MANAGED CARE: ENEMY AT THE GATES

Let’s start with the bottom line. An insurance company is not an optometrist. When any outside agency becomes directly involved in choosing what is best for an individual patient based on a statistical average, patient health outcomes invariably suffer.

In her in depth examination of how managed care has affected private practice doctors and their patients, investigative journalist for Texas Monthly Mimi Swartz writes, “They were on the phone all the time, haggling with insurance company clerks instead of practicing medicine. They were referring patients to doctors they didn’t know or didn’t trust because of insurance company rules. They talked about how they were going broke while insurance companies were getting richer and richer—the health insurance industry took in $265 billion in premiums in 1993.” (1)

Pharmacists know this, but have all but lost the war and the majority have become glorified pill clerks. Medical doctors know this, and watch patients suffer without having any recourse to provide the care they know is needed without getting permission from the insurance company, who are motivated purely by profit. Other medical branches, such as dentists, physical therapists and chiropractors have been able to maintain a level of independence that allows them to care for their patients with less outside intervention. How have they done so, and what can optometrists learn from all of these groups in order to achieve the best possible patient health outcomes?

LIFE ON THE OUTSIDE

The first step on the road to success in any venture is to find someone else who is doing what you want to be doing, and figure out how they got there. Dentists are currently operating within safe margins of independence, as they have been fighting against becoming the employees of hospitals and insurance plans for the last sixty years.

“As both the health insurance and dental insurance industries have evolved, cost concerns have over the past 20 years become paramount, and the idea of adding dental as a required service under a medical plan has been met with resistance.” (2)

By standing together and refusing to be included in networks that don’t offer fair pay, the networks haven’t been able to develop much of a foothold. HMOs and PPOs do exist for dental benefits, but any network with low payments have been refused or dropped. Like a cancer, HMOs need to be fed in order to grow. Cutting them off and losing patients might hurt initially, but it is crucial for the survival of the independent model. With more and more employee groups joining medical, dental and vision plans it is imperative to actively choose to work with only those plans that actually benefit the patient and the provider.

Every day we hear about vision plans that offer lower and lower reimbursements as their networks grow. Dentists have experienced this as well, but by resisting inclusion or dropping low paying plans have retained a high cash-pay patient load have managed to survive.

Also on their side, though, is that their industries are more focused on services rather than retail. With pharmacies, it was the retail focus on pill sales that let the corporations in the door, and it has been the same with optical as income from dispensaries shrink year after year. The optical dispensary has already been taken over by frame companies that paste on fashion brand names to entice patients and the gargantuan lens labs with billions in advertising budgets to tout their brand to unwitting patients who are then unsatisfied with any other option than the one they say on TV.

THE ENEMY AT THE GATES

Managed care. The pitch sounded great to patients and to politicians who were concerned with rising healthcare costs, but what it really means is that a clerk in an insurance office is making the final decision as to whether the test or procedure the doctor has ordered will be funded. Though this hasn’t come to pass with vision plans yet, how much more will reimbursements have to shrink before all doctors can afford to do are vision screenings? When that happens, will ODs be replaced by a smartphone app?

“And how do they know this? Are they coming to the office and examining and speaking to the patient and obtaining detailed histories like I am? No. They are checking off boxes on a sheet of paper. The patient has now been downgraded to nothing more than an ID number and a questionnaire.” (3)

Is this the future of optometry as well, or is it the present? Already many vision plans are providing tiny reimbursements, meaning you can’t spend enough chair time with a patient, or perform other tests that you’d like to include in a comprehensive exam. Then, when you go to prescribe, you have to sell the materials mandated by the lab the vision plan is connected to.

REMAINING INDEPENDENT TOGETHER

How to fight the rising tide? You can sell frames and lenses made by smaller, independent labs and manufacturers. You can refuse to allow low paying visions plans into your city by not accepting them at your office.

This is why VCD and VCD Labs exist. We were created by and are managed by independent optometrists that understand deeply the need to keep the decision making process between the doctor and the patient. So rather than take the HMO style approach and tell you how to run your business, we instead provide options that you can use the way you see best.

Sources:

1. http://www.texasmonthly.com/articles/not-what-the-doctor-ordered-2
2. https://www.quora.com/Why-is-dental-care-considered-separate-from-other-medical-care-in-the-US
3. http://www.kevinmd.com/blog/2016/07/time-doctors-tell-insurance-companies-really-feel.html