Two Sides of the Story



Published in the March/April 2014 issue

FORGET the endless political wrangling and start-up technical glitches. How is the Affordable Care Act working out for you so far?

Experts say healthcare reform offers a wealth of opportunities for eyecare providers to build their practices. Seizing the moment, though, could require some adjustments. The law is complex, ODs are dealing with myriad regulatory and reimbursement issues (see sidebar) and bigger patient loads may not necessarily mean higher profits.

The legislation “should be to the advantage of every optometrist in the United States,” says Dr. James Venable, vice president for clinical programs at Southern College of Optometry in Memphis, TN.

“They’ll be able to serve a population of Americans who have done without because they’re in the category that is often called the ‘working poor,’” he says. Until now, many people lacked sufficient resources or insurance for care.

To thrive under the ACA, experts say eye docs need to brush up on more complex medical care, create strong marketing plans and get used to caring for small children.

But even before that, eyecare providers should make sure that they and their staff members understand the insurance plans they’re dealing with.

“I personally have found that very little in the way of plan coverage explanation has been given to the provider from the health plans,” says Dr. Stephen Montaquila, chairman of the American Optometric Association’s Third Party Center. “Yet patients are already coming in seeking much-needed eye health and vision care services.”



The ACA is expected, through provisions such as private coverage subsidies and Medicaid expansion, to significantly reduce the number of Americans who lack health insurance.

The figure is likely to decrease to 30 million residents by 2017 from 55 million in 2013, the Congressional Budget Office estimates. That means more patients for clinicians of all types. But for optometrists, the 2010 act contains especially friendly provisions.

For example, the Harkin Amendment is meant to prevent health plans from excluding certain providers — including ODs — from their networks based on license or certification. They can’t require patients to see an ophthalmologist for services that are within the scope of an optometrist’s license. (Some plans, especially those organized under the federal Employee Retirement Income and Security Act, have frequently kept optometrists off their panels.)

The upshot is that optometrists need to “be much better on the medical side of optometry than just routine eye examinations,” says Tom Bowman, CEO of the consulting firm OD Practice Mentors. Otherwise, extensive revenue will be sent away via referrals.

And optometric offices need to let patients know what they can do. “Most consumers think an eye exam is a refraction,” says Bowman. “Savvy optometrists are going to market in a different way. They’re going to point out that sometimes optometrists can see signs of conditions such as hypertension and diabetes even before a family practitioner can.”

In fact, the California Optometric Association is pushing a bill to expand what optometrists are permitted to do in that state. The measure would allow them to offer services such as laser procedures for glaucoma along with flu vaccinations, says Dr. Fred Dubick, president of the group.

The larger role for ODs, he says, would help alleviate pressure on the wider healthcare system. The current supply of primary-care medical doctors could prove insufficient to care for the influx of newly insured patients under healthcare reform.

“The idea is to use all providers to the fullest extent of their training,” says Dubick, who practices with StudioEyes in California’s San Fernando Valley. “Doctors of optometry can help to ease the shortage of physicians.”

It’s important to note, though, that the ACA does not guarantee optometrists will get in-network status. It also doesn’t ensure that reimbursement will be equal to that of other providers for the same services. A few states have such laws.



Another key provision of healthcare reform makes pediatric vision care an essential benefit. All new health plans must offer such care — including a comprehensive yearly exam, treatment and medical eyecare — as a distinct benefit from well-child care. The AOA estimates that as many as 8 million previously uninsured children gain eyecare benefits through the reform.

Most optometrists are comfortable seeing older children. But Venable says many shy away from patients under age 4 or 5 because such small kids are harder to communicate with.

“If you’re not accustomed to working with small children, it’s time to get used to it,” he says. None of this means eyecare providers universally welcome healthcare reform.

In fact, “Most are against the ACA,” says Van Rue, vice president of marketing and business development for Single Vision Express, an optical lab in Kirkland, WA. “But optometry,” he says, “is one of the most change-resistant industries in the world.”

Fear of the unknown is one factor. Many ODs are still unsure how their practices will be affected as various healthcare reform provisions roll out, particularly if employers’ “addon” vision benefits are nixed at a later date.

Increased paperwork is another source of stress and trepidation.

“That definitely won’t be a misconception,” Bowman says.

Dr. Kurt Hofeldt, who practices at Benson Eye Clinic in Kent, WA, says overall, reform is working out well.

“Our schedule is completely full and booked out at least one week in advance,” says Hofeldt. “We’re in the planning stages of expanding to accommodate these changes.”

He notes that it’s great to be able to care for more patients. But like other optometrists, he’s concerned about low reimbursement rates for plans that arise from healthcare reform.

“A huge downside to the ACA,” Hofeldt says, “is that my staff and I work harder and longer hours for the same amount of income because of both lower rates and a hi gher administrative burden.”

It’s more important than ever, experts say, for optometrists to become good at evaluating insurance plans to see which ones are worth participating in.

“For the most part, optometrists have scientific minds and they don’t like accounting,” Bowman says. “But they’re going to need some business savvy.”



AS EYECARE PROVIDERS get used to life with the Affordable Care Act, some things that worry them are not ACA provisions at all — but issues that have to be dealt with at the same time as the ACA.

“ODs have said it’s too much all at once,” says Dr. Peter Cass, a Texas optometrist who is also managing partner of consulting firm Optometric Business Solutions. “Any one of them alone would be a lot to deal with.”

Here’s a rundown of other topics that eyecare providers are thinking about in 2014:

Meaningful Use 2. To get full federal incentives for using electronic health records, providers must demonstrate that they’re keeping patients engaged electronically. An objective this year is for practices to get at least 5 percent of their patients to interact with their data through a webbased portal.

ICD-10. Eyecare providers and other healthcare practitioners must switch by Oct. 1 to a revised set of codes for recording diagnoses. The codes, known more fully as the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, are far more descriptive compared with the current ICD-9. Key steps for eyecare providers in the coming months include making sure that staff members and software, as well as optometrists, are ready to use the ICD-10 codes.

Reimbursement. Inadequate reimbursement by Medicaid and other health plans is a common complaint among optometrists. They want increases, but they’re not sure the ACA is going to help — and they fear it might hurt. The rates sometimes force tough decisions. Cass, owner of Beaumont Family Eye Care in Texas, says: “We had to cut back on the number of Medicaid cases we accept by 25 to 50 percent. At times it was probably costing me to see the patients, by the time you account for rent, utilities, staff and overhead.”

Tom Bowman, CEO of consulting firm OD Practice Mentors, says many providers dread coping with more forms and insurance plans.

“I think there are going to be actual new businesses popping up,” he says, “to manage the administrative tasks for the doctors.”

But Kent, WA, optometrist Dr. Kurt Hofeldt says businesses may fall by the wayside, too.

“Many of the older docs close to retirement will be trying to sell or close their practice,” he says. Some won’t want to take the time and effort to implement the new rules. Others won’t be able to find a buyer.



More patients are covered, pediatric vision coverage is a required benefit and ODs can better position themselves as primary eyecare providers who can detect other health concerns. It’s uncertain how profitable new patients will be.

There could be more prescriptions to fill, but like optometrists, opticians worry that reimbursement levels will be too low to generate profits. Those in the high-end niche might see few effects.

High out-of-pocket costs for newly insured patients could mean a smaller-thanexpected increase in volume. Physicians may be pushed into larger group practices or hospital affiliations by changes in reimbursement structures.