STATE liCENSURE 
AND

DISCIPLINE OF 
OPTOMETRISTS

Richard P. Kusserow 
INSPECTOR GENERAL 
OAI-01-88-00582 
FEBRUARY 1989  .... .................. ............. .................................. ...................... ....... ......... ........ ................. .... ............... . ........................................ ............ .................... ................................. ................ .... .. ............. ....... ....................  ..................................... ..............................................    
.......... .... ....... .... 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
INTRODUCTION.............. ... 

................................................................................... 1
THE PRACTICE OF OPTOMETRY """"'"''''''''.''''''''''''''''''''''''''''''''_nnn_ 
''' 2
STATE BOARDS OF OPTOMETRY '''''''''''''''''''''''''''''''''''''''''_nnn 
'''''''''''''' 5
LICE NSU RE................... ........................................................................................ 6
THE DIVERSITY IN THE SCOPE OF PRACTICE ................................. 7
ROCITY ............................................................................................... 8
R ECI P 
EMPHASIS ON CLINICAL TESTING 
TION............................................... 

BACKGROUND VERI FICA 
DISCI PLINE ......................................................................................................... 12
INCIDENCE AND TYPE OF DISCIPLINARY ACTIONS 
TYPE OF VIOLATIONS ............................................................................... 16
SOURCE OF DISCIPLINARY ACTIONS.......................................... 

ADMINISTRATIVE PROCESS .................................................................... 18
NFORMA TION SHARING .......................................................................... 18
RECOMMENDATIONS ... .......... .......................... 
....... ....................... ..... .............. 20
APPENDIX I ............. ........... .... 

COMMENTS ON THE DRAFT REPORT AND OIG RESPONSE 
PHS COM ME NTS  ......... 23
HCF A COMM ENTS . ................................ ..................................................... 23
AMERICAN OPTOMETRY ASSOCIATION COMMENTS 
INTERNATIONAL ASSOCIATION OF BOARDS 
OF EXAMINERS IN OPTOMETRY 
COMMENTS............................... 26
NATIONAL BOARD 
COMMENTS............................................... 28
APPENDIX II .... ..... 
BACKG RO U N D  .... .............. 30
APPENDIX" I ....................................................................................................... 33
METHODOLOGICAL NOTES ................................ 
.......... ......... .................. 33
APPENDIX IV............................................ ....... .................................................... 34
END NOTES.................................................................................................. 34 EXECUTIVE SUMMARY 
PURPOSE AND OBJECTIVES 
The overal ai of this inspection was to promote a better understanding of State licensure and 
discipline practices concerning dentists, chiropractors, optometrsts, and podiatrsts. 
In regard
to these practices, it sought to identify the extent and type of changes 
occurrng, the major is
sues being addressed, and the kinds of improvements that might be made. 
BACKGROUND 
The inspection follows up on a simlar inquiry that was conducted by the Office of Inspector 
General in 1985 and 1986 that addressed medical licensure and discipline. It is based primar
ly on the lines of inquir: (1) telephone discussions with board members or staff of State 
licensure and discipline bodies in the four professional areas noted above, (2) a review of per
tinent liter tue and data bases, and (3) discussions with representatives of national profes
sional associations. 
This report focuses on the licensure and discipline of optometrsts. 
It is the four and final 
report issued as par of this inspection. Its organization and presentation closely parallel that 
of the previous reports concerning dentists, chiropractors, and podiatrsts. A number of the 
findings and recommendations also parallel those set fort in the previous reports. 
FINDINGS 
In both the licensure and discipline realms, State board officials tend to feel that they are un
derstafed and that, as a result, the effectiveness of both licensure and discipline operations is 
compromised. 
Licensure 
Optometrc practice acts var widely from State to State. During recent years, this 
diversity appears to have increased as a number of States have passed laws allowing 
optometrsts to use therapeutic pharaceutical agents. 
The considerable varation among State laws governing the use of pharaceutical 
agents has inhibited the use of reciprocity agreements among State boards, thus limiting 
the interstate mobilty of practicing optometrsts. 
Clinical testing of licensur candidates is a major focus of State optometr boards. The 
contents of these tests var as do the determinations of acceptable performance.  Among State optometr board offcials, paricularly in the larger States, there is an 
increasing sense of vulnerability about the adequacy of the infonnation they review on 
applicants for licensure. 
Discipline 
As of May 1987, all boards had the right to revoke a license and 48 had the right to 
suspend a license. Most boards, however, lacked the authority to invoke probation
, issue 
reprimands, impose censure, apply restrctions on optometrc practice, or levy fines. 
Most State boards lack the authority to issue subpoenas or to suspend immediately the 
license of an optometrst who poses a clear and present danger to the public. 
From 1984 to 1986, the annual number of State board 
disciplinar actions has increased 
moderately. For the 46 States from which we obtained data, the number rose from 157 
in 1984, to 209 in 1985, to 224 in 1986. In 1987, however, about 40 percent of all the 
disciplinar actions were in just one State. Ten States disciplined no 
optometrsts during 
the period 1984-1986. 
The more serious types of 
disciplinar actions--revocations, suspensions, and 
probations--account for a minority of the 
disciplinar actions taken against optometrsts.
In the 1984-1986 period, they composed 42 percent of all reponed actions. 
Higher rates of disciplinary action appear to be closely associated with above-average 
licensure renewal rates. Among the 10 boards with the highest rate of disciplinary 
action between 1984 and 1986, 8 had 1987 renewal fees equal to or above the median 
renewal of $50. 
About two-fifths of the 49 State boards we contacted cited "unprofessional conduct" as 
the most common tye of violation upon which disciplinar action was taken. Under 
this category, the most frequent specific violations cited were unlawful use of 
therapeutic pharaceutical agents and unlawful delegation of authority to opticians and 
other personnel. 
Consumer complaints are the major source of referrals for disciplinary actions taken 
against optometrsts. Only three States reported referrals from professional societies as 
the first or second most importnt source 
of referrals. 
About three-fifths of the 49 State boards we contacted identified some problems 
associated with the disciplinar process. Most of these concerned the amount of time 
required to complete a case or the lack of trained investigatory staff with knowledge of 
optometr .  Many State board officials expressed support for the national data ban to be established 
under the Health Car Quality Improvement Act of 1986 and the Medicare and 
Medicaid Patient and Program Protection Act of 1987. However, they and others raised 
concerns involving the accurcy, confidentiality, accessibility, and timeliness of the 
data, as well as the time and cost burdens associated with the reporting process. 
RECOMMENDATIONS 
State governments should ensure that State optometr boards have sufficient resources 
car 
to  out their responsibilties effectively. 
State governments should ensure that State optometr boards have sufficient 
enforcement authority and a full range of 
disciplinar options available to them. 
State optometr boards should move toward the development of a high-quality, 
standardized national clinical examination. 
State optometr boards should shore up their credentials verification procedures. 
The International Association of Boards of Examiners in Optometr (lAB) should 
accumulate and, on a regular basis, disseminate to State optometr boards: (1) changes 
in State practice acts and regulations, and (2) best practices concerning State licensure 
and discipline approaches. 
The American Optometrc Association (AOA) shoula encourage more extensive and 
effective interaction between its affiiated State associations and State optometr boards. 
The Public Health Service (PHS) should assist the lAB to car out a more effective 
leadership role in working with the State optometr boards. 
COMMENTS 
The PHS concuITed with the recommendation directed to it. The AOA and lAB expressed 
general support for the recommendations directed to them. The full comments 
of these or
ganizations and of the Health Care Financing Admnistration and the National Board of Ex
aminers in Optometr as well as our responses to them appear in appendix IV.  INTRODUCTION

