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    Thoughts From Your Colleagues

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    Myopia in the South Pacific

    I read with interest “What to Do About Myopia” (cover story, January). We have always seen more myopia in kids who spend most of their time reading, especially when there is a family histo­ry. (But this could be the result of myopia, rather than a cause.) The current increase in myopia and its progression seems to parallel the increase in the use of near vision for computer monitors, particularly with several daily hours on the small screens of personal phones. In our medical mission fieldwork throughout the South Pacific, we almost never see myopia, nor do we see personal cell phones.

    John Corboy, MD
    Mililani, Hawaii

    Scope of Practice and Midlevel Providers

    We would like to call attention to the Oct. 3, 2019, executive order by President Donald Trump: Protecting and Improving Medicare for Our Nation’s Seniors. This order received very little media coverage, and we are afraid that many ophthal­mologists are unaware of its far-reaching implications for medicine. While we support certain provisions of this order to preserve and improve Medicare, other components threat­en the quality of care that patients will receive in the future.

    Sections 5 (a), (b), and (c) of the executive order deal with midlevel providers (MLPs). These sections infer equivalency and interchangeability of the work done by physicians and MLPs. They call for the Secretary of Health & Human Services to develop regulations that would remove requirements for physician oversight of MLPs and equalize the reimbursement between physicians and nonphysicians.

    In most states, the MLP works alongside a doctor who approves each medical diagnosis or treatment. This arrangement accommodates the limited medical knowledge and training of an MLP with direct physician supervision as a safeguard against patient harm. With the proper physician oversight, the MLP can play a very helpful role in our health care system. But to remove this supervisory requirement and to assume that MLPs can function as physicians is both erroneous and dangerous.

    As a nation, we face more than a problem of access to health care. As our population ages, the complexity of medi­cal problems increases dramatically, requiring treatment that is given, or directed, by a physician. The current disparity in reimbursement between physicians and MLPs reflects this complexity in care and the significant training required to manage complicated conditions competently and safely.

    We feel that our political leaders, both at federal and state levels, are narrowly focused on expanding health care access without regard to the quality of that expanded care. Title V of President Barack Obama’s Affordable Care Act allocates tens of millions of dollars to expand and promote MLP training programs. Between 2010 and 2016, MLPs made up 78% of all new health care practitioners in primary care.1 The total number of licensed nurse practitioners in the United States is estimated to have doubled between 2007 and 2018, topping 270,000 in 2019.2 This has not resulted in healthier patients, improved access to health care (most MLPs practice in already saturated areas), or decreased overall cost.

    We must unite with our colleagues across specialties to stand against this misguided policy that puts patients, patient safety, and health care quality at risk. We must ensure that the independent practice of medicine and surgery remains the privilege of physicians.

    Elan M. Newman, MD
    San Diego, Calif.

    Heather Chang, MD
    South Pasadena, Calif.

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    1 Xue Y et al. JAMA. 2019;321(1):102-105.

    2 www.aanp.org/news-feed/nurse-practitioner-role-continues-to-grow-to-meet-primary-care-provider-shortages-and-patient-demands. Published online Jan. 28, 2019.

    Reply

    The Academy thanks Drs. Newman and Chang for highlight­ing this important issue. The Academy works closely with the American Medical Association and the physician community to oppose inappropriate expansion of the scope of practice of optometrists and other allied health providers. In response to the October 2019 executive order, the Academy and more than 100 national and state physician organizations filed comments that echo those of Dr. Newman and Dr. Chang. The Academy will continue to join with the rest of the phy­sician community to educate policymakers about the stark differences in education and training between physicians and nonphysicians; the value of supervision of allied health pro­viders, such as advanced-practice nurses; and the importance of the Academy’s surgery by surgeons efforts at all levels of government.

    Rebecca Hyder
    Academy Director of Federal Affairs
    Washington, D.C.