Busting the Vision Plan Myth

Optometric visits can identify ocular and systemic diseases early So why do insurers split this essential health care into a separate plan?

By Erin Murphy, Contributing Editor

The comprehensive eye exam is a key healthcare entry point for patients, many of whom may not have a primary care physician. As you know, optometrists not only evaluate and correct vision, they also diagnose eye diseases, such as glaucoma, cataracts, retinal disorders, lid abnormalities and infections. Their examinations also may identify signs of systemic diseases such as diabetes and hypertension — often at early stages.

Most optometrists agree that periodic, professional eye exams should be part of every integrated, cost-effective strategy for patient health. But insurance companies that don't cover eye care or isolate vision benefits in a separate plan don't fully understand this.

To many, the answer is simple: Coverage for an eye examination should be included in every health plan. But to make this happen, first we need to understand the problem.

Maureen West, director of the American Optometric Association (AOA) Third Party Center, and Chuck Brownlow, OD, FAAO, associate director of the AOA Third Party Center, offered to help shed some light on this issue. Ms. West has spent 30 years working in the managed care industry, and Dr. Brownlow is a frequent author and speaker on the current health system and the future of health care.

According to these experts, lack of coverage for eye examinations and the artificial division of “vision” and “medical” eye exams stand in the way of an integrated system that benefits all parties.

Millions Without Coverage

It's common knowledge that many Americans have no health insurance, and many of those who have health insurance still have no coverage for eye exams. Some patients pay out of pocket for the asymptomatic eye exam. Others may have medical eye coverage, which is accessed through a confusing process of claims submissions to their health plans for medical diagnostic tests that are subject to copayments and deductibles.

Many patients with vision care plans access eye exams based on frequency (once a year or once every 2 years), with other visits to eye doctors covered only if medical issues arise.

Even when primary care physicians get involved — for example, recommending that a patient at high risk for glaucoma receive an eye examination for medical reasons — the insurance company may not comply. Historically, insurance companies have shown little uniformity in approaching preventive eye care. Put simply, patients often come up short on eyecare coverage.

What are the results? According to Ms. West and Dr. Brownlow, when patients don't have a covered benefit, they tend to avoid seeking the service. They may not be able to afford it; they may think they can't, or they may want to save money. So, most of these people aren't accessing eye exams on a regular basis, and this type of avoidance could have damaging, expensive results.

For example, if a child doesn't have an eye examination in the first year of life, he is 17 times more likely to have amblyopia at age 8.¹ Because amblyopia costs the United States billions of dollars in lost earning power each year, each dollar spent on early amblyopia diagnosis and treatment has a return of $22.²

Without periodic eye exams, other diseases may go undetected in adults for years, often resulting in poorer visual outcomes and greater healthcare costs. The Centers for Disease Control and Prevention (CDC) estimate that 24 million Americans have diabetes, and 8 million of these people are undiagnosed.³ The disease, for which early intervention has a dramatic impact on the eventual visual outcomes and the expense of managing the disease, often is first discovered during a routine eye exam. However, 26% of adults who wear eyeglasses or contact lenses and 60% of adults who don't wear corrective lenses haven't seen an optometrist in the past 2 years.⁴

Finally, some patients increase healthcare costs because they seek ways to get around the broken system. In shopping for the lowest deductibles, they find that the most expensive place — the emergency room — has none. One patient's quest for short-term savings will result in a greater expense to the insurers and eventually to the patient through higher premiums.

Distorted “Vision” of Eye Exams

When a patient comes to your office asking for contact lenses, you may perform the same exam you'd use on patients who present with complaints of pain or blurred vision. Some insurers have created the artificial concept that these identical exams are two different entities: the vision exam and the medical eye exam. Medical exams are covered, while vision exams are only covered by stand-alone “vision plans” geared toward delivering eyeglasses and contact lenses.

As if giving the same exam two names and covering each exam name differently weren't confusing enough, many patients have problems that straddle both sides of this arbitrary fence. For example, a patient with health insurance and no vision plan may get an optometrist's exam for blurry vision. The insurer covers the exam if the doctor discovers a medical cause for the blurred vision. If the same patient enters the office without a medical complaint and says he thinks he needs eyeglasses, the medical insurer will not cover his exam. And patients with vision plans whose exam reveals both refractive and medical diagnoses must submit two claims — one to the medical insurer for the medical testing and one to the vision plan for the basic eye exam.

According to Dr. Brownlow, the idea of the “vision exam” goes back many years, before optometrists could treat or manage disease. This idea has long been obsolete. An eye exam is no different for patients with refractive problems, eye disease or systemic disease. Optometrists are required to address all of these potential health issues for every patient, regardless of the primary reason for the patient's visit.

An eye exam is no different for patients with refractive problems, eye disease or systemic disease. Optometrists are required to address all of these potential health issues for every patient.

Integrated Care Works Better

The concept that an integrated, holistic approach to health care has better outcomes is hardly surprising or new — it's the standard thinking behind healthcare reform. The AOA and other groups agree that rather than randomly removing eye exams from the list of covered benefits for general health insurance plans, insurers must acknowledge that the eyes are very much a part of the body, that having good vision is important and regular eye exams are a beneficial part of health care for people of all ages.

Key to making this change happen is the understanding of the optometrist's position — that eye care often is the entry point into the healthcare system. Patients feel comfortable going to the eye doctor, even if they choose to rarely or never see a primary care physician. Optometrists are poised to identify diseases that otherwise may go undetected. And they have a responsibility to search for all health problems they can detect — not just those they can treat.

Ms. West and Dr. Brownlow acknowledge that for this reason, the eye exam is a phenomenal benefit to the public, no matter what causes patients to visit the optometrist in the first place, and insurers should encourage or require eye exams. For example, all children need to have early eye exams to detect vision and health problems, and adults at high risk for glaucoma or other eye diseases should be examined regularly.

Despite the benefits of eye exams for both eye health and overall health, the division in coverage continues. What's more, Ms. West points to this separation of routine eye care from health plans as a perfect example of the inefficiencies that plague the current healthcare system. After all, unlike health insurance, the human body is superbly integrated. It makes sense that viewing the human body this way — and caring for it in this way — would work better.

Changing the Status Quo

The AOA and other optometry groups are working to help key healthcare decision-makers understand that separating eye care from their policies puts patients at risk. The education process is under way, taking the message to Congress, state legislatures, the Centers for Medicare & Medicaid Services, insurance companies, self-insured employers, union trust funds and employee benefit consultants.

Optometry groups see optometry as an integral part of the solution for responsible healthcare reform, and they say that together, optometrists can transform an outdated, disjointed system into one that recognizes and makes the most of optometry's role in healthcare outcomes and in cost savings for the entire healthcare system. nOD

References

1. Eibschitz-Tsimhoni M, Friedman T, Naor J, Eibschitz N, Friedman Z. Early screening for amblyogenic risk factors lowers the prevalence and severity of amblyopia. J AAPOS. 2000;4:194–199.
2. Membreno JH, Brown MM, Brown GC, Sharma S, Beauchamp GR. A cost-utility analysis of therapy for amblyopia. Ophthalmology. 2002;109:2265–2271.
3. The Centers for Disease Control and Prevention. Number of People with Diabetes Increases to 24 Million. Press release, June 24, 2008. Visit cdc.gov/media/pressrel/2008/r080624.htm. Last accessed July 9, 2009.
4. Third Annual American Optometric Association American Eye-Q Survey Executive Summary. Visit aoa.org/documents/2008-Eye-Q-Executive-Summary.pdf. Last accessed July 9, 2009.