managed care

The Stand-Alone Visioncare Plan Debate

Lindsey Getz, Contributing Editor

The debate regarding the possible exclusion of stand-alone visioncare plans in the Affordable Care Act’s insurance exchanges has reached a critical stage, with the American Optometric Association (AOA) and VSP Vision Care (VSP), standing on opposite sides of the issue.

Both the AOA and VSP agree that, as healthcare reform moves forward, optometry must be included as an active participant in the healthcare delivery system, and access to patients must be preserved. The AOA believes these and other goals are best achieved by excluding standalone visioncare plans from the state insurance exchanges; VSP argues that stand-alone plans would ensure patient access and secure optometry’s role in the healthcare system.

Last month, the two organizations met in St. Louis, Mo., for a VSP-hosted Open Forum on Healthcare Reform, which included three panelists from each organization. Here’s a look at each organization’s stance, including comments from the forum and separate interviews conducted with AOA and VSP leaders and private practice optometrists.

The AOA’s position

The goal of the insurance exchanges is to create a marketplace where the uninsured and employers are able to find health insurance at competitive rates. While stand-alone visioncare plans were initially included as direct participants in the exchanges, the AOA ultimately lobbied against their inclusion, seeing the path to better O.D. representation as being through major medical healthcare plans — that is, a plan in which vision care is a component rather than a separate entity. According to the AOA, stand-alone visioncare plans would participate in the state exchanges only by joining an exchange-qualified major medical healthcare plan, which is defined as a plan that provides 10 essential benefits, one of which is pediatric services, including oral and vision care. (Currently, it is up to each individual state to decide what plans they want included in their exchanges.) Recently, the Ohio Optometric Association and the Michigan Optometric Association both voted to back the AOA’s stance.

The AOA supports vision care as a component of major medical healthcare plans because:

► The optometric scope of practice is comprised of more than comprehensive exams and spectacle and contact lens dispensing, and stand-alone visioncare plans typically cover the exam and materials only. “Modern optometric care encompasses refractive, medical and some surgical care,” Stephen Montaquila, O.D., chair, AOA Third Party Center Executive Committee, explained at the forum. “Additionally, we are widely recognized as the experts in the area of low vision, vision therapy and contact lens services, and of course, eyeglass fitting and dispensing.”

► The AOA believes standalone visioncare plans, by virtue of their typically covered services, restrict patient access to an O.D.’s full scope of practice.
“We have found that the current model that segregates vision care from the rest of medical care has served to isolate and define optometry as primarily a refractive profession,” Dr. Montaquila explained.

► The AOA says integrated care is the focus of healthcare reform, and the organization wants to ensure O.D.s are included. At the forum, Roger Jordan, O.D., chair, AOA Federal Relations Committee explained that with the healthcare delivery system becoming more integrated, optometrists “have to adapt and evolve.”

When asked during the forum whether it might be more prudent to wait until more than about 10 states or preferably all states have any willing provider laws in place before eyecare becomes an integrated benefit, Robert L. Jarrell, O.D., chair, AOA State Government Relations Center Executive Committee said no. “… We have to move toward a model of integrated care. We have to say, ‘where do we want to be at the end of this, and that’s what we have to shoot for…”

► The AOA believes that vision through major medical healthcare plans will enable O.D.s to be treated the same as other medical providers, in terms of medical panel and patient access as well as pay parity.

“I’ve personally fought for you by standing up to angry medical specialties in front of CMS officials to convince Medicare to respect the value of eye care,” Dr. Jordan said. “Thanks to this continued vigilance, optometrists will receive more than $1 billion this year serving patients… with full scope” He also said that when states consider not including optometrists, the AOA “fights back and wins.”

With regard to reimbursement parity, Dr. Montaquila cited two studies — one performed by the AOA and the other by the Florida Optometric Association — that demonstrate allowing O.D.s to be medical eyecare providers saves the healthcare system money — a healthcare reform goal.

“… Our value is in having health plans have access, so-tospeak, to their patients for medical care specifically to divert them from other less cost-efficient resources, [such as emergency rooms]” he explained. “When you talk about where we’re going, that’s the direction. It’s being able to show the industry that optometrists do provide a very high level value in the system not by being paid less, but by being paid the same, and by providing the right care at the right place the first time.”

“… Whether we’re taking on organized medicine in a statehouse or in the U.S. Capitol or an insurance company when they discriminate against us, our goal is to do whatever is necessary to allow our patients to directly access O.D.s for the complete range of care we provide, and not just the very limited segregated vision services that the stand-alone plans want to continue to specialize in even after healthcare reform takes effect,” says AOA President Dori Carlson, O.D.

