Progressive Focus©
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Progressive Focus© Newsletter

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Volume 1, Number 2 Winter, 2000
Helping You Manage the Expectations of Managed Vision Care

What Makes One Managed Vision Care Plan "Better" Than Another?

In the first issue of Progressive Focus© we began an on-going discussion of how you can differentiate vision plans by looking at issues impacting the quality of care you're able to deliver. Topic number one was choice of optical lens labs. Here, we'll discuss additional factors impacting your optical dispensing services: covered spectacle lenses and frames, and the mandated use of specific brands.

Did You Know...?

In 1997-98, 94% of providers who participated in a vision plan that required them to use specific brands of optical goods reported the mandate applied to frames. 66.0% had to use specific spectacle lenses. 40.0% were required to use specific lens treatments. 39.6% were obligated to use specific contact lenses.

Source: Managed Vision Care Report ‘99/00,
Jobson Optical Group, pg. 23

Covered Spectacle Lenses

Poorly designed vision plans (or plans priced well below what others offer) typically over-restrict the types of spectacle lenses covered under the plan. Obviously patients can't expect to get and payors can't be expected to supply any eyewear no matter the cost. But it's appropriate that a patient's legitimate visual needs are addressed in the package of covered lens services.

Poorly designed vision plans tend to put patients into conflicts with providers and with sponsoring health plans by penalizing the very patients who need correction the most. Providers should try to avoid these plans.

For example, a problematic plan might cover single vision lenses but exclude bifocals and trifocals. Another might limit coverage to prescription powers of +/- 4 diopter sphere with 2 diopters cylinder. Those outside this range are "out-of-plan" or must pay an incremental difference for higher power lenses. And, incredibly, some plans still cover only glass lenses despite the fact that today glass lenses are hardly a blip on the optical radar screen.

To penalize those whose eyes require stronger or incrementally more costly lenses is fundamentally absurd. Yet eyeglass plans offering such flawed coverage are being marketed every day, and the problems fall on your shoulders when the patient presents in your office.

Of course the corporate purchasers of these vision plans should be particularly wary of vision vendors offering programs containing any of these flawed elements, even at an attractive price. But, sadly, they're usually unsophisticated purchasers and, often, don't know any better.

Patients will come to you with certain, pre-conceived expectations as to the level and quality of services they're entitled to receive. If they seek vision care services at your office only to find out that the "covered glasses" are limited beyond reason, or that there are significant out-of-pocket amounts payable to satisfy basic and necessary visual requirements, then that will generate complaints and dissatisfaction. You certainly don't need that.

One "slam dunk" clue to potential problems in benefit design is any statement in the plan documents containing the phrases "standard eyeglasses" and/or "standard lenses." Obviously, there is no such thing as standard in the optical industry. In reality standard is whatever the vision plan's administrator defines for itself. And if no one on the payor side knows enough about vision care to question "standard," that usually ends up being the least expensive (and least popular) lenses.

Another clue to a poorly designed vision plan and one certain to cause you problems is when you're mandated or "encouraged" to use a certain brand of lens or lens treatment (e.g., the "house brand" progressive when you know that the patient's visual needs are better served with something else). You're put into a no-win situation any time you must to explain to a patient why the lenses or lens treatments they can get at little or no cost are not as good as what you recommend at a greater out-of-pocket cost. No matter the validity of your recommendation the patient will have the impression that you're only trying to get into his wallet. That's a plan you don't need to be in.

On the other hand, quality vision plans allow, and savvy payors want you, the provider, to use professional judgement and act in the patient's best interests. With limited exceptions this means providing any single vision or multifocal lens necessary for a patient's visual needs, and always with either plastic or glass lenses of any prescription strength.

Better plans cover progressives or allow patients to apply an allowance for basic multifocals toward the cost of progressives. The premier plans allow providers to supply certain specialty lenses at little or no cost to the patient. For example, children or those with vision in only one eye can receive polycarbonates as a covered benefit.

Diagnosing the Health of Your Managed Vision Care Business

1)  Do your appointment and optical dispensing staffs have complete listings of all eligibility requirements and all benefits, limitations, and exclusions for each vision plan you're on?

2)  Do staff members have ready access to CURRENT contact names and phone numbers at each vision plan?

3)  Do optical dispensing AND reception staffs verify that they have collected ALL applicable co-payments for BOTH exam and eyewear services BEFORE the patient leaves the office?

4)  Does the optical dispensing staff track the average completion time for jobs sent to labs mandated by or "approved" by the vision plan?

5)  Does the optical dispensing staff track the reasons for and rates of rejections for lenses fabricated at labs mandated by or "approved" by the vision plan?

More diagnostics in the next issue of Progressive Focus©

Covered Frame Selection

As with spectacle lenses, vision plans differ widely in how they cover eyeglass frames. Most provide an allowance, for example covering the first $50. Upgrades are based on either wholesale or retail cost.

That difference probably won't affect providers nearly as much as the problems created by vision plans that overly restrict patient choice. Here, easily preventable friction is inserted into the provider-patient relationship.

Since eyeglasses have such a strong fashion component, any restriction that unreasonably impacts the patient's ability to get the frame he or she wants will cause problems for the provider and, ultimately, for the healthplan or self-insured employer. Patients should be able to choose from a wide selection of covered frames, and they should be allowed to pay any incremental cost over the covered allowance for any "upgraded" frame.

