Optometry’s wins over abusive vision plans stacking up

August 10, 2023
The AOA and affiliates in Illinois and Georgia score wins against vision plan abuses in a year in which doctors of optometry are making inroads across the country. When all else failed, including talks with the plans and appeals to one state’s insurance commissioner, affiliates did the hard work of helping push through bills in their legislatures that address the abuses.
Georgia and Illinois Flags

Even as the Federal Trade Commission considers a letter of inquiry sent by the chair of the powerful House Committee on Oversight and Accountability on the impact of vision plan consolidation and vertical integration, the AOA and affiliates are making gains that free doctors of optometry from discounts demanded by the plans, devalued care by doctors of optometry, and plans’ interference in the doctor-patient relationship.

In the past seven days, the Illinois Optometric Association saw its precedent-setting legislation signed by its governor and, in Georgia, a large vision plan notified that state’s affiliate that it would no longer require doctors to offer discounts on their materials and service after a legislative victory.

Says Chelsey Moore, O.D., president of the Illinois Optometric Association (IOA): “This significant piece of legislation regulates vision care organizations, ensuring fair fees, transparency and freedom of choice in materials and suppliers. It requires disclosure of out-of-network recommendations and allows doctors to negotiate contract changes. It aims to enhance doctors' control and patient communication while promoting accountability.”

“We want to work with the insurance plans,” Nacondus Gamble, O.D., Georgia Optometric Association (GOA) president, says. “But we don’t have to just take whatever they give us when it doesn’t benefit patients and optometry. This is a clear-cut message to these plans that we’re not going to play ball. I feel like this has set a precedent.”

In June, the governors of Texas and Nevada also signed groundbreaking bills meant to curtail unfair, anticompetitive practices by vision plans.

Illinois bill gives doctors choice versus vision plan demands

S.B. 764, or the Vision Care Plan Regulation Act, was signed by Gov. JB Pritzker on Aug. 4. What does Illinois’ bill do?

  • Prohibits vision care plans from issuing a contract that requires an eye care provider, as a condition of participation in a vision care plan program, to offer services or materials at a set fee when those services and materials are not covered under the plans.
  • Requires fees for covered services and materials to be reasonable and clearly listed on a fee schedule provided to the eye care provider.
  • Prohibits a vision care organization from misrepresenting the benefits of a vision care plan as a means of selling coverage or communicating the benefit coverage to enrollees.
  • Prohibits a vision care organization from restricting an eye care provider's freedom to choose suppliers, materials or labs, or from requiring an eye care provider to purchase materials from a source owned by the entity that issued the vision care plan.
  • Provides that the terms, fees, discounts or reimbursement rates in a vision care plan may not be changed unless mutually agreed to in writing by the eye care provider and the vision care organization.
  • Set forth prohibited contract terms that may not be required by a vision care organization as a condition of contracting with a medical plan.

Doctors and patients alike benefit from the new law, Dr. Moore notes.

“S.B. 764 promotes transparent pricing and out-of-network disclosures,” the IOA president says. “It offers access to in-network options, safeguards against misrepresentation, and encourages fair practices for better patient care.

“The IOA's achievement in passing this legislation is attributed to our CEO and lobbyist relationships with unions, pivotal in overcoming opposition,” she says. “Bill sponsors firmly stipulated the necessity of an agreement, prompting dedicated negotiations with insurers, showcasing the relentless efforts of our legislative team.”

Georgia perseveres against VSP discounts

Georgia’s new law, S.B. 27, passed in May and closes a key loophole in its state law—VSP continued to require discounts on noncovered services in order to be part of its Premier Edge program, despite a bill passed in 2021,  Dr. Gamble says. The GOA appealed to the Office of the Insurance and Safety Fire Commissioner but got no satisfaction.

“We already had a law in place here,” Dr. Gamble says. “The ink was barely dry on the document and it was out of compliance with the spirit of the law. That did not sit well with us, because our goal was to make it uniform across the board. The goal was not to force discounts on the eye care provider.”

When all else failed—talks with the vision plan and then an appeal to the insurance commissioner—the GOA decided to draft new and clarifying language and take it to the legislature, and in May the bill was signed by Gov. Brian Kemp. And last week, the GOA got further confirmation that indeed VSP would comply with the law this time and would notify doctors of optometry in the state that it would no longer require doctors to offer discounts on noncovered services under its Premier Edge program.

Doctors of optometry participating in the Premier program can opt out of the discounts on noncovered services and continue to be in the program. A summary of the bill says vision plans are now prohibited “from requiring an ophthalmologist or optometrist to extend any discounts on services that are not covered eye care services in order to receive increased payments, better reimbursements, preferential treatment.”

Doctors in the program were to be notified of the change by the vision plan. Dr. Gamble had high praise for the GOA’s legislative (John Whitlow, O.D., chair) and Third Party (Stuart Tasman, O.D.) teams, as well as members who reached out to their legislators.

“We’re now asking our doctors to reach out to their reps about the new contract,” Dr. Gamble says. “We are encouraging them to move forward in the way that best benefits their practice.

“Our goal was to make working as an optometrist, on the retail side, fair and give them more freedom,” she adds. “This is a big deal for us because the vision plans weren’t hearing us when we tried to speak with them one-on-one.”

What’s next for eye doctors on the vision plan front?

Persevering even amid progress, says Johndra McNeely, O.D., chair of the AOA State Government Relations Committee. The AOA has been gaining momentum in its fight to remove abusive practices by vision plans—a marketplace where there is little competition. The two most dominant vision plans provide coverage to roughly two-thirds of Americans with a vision benefit.

More affiliates are looking to their statehouses to advocate for solutions.

“Unfortunately, there's a lawsuit that's been filed in Texas over their vision plan,” Dr. McNeely says. “But overall, there is so much more awareness now nationwide over the vertical integration of these plans and how they are disrupting the doctor/patient relationship and what's in the best interest of the patient.

“Our Congress members and our state legislators have caught on to the difficulties that these plans are causing our patients and our small businesses,” she says. “We can actually push for change when the powers that be (the legislators who can actually make the change) are interested in reversing how these plans negatively affect our businesses. I think the connection between pharmacy benefit managers and vision benefit managers helps them understand the problem. The vision plans are having to resort to desperate measures like these frivolous lawsuits and changing doctors’ contracts to the detriment of the patient.”

Register for AOA Regional Advocacy Meetings

Have you signed up to attend one of the regional advocacy meetings across the country?

The meetings gather affiliates’ grassroots advocates, leadership and volunteers for best-practices discussions and a workshop-style approach to work on honing states’ advocacy strategies. Building on the overwhelming success of last year’s inaugural meetings, this year’s AOA State Government Relations Center (SGRC) Regional Advocacy Meetings promote a collaborative environment with seasoned statehouse veterans to put affiliates’ advocacy strategies first. The remaining meetings are:

AOA SGRC Regional Advocacy Meetings are supported by Johnson & Johnson Vision, Lumenis, the Health Care Alliance for Patient Safety and SightSciences.

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