Eye Care in the VA: Why it Matters
The Department of Veterans Affairs (VA) has a long, successful history of providing care to veterans with complex medical problems.1 Currently, with estimates of more than 20.1 million veterans in the United States, comprehensive eye exams are provided by more than 930 VA optometrists.2,3
However, veterans’ eye care services have been under scrutiny lately. A recent New York Times article quoted the new Secretary of Veterans Affairs, Dr. David J. Shulkin, as saying, “We make eyeglasses for our veterans. Last time I checked, every shopping mall in America has a place where you can get glasses in an hour. I don’t care about making eyeglasses. I care about getting that veteran his prostheses.”4 In the same article, the secretary goes on to acknowledge, “Many of the agency’s patients have a complex mix of physical and mental health issues. They can’t go get care in the private sector, at least not the comprehensive care the VA gives them.”4 In another report, an unnamed medical center director stated that Secretary Shulkin suggested all medical directors eliminate VA optometry and audiology at their facilities.5
But comprehensive eye care goes far beyond an eyeglasses prescription. Optometry provides the majority of the comprehensive eye care encounters at VA, and increasing access and reducing costs isn’t as easy as just outsourcing a specialty.
The Long Arm of VA Education
The majority of VA optometrists have completed additional training through hospital-based ocular disease, contact lens or low vision rehabilitation residency programs. Many optometrists pass additional exams designed to document competency in medical-based optometric care. The additional training prepares them to provide the unique care a veteran cohort requires.
The VA also has the largest optometry clinical training program in the United States, with more than 180 accredited resident positions and more than 1,400 student externships each year.6 Approximately 70% of all optometry graduates depend on VA for some part of their training. Clinical education, one of the pillars of VA, along with clinical care and research, would be lost if VA optometry is outsourced to the private sector.
VIP Care for VA Patients
Refractions are only one part of the comprehensive eye exams VA optometrists routinely perform to evaluate and manage a wide range of ocular diseases, as well as the ocular manifestations of systemic diseases.
VA optometrists also have the unique ability to address veterans’ visual needs as part of an integrated system. Optometrists specializing in low vision and vision rehabilitation provide services for veterans who are visually impaired, legally blind or who suffer from duel sensory impairment—no small feat, considering the VA estimates approximately 130,428 veterans are legally blind and more than one million are visually impaired.7 Integrated care with blind rehabilitation therapists aids our low vision veterans with orientation, mobility training and home skills training. As part of a team, VA optometrists prescribe low vision devices and technologies that help veterans maintain independence and a better quality of life.
Another area of particular significance involves traumatic brain injury (TBI), given an estimated 320,000 soldiers have experienced a TBI during deployment since 2001.8 Ocular manifestations from this injury can be devastating, and optometrists coordinate care with the subspecialty VA teams that aid in the veteran’s recovery or rehabilitation.
Additionally, optometric privileges in a hospital-based setting provide additional diagnostic and ancillary testing. For example, onsite imaging of the head, neck and orbits can save vision, and lives, with prompt diagnosis of conditions such as carotid occlusive disease, space-occupying lesions, aneurysm and stroke.
When it comes to technology, the VA has much to offer that the private sector cannot. The VA’s electronic medical record is integral to the instantaneous communication between providers, who can review complete records of patients who have received care at multiple VA facilities and in the Department of Defense.
Further, VA optometrists comprise the majority of providers who are certified in teleretinal imaging. This screening process, most often done at the time of a primary care visit, has expanded access to care and introduced prompt examination and intervention for diabetic and other eye diseases.
The Numbers Don’t Add Up
Outsourcing may not even be cost effective. VA, as with other government agencies, can contract for goods through a bidding process, ensuring access to top-of-the-line technology and goods at the lowest possible price. In addition, optometrists are cost-effective providers. The average VA optometric salary in 2015 was $103,044, compared with an ophthalmologist’s base salary of $186,177.9,10 With optometry providing the majority of eye care, ophthalmology can focus on surgical eye care and treatment of advanced disease—further cutting costs while maintaining exceptional patient care. As the scope of optometry practice widens, optometrists’ role will continue to expand, especially in underserved rural communities, where many of our veterans live and access to eye care is lacking.
Most importantly, outsourcing to the private sector creates new challenges in coordinating care delivered by both VA and the community, potentially delaying care while also driving up costs.
VA optometry provides far more than just eyeglasses. We are committed to continuing the mission President Lincoln promised, the VA mission: “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s veterans.
—Jarett Mazzarella, OD
1. Galea S. Editorial: Veterans’ Health. Am J Epidemiol. 2015;181(4):223-4.