New Texas law halts vision plans’ anti-competitive, monopolistic behaviors

Texas optometrists pen the next chapter in affiliates’ vision plan advocacy as novel, comprehensive reforms that promote fair valuation regain independent practice controls and ultimately seek to level the playing field against plans’ outsized influence.

Signed into law June 16 and taking effect Sept. 1, Texas H.B. 1696 has been called “groundbreaking legislation” with “first-in-the-nation” reforms checking many of the anti-competitive, anti-patient policies and requirements that doctors of optometry must contend with daily in dealings with major health insurers and vision plans. Such needed reforms come at a pivotal time in the AOA and affiliates’ redoubled vision plan advocacy with potentially far-reaching implications for optometric practice outside the Lone Star State.

“The Texas Optometric Association has sent a clear message that it will not tolerate abuses of optometrists and patients by vision plans,” Jennifer Deakins, O.D., TOA president, says. “The days of vision plans paying lip service to our profession while doing whatever they please are over.”

Nationwide, some 200 million Americans rely on supplemental preventive eye exam and materials benefits through vision benefit managers (VBMs). However, seeing as two-thirds of these people are covered by the two most dominant VBMs, plans can monopolize markets in communities and force costly mandates on doctors. In turn, doctors face a difficult decision of providing much-needed patient care in their communities or keeping their practices viable.

But Texas’ law draws a line in the sand. Outlining direct counters to plan mandates spoiling the relationship between patients and doctors, the law reins back plans’ infringement on doctors’ independent judgement and patient choice caused by the lack of competition and untenably low fee schedules through vertical integration and market consolidation. Specifically, the Texas law will prevent egregious plan abuses, such as:

• Patient steering. Plans cannot encourage or incentivize patients to seek services at any particular in-network provider, or at locations, retailers, or e-commerce sites that the plan owns or affiliates with.
• Doctor tiering. Plans cannot tier in-network providers based on noncovered service discounts, amount doctors spend on products or brands, etc.
• Practice control. Plans cannot offer different fee schedules based on doctors’ practice or business decisions, such as lab or supplier choice or affiliations.
• Chargebacks. Plans cannot utilize chargebacks when the plan isn’t paying for the cost of goods to be delivered.
• Covered services. Plans cannot call a product or service “covered” when there is no reimbursement from the plan to the doctor nor can plans require doctors to provide a covered service or product at a loss.
• Requiring unrelated information on claims. Plans cannot require reporting of unrelated or unneeded patient information to file a claim or receive reimbursement, e.g., prescription information or facial measurements and photographs.
• Extrapolation in audits. Vision plans cannot use extrapolation as a technique to complete an audit.
  

Additionally, the Texas law will require plans to provide transparency about in- and out-of-network coverage for both patients and doctors, as well as require a 90-day notice for contract changes. But importantly, the law also empowers doctors to call out violations directly to the state.

As Tommy Lucas, O.D., TOA director of advocacy, explains, the significance of Texas’ law comes from bolstering doctors’ ability to make independent judgements regarding patient care and business decisions, free from corporate influence.

“Vision plans exist because of doctors of optometry, not the other way around,” Dr. Lucas says. “Texas optometrists simply aren’t going to play along with the schemes that vision plans continue to cook up that tighten their control of our profession. Enough is enough.”

Adds Dr. Deakins: “Texas’ legislators have decided that giant conglomerates aren’t to have the final say between doctors and patients in local Texas communities, and we agree. On the contrary, the new Texas law ensures that optometric practices are protected from anti-competitive behavior by the plans.”

Furthermore, Dr. Deakins hopes that the plans will take the opportunity to reevaluate how they value the services provided by optometrists so that doctors will want to remain in-network and serving enrollee patients.

Patients aren’t going to stop buying vision plans and VBMs aren’t going to stop selling them, Dr. Lucas says, so it is incumbent on the plans to critically examine the relationship between plan and provider.  Future emphasis needs to be on how plans will respectfully treat network optometrists, by valuing their care appropriately for modern times. Toward that end, the TOA has written to each vision plan notifying companies of the new law and reiterating that doctors are ready to collaborate under fair conditions.

“We’re in the same sandbox with you and we want to be there for patients,” Dr. Deakins says of the letters. “Will you step up and make optometrists happy to accept vision plans once again?”

AOA, affiliates challenging vision plans

Members spoke, the AOA and affiliates listened. Tens of millions of Americans rely on their local doctors of optometry for their comprehensive eye health and vision care needs, and even despite historic advancements in optometry’s scope and level of care provided, plans haven’t sufficiently advanced alongside the profession. In fact, compounded by increased costs and new challenges to care delivery—be it supply chain disruptions to staffing issues—plans’ stagnant pay scales have put doctors of optometry in a difficult place.

“Health and vision plans are stuck in the 1990s,” wrote AOA President Ronald L. Benner, O.D., in AOA Focus. “They have not adapted and grown with the care we deliver but found a pathway to increase their profits and, in turn, hold back optometry’s momentum. In short, they publicly reinforce the quality care we deliver while devaluing our profession by continuing to follow an outdated model for how doctors are compensated for the essential care we provide.”

The AOA and affiliates understand this dynamic and are taking immediate action to address the disparity by moving toward an equitable system that fairly values optometric care. Among those actions, the AOA has:

• Demanded accountability with the National Association of Vision Care Plans (NAVCP). In June, the AOA logged concerns with U.S. House Oversight and Accountability Committee Chair Rep. James Comer, R-Ky., over the NAVCP’s collective activities and the outsized market power afforded to a handful of large, vertically integrated plans. Additionally, the AOA worked to stop NAVCP-developed model language from being introduced at the National Council of Insurance Legislators earlier this year.
  
• Initiated direct dialogue with plan CEOs. Focused on valuation of care, benefits coordination and resolution of barriers to care delivery and other member complaints, these AOA meetings keep up a constant refrain for the profession.
• Supported updating state laws. In addition to Texas, Nevada, Illinois and Georgia all enacted vision plan laws this year with more affiliates looking to their statehouse advocacy for solutions.
• Championed federal legislation and regulatory crackdown. Jointly backed by the AOA and American Dental Association (ADA), the Dental and Optometric Care (DOC) Access Act, H.R., 1385 / S. 1424, remains priority legislation to curb such plan abuses at a federal level. Additionally, the AOA’s advocacy with the Centers for Medicare & Medicaid Services (CMS) and members of Congress aided in the recent targeting of Medicare Advantage scams and attention on supplemental vision coverage under the federal program.
• Built alliances with physician and patient organizations. In addition to the ADA, the AOA allied with the Patients Rising advocacy organization to help bolster calls for Congress to cease increasingly harmful VBM abuses.

Additionally, the AOA continues to review and monitor such plan mandates and challenges alongside anti-trust experts, as well as provide enhanced transparency behind these actions with the AOA’s Health and Vision Plan Action Report. This daily accounting of the AOA’s actions regarding health and vision plans can be found in members’ First Look emails, Monday through Friday.

If you or your practice are experiencing difficulties with a health or vision plan, please report this to the AOA Third Party Center at stopplanabuses@aoa.org.