A vision plan that mandates you must sell from a special display of frames and frame lines it selects and puts into the optical shop (frames which you ordinarily would not use) is a plan destined to generate dissatisfaction for your patients and problems for you. Note, however, that this is different from a vision plan that requires you use a certain number of its frames that you'd probably use in any case with your private pay patients and other third party plans, and if the choice of those frames is up to you.

Did You Know...?

Frames.........................................................32.8%
Spectacle lenses and treatments....................32.0%
Contact lenses...............................................23.1%
Dispensing fees.............................................10.5%

Source: Managed Vision Care Report, 99/00,
Jobson Optical Group, pg. 10

HMO Enrollment and Growth Trends

InterStudy, the Minneapolis managed care research house, recently published an interesting report. It stated that while HMOs had enjoyed steady enrollment increases for many years, including double-digit jumps through the mid 1990s, enrollment actually dropped recently for the first time in two decades. HMOs experienced a 0.6% decrease (a loss of more than 500,000 members) between January and July 1999.

This is a fascinating development in an industry where growth has seemed inevitable, and where most HMOs have moved forward despite bad press, bad financial results, or regulatory activity.

Also recently, Medical Data International (MDI Online, May 18, 2000) reported that national HMO enrollment peaked at 30.5% in 1998. In certain markets HMOs were essentially the only game (e.g., Sacramento, 82% penetration rate; San Francisco, 72%).

But it appears now that the perceived inevitable growth has been halted, or at a minimum slowed considerably. HMOs are fewer and fewer. In part due to terrible financial performance, between January and July 1999 30 of the country's 643 HMOs closed their doors. And with falling reimbursements from HCFA, Medicare HMOs are leaving the marketplace in droves. InterStudy reports that between July 1998 and July 1999 Medicare HMO enrollment dropped from 18.6% of all eligible Seniors eligible to just 4%.

The downward trend in Medicare HMO enrollment should be of particular interest to anyone providing vision exams or optical dispensing services. As Seniors leave Medicare HMOs by choice or by closures their options are reduced. In many cities there no longer are any Medicare HMOs. This means that the Seniors who previously had exam and, possibly eyewear benefits through these HMOs are now being forced back into the private-pay world.

This is an opportunity to rebuild a private-pay patient base; to establish fees outside the control of any HMO or third party vision plan, and to provide the care you determine is in your patients' best interests.

Your challenge is to keep those patients coming back. As always, when there is no longer a third party paying the bill or directing patients into a tightly controlled provider panel, customer service (customer satisfaction) will rule the day. Carpe Diem!

Quotables...

"Among all the industries that we rate, including banks, insurers, and brokerage firms, HMOs currently have the largest percentage of endangered institutions. What's worrisome is that these financial pressures can sometimes impinge upon the quality of care afforded to customers, or, in a failure, potentially leave them stranded."

Martin Weiss, PhD, Chairman, Weiss Ratings
(in an industry report 10/30/2000)

Vision Plan Profile — Eye Med

To help providers and payers better understand the marketplace and players, Progressive Focus© will profile a vision plan in each issue. Here, we'll introduce EyeMed.

EyeMed is a division of Luxottica, a $2.6 billion eyeglass frame design and manufacturing company with over 39 years of experience. LensCrafters, with over 17 years experience and professed to be the nation's best-known optical retailer, is also part of the Luxottica family.

The EyeMed provider panel is a diverse provider network with over 7,000 providers, allowing third party plan Members to choose from among private practice Optometrists, Ophthalmologists, Opticians, and LensCrafters. This vertical integration of Luxottica, LensCrafters, EyeMed, and the independent providers that dispense Luxottica product provides a delivery system quite distinct from others in the vision care industry. As this issue goes to press EyeMed has contracts covering more than 46 million Members.

Both quality care and quality product are promoted as integral pieces of the EyeMed vision care program. To be considered for the panel, providers must meet specific credentialing requirements and agree to adhere to EyeMed's Quality Assurance Program. This helps ensure consistent, quality care among all providers.

From a product perspective, EyeMed offers third party plan Members a choice of eyewear featuring Luxottica brand name frames such as Armani, Anne Klein, and Persol. Additionally, providers are free to recommend the quality lens and lens options that best meet their patients' medical or lifestyle needs. And they are free to use their own lab or a quality lab of their choice.

For more information about EyeMed Vision Care or panel participation contact Dr. Ken Clanton, Medical Director at EyeMed Vision Care (513) 583-6622, or visit the website at www.eyemedvisioncare.com.

E-Vision Resources

http://www.medicalcomputingtoday.com
An excellent site if you'd like to learn more about using computer technology to manage the volumes of data flooding your office as a participant in managed vision care.

http://www.gilweber.com/index.php/resources/links
An extensive list of HMO and state HMO association URLs. Check these healthplan sites for information about HMOs, their patient care protocols, and administrative policies. You'll also learn a lot about how the plans market themselves (and you) to the public.

 

These materials are intended to provide useful information about the subject matter covered. The author believes that the information is as authoritative and accurate as is reasonably possible and that the sources of information used in preparation of the materials are reliable, but no assurance or warranty of completeness or accuracy is intended or given, and all warranties of any type are disclaimed.

The materials are not intended as legal advice, nor is the author engaged in rendering legal services. The materials are not intended as a replacement for individual legal or professional advice. Information contained herein is presented only for illustrative purposes, and it should not be used to establish any fees or fee schedules, nor is it intended and it should not be construed as encouraging any user of the materials to take any actions that would violate any state or federal antitrust laws, tax laws, or Medicare or Medicaid laws.

Copyright © 2001, Gil Weber, MBA. No part of this newsletter may be reproduced or distributed in any form whatsoever without the author’s prior written authorization.

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