In June 1987, the Offce of Inspector General began an inspection on State licensure and dis
cipline practices concerning dentists, chiropractors, optometrsts, and podiatrsts. The overrd
ing purose of the inspection was to provide the Federal and State governments and the 
respective professional communities with a better understading of these practices. More 
specifically, it sought to identify the extent and type of changes takng place, the major issues 
being addressed, and the kinds of improvements that might be made. (For more background 
on why the study was undertaken, see appendix II. 
This report, which focuses on the optometr profession, is the third in a series to be issued as 
par of the above-noted inspection. It is based on three major lines of inquir: 
(1) telephone discussions with board members or staf associated with optometr licensure 
and discipline bodies in 49 States; (2) a review of pertnent literature and data bases, includ
ing joural arcles, studies, prepared speeches, and statistical compilations of public and 
private organizations; and (3) discussions with representatives of varous professional associa
tions. These include the American Optometrc Association (AOA), the National Board of Ex
aminers of Optometr, the International Association of Boards of Examiners in Optometr 
and the Association of Schools and Col
(lAB), the Council on Optometrc Education 
 (CDE), 
leges of Optometr (ASCO). (For more methodological background, see appendix III.) 
Optometrsts are a growing presence on the national health care scene. In 1986, there were 
500 practicing optometrsts in the United States, an increase of 4  1 Under 
100 from 1975. 
the Federal Medicare program, the role of optometrsts, although limited, is increasing. 
Treat
ment eligible for coverage, once limited to examnations 
of aphakc patients (patients without 
lenses), was expanded in April 1987 to include examnation and treatment of specific medical 
conditions. Prescrptions for eye lasses, with the exception of eyeglasses for post-cataract 
surgery patients, ar not covered. Although data ar not yet available to reflect the expanded 
coverage, Medicare reimbursement to optometrsts is increasing. 
Medicare Par B expendi
tures for optometr services increased from $5.3 millon in Fiscal Year (FY) 1984 to $16. 
3 A 1987 surey of optometrsts in 
million in FY 1985. both solo and group practice indicated 
that Medicare expenditurs represented 3. 1 percent and 7.9 percent of their total revenues, 
respecuve y. 
Under Medicaid, the role of optometrsts and the level of expenditures are more 
diffcult to 
detennne. As of 1984, 48 States covered optometrc services as an option, and 19 of these 
limited the coverage to the categorically needy.5 Surveys of optometrsts in group and solo 
practice indicated that in 1986 Medicaid fees represented 5 percent and 5.8 percent of their 
total revenues, respectively. 
This report stas out with brief overviews of optometr practice and State optometrc boards. 
It then turs to an examination of the major changes and issues affecting licensure and dis
cipline. It closes with some suggested aras of action directed primarly to State boards of op
tometrc examiners.
 THE PRACTICE OF OPTOMETRY 
The American Optometrc Association defines doctors of optometr as: 
priar 
care health professionals who are specifcaly educated, clinically trained 
and state licensed to examine the eyes and vision system, diagnose problems or im
paients, and prescribe and provide treatment. Among the tyes of treatment 
used are prescription glasses, contact lenses, vision therapy, low vision aids, and in 
many states, phanaceutical agents for therapeutic puroses. 
Some optometrsts, especially those in group practices, are electing to focus on a specific area 
of vision care or on a specifc patient population. For example, some optometrsts are 
specializig in occupational vision needs, sports vision needs, or the specific vision needs of 
the elderly, children, or those with low vision. Of al private practitioners, approximately 60 
percent practice in solo settings, but group practice and specialization appear to be increas-
8 The Association of Schools and Colleges of 
ing. Optometr and the American Optometrc 
Association are promoting specialties and group practice in the belief that these practices offer 
the highest quality of care. Accordingly, they have developed through a joint effort a practice 
management cuniculum and are encouraging schools to implement it. 
For those optometr school graduates seeking specialzed training, there are cUITntly about 
50 optometr residency positions available in the United States. This represents only 6 per
cent of the most recent graduating class of optometrsts in the 
countr. However, only 8 per
cent of third- and fourh-year optometr students sureyed expressed an interest in a residency 
after graduation. 
strng 
One of the most  characteristics of optometr practice today is the rapid change occur-
rig in service delivery settings. Although private practice continues to dominate, an increas
ing proporton of optometrsts is employed by optical chains and health maintenance 
organizations (HOs). In 1986, 73 percent of the 24 500 active optometrsts practiced in 
private settings, representing a 10 percent decrease over the past decade. The 
number of op
tometrsts working for optical chains more than doubled in 10 years and by 1986 they repre
sented 17 percent of all practicing optometrsts. The number of those employed by HMOs 
followed a similar trend, composing 6 percent of practicing optometrsts in 1986. It appears 
that this trend wil 'continue at least into the 1990' s as new graduates facing education loan 
payments are likely to prefer to work for optical chains rather than 
star from scratch in 
private practice. A survey revealed that optometrsts who graduated in 1980 went 
into private
10 Over 12 percent of 1984 graduates 
practice twice as often as those who graduated in 1984. 
worked for optical companies and 10 percent of 1987 graduates who were recently surveyed 
antICIpate omg so. 
Accordingly, private practitioners ' share of the market has  decreasing. In 
grdually been 
1986, private optometrsts accounted for 27.6 percent of the ophthalmic market (i.e., 
optometrsts, ophthalmologists, and opticians), a 1.2 percent decrease from 1985, and a 16.4 
percent decrease from 1976. In contrast, HMOs and optical chains experienced the most  growth over the decade, controllng 28.5 percent of the ophthalmic market by 1986. In 
response to this development, many private practitioners have fonned buying groups in which 
parcipants receive discounts on ophthalmic supplies and equipment so that they can compete 
more effectively with optical chains. A recent survey revealed that 72 percent of optometrists 
belong to one or more buying groups. 
Some optometrsts are concerned that Increased competition may have an adverse effect on 
their income prospects. Their concerns are reinforced b
r the fact that over the last decade
their income has not kept pace with the rise in inflation. 3 More recently, however, it appears 
that optometrsts ' financial situation has improved. In 1986, the most recent year for which in
come data are available, the median income of optometrsts increased to $58,200; this repre
sents a 6 percent increase from 1985--about twice the national rate of inflation in that period. 
Income vares considerably by the type of optometrc practice. A 1986 nationwide survey of 
350 optometrsts revealed that those in group or parnership practices net the highest annual in
come, reach their income peak earlier in their careers, and maintain a higher level of earnings 
longer than salared or solo practitioners. Specifically, group practitioners ' average net in
come in 1986 was $78,000, which was $12,500 more than solo practitioners and $26,000 
more than salared practitioners. 
The number of active optometrsts has increased moderately in recent years. Between the 
years 1970 and 1984, the number of active optometrsts has increased from about 18,400 to 
about 23,600 (figure I) or from 8.9 per 100,000 population to 9.9. The U.S. Public Health Ser
vice projects that the national need for optometrsts wil reach 30,400 or 11.3 per 100 000 
1 On 
population by the year 2000, roughly the same as its projection for supply that year.  the 
other hand, the AOA maintains that a "reasonable rate " of optometrsts per 100,000 of popula
tion is 14.3 and estimates a need for 36,000 optometrsts in 1990,  600 more than the Public 
Health Service s year 2000 projection. 
FIGURE I 
TIMATED NUMBER OF ACTIVE OPTOMETRISTS: 
SELECTED YEARS, 1970-1984

Thousands of Optometrists 
25 r 
24 
1975  1980  '9c': 
Source: FIrtH REPORT TO THE PRESIDENT AND

CONGRESS ON THE STATUS OF HEALTH PERSC! :.EL, 
More r. 198f  ;j"'
Optometr is becoming populated by ever younger professionals. Sudden increases 
graduates in the mid-1970' s and the grdual increase in subsequent years until 1984 lowered 
the median age of the profession from 48 to 42 years. In 1984, the number of newly graduat
ing optometrsts exceeded the number of optometrsts leaving the profession by 50 percent. 
19 As in 
The median age wil continue to decrease as large numbers of optometrsts retire. 
other health professions, the percentage of women entering optometr has significantly in
creased. In 1984, women represented 27.4 percent of optometr graduates, a higher propor
entlstr an po latr. 
tlon t an t ose 
The distrbution of optometrsts has remained uneven. In 1984, for instance, there were 11. 
optometrsts per 100 000 population in the West, 11. 1 in the Midwest, 9. 9 in the Northeast 
and 8.0 in the South. 1 Ten States, 9 of them southern, have what AOA terms a "critical ratio 
of less than 7 practicing optometrsts per 100,000 population. Only 7 States, 3 of them 
western, have an "acceptable ratio" of more than 13 optometrsts per 100,000 population. 
The location of schools of optometr is a prime factor in determining where optometrsts prac
tice. Nearly thre-fourts of optometrsts under 45 who practice in States that have an op
tometr school  State school. The proporton of all active optometrists 
graduated from the in-
who graduated from a school within their State of practice is more than 93 percent in Ilinois, 
82 percent in California, and 80 percent in Massachusetts. 
Since 1981, the number of optometr schools has grown. In the years 1981-1982, three 
24 and one--
schools opened in Florida:-is anticipated to open in the near future. Currently 
schools of optometr are accredited by the Council of Optometrc Education. Three of these, 
the University of Waterloo, the University of Montral, and the Puerto Rican Inter-American 
University of Optometr, are located outside of the continental United States. Five of the 
25 All received a porton 
schools are free-standing, and 10 are university-affiliated. of the 
cumulative $75 millon of Federal aid distrbuted to optometr schools between the years 
1965 and 1980 under the authority of the Health Professions Education Act. 
The 1970' s were the major growth years for enrollment in optometr schools. During the 
1971-1981 period, total enrollment in optometr schools rose by about 60 percent. However 
since the peak year of 1981 , enrollments have been declining, albeit slightly (see figure II). 
FIGUR II 
GE!\ERAL TRE!\DS FOR FIRST-YEAR A!\D TOTAL 
ENROLLMEI\TS IN. AND GRADUATION FROM. U. 
OPTOMETRY SCHOOLS. SELECTED YEARS. 1972-1987 
500  irst-Yeor 
nroltment 
4500 
Totol EnrOllmE'

400 
Groauot.C"
3500 
3000 
2500 
2000 
1500 
100:' 
50:' 
1S":  1975  1978  19: .  1957 
5:. .;r;:e  A:"'!. I::C'" 
Colieges of Optometry  STATE BOARDS OF OPTOMETRY 
Two decades ago, State optometr boards, like State medical boards, were little noticed en
tities of State Government and were dominated almost completely by optometrsts. Most 
were independent bodies, having little operational interaction with other professional boards 
or even with optometr boards in other States. Although their responsibilities typically 
covered licensure and discipline, they focused priarly on the fonner and in pancular on the 
development and admnistration of their own licensure examnations. They would discipline 
optometrsts periodically, but their authority and readiness to do so were quite limited. 
pictu 
Now, the  is somewhat different. With the changing scope of optometr practice, a 
growing emphasis on continuing education in optometr, the development of the consumer 
movement, and the heightened concerns about the cost and quality of health care, optometr 
boards function in a more visible environment with a greater degree of public accountabilty. 
Although the scope and the intensity of the changes have not been as great as for State medi
cal boards, they have still been significant. 
About 60 percent of State optometr boards are now par of a centralized State agency, and at 
least 70 percent have one or more nonoptomenist members on their board of directors. Nearly 
all (96 percent) have responsibilty for both licensure and discipline, but the number and type 
of licensure examations admnistered by boards var considerably by State. 
The staf and financial resources available to the boards are not readily determined. Twenty-
five States reponed they have less than one full-time equivalent staf member assigned to the 
optometr board, but in many cases this does not include staff reportng to a central agency 
that may provide some assistance to the board. Simlarly, the budget of a board is often 
obscured within the budget of a larger agency. 
It is clear, however, that in nearly all States, the board revenues derive entirely from fees im
posed on optomenists. These include application , examination, and varous other fees. The 
major source of revenue is the annual renewal fee imposed on practicing optomenists. 
It ran
28 Fifty-
ges from $20 to $250, the median being $50. five percent of the boards either im
posed fee increases during 1986 or 1987 or scheduled them for 1988. Yet because boards 
typically ar par of the State budget process and subject to the same budgetar and personnel 
controls as other State agencies, fee increases do not necessarly mean increased resources for 
the boards. Thus, even though optomenic licensure and discipline has grown to become an es
29 many board representatives feel they are seriously un
timated $2 milion a year enterprise,
derfunded in caring out their extensive responsibilties.  LICENSURE

State boars of optometr have come to judge licensure applicants on the basis of three major 
requirements: (1) graduation from an accredited or approved optometr school; (2) passage of 
a National Board of Optometr Examnation (NBOE) or State-wrtten examination; and (3)
passage of a State clinical examation. 
Of these thee requirements, the first is the most 
unifonnly applied. All State boards except 
one require that those who attended optometr school in the United States be 
grduates of a
school accredited by the Council on Optometrc Education (CaE). The one exception wil
evaluate the equivalency of a licensure applicant s education to State standards if that ap
plicant has not graduated from a CaE-accredited school. For those seeking a State license 
who are grduates of nonaccredited foreign schools, eight State boards contract with parcular
accreditation services to detennne the adequacy of the training offered. 
The second requirement, concerning wrtten examnations, is much more vared in its applica
tion. Sixteen States require the examnation prepared and administered by the National Board 
of Examners of Optometr in lieu of a State wrtten examination; 16 require the National 
Board examnation in addition to a State wrtten examnation; and 6 do not accept the Nation
al Board examnation at all but require applicants to take State-specific 
wrtten examinations. 
The remaining States may delegate an examnation at the discretion of the board or contract 
with a thd par to constrct and admnister an examnation. Fort-six States re  uire 
evidence of board-approved continuing education courses for licensure renewal. 
Because 40 States require a wrtten examnation and 32 States consider the National Board 
wrtten examnation scores for licensur, approximately 4 000 candidates take the National 
Board examation each year. The National Board's test is a criterion-referenced examina
tion. With this procedur, which was first implemented by the National Board in 1981 
, grad
ing on the basis of a curve was eliminated and was grounded instead on a perfonnance index 
for each test item administered. 
In 1987, the National Board implemented a new content outline, which consolidated the pre
vious nine sections of the examination into two pars, basic science and clinical science. 
third par covering patient car, now being developed by the National Board, wil 
r:eplace the
retired clinical assessment section of the past examination in 1989. Eligible candidates 
for 
par I are those students who are at least in the second half of their second professional year in 
an accredited school, and eligible candidates for par II are those in the second half of their 
third year.

