Clearing the Mist Surrounding Healthcare Reform

By Daniel L. Mannen, OD, FAAO June 01, 2012
Sometimes the questions are complicated and the answers are simple.”
Dr. Seuss

Recently, an Open Forum was held with representatives from both the AOA and VSP discussing stand-alone vision plan direct participation in the newly forming state insurance exchanges. As I reflect on the forum and AOA communications following the event, it seems that we are in need of some additional clarification regarding access for optometry.

If we apply basic business principles, we would never abandon a successful approach for a new direction without making certain it will work.

Today, stand-alone vision plans provide access to more than 100 million patients for optometric practices—57 million by VSP alone. To enact policy that diminishes this important direct-access channel in favor of health-plan-controlled access—without solving the myriad discriminatory problems that are present with health plans—simply denies basic business logic. We cannot put our faith in untested assumptions regarding the unknown without incurring needless risk. It seems to me that not enough attention is being given to protecting current access to patients. Many problems must be solved with health plans before they gain greater control of optometric access.

Meanwhile, the rhetoric we see following the forum appears to overstate security of optometric access in an attempt to give you and me more comfort in the notion that excluding stand-alone vision plans will somehow lead optometry to parity with medicine.

Here are three examples:

1. Despite claims to the contrary, it is a fact that stand-alone vision plans cannot directly participate in the new insurance exchanges under the Affordable Care Act  as currently written. Stand-alone plans may participate with health plans; however, there is little opportunity to do so, as many health plans own vision plans and the remainder already have relationships with vision plans. The pie has already been carved up. Diminishing stand-alone vision plans simply advantages health-plan-owned vision plans like Spectera (UnitedHealthcare) and Davis Vision (Highmark/Blue Cross), which are characterized by lower reimbursements and marginalized materials. Further, participation in these health-plan-owned vision plans does not ensure medical panel access.

We know that health plans have a goal of cost reduction as a basic business strategy. That means they seek:  lower utilization, fewer providers, and lower doctor reimbursement. In fact, utilization drops by as much as 50% when the vision benefit is embedded in the health plan. Remember, we are talking about healthcare reform and the Affordable Care Act. It should be clear that motives of health plans are contrary to the goals of optometry regarding increased access to medical panels and reimbursement parity.

2. Though post-forum communications suggest that we are protected from discrimination,  this statement is only partially true. Clearly, if the new healthcare reform statute offered “any willing provider” protection, we would all feel better about our prospects for participation. However, the Harkin Amendment simply does not guarantee that all optometrists will be able to participate nor does it guarantee equal pay for equal work. If you have any question at all about the protections that are found in the Harkin Amendment, I would recommend that you read it for yourself and draw your own conclusions. (It is only three sentences long—116 words.) You can also read more about the evolution of the amendment according to the American Chiropractic Association and why “the amendment as agreed to was not ideal.”

3.  Finally, leaders are claiming that the new law designates optometric services as essential; yet, our participation in the new law is up in the air. Why? Because health plans—the very people we hope will give us a fair shake in the absence of direct access through stand-alone vision plans—are fighting to see that benefit become a screening rather than a comprehensive exam. Pediatric vision has been deemed essential, but the scope of the benefit and who will provide the service has yet to be decided. Both the AOA and VSP are advocating hard for the pediatric benefit to be a comprehensive eye exam and for optometry to provide that service.

So, what I am recommending here is just the simple application of common sense. We must protect our current access to patients while we fight to gain medical integration. Likewise, we must not let untested assumptions cloud our business acumen and impair our efforts for optometry to strengthen its rightful place in health care.

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