AFFORDABLE CARE ACT

Will the Affordable Care Act Affect Your Practice?

A look at what you will (and won’t) have to change to keep up with ACA requirements.

By Clarke D. Newman, OD, FAAO

Buddha once said: “We suffer because we want our situation to be different, not because of our situation.” As I have watched my colleagues respond to the changes in healthcare reform over the past few years, this quote haunts me. We have resisted change because we want our situation to be different. But the truth is, our situation is different, and it will be more different still.

According to research from The Vision Council, recent developments with the Patient Protection and Affordable Care Act (commonly called the Affordable Care Act [ACA] or Obamacare) have not had too much of an immediate impact on the optical industry (Figures 1 and 2). So much has changed so fast that few in the entirety of health care can wrap their arms around it. In fact, The Vision Council notes that the long-term prognosis of the ACA’s impact on the eyewear industry is still in doubt.

Figure 1. As a result of the Affordable Care Act, please indicate if any of the following situations applies to you. Source: The Vision Council’s VisionWatch Economic Situation Study: May 2014

Figure 2. How will the current state of the economy affect your intentions to get an eye exam in the future? Source: The Vision Council’s VisionWatch Economic Situation Study: May 2014

How will the ACA affect your contact lens practice? As with much legislation, the answer is nuanced. There are no ACA provisions that address contact lens practice directly. However, there are some indirect effects.

Direct and Indirect Effects

First, there is now a mandatory children’s vision benefit that includes a comprehensive examination and materials. While the ACA and the associated promulgated rules do not address contact lenses for children, inevitably, some of these children will want and will obtain contact lenses, even though they will be a non-covered expense.

Second, by law, the so-called “Harkin Amendment” (proposed by Sen. Tom Harkin, D-Iowa, and now codified as Section 2706(a) of the Public Health Service Act), which prevents the insurance market from discriminating against certain eyecare providers, will open up more qualified health plans that were not available before. These opportunities will open more doors for medically necessary contact lens prescribing for patients who were out-of-network before the ACA took effect.

Electronic Health Records

The major changes that will take place within the paradigm of healthcare reform may affect contact lenses in ways that you may not consider. First, in five years if not sooner, all of us will be using electronic health records (EHRs) exclusively. The statutory and regulatory burdens that will be in effect by then on those who do not comply will be so great that I predict that those unwilling to comply will simply close their doors or stop taking insurance.

For contact lenses, that reality poses special problems—especially for those of us who prescribe specialty lenses—in that the contact lens data areas of all of the current programs are terribly weak when it comes to recording contact lens parameters. This is a reason why I was a relatively late adopter of EHRs.

Currently, we use form fill PDF documents that we save to the record. It is not ideal, but it works. The health record companies are going to have to fortify these data record areas.

Accountable Care Organizations

Next, practices will likely realign into larger group practices and Accountable Care Organizations (ACOs) that are centered on medical care. When the ACA was written, ACOs did not include non-MD healthcare providers. However, the various professional organizations worked very hard to get rules included to allow non-MD healthcare providers to participate in almost all aspects of ACOs.

It is really difficult to predict where all of this is going, but I can see a scenario in which, as these ACOs become more closely aligned, these realignments may cause changes in how we prescribe contact lenses; the incentives may shift away from contact lens prescribing to medical eye care. I am sure that some will consider this view controversial to say the least, but it is one possibility.

Vision Care Plans and Qualified Health Plans

The other area in which there might be some impact on contact lens practice will be the continued consolidation of vision care plans (VCPs) with the qualified health plans (QHPs). We have seen several of the VCPs align with the QHPs. Some of the larger companies in eye care own vision care plans and vice versa. Examples of this include Luxottica’s EyeMed Vision Care and VSP’s ownership of Marchon Eyewear.

While the ACA does not offer adult vision benefits through the health insurance marketplaces (also known as health exchanges), the VCPs are adapting to continue offering stand-alone plans through the various employers. However, competition among the VCPs and the changing market pressures created by the ACA and healthcare reform measures will alter the VCPs’ offerings as they try to consolidate service and material purchases to maximize efficiencies and profits.

Requirement Changes

Looking beyond contact lens practice, the ACA has some broader implications for the profession. Contained within the act are provisions that extend and broaden the quality reporting measures that were contained in the Physician Quality Reporting System (PQRS). Starting in 2015, the ACA’s Title III, Subtitle A, Part I, Section 3002: Improvements to the Physician Quality Reporting System section makes the voluntary PQRS system mandatory for Medicare fee-for-service plans.

Additionally, there are other requirements that will create different payment amounts under Medicare. Currently, all Medicare physicians get paid the same amount for the same services. Under the new payment incentives contained in Section 3007:Value-Based Payment Under the Physician Fee Schedule, the CMS Monetary Conversion Factor (CF) will vary. One of the many metrics by which the monetary CF will vary is whether or not a physician is actively working on an American Board of Medical Specialty (ABMS)—or equivalent—Maintenance of Certification (MOC) Program.

So, while a number of optometrists in the United States have completed a board certification (BC) program, in 2015, to qualify for this program incentive, you have to have completed the BC and then be working on the MOC. At first, this extra bonus on your CF will be a voluntary program. However, it is slated to become mandatory by 2018—just as the PQRS system was voluntary before becoming mandatory in 2015 for all fee-for-service participation.

So, does CMS require you to become Board Certified? No, not now. However, if you want to get paid at the same level for the same services under the same plans, you will have to comply. Will more board certification programs gain the CMS ABMS Equivalent status? Possibly, but, so far, none have done so.

Another area that will create change is the new Physician Compare system (accessible at www.medicare.gov/physiciancompare/search.html?AspxAutoDetectCookieSupport=1). This system is designed to reflect the level of participation in the quality initiatives laid out in the ACA. The more physicians participate in the programs discussed in this article, the higher their ranking on the page will be. New Medicare enrollees will be encouraged to select from the providers listed on Physician Compare. Just like a Google search, new patients are more likely to select from those toward the top of the first page as opposed to someone way down on page three. Currently, you can only compare group practices; comparisons of individual physicians and other healthcare professionals will be available in the future.

One of the components of this new system is a patient ranking and comments section that will count toward the physicians’ ranking. It is like a governmental Yelp review that moves a provider up or down the page. So, jumping through all of the hoops will make life fun for everyone. There will be an appeals process for disposing of unfair things, but it will function similarly to rehabilitating your credit report.

The Bottom Line

The bottom line is this: the average eyecare practitioner will see practices realign in new alliances that will emphasize primary and medical care over contact lens care. I believe that the overwhelming majority of us will adapt our practices to make sure that contact lens practice remains a robust and profitable part of what we do each day. In other ways, we will change how we practice to improve efficiencies within our office and within interdisciplinary relationships that will improve the quality of care.

Collectively, the suffering will stop when we embrace our new situation instead of wishing it were different. Healthcare reform, and specifically the ACA, is here to stay. So, let’s move on to the task of figuring out how to maximize the environment to our advantage and the advantage of our patients. CLS

Dr. Newman has been in private practice in Dallas since 1986 specializing in vision rehabilitation through contact lenses as well as corneal disease management, optometric medicine, and refractive surgery. He is a Diplomate in the AAO and a consultant to B+L, AMO, and Alden Optical. Contact him at cdnewman@earthlink.net.