The third requirement for licensure, a practical examination, is the most inconsistently applied 
among States. Twenty-eight States require such an examnation, and nine consider it option
al. 34 (The remaiing States do not require a practical examination. 
) These examinations seek 
to detennne the clinical readiness of a candidate, although the content and stadard of accept
able perfonnance var by State.  In addition to the 3 core requirements for licensure, 42 States require the applicant to be in 
good moral standing, 39 have a minimum age requirement, 9 require U.S. citizenship, 5 re
quir an oral examnation (11 consider it an option of the board), 2 require a post examination 
internship of 6 months, and 3 require State residency. 
Over the past 3 to 4 years State licensure requirements have been the focus of much attention. 
Forty percent of the States (23) reported legislative or regulatory changes and 75 percent of 
these changes involved the scope of optometr practice. Two major consequences of these 
changes have been increased diversity in the scope of practice from State to State and thus 
reduced inter-State mobilty for practicing optomenists. Two other less prominent consequen
ces have been an increased emphasis on State clinical examinations and more attention to the 
adequacy of background infonnation on applicants. 
THE DIVERSITY IN THE SCOPE OF PRACTICE 
Although the definition of optomenists is by and large similar from State to State, the scope of 
optometr practice is becoming more diverse as a result of changes in State optometr prac
tice acts durng the past 3 to 4 years. About half of the States report such changes, nearly two-
thirds of which involve the use of pharceutical 
agents (drgs). CUlTently, 50 States 
specifically permt the optometrc use of phanaceuticals for diagnostic purposes and 23 
36 Sixteen of these States 
States permt their use for both diagnostic and therapeutic purposes.
have alowed the use of therapeutic phanaceutical agents (TPA) since 1985. Only one State, 
Marland, does not have any provision either providing for or prohibiting phanaceutical 
agents. 
Optometrc practice acts var widely from State to State. Nort Carolina, one of the first to 
authorize diagnostic treatment of eye disease, defines the practice of optometr to be: 
The examnation of the human eye by any method other than surgery to diagnose, 
to treat, or to refer for consultation or 
tratment any abnonnal condition of the 
human eye and its adnexa; 
The employment of instrments, devices, phanaceutical agents and procedures, 
other than surgery, intended for the purpose of investigation, examning, treating, 
diagnosing, or cOlTecting visual defects or abnonnal conditions of the human eye 
or its adnexa; 
The prescribing and application of lenses, devices to corrct, relieve, or trat 
defects or abnonnal condition of the human eye or its adnexa. 
In contrast, Wisconsin law states that optomenists cannot give medical tratment or prescribe 
therapeutic drgs and defines the practice of optometr as follows: 
The employment of any optomenic means, including topical ocular diagnostic 
pharaceutical agents, to determne the visual efficiency of the human visual sys tern, including refractive and functional abilties or preliminar diagnosis of the 
presence of ocular disease or ocular manifestations of systemic disease and other 
deparres from nonnal. 
The diagnosis and treatment of the refractive and functional 
abilty of the visual 
system and enhancement of visual perfonnance by prescribing, furnishing, fitting, 
or employing ophthalmic lenses, contact lenses, frames, aids, or prosthetic 
materials or admnistering visual training, 
ortoptics, visual therapy or any other 
optometrc means.

Because authorization of TPA use is a growing trnd, some State board officials predict it wil 
be penntted nationwide within 5 years. However, even in States where TPA legislation has 
been passed, it has been a controversial issue. One-third of the significant media coverage of 
licensur practice reponed by State board officials involved new TPA legislation. Improper 
prescribing by optometrsts who lack TPA cenifcation is a major concern expressed by offi
cials in States where the legislation has passed or is pending. And the use of TPAs by op
tometrsts has also crated uneasiness among ophthalmolo  sts who see them as invading 
what has trditionaly been the ophthalmologists' domain. 
The inconsistent authorization of TPA use nationwide has complicated State board licensure 
procedurs, adding an additional step to the licensure process in the States where it has passed. 
Founeen States now require applicants to pass the International Association of Boards of Ex
aminers in Optometr (lAB) examnation in Treatment and Management of Ocular Disease. 
This examnation documents an applicant s entr level competence in the use of drgs for 
40 Six States, two of which do not require lAB' 
therapeutic puroses. s examnation, require ex
tensive continuing education credits (an average of 5 hours annualy) or completion of board-
approved courses for certfication in the use of TPA. 
The verication and application process has also become more complex as States seek to 
detennne applicants' abilty to prescribe for therapeutic puroses. Fifty percent (8) of the 
States reportng changes in application procedures referrd to the need for more extensive 
documentation of course trscripts and test scores in this ara. The Continuing Optometrc 
Education Classification System developed by the lAB and funded by the Public Health Ser
vice has done much to standardize course names and contents. Despite these effons, however 
many State boards lack adequate resources for their increasingly complex 
administrtive func
tions. One board official said he .. doesn t feel comfonable with continuing education since 
the deparent lacks the resources to help the board. The hoard approves courses, but it has 
no way of monitoring attendance. " One-fifth of the boards reponed insuffcient funds and 
priar 
vulnerabilty in their licensure practices. 
staff as a 
RECIPROCITY 
The considerable varation among State laws governing the use of pharaceutical agents has 
inhibited the use of reciprocity agreements among State boards, thus limiting the inter-State 
mobilty of practicirig optometrsts. Reciprocity applies when two or more State boards deter mine that their licensure stadads are equivalent and enter into conttactual agreements grant
ing licenses to applicants from one another s State. Another practice, endorsement, is less 
restrctive in that a State board assesses the equivalency of any applicant s credentials to the 
State s own stadards regardless of conttactual agreements. 
Forty States recognize out-of-State licenses (16 by endorsement, 24 by reciprocity). But in ac
tual practice, the licenses recognized are limited by varations in the scope of practice 
authorized in the States. For example, half of the 16 States with TPA authorization that either 
grant reciprocity or endorse licenses wil do so only for applicants who have TPA certification 
41 Some 
even though aleady licensed, non- TPA certified optometrsts practice in the State.
States, such as South Dakota, have passed laws narowing reciprocity to only those op
tometrsts with TPA certfication. Others, in the words of one board official whose State had 
yet to grt a license under its reciprocity agreements, simply noted that it "is difficult to get a 
license with reciprocity because older practitioners must have the same skills as new ones. 
State boards that endorse licensure by credentials can save an applicant from having to take 
the National Board examnations a second time. But at least nine States (seven license byen
dorsement, two have reciprocity agreements) require clinical examinations before licensing 
out-of-State applican s. Acceptance of the National Boards encourages these limited agree
ments, as five of the six States not accepting the National Boards do not license by credential 
or grant reciprocity. However, many States recognize the National Boards only if the ap
plicant has taen them within 
the past 5 years. 
The overal effect of inconsistent State authorization of TPA and the subsequent emphasis on 
clinical testing by some States has been, in the words of one board official, "to make 
reciprocity a thing of the past." As a result, optometrsts' mobilty has become more and more 
restrcted. In addition, optometrsts with TPA certfication are less likely to move to a State in 
which the practice of trating diseased eyes is not alowed. Consequently, 85 percent of States 
with TPA authorization have an optometrsts-to-population ratio above the national average. 
In contrst, the availabilty of optometrsts in States without TPA authorization is limited. For 
example, 8 of the 10 States with a critical ratio of less than 7 
optometrsts per 100,000 popula
tion do not have TPA authorization. 
A representative of AOA recognized reciprocity as an "emotional issue" and stated that as long 
as States remai in ttansition toward a more unified scope of practice, the ttend against. 
reciprocity wil persist. During the last 3 to 4 years, 7 of the 10 States reporting changes in 
reciprocity restrcted the practice to varing degrees. Two States eliminated reciprocity com
pletely, three restrcted it to TPA-certified optometrsts only, and two limited the number of 
years the National Boards wil be recognized after passage. The remaining thre States incor
porated the National Boards into their reciprocity agreements.  EMPHASIS ON CLINICAL TESTING 
Testing, specifically clinical testing, has been a major focus of State optometr 
boards. Of the 
24 State boards that identified a licensure activity as an exemplar practice, almost half (11) 
cited the content and comprehensiveness of their clinical examination. Each 
of these examina
tions seeks to assess the clinical readiness of candidates, and some require them to conduct 
procedurs on patients. However, the contents of the tests var as do the detennations of ac
ceptable performance. The coverage of comprehensive tests, as reported by board officials, 
ranged from five to eight diferent skill areas, and one State introduced a laser video examna
tion with no grades involved at all. Many States reported they 
constatly review and revise 
their examation. 
Because of these dynamcs, the National Board of Examners in 
Optometr (NBEO) has taken 
the lead in standardizing the clinical examnation. Revisions of the 1979 Manual for the As
sessment of Entr Level Clinical Skills include a grater number of clinical modules in which 
patients are used to evaluate the candidate s skill in conducting pretest optometrc procedures, 
administering optometrc tests, and presenting the outcome data. The manual stresses process-
oriented assessment methodology and provides checklsts for each module. Although the 
manual was well- received in 1979, NBOE has recently sponsored workshops for 
11 State 
boards to promote its use and help States develop a re  esentative sampling procedure for 
determning skill areas to be tested for each applicant. Accordingly, Oregon, one of the 
States visited by the NBOE, has made a concerted effort to standardize its practical examina
tion in response to public concern over its validity. In a similar effort, Pennsylvania has con
trcted with the International Association of Boards of Examiners (lAB) in Optometr for the 
admnistration of a clinical skills examnation developed by the 
lAB. However, specific scor
ing, standard settig and traiing of examners remai the responsibilty of individual States. 
BACKGROUND VERIFICATION 
Durg 
the early 1980' s, State medical boards were severely shaken by scandals involving 
fraudulent credentials from two Carbbean medical schools and by breaches of securty on 
some medical licensure examnations. State optometr boards have not had to face any com
parable developments. Yet there is an increasing sense of vulnerabilty, parcularly in larger 
States, about the adequacy of information they review on applicants for licensure. The 
validity of crdentials has not been a major issue, but completeness of information 
bearng on 
the applicant s professional conduct is becoming more of a concern. 
In the past 3 to 4 years, one-third of the States have introduced changes that call for more 
detailed information on applicants. Over half of these changes require proof of 
TPA certifica
tion or passage of the National Board examinations. The remaining changes require more ex
tensive references or fuller accounts of the applicants ' past, including the record of their 
practice in other States or any discipline problems they may have had. 
Overal, however, the scope of these changes is limited, and many board offcials suggest
, in
adequate. Because information on recent 
graduates can be readily obtairied from their op tometr schools, board officials feel that the gratest problem lies in the inadequacy of infor
alady 
mation provided by  licensed out-of-State applicants. Boards are compelled to accept 
this infonnation at face value, with the possibilty of omissions increasing their uneasiness 
over its reliabilty. At least one-third of the State boards contact other States where applicants 
have listed being licensed. One board representative expressed concern over the inadequacy 
of this system primarly because the board "doesn t see qualty practitioners coming in. 
More and more States, parcularly the larger ones, ar caling for a better tracking system. 
Californa, for example, emphasizes the need for better coordination between States in order 
that the board can obtai infonnation on the 2 000 optometrsts who are licensed in California 
but not curently practicing in the State. Although other State boards are the primar source 
of infonnation on out-of-State applicants, some board representatives believe communication 
problems between States have made it increasingly difficult to trck applicants in this manner. 
A second factor that inhibits more effective board action in reviewing applicant backgrounds 
is the widely perceived inadequacy of the national 
disciplinar action clearnghouse main
taied by the International Association of Boards of Examners in Optometr (lAB) and the 
National Clearnghouse on Licensur, Enforcement, and Regulation (CLEAR). In their 
responses to us, only six States reported using CLEAR, and only two hav  used lAB to obtain 
infonnation on licensur applicants. The majority feel that contacting State boards directly 
provides more tiely and accurte infonnation at less cost. Some CLEAR members ex
pressed doubts that complete infonnation is distrbuted to the States and others said that 
the 
lack of parcipation by al 51 States limits the usefulness of the infonnation. Up until Septem
ber 1987, in fact, lA, on the advice of its counsel, would not release 
disciplinar infonnation 
it had been collecting on a quarerly basis. But, lAB is now tang a more active though stil 
limited role as a disciplinar clearnghouse. It provides the name of the State in which a prac
titioner has been disciplined and refers the request for infonnation to a board 
offcial within 
that State for more details. Changes are in order if either clearnghouse is to be more effec
tive. Four States were unaware of their services altogether, and others did not know how to 
gain access to the infonnation.  DISCIPLINE