The AOA’s position on this issue has created two primary concerns by optometrists: 1) that, should the AOA’s lobbying efforts be successful, stand-alone visioncare plans are going to vanish come Jan. 1, 2014, and 2) that optometrists are going to lose their stand-alone visioncare patients.

Sally Halim, O.D., who practices privately at Village Eyecare in Woolrich Township, N.J., says she thinks some O.D.s, including herself, will see a decline in patients, should stand-alone visioncare plans be excluded from the exchanges, though she also believes medical treatment will retain much of this patient base.

“A lot of these [stand-alone visioncare] plans… do not usually cover any type of medical conditions, like conjunctivitis, uveitis, glaucoma or eye injuries,” she says. “These conditions are generally billed to the patient’s medical insurance anyhow.”

For this reason, she says she believes O.D.s who educate their patients on the importance of eye exams in identifying medical conditions, such as cancer and high blood pressure, will thrive, should stand-alone visioncare plans be excluded.

The AOA disputes concerns that stand-alone vision plans will vanish in 2014 and that O.D.s will lose “stand-alone” patients.

Dr. Montaquila said expert estimates reveal that at least until 2016, the number of Americans entering the exchanges is dwarfed by both the number who have a vision plan today and the overall population.

“Today, 38% of Americans have a vision plan. At their inception, the exchanges are expected to provide health insurance options for 6% of the population. The highest year of enrollment that’s currently estimated, that will reach 8%,” he explains. “The numbers just don’t support this assertion [that stand-alone visioncare plans are going to immediately vanish]. The 38% who currently have a vision plan will most likely still have one, and there is no prohibition from… purchasing a benefit outside the exchanges.”

Dr. Jarrell said at the forum that the AOA doesn’t see any evidence that employers are going to stop offering the vision benefit to their employees.

“Everyone is going to keep their (existing) stand-alone vision plan. Two-hundred-and-seventy million Americans are going to keep their coverage. So, nothing is going to happen to those folks,” he said. “… As large companies move to the exchange, simply because of how that’s set up, we just don’t see any evidence that those companies are going to stop offering this vision benefit to their employees.”

He added that the exchanges are going to add patients, citing the children’s visioncare component, which will cover 10 million children who previously had little or no access to comprehensive care.

Dr. Carlson, O.D., agrees with Dr. Jarell: “If patients don’t see optometrists who are they going to see? There are not enough ophthalmologists,” she says. “I don’t believe optometrists are going to necessarily lose patients. How patients end up having their care paid for may change, but they’re still going to go see their optometrist because they’re still going to need care.”

VSP’s stand

VSP wants to ensure standalone visioncare plans can directly participate in the exchanges, citing ensured patient access to O.D.s — currently more than 100 million, with 57 million through VSP — and a desire to compete for the 30 million uninsured and small employers (less than 100 employees) who are going to be eligible for the exchanges beginning in 2014.

“Until we have absolute assurance that all optometrists will be able to participate in all medical plans, just like our medical colleagues, we absolutely have to protect our current access to patients and fight for medical equality,” Dan Mannen, O.D., F.A.A.O., director, VSP Board of Directors, said at the forum.

He added that access to patients under major medical healthcare plans should be a concern for optometry for five reasons:

1. O.D.s may struggle to gain medical panel access to these plans, as O.D.s are not part of the contracting groups major medical healthcare plans typically seek to build their doctor networks. “… To think that diminishing stand-alone vision plans is somehow going to make health plans suddenly invite all of optometry to (participate) as full members of the brotherhood at full medical reimbursement, simply defies logic,” Dr. Mannen said.

Dr. Halim says she has heard this concern quite a bit.

“If that were to happen, it would obviously hurt our profession,” she says. “But if we are able to treat patients medically, we just have to modify our practice model to remain relevant.”

Dr. Mannen also said that vision plan participation in one of the integrated health plans does not guarantee an O.D. gets to be a member of the medical panel.

“… And even with medical panel participation, we all know that M.D.s like to refer to other M.D.s. Certainly their first choice is not the optometrist, to the frustration of all of us,” he said. “And let’s not forget with health plans in charge of these healthcare exchanges, there is certainly the possibility that vision plans like Spectera and Davis (both of which now participate in integrated plans) may become the primary access channel to our practices.”

In a statement released after the forum, Dr. Mannen said that there is little opportunity for stand-alone vision plans, such as VSP, to partner with health plans, “as that pie has already been carved up” — that is, health plans already own vision plans, such as Spectera and Davis.

2. Major medical healthcare plans have been known to discriminate against O.D.s. Dr. Mannen cited a letter from Dr. Carlson to HHS Secretary Kathleen Sebelius, in which she wrote, “Optometrists are regularly the victims of health plans that discriminate against non-M.D. providers.” As a result, he said granting health plans control of optometric access is a big mistake. “… If health plans become the controlling factor in these health exchanges, it will be they who determine who gets to play on the panel, it will be they who determine what procedures will be done by whom, and it will be they who determine who gets paid what,” Dr. Mannen said. “That’s a position that optometry has always been trying to stay away from. We’re trying to be in charge of our own future. We certainly don’t want to trust it to health plans that routinely discriminate against optometry.”

