OD TO OD
Expanding the Scale
We've weighed the pros and cons of participating in managed care plans, but do we have any options?

BY NEIL B. GAILMARD, O.D., M.B.A., F.A.A.O., Chief Optometric Editor

Of course we do. Optometrists don't have to participate in managed vision care plans or medical plans. But over time, managed care has become a routine fact of life in health care, so it seems like there is no choice left. After all, would patients really pay out of pocket to stay with their family eye doctor when they could see another doctor for free?

Intuitively, you'd doubt it, but many management experts say that it does happen. What percentage of patients on a discount vision plan could you afford to lose (assuming the rest would stay with you and pay your usual fees) and still earn the same net income? That's a good question that smart managers continue to re-evaluate in their practices. After all -- why not see fewer patients for the same income? We explore the concept in this issue's cover story.

Critical points to ponder

Evaluating new plans or existing plans in your practice should revolve around an understanding of your cost of doing business, and your availability of appointments. Remember these two additional points: 1) Some plans allow the patient to file a claim directly and receive some reimbursement when they see a non-panel provider -- so it's not necessarily all or nothing for the patient. 2) Routine annual vision care isn't prohibitively expensive, like some other aspects of health care, such as surgery. Most people could afford to pay for it if they wanted to.

The pendulum swings

It's interesting to note some typical ups and downs in optometric thinking with regard to managed care participation over time:

Optometrists think it would be a good idea if people had vision care insurance, which would cause patients to come in more regularly for eye care.

• Then, we realize that some plans don't allow us to balance-bill for our usual fee, and the paperwork is intrusive, so we think we may be better off without insurance plans.

Then we hear that many new plans are coming to our area, and if we don't sign up, we may be locked out of panels and have no access to our local population.

• Then we realize that some vision plans pay so poorly that we lose money on every patient we see. You can't make that up on volume.

But we also realize that if the exam chair is empty -- even a low fee is better than no fee.

• With our scope of practice well established in medical eye care, we realize that we could bill third parties for most services, if we just find the right procedure code.

Then we strategize that we're better off with non-covered services and products for which patients will pay privately, so we seek to provide services that don't have a procedure code.

• Then we notice that medical doctors are increasingly billing insurance and not asking for payment in the office, so we try to duplicate that approach.

Then we realize that many health plans don't allow O.D.s on their panels, or require gatekeeper approval for eye care, so we often don't get paid . . .

•  . . except by Medicare, which actually pays pretty well and doesn't discriminate against O.D.s, so we do participate in that program . . .

 . . . unless it's an HMO-Medicare program, which can make it difficult for O.D.s to collect.

Will you buck the trend too?

It goes on and on, but with each negative swing of the pendulum, more doctors decide to buck the trend and say they've had enough. Through excellent patient service and advanced clinical care, they're building a local reputation that supersedes the list of participating providers -- and they're attracting patients who want to see them badly enough to pay for it.

Dr. Gailmard moderates the OM forum at www.optometric.com. Please post your comments.