Confrontation Fields (as required).

Diagnosis.

No. 102 case work up. Consultation and prescribing (nonpresbyope) 50 units. Analysis of visual needs.

Determination of required treatment/or.

Programming treatment/or

Writing prescription.

Prescribing responsibility/or.

Post-prescription visit.

All other services in accordance with AOA Relative Service Value Schedule.

(The following supplemental statement was received by the committee:)

SUPPLEMENTAL STATEMENT BY THE AMERICAN OPTOMETRIC ASSOCIATION

INTRODUCTION

Mr. Chairman and members of the Committee: the American Optometric Association appreciates the courtesy of the Chair in allowing submission of this brief statement and further recommendations, as a supplement to our testimony by Dr. V. Eugene McCrary before the Committee on October 30.

CONTENTS OF STATEMENT

This statement will deal with matters involving the blind under programs established by Titles II, X, and XVI of the Social Security Act; with the maternal and child health benefits programs authorized by Title V; and with some aspects of the Title XIX Medicaid program.

PROGRAMS FOR THE BLIND UNDER TITLES II, X, AND XVI

As the American Optometric Association's witness stated before the Committee on Ways and Means, the Congress has recognized optometrists as professionally competent to determine the eligibility of an individual for benefits under three different Titles of the Social Security Act.

These are: Aid to the Blind under Title X; Grants to States for Aid to the Aged, Blind or Disabled under Title XVI; and Title XIX, Medicaid.

OPTOMETRISTS SERVE THE BLIND AND PARTIALLY BLIND

The profession of optometry and its practitioners are primarily concerned with the general visual health of the American public, through preservation and enhancement of functional vision. However, in the course of providing their services to the public, optometrists see a great many individuals of all ages who have lost all or part of their capacity of vision, or who are at some point down the scale in the deterioration of their vision. Those who are blind or who have minimal residual vision are still in a category of concern to the optometrist. The optometrist in mnay cases designs and prescribes special low-vision aids for the partially sighted which are sufficient to improve residual vision and restore some degree of function, thereby increasing the patient's visual comfort and overall efficiency. Optometrists also occasionally fit artificial eyes.

AOA SUPPORTS RECOMMENDATIONS OF ORGANIZATIONS FOR THE BLIND Earlier in these hearings on Social Security, the Committee heard testimony by a representative of an organization for the blind, interested in obtaining the best possible services and benefits for individuals who are totally blind or legally blind. The witness addressed his comments only to H.R. 3782. and urged that Title II be amended to liberalize conditions governing eligibility of blind persons to receive disability insurance benefits. The American Optometric Association endorses that position and H.R. 3782. In addition, we urge this Committee to take similar action with respect to benefits for the blind under Title X and Title XVI.

We do not have specific amendments to recommend at this time, but would like the record to show our support for adoption of amendments which would

serve to make the maximum possible benefits fully and readily available to those eligible to receive them.

TITLE V

President Nixon in a recent speech cited figures which show that some 10,000,000 children of school age are in need of vision care. We believe that certain amendments should be made to Title V to insure that optometric services will be available to all beneficiaries under this Title and that optometrists may serve as participating members of health care teams. We also believe that vision care programs could be enhanced and enriched by the full cooperation and guidance of a school or college of optometry. Artificial and prejudicial barriers to full optometric participation and utilization must be removed if we are to begin to meet the visual needs of this nation's youth.

INEQUITIES INHERENT IN LANGUAGE OF TITLE XIX

Thirty-one of the forty-two jurisdictions which have initiated Medicaid programs under the provisions of Title XIX have included optometric services among their benefits. This has added great strength to these programs at minimum cost.

The American Optometric Association is concerned that administrative regulations and interpretation of certain sections of Title XIX might create reluctance on the part of optometrists to become involved as providers of vision care services.

Reluctance on the part of optometrists could result from inequities inherent in the language of Title XIX and administrative regulations based upon that Title. We want optometrists to fully and equitably participate in this FederalState partnership program.

EYE CARE PRACTITIONERS SHOULD BE TREATED EQUALLY

All vision care specialists should receive equal treatment under Medicaid. It is unjust to permit a situation where a physician may perform services and be paid under terms of category 5, Section 1905 (a), Title XIX, for the same or equivalent services for which the optometrist is not reimbursed. This could happen if the State plan did not provide explicitly for optometric vision care services by accepting as part of its Plan either category 6 or category 12 of Section 1905 (a).