3. The Harkin Amendment is not an any willing provider statute and neither guarantees all O.D. participation or equal pay with ophthalmologists for the same service. Dr. Mannen stressed that more than 100 million patients come directly to private practices unencumbered by health plans by way of standalone visioncare plans.

4. Healthcare reform is predicated on cost reduction, and the logical way to accomplish that is through lower utilization, which can be achieved with fewer providers and lower reimbursement. “… Certainly there is going to be an effort to keep reimbursements down,” Dr. Mannen said. He added that this isn’t good for optometry, especially when the profession is trying to gain access to medical panels and fight for fee parity.

5. Healthcare experts have predicted that a significant number of small employers (less than 100 employees) will opt for the major medical healthcare plans under the exchanges rather than sticking with their current plans, thus, threatening current patient access. “Our concern is that this will impact us negatively if we’re not able to involve ourselves in the state exchanges,” said Tim Jankowski, O.D., F.A.A.O., immediate past chair, VSP Board of Directors, at the forum.
…“We’re going to see a migration of patients from one set of plans to another set of plans. So, we need to be able to maintain our access to patients and our ability to compete in the exchanges in order to continue to provide a regular flow of patients into private practice doctor’s offices.”

Rob Lynch, CEO, VSP Global said at the forum that studies have shown a low of 12% of employers putting there employees into the exchanges, and the high is about 30%. So, he says, with 100 million people current-ly covered through third-party vision plans, either 12% or 30% are going to move into the exchange, effective 2014.

“All we want to do is be able to compete for those populations the way we do today,” he said. “That’s all we want.”

VSP Global’s Chairman of the Board, Stuart J. Thomas, O.D., provides an additional reason O.D.s should be concerned about patient access: When a patient has a stand-alone visioncare plan, he is much more likely to use it, as it’s more visible than when the benefits are buried in the patient’s overall medical plan.

A National Association of Vision Care Plans (NAVCP) study concluded that healthcare consumers who participate in standalone vision insurance plans are two times more likely to receive an annual comprehensive eye exam than consumers who have visioncare coverage “bundled” with their major medical plan.

Michael P. Lange, O.D., C.N.S., owner and founder of Florida-based Lange Eye Care and Associates agrees that those patients who have their vision plan bundled with their health insurance won’t even be aware of the coverage.

“ …They [these patients] simply won’t get eyecare until there is a problem, and by then it could be too late,” he says. “Prevention is the name of the game, and the key is early detection. Vision plans allow for early diagnosis and quicker treatment.”

Dr. Lange adds that small practices, which rely heavily on stand-alone visioncare plans, may actually go under, should these plans be excluded.

Thus far, VSP’s argument to include stand-alone visioncare plans as direct competitors in the exchanges has garnered support from the California, Maryland, Hawaii and Arizona Optometric Associations and the Optometric Society of the District of Columbia. Also, Carl Zeiss Vision and Transitions Optical have come forward with their support.

“Carl Zeiss Vision supports patient access to eye care and recognizes the importance of annual comprehensive eye exams. We realize that eyecare providers play a critical role in overall health care, and we understand how important it is for them to stay connected to their patients. Therefore, we believe that preserving broad coverage choices for patients, employers and eyecare practices are an important component in the healthcare reform legislation in order to maintain regular, frequent access to eye exams that is essential to visual health.”

“Transitions Optical supports patient access to eyecare and recognizes the importance of annual comprehensive eye exams. We realize the critical role both ophthalmologists and optometrists play in the overall healthcare and know it’s important for them to stay connected with their patients. To help ensure continuity of care between eyecare professionals and their patients, we support inclusion of all visioncare plans in the current healthcare reform debate.”

Mr. Lynch said VSP is hopeful HHS will rule on a national basis to continue stand-alone vision plans alongside the other types of delivery in the national exchange and as a result in all 50 state exchanges.

Now what?

When asked at the end of the forum whether AOA or VSP have any ideas as to how a possible compromise could be reached between the two organizations regarding the stand-alone visioncare plan debate, neither association offered any specific ideas, though they did discuss the challenges of reaching a compromise and their willingness to keep the channels of communication between the two organizations open. OM

Lindsey Getz is a Philadelphia-area-based freelance writer, who has written for several consumer and trade magazines. She is also a former editor of Eyecare Business magazine (a sister publication of Optometric Management). E-mail her at lindsey.getz@yahoo.com, or send comments to optometricmanage ment@gmail.com.