, a written report on the results of the referral. Requires the therapeutic optometrist to maintain the report in the patient's records. Requires a physician who, for a medically appropriate reason, does not return a patient to the therapeutic optometrist who referred the patient, to state in the physician's report to the optometrist the specific medical reason for failing to return the patient. (r) Prohibits a therapeutic optometrist from administering or prescribing an oral or parenteral medication or treating glaucoma without holding a certificate issued by the board. Requires a therapeutic optometrist certified under this subsection to be known as an optometric glaucoma specialist. Provides that in order to obtain a certificate, a therapeutic optometrist must complete certain review courses and pass an examination as required under Section 1.03A of this Act. SECTION 3. Amends Article 1, Texas Optometry Act (Article 4552-1.01, et. seq., V.T.C.S.), by adding Section 1.03A, as follows: Sec. 1.03A. OPTOMETRIC HEALTH CARE ADVISORY COMMITTEE. (a) Provides that the Optometric Health Care Advisory Committee (committee) to consist of six members. Sets for the composition of the committee. (b) Provides that committee members serve staggered two-year terms, with terms of half of the members expiring September 1 each year. (c) Requires the committee to make recommendations with respect to: _education and clinical training necessary for certification as an optometric glaucoma specialist; _parameters of care for treatment of certain ocular diseases and conditions; and _classes of pharmaceuticals that may be effectively used by certified optometric glaucoma specialists. (d) Provides that a person is ineligible for appointment as a pharmacologist member of the committee if the person is licensed as a therapeutic optometrist or ophthalmologist or is related within the second degree by affinity or consanguinity, as determined under Chapter 573 (Degrees of Relationships; Nepotism Prohibitions), Government Code, to a person who is licensed as a therapeutic optometrist or ophthalmologist. (e) Requires the committee, in making recommendations, to consider patient safety, patient costs, the effect on a patient's access to health care, patient convenience, and any added efficiencies to the health care delivery system the decision may involve. (f) Provides that the board and the Texas State Board of Medical Examiners must adopt recommendations made by the committee before they become law. Provides that if either board fails to adopt a recommendation of the committee, that board must articulate a sound, scientific reason for the failure to adopt. (g) Provides that unless continued in existence by legislative act, the committee is abolished and this section expires September 1, 2005. SECTION 4. Effective date: September 1, 1999. Requires the initial committee members to be appointed no later than October 1, 1999 and sets forth the composition of the three appointments which expire September 1, 2000, and the three appointments that expire September 1, 2001. SECTION 5. Emergency clause. COMPARISON OF ORIGINAL TO SUBSTITUTE C.S.H.B. 1051 differs from the original bill as follows: SECTION 1. The substitute modifies Section 1.02, Article 4552-1.02, V.T.C.S. (Texas Optometry Act) of the original, by adding Subdivision 11 to include the definition of "surgery," rather than amending Subdivision 8 to expand the definition of "adnexa." SECTION 2. The substitute modifies Section 1.03, Article 4552-1.03, V.T.C.S. (Texas Optometry Act) of the original by amending Subsections (b) and (d)-(g) and adding Subsections (h)-(r), as follows: (b) The substitute adds a provision which prohibits a therapeutic optometrist from performing surgery or laser surgery and makes a conforming change. (d) The substitute gives the Texas Board of Health (board) the option to adopt recommendations submitted under Section 1.03A of this Act, or rules, setting forth additional classifications of pharmaceutical agents therapeutic optometrists are authorized to use in their practice. The board is required to adopt either the rules or the recommendations. (e) The substitute includes an optometric glaucoma specialist, in addition to a therapeutic optometrist, as a person subject to the same standard of professional care and judgment as a person practicing as an ophthalmologist. (f) The substitute adds this new subsection to authorize a therapeutic optometrist to prescribe certain oral medications and sets forth the classifications of these pharmaceuticals. The original authorized the optometrist to perform certain medical procedures if they are performed without the use of lasers. (g) The substitute add this new subsection to authorize a therapeutic optometrist to independently administer oral carbonic anhydrase inhibitors under certain conditions. The original required the optometrist to be certified by the board in order to treat glaucoma, and set forth conditions under which the optometrist could treat glaucoma. The following Subsections (h)-(r) are new text added to this section, as follows: (h) Authorizes a therapeutic optometrist to inject appropriate