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Doctor's letter in ''eyeball wars'' offers window into special interest fights

A day after the Florida Medical Association agreed to trade its decades-long feud with optometrists over prescribing drugs for long-sought lawsuit protections, the head of the organization sent out a letter explaining the compromise to his colleagues.

The letter, by Dr. Miguel A. Machado, a St. Augustine neurosurgeon, blamed his ophthalmologist brethren for being outgunned and offered a rare and candid observation about the power of campaign cash.

“Strength in the legislative and political arenas is measured by relationships and political resources,’’ Machado wrote. “In this case, the optometrists have far more political strength than the ophthalmologists. The optometrists have raised $668,499 for their political action committee during the past year compared to $46,842 by the ophthalmologists.”

The proposal would make it harder to prove that doctors are negligent for not performing certain diagnostic tests on patients. It would also allow doctors and other health care providers to ask patients to sign agreements to allow any future malpractice claims go to arbitration instead of jury trials in an attempt to limit damages.

Here is Machado’s letter:

February 10, 2012
A letter from Miguel A. Machado, M.D.
President, Florida Medical Association

Dear colleagues:

For the past year, we have known that the optometrists have made significant progress in their efforts to persuade state lawmakers to support legislation giving them the authority to prescribe a limited number of oral medications. We have been working on this issue for many years, utilizing a great deal of political capital. We've also been swimming against the tide, as 46 other states have already passed legislation allowing optometrists to have limited prescribing authority for oral medications. Our organization's focus on this single issue dealing with eye care has come at the expense of other matters that affect all physicians. Unfortunately, we have reached the point where even our good friends in the Legislature have informed us that they can no longer hold back the tide on this issue. Legislators who have a long record of supporting organized medicine tell us that the intransigent position that we have taken on the eye care issue is eroding support for other key issues on our legislative agenda.
The following is a direct quote from Senate President-Designate Don Gaetz. "This battle uses up so much bandwidth in health care, so much oxygen in the room, that we find ourselves unable to deal with more serious issues in health care because we are consumed with the eyeball wars." The message was clear: Legislators have grown tired of dealing with what they perceive to be a turf war in the area of eye care.
In November of last year, I met with the leadership of the Florida Society of Ophthalmology and informed them of this situation. I made it clear to them that they needed to dramatically increase their legislative and political involvement or else they were at risk of losing their battle with the optometrists. I also told them that they had a problem within their own ranks with many ophthalmologists supporting the optometrists' position, and that division within ophthalmology confuses legislators and makes them believe that this issue is nothing more than an industry "food fight."
Last week, influential members of the Florida Legislature requested that the FMA sit down with the optometrists to see if a compromise could be worked out. A commitment was also made that any compromise reached on the eye care issue would be placed in a legislative package that also included significant medical liability reforms that would help all physicians. As President of the FMA, I felt that it was my obligation to honor this reasonable request, so I asked FMA Council on Legislation Chairman, Neal Dunn, M.D., to engage in a dialogue with the optometrists.
After several days of around-the-clock negotiating, we reached a compromise that in my judgment was an important step forward in resolving this issue. The final package included several provisions that the FMA insisted on, including: 

* A definition of surgery (with a strict prohibition on surgery by optometrists);

* A requirement that optometrists report any adverse incidents related to prescribing a limited number of oral medications;

* A requirement that optometrists complete a pharmacology certification process jointly developed and administered by the FMA and the FOA; and

* New requirements that optometrists refer any patients who experience progressive glaucoma due to failed pharmaceutical intervention to an ophthalmologist in a timely manner. 
In addition, the compromise requires co-management of post-operative care to be conducted pursuant to an established protocol that governs the relationship between the operating surgeon and the optometrist, and includes a provision that requires the patient to consent in writing to the co-management relationship and to be informed that either the physician or the optometrist will be available for emergency care throughout the postoperative period. The compromise also prohibits an optometrist from administering or prescribing Schedule I or Schedule II pharmaceutical agents.
 More importantly, the final legislative product also includes three major medical liability reforms that the FMA has long advocated, including:

* A provision allowing a prospective defendant or his or her legal representative to interview the claimant's treating health care providers without the presence of the claimant or the claimant's legal representative;

* A provision that would increase the burden of proof in medical liability cases involving diagnostic testing to a "clear and convincing" standard; and

* A provision that allows physicians and patients to enter into an arbitration agreement that includes a limitation on damages.
Prior to the beginning of the session, the FMA sent a survey to our members seeking their views on state legislative issues. The results were very informative and have been used to guide us as we prioritize the many issues that we deal with during the legislative session. The number-one ranked issue by a large margin was passing medical liability reform. Opposing scope-of-practice expansion of allied health professionals ranked fourth out of five. The following are the results of that survey:

1.    Passing medical liability reform legislation
2.    Reducing burdensome regulations
3.    Passing managed care reform legislation
4.    Opposing scope-of-practice expansion of allied health professionals
5.    Medicaid reform
Furthermore, when we asked our members to rank scope-of-practice issues in order of priority, we received the following result:

1.    Oppose licensing of naturopaths
2.    Oppose ARNP prescribing of narcotics
3.    Oppose psychologists prescribing psychotropic drugs
4.    Oppose optometrists prescribing oral medication
5.    Oppose pharmacists administering shingles and pneumonia vaccines
I hope everyone understands that this is a difficult process. In a perfect world, we would never have to compromise on any issue. In the legislative process, all of us would prefer to be idealistic; however, we have to deal with reality. The reality is that failure by one specialty to fully engage in the political process has adversely affected our position. Strength in the legislative and political arenas is measured by relationships and political resources. In this case, the optometrists have far more political strength than the ophthalmologists. The optometrists have raised $668,499 for their political action committee during the past year compared to $46,842 by the ophthalmologists. In addition, there is a split within the ranks of ophthalmology, with more ophthalmologists sending letters to legislators in support of optometrists prescribing oral medications than from ophthalmologists sending letters in opposition.
The FMA will continue to do everything that we can under trying circumstances to represent the interests of all physicians. However, when one specialty is politically disengaged and inconsistent in how its members support or oppose an issue, it is unreasonable to expect the FMA, which represents all physicians on a multitude of issues, to spend a disproportionate amount of resources and political capital on that issue. The battles going forward are not going to be any easier. In fact, much more is at stake and we will focus our energy on fighting proposals that would harm the viability of medical practices in Florida.
It is important that we all understand how the legislative process works. It is also important to know all of the background information that goes into making these tough decisions during the legislative session. The clear message is that we must have a strong political presence in Tallahassee. If you would like to be more engaged in the political process, please join the FMA PAC.


Miguel A. Machado, M.D.
President, Florida Medical Association