Over the years, the authority of State boards to discipline optometrsts has gradually been in
creasing with respect to both the grounds upon which they can tae disciplinar action and the 
type of action they can take. Durng the past 3 to 4 years, about one-third of the boards have 
experienced some legislative or regulatory change concerning their disciplinar authority. 
Nearly all the changes have increased that authority, either enhancing their range of options ur 
expandig the number of areas in which they can take action. However, a rule recently 
proposed by the FrC ("Eyeglass II"), would disallow State restrction of commercial op
tometr. When promulgated, this rule wil preclude State boards from: placing prohibitions 
on employer-employee agreements between optometrsts and persons who are not op
tometrsts, prohibitig the use of trade names, limiting the number of branch offices that op
tometrsts may operate, or prohibiting the practice of optometr in commercial locations such 
as shopping malls. 
As of May 1987, all boards had the right to revoke a license and 48 had the right to suspend a 
license. In most States, however, the other tyes of disciplinar action that could be imposed 
were limited: 11 States had the right to invoke probation, 8 States could issue repriands, 6 
States could impose censur, 4 States could apply restrctions on an optometrc practice, and 5 
47 These numbers are increas
States (with the recent addition of Calfornia) could levy fines.
ing as more States gai a grater rage of disciplinar actions. Yet most still lack a full com
plement of options as well as basic authorities, such as .the power to issue subpoenas or to 
suspend immediately the license of an optometrst who poses a clear and present danger to the 
public. 
INCIDENCE AND TYPE OF DISCIPLINARY ACTIONS 
How many and what tye of disciplinar actions are being taen against optometrsts in the 
United States? This question is a basic one, but one that we leared could not be readily 
answered. The existing infonnation bases were too limited, even to provide reasonable es
timates. 
Accordigly, in discussions with representatives of 49 State boards, we asked them to indicate 
the number and type of disciplinar actions imposed on optometrsts during each of the past 3 
years. We received data from 47 States. The result was a nearly complete picture of the ex
tent and nature of disciplinar actions taken in 1984  1985, and 1986. 
Durg 
this 3-year period, there was a moderate increase in the annual number of disciplinar 
actions taken (see figure il). In 1984 and 1985 the number of actions reported was 157 and 
204, an increase of 30 percent. The following year 224 actions were reported, an increase of 
only 10 percent. However, in 1986, 1 State reported almost 100 disciplinar actions, account
ing for 40 percent of the total for that year. If that State s rate of disciplinar actions had 
remained constant with its rate for the 2 preceding years, the total national 
disciplinar actions 
reported between the years 1985 and 1986 would have decreased by 10 percent.  - --- --- --- -. - .-- -- ---- -- --- --- -------- - ---- - ------ -- --------- -- -- -- -------- -- ---" '--..-.---. -------.-. .-.- -'--- -." .-. -------- - --- - -- --- -- - - -. ,-, . -" - - -- --_ -- - -- 
FI G URE III 
NUMBER OF STATE DISCIPLINARY ACTIONS, 1984-1986 
Total
240 
220 
Other 
200 
r7 
180  Revocations. Proca
lions. &0 Suspensions
160 
140 
120 
100 
1984  1985  1986 
Source: State Optometry Boards as Reported to

the Office of Inspec tor General

year period, tier 1 actions--the more serious ones involving revocation, probation, or 
In this 3-
suspension--accounte overal for 42 percent of the reponed actions. They composed 38 per
cent of the actions in 1984, 54 percent in 1985, and 35 percent in 1986. The tier 2 actions in
volvig less serious actions such as reprimads and fines (and designated in figuC? IV as 
other ) accounted for somewhat over half of the actions reponed for the 3 year. However 
durg 
actions taen by just one State boar of optometrsts made up hal of the tier 2 actions 
this period. 
FIGURE IV 
TYPE OF DISCIPLINARY ACTIONS, AS A PERCENTAGE 
OF ALL REPORTED ACTIONS, 1984-1986 
OTHER 
"",0",,-
SUSPENSIONS 
REvOCATIO 
PROBATIONS 
. 0 
1984  1985  1986 
Percent 
Source: State Optometry Boards as Reported to

the Offic e of Inspec tor General  Suspensions accounted for 52 percent of all tier 1 actions reported. Probation, a disciplinar 
option for only 11 boards and considered an exemplar practice by 1 board, represented 
23 percent of tier 1 actions and 8 percent of all disciplinar actions reported. Compared to 
other State professional boards, optometr boards make much less use of probation as a dis
ciplinar tool. State dental boards and chiropractic boards imposed probation in 25 percent 
and 20 percent of the reported cases, respectively, during 1984-1986. 
When the disciplinar performance of State optometrc boards is compared to that of State 
medical boards and denta boards, other notable differences emerge. Within the tier 
category, the medical doctors have been more inclined to impose the severest action of all: the 
revocation of a license. While revocation accounted for 19 percent of al 
disciplinar actions 
taken against medical doctors in 1984 and 1985, it represented 14 percent of actions against 
optometrsts by optome  boards and 9 percent of actions against dentists by dental boards 
durig the same 2 years.

Stil other differences exist. First, optometr boards have been more active in disciplining 
members of the profession than both State dental boards and State medical boards. 
In 1985, 
the latest year for which compartive data ar avaiable, optometr boards disciplined 8.5 op
tometrsts per 1 000 active optometrsts, dental boards disciplined 5.4 dentists  5 eIrt  1 000 active 
dentists, and medical boards disciplined 4.2 doctors per 1 000 active doctors.  is important 
to recognize, however, that the differential has been decreasing and that since a much smaller 
proporton of optometrsts and dentists are subject to hospita peer review practices, the 
reviews of the State optometr and dental boards may be of somewhat greater overall impor
tance. 
The varations in disciplinar performance ar no less apparent when State optometr boards 
are compared among themselves. Durng the years 1984-1986 for which we collected data, 
we found that two States disciplined optometrsts at a rate far exceeding that of any other 
States. In fact, in one of these States disciplinar ac  ons accounted for 40 percent of all ac
tions taken in 1986, 21 percent in 1985, and 27 percent in 1984. At the other extreme, 10 
States (out of the 47 which reported) disciplined no optometrsts at all during the 3-year 
period. Thus, the State boards' rates vared from a low of zero to a high of 41 actions per 100 
licensees. The national average was 3.6 actions and the median was .78 actions per 100 licen
sees. 
Substantial varations among the boards are also apparent when their rate of 
disciplinar ac
tivity is corrlated with size and location. Since year-to-year fluctuations may be misleading, 
we aggrgated and analyzed the data over a 3-year period, 1984 to 1986. Our examination 
made it clear that the rate of disciplinar actions agaist optometrsts tends to be much lower 
in the States with the largest numbers of practicing optometrsts than in States with the smal
lest numbers. Thus, among the four categories of States (ranked according to their number of 
active civilan optometrsts), the top two categories, which accounted for 61 percent of all ac
tive civilan optometrsts in the United States, represented only 28 percent of all reported dis
ciplinar actions imposed on optometrsts from 1984 to 1986 (see figure V).  ~~~ ..  ~~~'" ..
FIGUR V

PERCENT DISTRIBUTION OF ACTIVE CIVILIAN 
OPTOMETRISTS (1984) AND OF REPORTED DISCIPLINARY 
ACTIONS (1984-86). BY SIZE RAKKI!'G OF STATES

_26:1 
lRG. 
E). LRG. 8UO: 
-;r 
EX. LAC. 
-'(r 
5" -9:1  Mt. -62'  SM.
M(D. -3D 
Reported Disc ipiinory 
Ac tive Civjk: 
Optomet  Ac tions 
Sourc : rU:"THR
rpOp.T TO THE PRESIDEt.'T AND 
tONCRes!:  ON THE ST"'l.S or HEATH PERSOJoN(L and 
Stat  Ot"tomelry BoardS 01 Reported to tne OiG 
rate was highest in the Norteast 
With respect to regional comparsons, the disciplinar action 
and the South, and lowest in the West Although the Norteast and the South collectively had 
48 percent of the active civilan optomenists, they were responsible for 71 percent of the 
actions (see figure VI). On the other hand, the comparable figures for 
reponed disciplinar 
the Western States were 24 percent and 9 percent (figure VI). 
FIGUR VI 
PERCENT DISTRIBUTION OF ACTIVE CIVILIAN 
OPTOMETRISTS (1984) AND REPORTED DISCIPLINARY 
REGIO:" 
ACTIONS AGAINST OPTOMETRISTS (1984-86) BY 
"lDwe:;_2 
E:AS' 
"lDweST.20 
wtST-'" 
SQUH-27: 
weST_:'" 
SOIJH.3! 
Ac tive Civilian  Reported Disc iplinory 
Opto!'etrists  Actions 
'ce n:-"  t:=::": i;:. T..  cc:t:s;
c.::u  ES5 or T..  ..S Co':- Ht,r"!H CE  C": 
Stellt  to""et' ) a:lClrCf cs: ,"fD:I'leC to , ,fI. 01(. 
Why is the rate of disciplinar actions higher in some States than in others? Is it because prac
ticing optometrsts in some States ar more incompetent, dishonest, or unprofessional than in 
tae 
others? Is it because of difering levels of board commtment to  action? Is it because of 
Each of