The American Optometric Association believes the fees for services performed by an optometrist should be equal to the fees paid physicians for identical services. This would apply to all aspects of vision care except those procedures physicians perform in the line of medication and surgery, areas in which they are uniquely trained by virtue of their medical degree. In too many instances, the physician's "usual and customary" fees, even with a "fee ceiling", based on reasonableness for the specific geographic area, exceed the fees authorized (usually a negotiated flat fee) for optometrists performing the same services. We hasten to point out, however, that in some States optometrists and physicians skilled in diseases of the eye are being treated equally, with both types of practitioners abiding by the same fee structures and the same authorization procedures. We feel the whole subject area should be more closely spelled out through amendments to Title XIX. An unhealthy discriminatory situation exists here which deserves attention and correction by the Ways and Means Committee.

CODE OF ETHICS SHOULD BE USED AS BASIS FOR QUALIFICATION

The quality of vision care provided under Medicaid programs is closely tied to the professional standards and behavior of those providing the services. The American Optometric Association applauds those jurisdictions-notably the District of Columbia-which have accepted the American Optometric Association Code of Ethics and Standards of Practice as the yardstick by which professional optometric conduct is measured. We encourage extension to all jurisdictions of this method of qualifying optometrists as providers of vision care services under Title XIX. We believe standards must be established and monitored for professional services as well as materials consumed.

NEED TO CLARIFY "COMPREHENSIVE CARE" PROVISIONS EFFECTIVE IN 1977

Looking toward the date in 1977 by which every State must have an ongoing program of "comprehensive health care services," we believe it is time now to amend Title XIX to more clearly spell out vision care and optometric services provisions in the following subsections of Section 1905(a): (1) inpatient hospital services; (4) visual care under skilled nursing home services; (6) scope and more definitive description of "remedial care"; clarification of "clinic services" as that term relates to private and public optometric centers and the optometry clinics of universities and colleges under item (9); a clearer definition of "prosthetic devices" under item (12); clarification of "other diagnostic, screening, preventative and rehabilitative services" under item (13); and spelling out of types of services under item (15) now defined as "any other type of remedial care recognized under the State law, specified by the Secretary."

BROADENING SCOPE OF MEDICAID BENEFITS THROUGH TERMINOLOGY CHANGE

To assure that all health care professionals licensed to independently examine and prescribe for correction of human deficiencies are permitted to take their rightful places in the provision of services under Medicaid, the American Optometric Association urges that the term "medical" be replaced by the word "health" in all references within Title XIX except those specific conditions which must clearly be handled only by a physician. Only in this way may the beneficiaries of Medicaid have assurance of availability of the full range of services envisioned by the Congress when it adopted Title XIX. Such a change in terminology would reflect the "team concept" of health care and would provide the framework for "complete comprehensive health care" as directed by Public Law 89-97 and amendments thereto.

AMENDMENTS RECOMMENDED

Title II.-Should be amended by adoption of language proposed in H.R. 3782. Title V-Amend by deleting the parenthesis following the word "dentistry” on line 10, section 509 (shown on page 206 of "Compilation of Social Security Laws, Volume 1") and by inserting the following: "or a school of optometry)." Further amend Title V by adding the word "optometric" after the word "medical" on line 29, Section 509, also on page 206 of the Compilation.

Title XIX.-Section 1950 (a) should be amended by adoption of appropriate language to correct those points discussed on pages 3, 4, 5 and 6 of this statement. Dr. MCCRARY. Thank you very much, Mr. Chairman. Mr. BURKE. Thank you very much for your testimony. Our next witnesses are Dr. Jaeckle and Dr. Gordon.

STATEMENT OF DR. CHARLES E. JAECKLE, VICE PRESIDENT ON SOCIOMEDICAL AFFAIRS, AMERICAN ASSOCIATION FOR OPHTHALMOLOGY; ACCOMPANIED BY DR. DAN M. GORDON, MEMBER, COMMITTEE ON AGING

Dr. JAECKLE. Mr. Chairman and members of the committee, my name is Charles E. Jaeckle. I am a physician, a doctor of medicine, residing and practicing in Defiance, Ohio. I confine my practice to ophthalmology. I am consultant to the U.S. Public Health Service for the Ophthalmology Manpower Survey. With Prof. Dan M. Gordon, member of the Committee on Aging of the American Association of Ophthalmology, I am here on behalf of the association, of which I am a vice president and chairman of the Committee on Medical Services and Prepayment Plans.

Ophthalmology is that medical specialty which is concerned with all diseases and all conditions of the eye and of the visual system as a whole-the eyes, the related structures, the ocular mucles, and the nerve pathways to and from the brain. We are here to support the present

provisions of title XVIII of the Social Security Act as they apply to patients with ocular or visual problems, and oppose the change of those provisions as is proposed by H.R. 13155 and H.R. 2367.

H.R. 13155 states its purpose to amend the act "to include eye care among the benefits." We wish to point out that the present law now provides almost 100 percent coverage for eye care. No different principle applies to the care of the patient with ocular symptoms than to the care of any other patient. The patient with an eye problem requires medical examination and diagnosis. Ocular manifestations cannot be evaluated as isolated disorders of a particular organ. The eye and the visual system must be evaluated in the light of the patient's entire medical status.