medication for a patient who has an anaphylactic reaction to counteract the anaphylaxis. Requires the optometrist to immediately refer the patient to physician. (i) Requires a therapeutic optometrist to engage in consultation with an ophthalmologist to develop an individual treatment plan approved by both caretakers no later than the 30th day after the initial diagnosis of glaucoma. Requires the parameters of the consultation to be at the discretion of the ophthalmologist, but must at least include confirmation of the diagnosis and a plan for comanagement of the patient, including periodic review of the patient's progress. (j) Requires a therapeutic optometrist required to engage in the comanagement consultation with an ophthalmologist to inform the patient diagnosed with glaucoma that the therapeutic optometrist is required to have the diagnosis confirmed and comanaged with an ophthalmologist or the patient's choosing, or if the patient does not choose an ophthalmologist, an ophthalmologist practicing in the geographic area in which the therapeutic optometrist practices. (k) Requires a therapeutic optometrist to refer a patient to an ophthalmologist based under certain conditions with respect to the patient and the patient's diagnosis. (l) Requires a therapeutic optometrist who refers a patient to a physician or specialist to inform the patient that the patient may go to any physician or specialist the patient chooses. Provides that this subsection does not prevent a therapeutic optometrist from recommending a physician or specialist. (m) Requires a therapeutic optometrist, upon diagnosing glaucoma, to set a target pressure that is no more than 80 percent of the initial intraocular pressure. Provides that the patient's glaucoma is considered to not be appropriately responding to treatment if the patient fails to achieve the target pressure within an appropriate time. (n) Provides that before a therapeutic optometrist prescribes a beta blocker, the optometrist must take a complete case history of the patient and determine whether the patient has had a physical examination within the 180 days preceding the date of taking the history. Requires the therapeutic optometrist to refer the patient to a physician for a physical examination prior to initiating beta blocker therapy, if the patient has not had a physical examination or if the patient has had a history of congestive heart failure, bradycardia, heart block, asthma, or chronic obstructive pulmonary disease. (o) Authorizes a therapeutic optometrist who diagnoses acute closed angle glaucoma to initiate appropriate emergency treatment for a patient, but requires the optometrist to refer the patient to a physician in a timely manner. (p) Authorizes a physician to charge a reasonable consultation fee for a consultation given as provided by this section. (q) Requires a physician to whom a patient is referred under this section to forward to the referring therapeutic optometrist, no later than the 30th day after seeing the patient, a written report on the results of the referral. Requires the therapeutic optometrist to maintain the report in the patient's records. Requires a physician who, for a medically appropriate reason, does not return a patient to the therapeutic optometrist who referred the patient, to state in the physician's report to the optometrist the specific medical reason for failing to return the patient. (r) Prohibits a therapeutic optometrist from administering or prescribing an oral or parenteral medication or treating glaucoma without holding a certificate issued by the board. Requires a therapeutic optometrist certified under this subsection to be known as an optometric glaucoma specialist. Provides that in order to obtain a certificate, a therapeutic optometrist must complete certain review courses and pass an examination as required under Section 1.03A of this Act. SECTION 3. The substitute modifies the original by amending Article 1, Article 4552-1.01 et seq. (Texas Optometry Act), by adding Section 1.03A, rather than Section 1.04. The original bill added Section 1.04 (Study Regarding Laser Surgery), which provided for a joint study between the University of Houston and the University of Texas Health Science Center regarding the safety, efficacy, and cost-effectiveness of laser surgery performed by therapeutic optometrists. The substitute adds Section 1.03A (Optometric Health Care Advisory Committee), which establishes the Optometric Health Care Advisory Committee (committee), sets forth its composition, and requires the committee to make certain recommendations. Additionally, the new section sets forth provisions regarding who may serve as a committee member, recommendation methodology, and the process by which a recommendation becomes law. SECTION 4. The substitute adds this new section, establishing an effective date of September 1, 1999, requiring the committee to be appointed no later than October 1, 1999, and providing that certain committee members' terms will expire on certain dates. SECTION 5 (short emergency clause) of the substitute is redesignated from SECTION 4 (long emergency clause) of the original.