operational constraints associated with inadequate authority or insuffcient resources? 
these factors may be explanatory to some extent, but in the case of onc  insufficient resources 
--we have some data to suggest an association.  We found that of the 10 boards with the highest rate of 
disciplinar actions between 1984 and 
1986, 8 had renewal fees equal to or above the median annual renewal fee of $50 in 1987. 
the other end, however, the association was not as strong. Of the 10 boards with the lowest 
rate of disciplinar actions, 5 imposed fees equal to or exceeding $50, and 5 had lower fees. 
Thus a compartively high renewal fee, although closely associated with above-average dis
ciplinar performance, in itself is no guarantee of a higher level of disciplinar activity. 
Finaly, it is important to recognize that State optometr boards are not the only forums for dis
ciplining optometrsts. Another, as noted in appendix I, is the Office of Inspector Genera 
(DIG) which can impose sanctions on professionals who have committed fraud or abuse. 
During the past 5 years DIG sanctions against optometrsts have averaged 2.2 percent of all 
DIG sanctions imposed, rising from 3 in FY 1982 to 11 in FY 1986. 
TYPE OF VIOLATIONS 
In our prior review of State medical boards, we found that the inappropriate writing of 
prescriptions was by far the most common violation upon which 
disciplinar actions against 
medical doctors were based. This was followed by violations concerning self-abuse of drgs 
and alcohol. Despite the shar rise in medical malpractice cases in recent years, very few ac
tions were based on inadequate clinical performance. 
For optometrsts, the information available is less definitive, but judging from our discussions, 
it appears that the pattern is quite different. Among the 49 boards we contacted, 38 percent 
cited unprofessional conduct as the most common type of violation upon which disciplinar 
action was based. The most frequent specific violations cited by respondents for this category 
included unlawful use of TPAs, unlawful delegation of authority to opticians and other person
nel, and inadequate patient examnations. Not one board representative reported self-abuse of 
alcohol and drgs as the most common type of violation. Ten percent of the respondents cited 
clinical misjudgment as the most common type of violation, and 17 percent as the second 
most common type. 
The greatest discrepancy appears to be in the propensity to take action because of poor clinical 
performance. In the case of medical doctors we cited three factors that seemed to account for 
minimal actions taen: (1) the complexity, length, and cost of such cases, (2) the substantial 
burden of proof required, and (3) the considerable varations among doctors themselves about 
what constitutes acceptable practice. In the case of optometr, the use of minimum patient ex
amination requirments makes it easier for boards to take action against optometrsts. The 
four States (South Dakota, Florida, Ohio, New Jersey) that reported having such a requirement 
believe it to be an effective investigatory tool and an exemplar disciplinar practice. More 
natu, 
proactive in  investigators in these four States can check the optometrst s records to see 
if the minimum examnation requirement has been met. In another technique, Illnois random
ly selects a 10 percent sample of optometrsts durig relicensure. Minimum test requirements 
and proof of diagnostic pharaceutical agent certification ar priorities of the investigation.  Although representatives of the four State boards with minimum patient examnation require
ments reported disciplining at least one optometrst on the basis of clinical misjudgment, offi
cials from hal of the State boards reported no such action. Overal, the abilty to discipline on 
the basis of clinical misjudgment seems related to the number of optometrsts in the State. 
Among the 17 smallest States, in tenns of the number of active civilian optometrsts, 3 (17 per
cent) reported takng such disciplinar actions durng the past 3 to 4 years. This compares 
with 45 percent of the States in the medium category, 81 percent in the large category, and 100 
percent in the largest category. The reason for these differentials are not readily apparent. 
There has been some discussion in States in the smallest two categories about the kind of ac
tion needed to avert the poor clinical perfonnance that can lead to disciplinar violations. 
Board officials from the majority of these States believe that mandatory education works well 
and one State official expressed the need for a reexamination policy to detennine clinical com
petency durng relicensure. The effectiveness of investigatory site visits was also noted. One 
State that conducts such visits--Mississippi--offers a temporar license to new practitioners, 
and each board member, responsible for a congressional distrct, wil periodically investigate 
to see if equipment and records meet the board' s standards. 
SOURCE OF DISCIPLINARY ACTIONS 
Consumer complaints are the major source of 
disciplinar actions agaist optometrsts. In 80 
percent of the States, optometr board representatives reported that such actions are at
trbutable to consumer complaints more than to any other source. This pattern holds regard
less of a State s size or region. In the remaining States, board representatives reported other 
optometrsts to be the primar source of complaints. Of the 35 States indicating a second 
most common source, 30 percent reported other optometrsts and 
ophthalologists. These 
complaits ar often prompted by the competitive situation and relate most often to adverts
ing practices or substadard office practices. Sixty percent of all eye surgery is now being 
51 Some optometr board 
done by 25 percent of all ophthalmologists.  officials suggested that 
as a result some complaints come from ophthalologists whose surgical practices may be suf
fering owing to insufficient referrals from optometrsts. 
In contrst, only three States reported referrals from the professional societies as the first or 
second most common source of referrals, and in each case these referrals were considered a 
second most common source. Board-initiated cases, representing 10 percent of the second 
most common source of complaints, derived mostly from those boards which make automatic 
site visits and impose sanctions for tardy license renewal. 
One-fifth of the States have provisions allowing other agencies to report possible violations to 
the optometrc boards. The majority of these relate to malpractice cases, but these referrals 
often serve as a flagging mechanism since in many instances the boards are restrcted from in
itating a complaint based on the case  outcome and process. 
s ' ADMINISTRATIVE PROCESS 
Board representatives in 30 States identified some vulnerabilty or consttaint in the discipli
nar 
process. One-third of the comments pointed to the considerable length of time required 
to initiate and complete a case, citing the complexity of the hearng process and dependence 
on State attorney general offices as key factors. An additional 30 percent of the responses 
specifically mentioned the lack of trained investigatory staff with knowledge of optometr. 
All the States in the large category (based on the number of active optometrsts) reponed 
problems in the hearng and investigatory process. In many States, staffing and budget limita
tions increase the severity of these problems. 
Board representatives from 14 States reponed that changes have been made in recent years 
with the intent of expediting the boards ' investigatory and review procedures. Most 
prominent of these changes was the hirng of additional investigators and reorganization of 
the board to place an increased emphasis on investigation. Nearly one-third of the States 
have, in accordance with the American Optometrc Association s model optometr act, "The 
Components of an Optometr Act, " made changes that to varing degrees separate the inves
tigatory process from the board itself. Examples of these changes are the naming of investiga
tion teams with a board representative, the appointment of a complaint and hearng officer, the 
use of consultants, or the establishment of a new investigatory division.. Although some repre
sentatives of these States consider the separation of the investigatory function to be an effec
warts 
tive device, saying it  widespread consideration, others look upon it as a constrnt 
and would like to see the function returned to the board. Other changes made to improve the 
efficiency and effectiveness of the judicial and investigatory processes ar wonh.noting: 
At least four States--Marland, Georgia, Wisconsin, and Mississippi--are using more 
and more prehearng settlement conferences which, in the words of one representative, 
provide real incentive for the licensee to shape up. 
At least two States-- Virginina and California--have a computerized complaint tracking 
system which encourages expeditious processing and follow-up of complaints. 
New York publishes guides for investigators to use in optometrc investigations. 
Illinois now can use all fees collected from examinations and license renewals for board 
has been able to hire an additional investigator as a result. 
puroses. The board 
INFORMATION SHARING 
Infonnation on optometrsts who have been disciplined should be computerized and made 
available to all State boards. 
This comment made by a State optometr board official suggests the current limitations of the 
disciplinar action clearnghouses maintained by the National Clearnghouse on Licensure, En forcement, and Regulation (CLEAR) and the International Association of Boards of Ex
aminers in Optometr (lAB). Simply put, most optometr boards discount the clearnghouses 
as relatively ineffective mechanisms and tend to rely more heavily on communication among 
themselves. 
In our review, 21 of the boards reponed that they are regularly sending infonnation on discipli
nar 
action to CLEAR and/or lAB: 11 to CLEAR only, 8 to lAB only, and 2 to both. Half of 
the States not panicipating in the clearnghouses either offered no reason for not panicipating 
or saw no need to do so. The remaider were not aware of the services or felt that the clearn
ghouses did not provide substantive infonnation. 
In addition to the low levels of State parcipation, several other factors severely limit the 
effectiveness of the two clearghouses. State boards typically do not report infonnal actions 
which account for an increasing percentage of board actions. Many do not report in a timely 
manner, sometimes waiting for months before sendig the data to a clearnghouse. For ex
ample, lAB, of which all States ar members, had infonnation on only 19 fmal actions taken 
by State optometr boards during the first 6 months of 1987: 5 revocations, 6 probations, 7 
licenses voluntary withdrawn, and 1 fine related to an advenising violation. 
When a report is made, infonnation on the applicant can be limited, often not including the 
Social Securty number, the date of birh, or the name of the optometr 
school attended. Al
though the report usually specify the tye of disciplinar action taken, they reflect 
widespread inconsistencies in how the underlying violations are described and the type of 
disciplinar actions imposed. Within individual States, only seven boards noted that they 
have a clearly defined set of guidelines for detennning an appropriate level of 
disciplinar ac
tion. 
Many of the board officials with whom we spoke expressed support for the soon-to-
be estab
lished national data ban under the Health Care Quality Improvement Act of 1986 (title IV), 
and the Medicar and Medicaid Patient and Program Protection Act of 1987 (section 5). They 
tend to see it as a helpful national response to the need for better infonnation sharng of 
disciplinar actions and the reasons for them. At the same time, however, they and others 
raise a number of questions that reflect concerns associated with the implementation of the 
data ban. These concerns involve the accuracy, confidentialty, accessibility, and timeliness 
of the data as well as the time and cost burden  associated with the reporting process. 
Finally, it is important to recognize that the infonnation sharng that occurs within a State is 
also signifcant. Thirt-two States reponed sharng optometrc disciplinar actions, the
priar 
means of dissemination being a newsletter or publication sent to optometr licensees 
or other health professionals. However, almost one-third of the States (9) that publish discipli
nar 
actions do so in the fonn of a press release to the general media or specifically to newslet
ters in the communities where sanctioned optometrsts practice. Fewer States send the 
infonnation to State insurance agencies, welfare agencies or attorney general offices.  RECOMMENDATIONS 
priar 
Given the situation described so far, we offer two  recommendations. First: 
effectively. 
State governments should ensure that State optometry boards have suffcient resources 
to carry out their responsibilties 
In most States this is not now the case. In both the licensure and discipline realms, resource 
limitations (manly  undennining the capacity of the boards to do their 
staf limitations) are 
jobs. With the forthcoming implementation of the national data bank and the additional 
responsibilities it wil place on the State boards, the strains generated by the current resource 
shortal are likely to become even greater. 
Since most of the revenue of the State boards derives from fees charged to practicing op
tometrsts, they are probably the best source for generating additional revenue. As noted ear
lier, the median annual revenue fee in 1985 was only $50. 
Our second primar recommendation is this: 
State governments should ensure that State optometr boards have suffcient 
enforcement authority and a full range of disciplinary options available to them. 
Most boards, as noted, have few if any disciplinar options beyond revocation or suspension 
available to them. To operate effectively they must be able to draw upon a full complement of 
disciplinar actions including revocations, suspensions, probations, practice restrctions, fines, 
censures, and reprimands. With such a range to choose from, they can gain valuable 
flexibilty in detennning how best to respond in parcular cases. 
No less important is the boards' having the power to issue subpoenas and to suspend im
mediately the license of an optometrst who poses a clear and present danger to the public. 
Such authority can enhance their enforcement capabilty and enable them to conduct more 
rigorous and effective oversight on behalf of the public. 
In addition to these two primar recommendations, some other importaIt ones are diected to 
State optometr boards, the International Association of Boards of Examners in Optometr, 
the American Optometrc Association, and the U. S. Public Health Service. 
State Optometry Boards 
State optometry boards should move toward the development of a high-quality, 
standardized national clinical examination.  Among State optometr board officials, this is a sensitive topic because it involves States 
rights and prerogatives. Yet, frm a 51-State perspective, the existence of separate clinical ex
amnations appear to be increasingly counter-productive. It restrcts mobilty of practicing
optometrsts. It suggests that the professional community canrlOt agree on the minimum level 
of knowledge and skills necessar to practice optometr. It results in a duplication of resour
ces devoted to testing. And it diverts State board attention and resources that might otherwise 
be devoted to enforcement and discipline activities. Other professional boards have success. 
fully established a national clinicallicerisure examination; it would appear to be constrctive 
for State optometr boards to do the same. 
State optometry boards should shore up their credentials verifcation procedures. 
A number of boards have aleady moved in this direction. But, as some State board officials 
indicate, more must be done in tenns of the extent and type of (1) infonnation requested.of 
licensur applicants and (2) verification undertaken by board officials. Without these 
safeguards, many boards wil remain too vulnerable to irrgularties that could result in some 
undeserving individuals receiving an optometr license and in an undennining of public con
fidence in the licensure process. 
International Association of Boards of Examiners in Optometry 
The lAB should accumulate and on a regular basis disseminate to State optometry 
boards changes in State practice acts and regulations and best practices concerning 
State licensure and discipline approaches. 
For many years, the American Optometrc Association has been disseminating infonnation to 
State boards and other entities on the changes in State practice acts and regulations and on per
tinent court cases. This appear to have been a useful service. In the years ahead, however 
we feel it would be desirable for the lAB, as the organization directly representing State 
boards of examners in optometr, to assume more of this infonnation dissemination respon
sibilty. In this context, it should be parcularly attuned to identifying and sharng infonna
tion about especially effective approaches to licensure and discipline. 
The American Optometric Association 
The AOA should encourage more extensive and effective interaction between its 
affliated State associations and State 
optometry boards. 
Such action is important because most State optometr associations appear to make few refer
rals to State optometr boards. We urge that the AOA explore why that is the case and what 
might be done to encourage more extensive and effective communication between the associa
tions and the boards.  The Public Health Service

