• Opinion

    The VA Federal Supremacy Project and Scope of Practice

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet


    Most ophthalmologists receive part of their training, as either a student or a resident, at a VA facility. The U.S. Department of Veterans Affairs currently pro­vides 320 ophthalmology residency positions, and 107 of the 125 U.S. medical schools are affiliated with a VA hospital. More than 1,200 ophthalmologists treat our veterans and teach residents there. Almost all of us can tell a story about our time at the VA and have experienced firsthand how important it is to provide superb medical care to our 9 mil­lion veterans. Now, all of ophthalmology, and our patients, could be impacted by the Federal Supremacy Project, a VA endeavor to develop national standards of practice.

    Why does this matter to ophthalmologists who don’t work at the VA and to patients who aren’t veterans?

    Because the VA is the largest integrated U.S. health care system, its policies have wide impact. In 2004 the VA estab­lished a policy that laser eye surgery could only be done by an ophthalmologist; it has reaffirmed that position three times since. Even in states that allow optometrists to perform laser eye surgery, only ophthalmologists perform the procedures at VA facilities. However, that standard is under threat.

    The Federal Supremacy Project is developing national standards of practice for 50 health care occupations including registered nurses, audiologists, physical therapists, podiatrists, dentists, dance movement therapists, and optometrists. (There’s even a category for “Physicians,” which presumably will create a national standard for all MDs.) These standards are described as “a standardized set of services that all health care profes­sionals in a given occupation can perform regardless of what is permitted by a state license, certification, or registration.”1

    Each category of the 50 health care professionals has its own internal work group to develop the standards without input from relevant stakeholders. Because the process is opaque, the Academy and the AMA are concerned that VA-employed nonphysician providers could expand their scope of practice with new standards. It’s probable that the optomet­ric work group could develop a national standard of practice that allows optometrists to perform eye laser procedures at all VA facilities. Such a national standard might supersede state scope of practice laws and longstanding VA policy that requires laser surgery to be performed by ophthalmologists.

    It’s obvious that allowing optometrists to perform laser eye surgery at VA facilities in every state would profoundly negatively impact surgical scope battles. The antic­ipated optometric argument is, why should a state limit opto­metric surgery if the federal government already allows it throughout the country?

    In the history of scope battles, the Federal Supremacy Project potentially raises the most significant issue for oph­thalmologists yet. What should ophthalmologists do? Jennifer Lindsey, director of resident education at Vanderbilt and president of the Association of Veterans Affairs Ophthalmologists, asks ophthalmol­ogists to be prepared. “Once the draft is published in the Federal Register for public comment, if there is an issue, ophthalmologists and their patients will be asked to com­ment and to write letters to their member of Congress.” As the comment window is only 60 days, it’s important that ophthalmologists are well-educated about the Federal Supremacy Project, even in its developmental state.

    Ophthalmologists care about scope battles in other states but don’t know how to help other than to donate to the Surgical Scope Fund and OphthPAC. If the Federal Suprem­acy Project results in a draft national practice standard that allows optometrists to perform eye laser surgery, every one of us can play an active role in reversing the proposed policy. Jennifer emphasizes that “we are committed to patient safety and to providing quality eye care to every person, especially our veterans.”

    Stay tuned. Be ready to write a letter if it’s needed. August, when Congress is in recess, is a good time to reach out to your representatives (see this month’s “D.C. Report”).

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    1 www.va.gov/standardsofpractice/faq.asp. Accessed May 16, 2022.