Bipartisan bill to ban abusive policies of discount plans gets boost from policy expert report

Federally regulated vision and dental discount plans that mandate fees for noncovered services and materials and require the materials be provided by specified laboratories do harm by leaving patients and doctors of optometry, dentists and other providers to pay the price in terms of higher costs, less convenience and worse health outcomes, a new study by a policy research group concludes.

What can be done to end these abuses, to preserve the doctor-patient relationship undercut by these plans? The AOA- and American Dental Association (ADA)-backed Dental and Optometric Care Access Act, known as the DOC Access Act (S. 1793 and H.R. 3461), is the solution, the research group says. The conclusion was reached in Avalon Health Economics’ “Analysis of Dental and Vision Plan Non-Covered Services and Materials Mandates: An Update” released in December 2021.

The DOC Access legislation, which has earned bipartisan and bicameral support in Congress, would combat abusive practices in the federally regulated vision and dental coverage marketplace by preventing among other abuses:

• Limits on doctors’ choice of lab for materials.
• Mandates on noncovered services and materials.

The DOC Access Act would “align” federally regulated plans with state laws for noncovered services and materials, as well as lab freedom of choice, the researchers say.

To see the measure advance on Capitol Hill in 2022, the AOA and the ADA—along with dozens of early congressional champions—are urging other Senate and House members to officially join as co-sponsors of the legislation—a key indicator of support—and help move the bill through Congress right away. Discount plans and their lobbyists oppose the DOC Access Act and are trying to block any further review by congressional committees of abusive plan policies.

“Federally regulated dental and vision plans are still allowed to set fees for noncovered services (and materials) and require materials be provided by specific laboratories, which results in cost-shifting and worse outcomes for patients,” the researchers say. “The DOC Access Act would end these practices that are harming patients and allow dentists and doctors of optometry more freedom to make the best decisions for their patients.”

Vision plan abuses will be the major topic at the joint AOA on Capitol Hill and AOA Payer Advocacy Summit April 24-26.

“This new report makes it clear that certain plans are continuing to employ anti-doctor and anti-patient policies, even as more and more evidence points to the negative impact their tactics have on patient care,” AOA President Robert C. Layman, O.D., says. “Together with concerned health policy leaders in Congress and supportive organizations such as the ADA, the AOA and our affiliates will be working to make the DOC Access Act a priority on Capitol Hill.

“Every AOA doctor and student can take a stand for doctor-patient decision-making and against plan abuses by contacting their senators and House members right now through the AOA Action Center and seeking new support for this important and much-needed legislation,” Dr. Layman says. “We can and will assist doctors and patients in speaking out and ensuring that our voices are heard loud and clear in Washington, D.C., including through our AOA on Capitol Hill advocacy event in April.”

Findings: Vision plan abuses

Avalon Health Economics’ researchers make a number of observations about the state of federally regulated vision plans, citing its 2016 study on the same subject. One, they emphasize that patients and doctors are at the mercy of vision plan schemes.

“Due to vertical integration in the vision insurance industry, laboratory, supplier and manufacturer industries, optometry practices are often forced to act as the ‘middleman,’ being forced to use specific laboratories and manufacturers that vision plans own to provide materials to their patients and only being reimbursed for their services at the levels dictated by the vision plans,” the report reads.

Second, a key concern first identified in its 2016 study—which suggested that plans’ “monopsony” over the market may enable them to leverage or influence prices and stifle competition—appears to remain unchecked. And less competition means fewer choices for patients and doctors. Two of the nation’s most dominant vision plans provide coverage to roughly two-thirds of Americans. Unfortunately, special legal treatment (vision plans often aren't regulated like health insurers) and a lack of competition in the market results in plans too often inserting themselves into doctor-patient decision making.

“Forced fee limits” and mandated discounts had repercussions for providers, who reported corresponding cost-shifting to help subsidize their losses, “harming patients who are not enrolled in plans with special discounts and patients enrolled in such plans who pay a premium to avoid the resulting price,” Avalon’s researchers reported from 2016.

To counter these abuses, more than 40 states have enacted legislation addressing vision and/or dental plan abuses; however, up to one-half of plans operating in any given state can sidestep these state laws because they are instead federally regulated.

In the new study, Avalon Health Economics sent surveys to doctors of optometry and dentists seeking to find out how they had reacted to state noncovered services prohibitions, compared to federally regulated plans. Survey recipients practiced in 10 states between May 10 and Oct. 2, 2021, compared to the 2016 study by Avalon Health Economics that looked at only two states. The states in the new study were Alabama, Arkansas, Florida, Georgia, Kansas, Maryland, New Jersey, North Carolina, Texas and West Virginia. (North Carolina and Texas were the focus in the first study.)

The new report found, consistent with Avalon’s 2016 research, that dentists and doctors of optometry are not charging unreasonable prices for noncovered services after state-level laws passed prohibiting insurers from setting fees on noncovered services and materials. In fact, their research clearly suggests that the plan mandates, in the end, do not significantly benefit patients with that coverage and are particularly harmful for the uninsured and patients with other coverage.

The new report also found:

• That the majority of survey respondents reported their voluntary discounts, after state-level laws targeting plan abuses passed, were “only marginally less or about the same” as those previously mandated by plans.
• That the average wait time for eyeglasses was 15 days using a plan-required laboratory compared to seven days when doctors selected the laboratory.
• That doctors of optometry deemed the materials from a laboratory they chose, for eyeglasses and related supplies, of better quality (a combined 58% say the materials were either of higher quality or significantly higher quality) than those proposed by their plans. “As previously described in this report, economic theory would suggest that restricting the options for laboratories can only reduce the ability of the doctor to make the most efficient choice and is likely to lead to worse outcomes for patients,” the research suggests.

DOC Access Act: AOA priority legislation

The AOA’s advocacy team, which is holding regular meetings across Capitol Hill on the DOC Access Act, confirms that Congress would welcome information from doctors about the impact on patients and practices that these mandates have had during the pandemic, including plan price fixing and limits on lab freedom of choice.

Doctors and students can contact AOA staff in the Washington, D.C., office by emailing advocacy@aoa.org or calling 800.365.2219 for assistance in setting a meeting or videoconference with their representatives, or take these steps:

• Save the date for the joint AOA on Capitol Hill and AOA Payer Advocacy Summit April 24-26.
• Visit AOA’s Action Center to urge your House and Senate members to co-sponsor H.R. 3461/S.1793 or text “DOC” to 1.855.465.5124.
• Consider investing in AOA-PAC, the only federal political action committee dedicated to fighting and winning for optometry.