The Public Health Service should assist the lAB to extend and improve its technical 
assistance and information dissemination activities. 
The PHS has long provided such assistance to professional bodies, but in recent years it has 
had minimal interaction with lAB, the national body that is most closely and diectly tied to 
the State optometr boards. It is now an opportune time to extend whatever support is avail
able to lAB to help it playa more effective leadership role vis-a-vis its member boards. This 
is parcularly important with respect to the enforcement and discipline areas, where the need 
for such leadership is compellng.  APPENDIX I 
COMMENTS ON THE DRAFT REPORT AND OIG RESPONSE 
Within the Deparent of Health and Human Services, we received comments on the draft 
report from the Public Health Service and the Health Care Financing Administration (HCFA). 
In addition, we received comments from a number of organizations outside of the Deparent: 
The American Optometrc Association (AOA), the International Association of Boards of Ex
amners in Optometr (IAB), and the National Board of Examiners in Optometr (National 
Board). 
Following ar the comments, in full, of each of the above pares and our response to them. 
PHS COMMENTS 
We concur. PHS through the Health Resources and Services Administration, wil provide tech
nical assistace to the International Association of Boards of Examiners in Optometr as par 
of its professional collaboration with the organization. Limited funds, as available, wil be 
used to extend PHS support in the enforcement and disciplinar activities of lAB. 
DIG Response

We ar pleased with PHS' readiess to extend assistance to the lAB and expect it 
wil faciltate a more effective leadership role by that organization. 
HCFA COMMENTS 
We have reviewed the draft report which focuses on State licensure and discipline practices 
concerning optometrsts. The major finding in the report is that in both licensure and dis
cipline realms, State board offcials tend to feel they are seriously understaffed and, as a result, 
the effectiveness of both licensur and discipline operations is compromised. Since none of 
the recommendations in the report require action by HCFA, we have no specific comments to 
offer. 
We concur with the report s findings and recommendations, and we support the efforts of the 
ala to improve the curent State practices. Thank you for the opportnity to comment on this 
report. 
AMERICAN OPTOMETRY ASSOCIATION COMMENTS 
you sent to Earle L. Hunter, O.D., Executive Dirctor of the American Optometrc Associa
tion, has been referred to me (Thomas E. Eichhorst, J.  ), as Director of the State Legislation 
Center, for reply. The American Optometrc Association appreciates the opportunity to review  this draf report and to comment on it. We also appreciate that you have extended the time for 
us to comment, because there was some delay in our receipt of the draft report. 
The comments of the State Legislation Center of the American Optomettc Association, are as 
follows: 
Page 2:  It should be noted that the AOA definition of Doctors of Optometr now says, in . 
line 7  many states " rather than " some states," as there are presently 23 states in 
which optomettsts are authorized to use pharaceutical agents for therapeutic pur
poses. 
Page 7:  In the second paragraph, line 7, it should state "COE-accredited school" rather than 
COE-approved school." (This is the sole comment that Joyce Urbeck, staff of the 
drt 
Council on Optomettc Education, who also received a copy of the  report, 
asked me to include in our comments. 
Page 8:  Further updating the figures, in the first paragraph in the section entitled " 
TI 
DIVERSITY IN  SCOPE OF PRACTICE " there are now 49 states, the Dis
ttct of Columbia and the Terrtory of Guam, which specifically pennit the op
tomettc use of pharaceuticals for diagnostic puroses and 23 states which pennit 
their use for both diagnostic and therapeutic  of these states 
puroses. Thus, 16 
have alowed the use of therapeutic pharaceutical agents (TPA) since 1985. Only 
one state, Marland, does not have a provision for any pharaceutical use. In
cidentaly, diagnostic pharaceutical agent (DPA) legislation in Marland was 
passed by the legislature in 1988 but was vetoed by the governor. We understand 
that an effort wil be made in 1989 to overrde the governor 
s veto and enact this 
legislation. Alaska did enact DPAlegislation in 1988. 
Page 9:  In regard to the Wisconsin law used as an example, it should be noted that TPA 
legislation was introduced in 1987, and we understand that it wil again be intro
duced in 1989.

Page 11:  In regard to the phrase in the first full paragraph relating to the mobility of op
tomettsts, it should be noted that the optomettc utilzation of pharaceutical 
agents for therapeutic puroses has been recognized as a cost-effective mode of 
providing such treatment in the 23 states with TPA authorization. 
Page 13:  In the first pargraph relating to "DISCIPLINE," please be advised that Eyeglasses 
II at this time is a proposed FrC trade regulation rule, and is not a "case. 
" It has 
not yet been promulgated (it wil not be "enacted"). When it is promulgated by the 
Federa Trade Commssion, the rule wil be subject to judicial review. The 
American Optomettc Association plans to appeal any FTC trade regulation rule 
which purports to preempt the state consumer protection laws which were enacted 
to preserve the doctor-patient relationship and prevent abuses in the eye care field. 
The position of the AOA is that the FTC does not have the power to strke down  vald state laws in the health care field and that the rulemakg 
record does not sup
port the proposed Eyeglasses II rule. 
Page 19:  Last sentence of the fist paragraph, in reference to llinois, "TPA" should be 
DPA" 
Page 20:  In the second paragraph under "ADMINISTRATIVE PROCESS," the reference to 
the "Model Optometr Act" should be to its correct title, the " Components of an 
Optometr Practice Act. " In addition, the American Optometrc Association State 
Legislation Center s Licensur and Regulation Commttee, composed of several 
members who have had experience as members of state optometr boards, is 
developing a Guidebook on Optometrc Discipline, which, like the Components, 
wil be shard with the members of the International Association of Boards of Ex
amners in Optometr and others interested in the licensure and regulation of the 
profession of optometr. 
Page 24:  In regard to the recommendation to the IAB, it should be noted that for the last 23 
years, the American Optometrc Association, mindful of the fmanciallimitations 
and shortage of staf of the IAB, has attempted to disseminate informtion to the 
profession and to governmental officials on the changes in state practice acts and 
regulations. As previously noted, the extensive study of the components of an op
tometr law and the guidelines for the discipline of licensees are curent examples 
of these public-spirted efforts to help protect the visual welfare of the AmeriGan 
people. 
Page 24:  When this report is made public, the Licensure and Regulation Committee of the 
State Legislation Center of the American Optometrc Association wil be pleased 
assist in its dissemination and to panicipate in the laudable efforts to further im
prove the licensure and regulation of the profession of optometr. In that regard 
the committee wil then consider appropriate effons to implement the recommenda
tion encouraging more extensive and effective interaction between state optometrc 
associations and state optometr boards. It should be noted that the word "af
fIiated" should be insened between the words "its " and "State association " as the 
American Optometrc Association is a federation of autonomous affIiated state op
tometrc associations. 
Again, we appreciate the opponunity to have received a copy of the draft report and to make 
these comments. If there is any other way in which the American Optometrc Association 
State Legislation Center can be of assistace to you in your studies of the profession of op
tometr, please let me know. 
OIG Response 
We appreciate AOA' s readiness to help disseminate the final report and its wiling-
ness to consider the matter of more extensive and effective interaction between  State optometrc associations and State boards. We also appreciate its many help
ful suggestions. In each case we have made changes that 
ar responsive to the sug
gestions. 
Of parcular note is AOA's comment about its long-established efforts to dissemi
nate infonnation on State practice acts. In recognition of that and of lAB' 
s interest 
in playing a more active role in this area (as expressed in its comments), we have 
completely revised the paragraph elaborating on our recommendation directed to 
lAB. Since lAB is the organization representing the State boards, we feel that over 
time it would be more appropriate for it, rather than the organization representing 
the profession of optometr, to emerge as the leading agent for disseminating infor
mation to State boards. 
Finaly, we have made the corrections and/or clarcations called for on pages 2, 7, 
9, 11, 13, 19, and 20. 
INTERNATIONAL ASSOCIATION OF BOARDS OF EXAMINERS IN OPTOMETRY 
COMMENTS 
On September 20, 1988, the International Association of Boards of Examners in Optometr
received a copy of the above-captioned Draft Report prepared under the direction of Mark R. 
Yessian, Ph.D., Regional Inspector General for Analysis and Inspections in your Boston of
fice. The lAB was invited to comment on this draft, and it was indicated that such comments 
would be taken into account in preparng the final report. Please forgive our tardiness in 
responding, which is related to the fact that we moved our office in Washington and acquired 
a full-tie Executive Director, Kenneth G. Crosby, Ed.D., during the specified comment 
period. 
On behal of the lAB , I wish  compliment your office on the insightfulness and quality 
fist to 
of the draft report We do believe, however, that certain areas and items need to be brought up 
to date or clarfied in order to ensur its overall accuracy and completeness. 
The lAB has been strving diligently for the last four years to develop the basis for a high-
quality, standardized, validated, and psychometrcally sound clinical 
skils assessment that can 
be used by state boards of optometr for licensure pUIposes. A contract has just been signed 
by the lAB and the Commonwealth of Pennsylvania for the first administrtion of the resul
tant examnation, which wil occur in July of 1989. Several other states in the northeast have 
requested the lAB to develop this test furter for a stadardized, regional, clinical skils assess
ment, the results of which wil be recognized by at least thre or four states in the region begin
ning in July, 1990. The lAB anticipates that additional states in the northeast wiUjoin with 
the origial ones to fonn a larger group, as the results and reputation of the examination be
come evident. In addition, several states in the central, mid-west region have indicated an in
clination to follow a similar path.  The lAB' s development of its own offce, professional sta, and facilties places it in a much 
improved position to service its constituency--the state boards of optomett--and other 
regulatory agencies. A computerized program for classifying continuing education and verify
ing attendance at meetings for this purpose wil be integrated into a national data bank on 
licensed optometrsts, which wil begin to meet the needs and demands established under the 
Health Care Quality Improvement Act of 1986 and the Medicare and Medicaid Patient and 
Program Protection Act of 1987. We look forward to working with the Public Health Service 
to solve problems concerning the accuracy, confidentialty, 
accessibilty, and timeliness of the 
data, as well as the time and cost burdens associated with the reponing process. Provision of 
assistace to state boards in the sometimes overwhelming admnistrative task of maintaining 
and sharng infonnation regarding disciplinar actions, along with verifying, classifying and 
credentialling of continuing education for relicensure, and the 
credentiallng of candidates on 
the entt level, is a necessar, appropriate, and ongoing goal of the lAB. Development and 
use of a national data base wil help eliminate or reduce many of the ineffective and inefficient 
procedurs curently being employed in this area. 
The IAB has cooperated and worked with the American Optometrc Association (AOA) on 
progrs 
many  and in many areas. In these effons, the lAB has recognized the need for each 
organization to maintain its independence, so as to be able to meet its own 
responsibilties to 
state and regulatory agencies, the public, and the optometrc profession. The IAB looks for
ward to a tie in the near futue when it can administrtively be solely capable of accumulat
ing and disseminating to state boards, on a regular basis, changes in state practice acts and 
regulations, along with recommendations tconcerning state licensure and discipline ap
proaches. We concur with the recommendation hat the AOA should encourage more exten
sive and effetive interaction between its state associations and state 
optomett boards 
concerning cenain topics only, such as disciplinar actions, ethics, and appropriate standards 
of professional car. Greater communication between state associations and state boards in 
this area can enable practitioners to be better educated and advised as to what is appropriate 
and acceptable professional behavior and what is not. However, the lAB believes that such in
teraction should not go beyond the limits necessar to maintain the independence of action by 
state boards that is required to fulfill their responsibilties for the public welfare and to ap
propriate state and federal regulatory agencies. The IAB wil welcome the assistance of the 
Public Health Service in improving and extending its dissemination activities. It should be 
noted that the PHS previously provided much needed and appreciated suppon for develop
ment of the lAB' s Continuing Education Classification System. 
The lAB is most appreciative of this opponunity to comment on the draft report, and it hopes 
that its contrbution can be used constrctively in preparng the fmal version. 
Response 
o IG 

