Health plans changing tone, vision plans not so much
Coordinated advocacy efforts pressure health and vision plans to drop anti-competitive, anti-patient practices, lending credence to AOA legislation that reins back these abusive policies.
Fragmentation of eye health and vision services from mainstream health plans creates an unnecessary barrier, disrupting doctors' ability to provide seamless patient care—it's a message that AOA has long espoused, and one that's convincing legislatures and plans, themselves, to make appropriate changes.
"Vision plan abuses hurt our patients and our practices, and we've had enough," says AOA President Steven A. Loomis, O.D. "That's why the AOA and our state associations are taking the fight for fairness and patient access to the U.S. Capitol and statehouses across the country, and it's why we're getting results."
Contractual arrangements that require doctors' participation in a vision care plan to access a health plan have become undone in a growing number of states. One of the nation's largest health plans, Cigna, already eliminated this requirement in states, including:
This change in business model allows doctors to participate directly with Cigna's medical network without participation in VSP's Integrated Primary Eyecare Program (IPEC). Doctors in many of the affected states have received letters notifying them as such, and Cigna intends to reach out to VSP network providers individually to credential directly with the health plan.
"We anticipate that many of our members who were previously restricted from directly joining the Cigna network (or panel) will be contacted by VSP and Cigna with an offer to join Cigna directly," says Stephen Montaquila, O.D., AOA Third Party Center (TPC) chair. "We encourage members to carefully examine this opportunity and, as with all contracts, to carefully evaluate the terms to ensure that it makes good business sense for their practice."
Educate, negotiate, and—when all else fails—legislate
Cigna's reversal stems from direct advocacy and outreach by AOA and affiliates to not only highlight the discriminatory and counter-logical practice of requiring doctors of optometry to join an ancillary benefit discount vision plan as a condition for credentialing on a health plan, but also that it simply makes financial—and more importantly, quality patient care—sense to integrate doctors of optometry directly into medical plans.
"We see this as a significant step for the health care delivery system as a whole," Dr. Montaquila says, referring to Cigna's de-tying arrangements. "Understanding that optometrists are taking on an ever increasing role in providing much needed medical eye care services, with numbers cited as high as 70% of all eye care, access to these services is paramount."
He adds: "The old system is broken. Access was restricted only to those doctors who could participate with a given discount materials benefit program rather than focusing on those doctors who provide high quality, efficient and cost-effective care."
These changes represent a paradigm shift that acknowledges the important role doctors of optometry play in delivering quality care, Dr. Montaquila says, and as the health care delivery system continues to evolve, integration into medical panels will be a key factor for doctors of optometry to have the greatest positive impact.
"We applaud companies such as Cigna for taking this much needed step, moving away from systems that just do not make sense and toward building an eye health and vision care delivery system for 2016 and beyond," Dr. Montaquila says.
It's about making progress one state, and one insurer, at a time. The AOA's State Government Relations Center (SGRC) notes dozens of states have passed one form of access/nondiscrimination legislation in recent years, slowly closing these gaps. These laws and regulations, designed to protect doctors of optometry and their patients, include:
- willing provider laws.
- General nondiscrimination laws.
- Direct access laws.
- Freedom of choice laws.
- Payment parity laws.
Deanna Alexander, O.D., AOA SGRC chair, says since the original bills in Texas and Rhode Island were passed in 2011 to eliminate the requirement that doctors of optometry credential through vision plans to have access to medical plans, we have had at least 17 states pass this type of legislation and more are coming on board this year as their sessions come to close.
"Access to patients for medical eye care should not be limited by a requirement of participation in a vision plan," Dr. Alexander says, and as more of these kinds of state laws come into effect to untie health and vision plans, national contracts may be affected by the momentum of state laws passing.
"Doctors of optometry will be able to contract directly with health plans just as all other health care provider groups do and have more control and choices over what is best for their patients and business."
Fighting back against a range of health and vision plan abuses
To ensure doctors and patients reap the full benefits of states' nondiscrimination and other efforts aimed at reforming health and vision plans abuses, federal action is necessary to complement—not supersede—state law, and ban these kinds of practices by plans regulated on a federal level. That's why AOA and the American Dental Association (ADA) are backing H.R. 3323, the Dental and Optometric Care Act (DOC Access Act), to round out protections and add to the 40 states that already have laws prohibiting some vision and/or dental plan abuses. Aside from outlawing forced participation in a vision plan as a condition for health plan participation, the DOC Access Act would also bar non-covered services and materials mandates.
A new study by Avalon Health Economics—presented in a Capitol Hill news conference during AOA's Congressional Advocacy Conference, April 19—showed the impact of vision and dental plans' NCS provisions (or the absence of such provisions) on patients' true costs really benefited the plans, themselves, as opposed to the patients they claim to help. The study authors described the concentrated nature of the vision plan market and noted that while such a "monopsony" behavior usually benefits consumers if providers were "overcharging," in this instance, plans' monopsony-like behavior lead to higher overall costs, with NCS mandates forcing doctors to compensate for the "transfer" of operating margins to plans, the study notes.
Matthew Burchett, O.D., AOA SGRC member and Kentucky Optometric Association past-president, anecdotally described how, even after passing such NCS legislation at the state level in Kentucky, vision plans still tried to exploit loopholes to continue operating business as usual.
"Which is why we're happy to put forth this legislation [H.R. 3323] that has more backbone to speak to some of those issues, and has more repercussions for those vision plans to hold them accountable," Dr. Burchett said.
Although AOA doctors and students work hard to build support for H.R. 3323, already with nearly 50 bi-partisan, co-sponsors, public lobbying disclosures indicate the National Association for Vision Care Plans (NAVCP)—the group working against optometry at federal and state levels—has hired a high-profile, Washington, D.C., lobbyist to fight against the DOC Access Act.
Given the company's role as a leading member of the NAVCP, VSP was sought for comment on the vision plan's stance toward H.R. 3323. VSP did not take a direct position on the bill, and when asked about NAVCP's opposition to H.R. 3323, a VSP spokesperson had no additional comment.
Jon Hymes, AOA executive director, says AOA and state associations are building support for an important and much needed bill in H.R. 3323, and disapproved of the double-speak of some vision plans.
"We don't spend a lot of time trying to interpret what vision plans or their lobbying arm, the NAVCP, are saying at a given moment to different audiences," Hymes says. "The fact is their aggressive opposition to this AOA priority and their misrepresentation of this entire issue to federal and state officials makes it even more urgent that we spotlight their abuses and hold them accountable."
The prior-authorization requirement ended July 1, 2022, for all patients—except Medicare Advantage in Georgia and Florida—a year after the AOA and other groups decried Aetna’s decision.
Medicare Advantage Organizations’ denials of prior authorization requests raise flags in HHS report and prompt AOA’s third-party advocacy outreach on behalf of optometry practices.
Direct third-party advocacy remains a critical component of the AOA and affiliates’ mission, helping support practice success by ensuring patients can freely access the broadening scope of eye health and vision care delivered by optometry. But advocacy requires a team effort, and optometry’s advocates have an opportunity this spring to help bring about the payer changes the profession needs.