Passage of Kentucky’s Optometry Bill into Law.
Gov. Beshear signed Kentucky’s optometry practice expansion bill into law yesterday. Thus ends the remarkable passage of Senate Bill 110 that in one fell swoop transforms the practice of optometry in Kentucky from correcting vision with lenses, to the practice of treating eye disease with medicine and surgery.
Much can be said about many aspects of this episode. For example, the erosion of the monopoly of MDs to practice medicine. However the special privilege of caring for the sick has been drifting away from us physicians for some time. Some of these sharings are not all bad: you don’t have to be a brain surgeon to manage an immunization schedule or treat a sore throat. I predict that we physicians will continue to share the responsibility of treating illness and that the pace of the sharing will increase dramatically with the inclusion of the concepts of wellness and disease prevention into our financial structure of treating illness. (There is no limit to the demand for wellness, disease prevention, or screening by the public; nor limit to the willingness of healthcare workers of all levels of competence to provide.) This optometry bill was not the only scope of practice legislation before this General Assembly. Why have not the others passed as well? Is this optometry bill a crack in the dam? Did we physicians do something to bring this on ourselves?
Changes in scope of practice are not occurring in isolation from other major shifts in the landscape of healthcare delivery. I am informed that the considerable majority of primary care physicians in Louisville are now direct employees of hospitals. A large and increasing fraction of specialists are also hospital employees. I predict this trend will do more to change the practice of medicine than the sharing of professional responsibilities with optometrists, or nurses for that matter. What is happening is that systems of medical care are largely replacing Mom and Doc operations. That’s probably for the better. Even in a given specialty, there is too much to know, too much to do, and too much efficiency required. What is most important is that the primary obligation of the physician to their patient retains its primacy. That is what we are most at risk to losing. That may not be for the good.
What you do need most of the training of a brain surgeon for, is to pick out those who have significant disease from those who do not, or to supervise the diagnosis and care of patients for whom things are not going well. I am not worried that we physicians will ever be out of a job. I am sure we will talk about such issues again in the future.
Senate Bill 110 was about more than sharing. It was all about money: its driving force in determining who does what medically and how often; and its driving force in the passage of legislation and the electing those who make it. Here I am not so sanguine. This was a bad affair. Jefferson County Clerk Bobby Holsclaw has called for an investigation of the circumstances surrounding the amazingly rapid passage of SB 110. I have heard the matter compared to the historic BOPTROT scandal in the Kentucky legislature for which people went to jail for bribery in the 1990s. That Kentucky legislators were willing to sell their votes is a matter of public record. Ms. Holsclaw is herself a candidate for governor so it is not unexpected that she would seek to highlight the possibility of corruption in current government. I, however, am not seeking public office but I do seek to highlight the systematic and institutional incorporation of potential conflicts of interest into our current system of campaign finance. I was a professional lobbyist for over five years. I’ve talked to legislators, lobbyists, and the people who hire them. It beggars reality to deny that legislation, regulation, earmarks, and other political favors are regularly bought and paid for. Of course sitting legislators and others with a dog in these fights will deny that money has any effect on their decisions. But as we say in Washington DC, “That dog won’t hunt.” Even if there is no quid pro quo involved, the appearance of potential conflict of interest is equally damaging to our social fabric. That is what is so bad about this affair: it is too easy to believe that something inappropriate happened.
Peter Hasselbacher, MD?
25 Feb, 2011