We agree with the IAB that while greater communication between State associa
tions and State bords is desirable, it is imponant to assure that State boards retain 
the necessar independence to fulfull their public responsibilties. Also, we are 
pleased that the lAB looks forward to a more active role in accumulating and dis seminatig information to State boards. Finally, we have noted in our final report 
the contract signed by the lAB and the Commonwealth of Pennsylvania. 
NATIONAL BOARD COMMENTS 
This is in response to the letter dated September 20 I received from Richard P. Kusserow
, In
drt 
spector General, Deparment of Health and Human Services, with the  report entitled, 
State Licensur and Discipline of Optometrsts. 
First, let me point out that this is not a formal response from the National Board of Examiners 
in Optometr. The National Board provides a national standardized examination for op
tometrc state boards to accept, voluntarly, as par of the licensure process in the varous 
states. In addition to the National Board wrtten examination which is accepted by 
all but five 
of the 53 licensing jursdictions in the United States and its terrtories, optometrc state boards 
administer addtional examations within the state prior to licensure. Consequently, my 
remarks ar those of the Executive Director of the National Board and address the factual con
tent of the report regardig your mention of the National Board, and raise one or two ques
tions on certain issues that I trst wil be useful. 
On page 2 you state that " (my emphasis) in occupational vision 
optometrsts are  specializing
needs, sports vision needs, or the specifc vision needs of the elderly, children , or those with 
low vision. " Given that no recognized specialty certifying bodies exist in 
optometr, I am con
cerned that your use of the word "specializing" may be misplaced. If you have found from 
your studies that optometrsts do specialize in these areas of eye care, then the word "specializ
ing" should remain. This is an importt issue for the future of the profession, parcularly in 
areas that requir additional trning and/or expertse to provide car to special categories of 
patients or in special technical areas of optometrc practice. Similarly, the statement that 
group practice and  specialization  (my emphasis) ar increasing" is an important statement
that should not be allowed to stand without 
furher review. 
On page 7, your use of the "NBOE" (note order of letters) and "National Board of Optometr
Examination" is incorrect. The National Board of Examiners in Optometr is a 
501(c)(3) tax 
exempt corporation, providing testing services to the profession of optometr. It does not use 
an acronym, or a combination of initials (such as NBEO or NBOE). If a shortened fonn of its 
full name is to. be used we prefer to be referred to as the "National Board. 
" Further on page 7 
in the fourt paragraph, you make the statement "Between the years 1981 and 1986 an 
average of 79% of the candidates takng the examination met or exceeded the passing score of 
75." I am not sure I understand where you obtained these data. The National Board' s ex
aminations during the period under study (1981-86), were admnistered in thre pars; Par I 
Par ITA and Par lIB. The passing score for each Par is a scaled score of 300, on a scale of 
100 - 900. Consequently, the use of the passing score of "75" (note also that no indication is 
given as to whether this is a scaled or a percentage score) is totally inaccurate. To be sure that 
you quote the National Board standards accurately, I suggest that you contact me by telephone 
so that I can discuss this with you diectly. To imply that the National Board, which was the 
first national board of a licensed health profession to institute criterion-referenced standard set ting in 1981 , uses 75 as a passing score, does not add to the quality of your report nor the 
reputation of the National Board. This is an issue that is often not well understood by govern
ment officials. Because of the importance of your report we are wiling to take the time to be 
sure your statements are corrct.

On page 24, your recommendation that "The AOA should encourage more extensive and effec
tive interaction between its State associations and State optometr boards" suggests the begin
ning of a new diection for the Federal Government. It has been commonly understood in the 
credentialng community, and parcularly with those of us who deal with the licensure of can
didates for practice in the health professions, that the state associations which represent the 
vested business and professional interests of the  practitioners  should  not  influence the 
decision-makng of the state regulatory boards which are charged with protecting the health, 
To recommend in an Inspector General's report that state as
safety and welfare of the  public. 
sociations should "effectively interact" with the state boards, undennines much of the work 
over the past two decades to assure independence of state board action. If this is 
trly the In
spector General' s recommendation, then let it stand. However, if this is a statement that has 
been not given full consideration then I recommend that this be reconsidered prior to printing 
the final report. 
I appreciate the opportunity to react to your report. Again, please understad that this letter 
not an offcial position of the National Board of Examners in Optometr. It is nothing more 
than the reflections of its Executive Director after having read through the draft copy of the In
spector General' s report you provided. 
DIG Response 
The National Board sttesses the importance of the independence of State boards. 
As noted in our previous comment, we concur. Yet, such independence does not in
clude more effective coordiation between State boards on matters concerning the 
referr of cases to the Boards. Such interaction takes place between State boards 
and professional associations in many other fields. It would appear to be war
ranted in the field of optometr as well. 
With respect to the technical connections suggested by the National Board, we 
have made the suggested changes in the final report.  APPENDIX II

BACKGROUND 
The licensure and discipline of health care professionals is a traditional function of State 
Government. It dates back to the pioneering efforts of the American colonies in the 1600'
s. . 
But it did not gain pennanence until the late 1800'  , when Texas passed the first modern medi
cal practice act (1873) and the U.S. Supreme Coun upheld West Virginia s act as a valid exer
cise of State police powers (1889). 
In recognition of this traditional State role, Congress, when it established the Medicare and 
progrs 
Medicaid  in 1965, left it to the States to detennne whether physicians and other 
health care professional were legaly authorized to parcipate in these progrs. Sub
sequently, Congrss has empowered the Deparent of Health and Human Services (HS)
and its predecessor (Health, Education and Welfare) to impose sanctions on those profes
sionals (and other provider groups) who have abused or defrauded these 
progrs. However
the Federal Government has continued to depend on the States to serve as the disciplining 
agent for trsgressions that do not diectly relate to the Medicar or Medicaid programs. 
Thus, States have been providing an important front line of protection for beneficiares 
progrs. 
these two Federally funded  This protection has been at no cost to the Federal 
Government and at only minimal cost to State Government. Nearly 
al the costs have been 
covered by licensure fees imposed on the health car professionals. 
As Medicar and Medicaid expenditures have grown to a point where they now account for 
more than one-four of United States health car expenditues, Federal interest in the effec
tiveness of State licensure and discipline practices has increased. For the most par
, this 
heightening interest has focused on those practices concerning medical doctors. In essence 
this is because they ar the most prominent of the health car professionals and because they 
account for a larger share of Medicare and Medicaid expenditures than any of the other 
groups. More specifically, serious concerns about the adequacy of State medical licensure and 
disciplie practices were rased by Genera Accounting Office reports, media investigations, 
and scandals involving 
frudulent medical crdentials frm two Carbbean medical schools. 
Accordigly, in 1985 and 1986, the Office of Inspector General conducted an inspection ex
amining the activities of State medical boards. Based primarly on visits to 14 State boards 
and telephone discussions with the executive dictors of another 10, the inspections sought to 
provide an overview of the major developments and issues facing the boards. The final report, 
issued in June 1986, received widespread publicity and helped generate refonns to improve 
the effectiveness of State medical boards, parcularly with respect to their 
disciplinar prac
tices. 
Given the positive response and effects of that inspection, the OIG decided that a similar one 
directed to other health care professionals eligible for Medicare or Medicaid reimbursement  warted. 
would also be  For these other professionals no less than for medical doctors, State 
licensur and discipline boards offer a vital front line of protection for the beneficiary. 
We chose dentists, podatrsts, chiropractors, and optometrsts as a focus because, like medical 
doctors, they ar diect care professionals who have diagnosing and prescribing respon
sibilties, who can receive dict Medicare reimbursement, and who, overal, represent a major 
presence on the health care scene. Dentists, podiatrsts, chiropractors, and optometrsts 
together with doctors of medicine and osteopathy are the six groups of health care profes
sionals defined as "physicians " under Medicare law. 
Recognizing the value of obtaining a better national picture of the licensure activities of these 
and other health care professions, HHS (through the Public Health Service) awarded a 3-
year
conttct in July 1984 to the Council of State Government (CSG) and the National Clearn
ghouse on Licensure Enforcement and Regulation to develop a composite State-
by-
State infor
mation system on the credentialing of health professions. The project generates informational 
repons on the varous professions, drwing primarly on State practice acts and State board 
regulations. The repons present data in separate tables that addrss such matters as the or
ganizational pattern of the State boards, the administrative and enforcement functions of the 
boards, the types of examnations required, and the fees imposed. Overall, the descriptive in
formation provided focuses more on licensing than on disciplinar activity. The CSG and 
CLEAR have published repons on each of the four groups to be addressed in this inspection--
chiropractors (1986), podiatrsts (1986), dentists (1987), and optometrsts (1987). 
The CLEAR, which is composed of State offcials involved with occupational licensing and 
regulation issues, also runs the National Disciplinar Information System (NDIS). This is an 
interstate servce that provides parcipating State agencies with bimonthly repons on discipli
nar 
actions taken agaist licensed professionals in a number of professional disciplines. Den
tists, podiatrsts, chiropractors, and optometrsts are among the occupation groups included in 
the system. The disciplinar actions taken against these and other groups ar sent to NDIS on 
a voluntar basis and at this point involve only 32 States. The Federation of State Medical 
Boards operates a similar but more detailed and complete system that focuses on disciplinar 
actions taken agaist medical doctors. 
Two recent congressional actions provide an imponant stimulus toward the funher sharng of
data on disciplinar actions. First of all, the Health Care Quality Improvement Act L. 99-. 
, (P.
660), passed in 1986, calls for the establishment of a national data bank to be run by the HHS 
Secretar (or a designee thereof). It stipulates that entities making malpractice payments as
sociated with the work of physicians and other licensed health care professionals must report 
pertnent information concerning those payments to the data bank. Similarly, it mandates the 
reportng of disciplinar and peer review actions taken against medical doctors, osteopaths 
and dentists. The information maintained in the data bank is to be available, upon request, to 
State licensur and discipline boards, health care entities, attorneys who fied a malpractice 
complait with a coun against a specific practitioner, and individuals interested in records on 
themselves.  100-93) is the Medicare and Medicaid Patient 
The second pertnent congressional action  (PL. 
Progr 
and  Protection Act. Passed in 1987, this legislation includes a provision that would 
extend the national reportng responsibility of State licensure and discipline boards to encom
pass disciplinar actions taen against podiatrsts, chiropractors, optometrsts, and other 
licensed health care practitioners. 
Thus, on the basis of the authority provided by these two acts, State boards 
wil be able 
draw upon a national data ban to detemrne if any disciplinar actions have been taken 
agaist an applicant for licensur. It is expected that this data ban wil be operating in the 
near futue.

