Optometry

The word “vision” appears exactly twice in the 906-page House version of the Patient Protection and Affordable Care Act passed in March 2010, and the phrase “vision care” only once. These very brief mentions have become the focus of a rift between practitioners and the vision plans that cover some 85 million Americans.

According to vision plan executives, those few words could drastically alter how they do business and possibly their subscribers’ overall eye health.

The act mandates that in 2014, health exchanges would come online to provide health insurance for people who have no insurance through an employer, and that the coverage must include “oral and vision care” for children. However, the act would limit vision plans to participating in the exchanges only if their coverage for children is bundled with a health insurance plan.

Efforts to repeal bundling provision

The National Association of Vision Care Plans (NAVCP), which represents 17 such plans in the United States, is lobbying to get that provision repealed so its members can participate not only as a bundled benefit for children, but also as a “stand-alone” benefit that subscribers could purchase outside of their health insurance, according to NAVCP President Richard Sanchez, who is also president and CEO of Advantica, a vision benefits company in Clearwater, Fla. Dental plans, meanwhile, may participate either as a bundled offering or as a stand-alone.

“We think that the exchanges should have even more access to care,” Mr. Sanchez said in an interview. “They should have stand-alone vision plans ‘and’ health plans, not ‘or.’”

Source: Ingenix Consulting, National Association of Vision Plans. Vision Exam Utilization Study (Study period: 2008–2009)

While the organization has already engaged congressmen and senators to get the ban on stand-alone vision plans repealed in 2011, no sponsor has stepped forward, he says.

Treating vision and dental plans differently in the exchanges could potentially alter how vision plans operate if the health exchanges become major purveyors of health insurance, said Al Schubert, vice president with VSP Vision Care in Rancho Cordova, Calif. This could, over time, alter the vision care delivery system, he said.

“When you look at dental and vision care in United States today, about 90% of the care is delivered by stand-alone dental and vision plans,” Mr. Schubert told Primary Care Optometry News. “So if the exchanges catch fire and they get large, you may have the opposite effect to where stand-alone plans are not delivering the majority of the care in the United States. That may have downstream impacts.”

AOA, ophthalmology group oppose stand-alone plans in exchanges

Both the American Optometric Association and American Academy of Ophthalmology in 2009 opposed the concept of having stand-alone vision plans in the exchanges, whereas the American Dental Association and the National Association of Dental Plans (NADP) were united that dental plans should participate both by contracting with health plans and also as stand-alone players, according to NADP executive director Evelyn Ireland.

Source: VSP Vision Care

The AOA and AAO stated their opposition to stand-alone vision plans in the exchanges in a joint letter sent in 2009 to Sen. Debbie Stabenow (D-Mich.), sponsor of the failed amendment that would have allowed stand-alone vision plans in the final bill.

“In contrast to increasing the essential integration of vision and eye health services into covered services, stand-alone vision plan companies aim to turn back the clock by continuing to segment vision from eye health and seeking to impose misguided limits on the care that our patients — especially children — receive,” the letter stated. “Such plans are routinely mislabeled as complete or comprehensive when in fact they are not.”

Michael X. Repka

“Because of this opposition, the sponsoring senator took the references to vision out of the amendment when push was coming to shove,” Mr. Schubert said.

“The fact that we weren’t unified with a provider organization had us excluded,” Mr. Sanchez concurred.

Michael X. Repka, MD, medical director of government affairs for the AAO, was not aware of NAVCP’s efforts to get stand-alone vision plans in the exchanges, but he was not surprised either. “I would expect that this is the time everybody is going to be out there looking to do those tweaks and adjustments to the bill,” he said in an interview.

Vision health vs. eye health

The objection to stand-alone vision plans in the exchanges gets to the heart of defining what precisely “vision care” comprises, Stephen Montaquila, OD, chair of the AOA’s Third-Party Center, told PCON. The AOA’s stand has to do with tying eye care more closely to overall health care and getting the health exchanges to recognize that an eye examination should include a health assessment, not only a refraction for vision correction, he said.

Stephen Montaquila

“Our goal is for every American to get their eyes examined,” Dr. Montaquila said. “The intent of health care reform is to develop a better system for the delivery of health care. Mandating that a vision care plan partner with a qualified health plan gets to that point. And they will be required to comply with the important consumer protections afforded through the law. These include oversight through guaranteed public participation and assurances of adequate supply and access to providers.”

He called the concept of bundling vision with health care “a better system for the delivery of eye care services, with the goal of providing total care rather than an a la carte program where the patient could end up missing a piece. Otherwise, it’s conceivable that a person could have health care coverage but not vision care coverage.”

Added Dr. Repka, “It is difficult to separate vision and eye health from each other; we have an arbitrary divide of refractive correction or routine eye care from medical eye care. This is confusing for the patients and the providers.”

Interpreting ‘vision care’ in the act

Writing the regulation of what precisely “vision care” means in the act is another task that the AOA, AAO and vision plan providers have engaged in. Mr. Sanchez and Mr. Schubert said their concept of “vision care” mirrors that of the professional societies, but that stand-alone vision plans are better equipped to meet the broader goals of improving access to eye care.

NAVCP has called attention to its own study that showed consumers with a full-service, stand-alone vision plan are twice as likely to get an annual comprehensive eye examination as those who get vision coverage bundled with their health plan. The study, which Ingenix Consulting conducted, showed a utilization rate of 33% for the former vs. 16% for the latter.

The study also revealed that 36% of patients with stand-alone coverage received an eye examination in consecutive years compared with 22% of patients with a bundled plan.

“Patients with stand-alone vision benefits develop longer, deeper and more lasting relationships with their eye doctors than those with bundled insurance,” Rob Lynch, CEO of VSP, told PCON in an interview. “As such, stand-alone patients are more likely to have a health care experience that has a more impactful role on the broader spectrum of their general health.”

VSP offers subscribers an Eye Health Management Program, which focuses on early detection and management of both eye and related health conditions. A study commissioned in 2008 found that patients with diabetes in the program had annual health plan costs of $6,682 vs. $8,074 in the traditional health care model group and claimed other cost benefits in lost time and turnover.

Heading into 2011, NAVCP members are having an “ongoing dialog” with the provider groups to try and bridge their differences, Mr. Sanchez said. – by Richard M. Kirkner

• The American Optometric Association can be reached at 243 N. Lindbergh Blvd., St. Louis, MO 63141; (800) 365-2219; www.aoa.org.
• The American Academy of Ophthalmology Governmental Affairs Division can be reached at 1101 Vermont Ave. NW, Suite 700, Washington, DC 20005-3570; (202) 737-6662; www.aao.org.
• The National Association of Dental Plans can be reached at 12700 Park Central Drive, Suite 400, Dallas, TX 75251; (972) 458-6998; info@nadp.org; www.nadp.org.
• The National Association of Vision Care Plans can be reached at 91 Purdue Road, Suite 200, Indianapolis, IN 46268; (317) 328-4633; www.navcp.org.
• Vision Service Plan can be reached at www.vsp.com.