Medical diagnosis and the treatment of disease and injury can only be performed legally by a physician licensed to practice medicine and surgery. The eye patient, like all other patients, needs the services. of physicians.

The Social Security Act now provides coverage for those services. It is important that the Congress understand the nature of eye care and the manner of its provision.

The conditions and diseases of the eye are bound up with conditions and diseases of other parts of the body. General disease is an important cause of blindness.

All physicians are concerned with the eye. The physicians chiefly responsible for treating eye conditions are the 68,000 family physicians, 42,000 internists, 17,000 pediatricians, and 10,000 ophthalmologists. One-third of all eye medications are prescribed by physicians who are not specializing in ophthalmology. The major portion of the responsibility for the provision of eye care, however, falls on the ophthalmologist, supported by an estimated 20,000 ophthalmic medical assistants.

Whatever the necessary treatment may prove to be-local or general medications, lenses, surgery-the care of the eye patient begins with medical examination and diagnosis-with examination of a patient, not an organ or an optical system, with diagnosis of whatever conditions the patient has, and with the interpretation of the relation of all abnormalities present-whether inflammation, refractive error, diabetes, glaucoma, or brain tumor-to each other, to the patient's complaints, and to his needs. When the condition requires it the ophthalmologist will, in the course of and as an integral part of diagnostic examination, perform a determination of the refractive state of the eye. The present medicare law covers all of these services except "procedures performed for the determination of the refractive state." The law covers ophthalmic surgery, except cosmetic surgery, and it covers the supply of the artificial eye prosthesis and of the special spectacles required by the patient who has had cataract surgery-the prosthesis for aphakia-when they are prescribed by a physician. They may be supplied, I may add, by anyone who can legally perform that service. H.R. 13155 would add coverage for other eyeglasses.

If the Congress in its wisdom where to include coverage for eyeglasses, the decision should be taken with full realization of the cost. Perhaps one-half of the approximately 20 million insured would seek examination including determination of the refractive state in a year. The added cost of the refractive portion of that examination in the physician's office could be of the order of $40 million, of which medicare

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would pay $32 million and the patients, $8 million. However, if eyeglasses were covered under medicare, the cost of medicare would rise sharply.

Virtually everyone over 65 years of age requires eyeglasses, almost invariably bifocal or trifocal lenses. Eyeglasses break. The refractive state changes. Eyeglasses must be replaced. No studies are available on the percentage of patients over 65 who obtain eyeglasses in a given year, but on the basis of available information it is estimated at about 50 percent. If one-half of the persons insured under medicare are examined and half of these utilize this proposed eyeglass coverage in a year, at an estimated average cost of $50 per patient for multifocal eyeglasses with safety lenses, the estimated cost of eyeglasses in the first 2 years would be $2 billion, of which medicare would pay 80 percent. This does not include the additional $40 million estimated above for physician services. This is that portion of the examination which presently is not paid for. If the refractive services were provided independently of the physician, the cost would be much higher. The benefits of insurance are gained substantially by spreading the cost over a population not all of whom will require reimbursement and by spreading the cost over a prolonged period of time. The need of the elderly for eyeglasses being virtually universal and the need being regularly recurrent, these customary insurance benefits are not derived. When such services are insured, administrative costs are added to the basic costs which none can escape.

If the elderly have virtually universal need for eyeglasses, they also have in most instances some evidence of ocular disease or ocular evidence of systematic disease. Dr. Dan. M. Gordon will present data on this subject.

Section 4 of H.R. 13155 and the provisions of H.R. 2367 would change the definition of "physician" to make that word include an additional group of nonphysicians, persons not licensed to practice medicine and surgery, who do prescribe eyeglasses. Thus coverage would be provided for nonmedical procedures for the purpose of prescribing eyeglasses, in addition to the existing coverage for diagnostic and treatment services of physicians.

Were the Congress desirous of providing coverage for the services of nonphysicians, this should be specifically stated, rather than introduce a confusing and artificial definition of the word "physician.” Such a dual coverage, however, would appear to offer a substitute for the services of the physician.

The then Secretary of Heath, Education, and Welfare, Mr. Wilbur Cohen, reported to the Congress on December 28, 1968, that such provision "would, to some extent, compromise the quality of care provided by medicare."

We suggest that even greater caution should be exercised in undertaking coverage for eyeglasses than coverage for prescription drugs. We recommend that the committee not approve H.R. 2367 and section of H.R. 13155 because their enactment in their present form would offer a new and lower quality of care.

We recommend that the committee not approve the remaining sections of H.R. 13155 unless it is indeed the intent of Congress that the Medicare program assume the enormous financial burden that the provision of eyeglasses would entail.