Finaly, with respect to optometrsts, on whom this report focuses, it is important to add that 
since 1984, the International Association of Boards of Examners in Optometr has collected 
information on the disciplinar actions of State optometr boards on a quarerly basis. All 51 
States (DC included) ar members of the lAB. Yet for the last 2 years, an average of only 25 
percent have actually reported to lA. Up until September 1987, lAB, on the advice of its 
counsel, did not release disciplinar informtion to State boards. However, in anticipation of 
the establishment of a national data bank, lAB is taking a more active role as a disciplinar 
clearnghouse. It now provides the name of the State in which a practitioner has been dis
ciplined and refers a request for information to a State board official within that State.  APPENDIX II 
METHODOLOGICAL NOTES 
We held discussions with representatives of 49 State boards. (New Hampshire and the Distrct 
of Columbia did not parcipate.) Usually, we taled with the executive director of the board 
and often with a chaian or other member of the board. Our aim was to obtain infonnatiori 
and discuss issues with a board representative who was well infonned about board activities 
both at the tie and over the previous 3 to 4 years. 
The major ara in which we sought quantitative infonnation concerned the disciplinary ac
tions taken by the boards agaist optomettsts in 1984, 1985, and 1986. Here, we asked for 
the number of fonnal actions taken and a breakdown of the type of actions--whether as revoca
tion, suspension, probation, or other. 
Forty-seven of the boards were able to provide us with totas for disciplinar actions taken in 
each of the 3 years. (Georgia and Missouri were the exceptions.  Two State boards that par
ticipated in the interviews could not provide the data within the sufficient time period. 
confi 
We cannot  that the infonnation is all-inclusive or completely accurate. However, we 
did stress that we sought all board 
disciplinar actions against optometrsts, and we often 
checked back when we suspected there might be errors. The board offcials, typically, were 
quite responsive in checkig their records and providing the data in a timely fashion. 
In analyzing the differential perfonnance of the States in disciplining 
optometrsts, we decided 
to aggregate the disciplinar data over the 3-year period. We felt that comparsons over only a 
1- or 2-year period would be of questionable value because of distortons that might arse be
cause of year-to-year fluctuations. 
In this context, we treated perfonnance as a dependent varable and considered two major in
dependent varables: size and region. With respect to size, first of all, we identified the num
ber of active civilan optometrsts in each State and, then, using varance analysis, identified 
four clusters of States differentiated on the basis of the number of active 
civilan optometrsts. 
The clusters and associated States are as follows: (1) small (DE, DC, VT, AK, WY, ND, SD 
, NV, NH, UT, RI, MT, il, NM, MS, NB , ME, and WV); (2) medium (SC, CT, AZ, AR 
KS, AL, CO, MD, KY, GA, OK, OR, lA, NJ, VA, MO, MN, NC, WA, and LA); (3) large (TN 
WI, IN, MA, PI, MI, OH, TX, PA, IL, and NY); and (4) 
extr large (CA). 
With respect to region, we used U.S. Bureau of the Census categorizations to identify four 
regions of the countr. The categorizations and associated States are as follows: (1) Northeast 
(CT, ME, MA, NJ, NH, NY, PA, RI, and VT); (2) South (AL, AR, DE, DC, FL, GA, KY, LA 
MD, MS, NC, OK, SC, TN, TX, VA, and WV); (3) Midwest (lA, IL, IN, KS, MI, MN, MO, 
NE, ND, OH, SD and WI); and (4) West (AK, AZ, CA, CO, HI, il, MT, NV, NM, OR, UT 
, and WY).  APPENDIX IV

ENDNOTES 
For the 1975 data, see U.S. Deparment of Health and Human Services, Public 
The First Report to the President and Congress on the Stare of 
Health Servce, 

Health Personnel in the United Stares,'March  1986, pp. 6-13 and for the 1986 dam, 
see Iring Bennett, O. State of the Ophthalmic Industr: 
D., Advisory Enterprises, 
1987, 1987, p. 
Spread the Good News,  March 1987, p. 47.
Review of Optometry, 

S. Deparent of Health and Human Services, Health Care Financing Ad
ministrtion, Health Statistical Information Service, phone interview. 
Annual Income Surey:  July 
How Do You Compare?"  Optometric Management, 
1987, p. 42. 
vol. 3, section 15, 504 
Commerce Clearinghouse Medicare and Medicaid Guide, 

1984. 
Annual Income Surey: How Do You Compar?" p. 42. 
State Regulation of the Health Occupations and 
Council of State Governments, 

June, 1987 p. 48. As noted in the American Optometrc Association 
Professions, 
(ADA' s) comments in appendix IV, the ADA's definition was recently revised to in
dicate that "many" rather than " some" States use pharaceutical agents for 
therapeutic puroses. 
American Optometrc Association  1985, pp. 8-17.
Optometry Today, 

Students Forecast Their Futures,  May 1987, p. 92.
Review of Optometry, 

10. State 
of the Opthalmic Industry,  pp. 1
11. "Students Forecast Their Futures. 
12. Stare of the Opthalmic Industr,  pp. 1-16. 
13. Ibid., 
p. 6. 
14. Annual Income Survey: How Do You Compare?" pp. 30-42. 
15. Ibid., p. 42.  16. U.S. Deparent of Health and Human Services, Public Health Service,  The Fifh 
Report to the President and Congress on the State of Health Personnel in the 
March 1986, pp. 1-10. 
United States, 

17. Optometry Today,  p. 7.

Fifh Report to the  lO. 
18.  President, 
19. Ibid., 
p. 6, 1. 
20. As provided to the Health Resources and Services Administration by the American 
Optometrc Association and the Association of Schools and Colleges of Optometr. 
Fifh Report to the 
21.  President,  p. 6; 2. 
22. Optometry Today,  p. 7. 
23. Fifh Report to the President,  p. 6, 5.

24. 
Ibid., p. 4. 
25. Optometry Today,  p. 6. 
26. The International Association of Boards of Examiners in  A Continuing 
Optometr, 
Optometric Education Classifcation  May 1985, p. 6. 
System, 
27. Here and elsewhere in this repon, unless otherwise noted, the data are derived 
frm our survey of the 49 States. See appendix IV. 
28. 
State Regulation of the Health Occupation,  p. 62. 
29. We developed the $2 millon estimate as follows: For each State, we multiplied the 
total number of licensed optometrsts in 1984 by the renewal fee that year. That 
resulted in a total of $1.6 millon. We then assumed that renewal fees accounted 
for two-thirds of overal fee income from optometrsts and, accordingly, added one-
third to the total. This resulted in a new total of $2. 1 millon. 
30. State  pp. 60-61. 
Regulation of the Health Occupations, 
31. National Boards of Examners in  1987. p. 75.
Optometr,  Candidates Guide, 

32. 
pp. 49-59. 
State Regulation of the Health Occupations,  33. 
National Board of Examners in  An Era of Achievement 1980 -1986 
Optometr, 
pp. 14-15. 
34. Council of State Governments, p. 47. 
35. Council of State Governments, p. 59. 
36. 
International Association of Board of Examners of  State Board 
Optometr, 
Februar, 1987 and updated infonnation provided by the American Op
Forum, 
tometrc Association. 
37. Council of State Governments, p. 47. 
38. 
Ibid., p. 47. TPA legislation was introduced in Wisconsin in 1987 and is expected 
to be introduced agai in 1989. 
39. 
State of the Opthalmic Industry,  p. 5. 
40. 
International Association of Boards of Examiners in  Candidates 
Optometr, 
November 
Guide; Examination in Treatment and Management of Ocular Disease, 

1987, and April 1988.

41. Council of State Governments, p. 64. and the International Association of Boards 
in Optometr 
 Candidates Guide; Examination in Treatment and Management of 
November 1987 and April 1988 p. 7. 
Ocular Disease, 

42. Ibid., pp. 58-68. 
43. 
Ibid., p. 58. 
44. An Era of Acheivement, p. 11. 
45. 
International Association of Boards in  Assessment of Entry Level Skils 
Optometr, 
1987, p. 10. 
46. 
p. 15: The AOA, in its comments in appendix IV, 
State of the OpthalmicJndustry, 
notes. that when the rule is promulgated, it plans to appeal it. 
47. Council of State Governments, pp. 56-57. 
48. The national data bank-now being established under title IV of the Health Car 
Quality Improvement Act of 1986 wil provide a basis for answering this question 
in the years ahead.  , p. 
49. From Federation of State Medical Boards and Office of Inspector General discus
sions with State optometrc boards and State dental boards. 
50. See Federation of State Medical Boards and 
 Fifh Report to the President,  p. 6, 14. 
The actual rate of discipline is probably slightly less that that indicated in the text, 
because in a few instaces, the discipline action totals involve actions against the 
same optometrst, dentist or medical doctor. Also, to arve at a 1985 estimate of 
the number of active optometrsts, we assumed that the increase from 1984 (the 
latest date for which national data were available) and 1985 equaled the average in
crease of 315 that applied between 1980 and 1984. 
51. "Opthalmology s Fragmented Future,  Februar, 1987  55. 
Review oj Optometry,