OPTOMETRY’S ROLE IN HEALTHCARE REFORM

TO PROSPER, WE MUST INTEGRATE INTO HEALTH SYSTEMS OR ADOPT THE HYBRID-CONCIERGE MODEL

Aaron Lech, O.D., F.A.A.O., Roseville, Calif.

WITH THE SIGNING into law of the Patient Protection and Affordable Care Act (PPACA), U.S. health care is significantly more complex than it was in 1965 or for that matter, in 1989, when optometrists were first recognized as physicians under Medicare. Yes, we, as doctors, and patients are still the major participants in our healthcare system. Yet, the government has taken greater control of health care through the PPACA, EHR meaningful use requirements and quality mandates, as the initial steps toward a healthcare system focused on value-based outcomes instead of the pay-for-procedures system under which we currently operate.

So, how can we, as optometrists, continue to thrive? In my opinion, we must integrate into large health systems or adopt the hybrid-concierge model.

Here, I explain.

INTEGRATING INTO LARGE HEALTH SYSTEMS

For decades, we’ve leveraged our inclusion in Medicare fee-for-service to develop provider pathways into commercial insurance and self-funded employer groups.

Health plans, in an effort to ensure consistent profitability and eliminate expenses associated with maintaining large and diverse provider networks, partnered with multi-specialty Independent Physician Associations (IPAs). This partnership allowed the plans to delegate the financial and administrative risk to the provider groups. The IPAs, largely unregulated, as they are not insurance companies, were and continue to be free to create select networks that largely exclude O.D.s as long as they meet their contractual obligations with the payers. Provider-led specialty insurers developed, connecting patients to the same providers for routine vision services. Much like the rest of the healthcare system, how visioncare services are being paid is changing. There is an ever-increasing cost shift to the consumer in the form of higher copays, higher deductibles and less overall covered services, leaving higher overall expenses for the consumer to pay out of pocket.

As our profession seeks continued inclusion in many of the new channels of healthcare that are developing, we are forced to acknowledge utility of accountable care organizations, health maintenance organizations, IPAs, management services organizations and the like. Entities such as these, by virtue of their financial and organizational power, are the only ones positioned with the resources needed to adapt to and navigate the minefield of the new healthcare landscape.

One of the major challenges is that to curb utilization and panel participation, many network insurers are simply changing the language of their provider contracts to require hospital privileges — something most O.D.s don’t have, given our scope of practice and lack of need for surgical admission.

In optometry circles, we may be fearful of a health system wherein our individually governed profession must submit to a medical hierarchy not likely to look kindly on its non-M.D. brethren. But large health systems do not tolerate individuality well. As long as we can demonstrate that optometry can provide quality outcome measures at an equal or more effective value than others in a similar profession, we will be attractive to these healthcare management entities.

Action steps. To accomplish this, we, as O.D.s, must determine our chair costs for the various conditions that may present to the office. Second, we must track outcomes. Third, we have to improve efficiencies within the practice. Finally, we must think and act like medicine by demonstrating our contributions; not defending them with a list of esoteric abilities and certifications. We must be the doctor.

Optometry can successfully integrate into a variety of health systems though a marketing strategy that is both medical-political and practice-specific, care-centric. That said, inclusion in these health systems will require continued advocacy. The healthcare marketplace is seeking business solutions to health-economic problems. As a result, leadership must come from O.D.s versed in the issues that ail health systems and respect quality healthcare.

The politics and strategies that have won amazing gains in scope will have to transition. With much of the efforts around such integration falling on leadership, it is also critical that the rank-in-file provider develop a basic understanding of the medical and economic impact of care. Forming practice patterns around evidence-based medical strategies and primary care physician extension will trump traditional “cover your butt” medical practices. This will cement optometry’s value in unique and innovative ways inside these systems.

ADOPTING A HYBRID-CONCIERGE MODEL

As providers, the traditional business model for care in many optometric practices relies on fee-for-service reimbursements from Medicare, insurance plans and vision care plans. As explained, an increasing share of healthcare costs is being shifted to the consumer. Therefore, providers committed to the independent-practice model must reorient their practices to create value for the changing patient-doctor relationship by developing more of a concierge-style practice or some hybrid of this model. (See “Concierge Eye Care: Opportunity or Impossibility?” at bit.ly/1Km6LVr.)

The United States saw a similar financial impact with 401K and HSA plans many years ago. Under increasing fiscal pressures in the late 1980s, pension funds were phased out in favor of employee-funded retirement and investment accounts. With employees taking on responsibility for their financial future, “exchanges” of sorts were developed wherein employees could invest among a set of vetted funds. Ultimately, the employees took his or her business where they saw the most value. Some opted for security without choice (managed care). Others found great value and opportunity in maintaining their individuality with self-pay and have reaped the rewards by allocating their own healthcare dollar by disciplined financial management (such as an HSA or even healthcare co-ops). As a result, the patient tolerates a degree of uncertainty, but through time retains a share of monies they contribute that once would have remained inside an insurance company as profit. When consumers are spending their own money, they have negotiating power and often will shape their behavior patterns to be more compliant with treatment plans and preventative living strategies. This puts money in their pocket and develops a deeper sense of value with their providers.

Health care is following suit. For the foreseeable future, specialty plans and fixed-reimbursement medical plans will remain players in the market. But the increasing financial responsibility patients face creates an imperative that private-practice owners focus on strategies that communicate and deliver value (not price).

The evolution of the private practice owner will hinge on his or her ability to leverage what optometry has always had with patients: trust. In a world of infinite choice, private-practice owners must eliminate the noise that consumers face, and replace this with clear services and solutions a patient can understand.

Action steps. To accomplish this, beginning with care, employ the techniques of a diagnostic-driven exam. Patients want quality, so communicate how your office offers quality at the visit. Do not leave that responsibility to chance on a 30-second phone call. Help staff learn to leverage the currency of trust with simple benefit-oriented language.

Patients expect us to solve problems, simplify and strip inauthenticity out of the consultation process. In the optical, this means distilling 50 different progressives, 15 AR coatings and 10 different optical materials into three lifestyle lenses. Finally, design care packages around dry eye disease, glaucoma, AMD, etc., that may make it even more inviting for patients to forgo using insurance.

A LOOK AHEAD

Before us is an exciting time of change ripe with opportunity. Optometry must continue to invest in patient trust and to leverage our hard-fought victories in transforming the role we will play. OM

AARON LECH, O.D., F.A.A.O. practices at ClearVue Eye Care in Roseville, Calif. He developed his practice with integrated managed care medical contracts and lectures and consults on managed care and healthcare reform. He is on the Primary Eyecare Network Advisory board, a member of Professional Eyecare Resource Co-operative and consults for Allergan, Carl Zeiss Meditech and ABB Optical Group. Email him at drlech@clearvue.org, or visit tinyurl.com/OMcomment to comment on this article.