HBA-MPM H.B. 1051 76(R)BILL ANALYSIS Office of House Bill AnalysisH.B. 1051 By: Brimer Public Health 7/21/1999 Enrolled 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 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 DM152 states that the use of certain drug classifications to regulate practice by therapeutic optometrists is appropriate. 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, Article 4552-1.02, V.T.C.S. (Texas Optometry Act), 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. Makes a conforming change. (11) Defines "surgery." SECTION 2. Amends Section 1.03, Article 4552-1.03, V.T.C.S. (Texas Optometry Act), 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 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. Authorizes a therapeutic optometrist to additionally administer medication parenterally for the purposes and the manner set out in Subsection (h). 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 setting forth the classifications of pharmaceutical agents therapeutic optometrists are authorized to use as authorized by this Act. Authorizes additional classifications of medications as authorized by Section 1.03A(c)(3), V.T.C.S., to only be approved as provided in that section. 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 and how many days they may be supplied. (g) Authorizes a therapeutic optometrist to independently administer oral carbonic anhydrase inhibitors for emergency purposes only and requires the optometrist to immediately 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 of 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 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 certain medical conditions. (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 first 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, Article 4552-1.01, et. seq., V.T.C.S. (Texas Optometry Act), 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) consists 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 that expire September 1, 2000, and the three appointments that expire September 1, 2001. SECTION 5. Emergency clause.