Optometry enters crucial year of health care reform prepJanuary 2, 2013
With full implementation of the federal Affordable Care Act (ACA) less than a year away, optometrists across the nation should be preparing now to serve patients under a changing health care system, according to AOA President Ronald Hopping, O.D., MPH.
Implementation of the major provisions of the health reform law on Jan. 1, 2014, including the AOA-backed Harkin Amendment and pediatric eye care essential benefit, are projected to help millions of Americans gain access to an expanded range of eye and vision care services through optometric practices. The Harkin Amendment bars anti-optometry discrimination by health plans.
“To help ensure as many patients as possible have access to optometric care under the nation’s changing health care system, optometrists and their state optometric associations must act now to ensure optometrists are properly included in health plans offered through newly established health insurance exchanges, as well as in health information exchanges, expanded Medicaid programs and other reform-related efforts,” Dr. Hopping said.
Optometrists and their staff members should be readying their offices now for the changes in day-to-day operations that will be required as the law is fully implemented.
“The AOA Advocacy Group has been highly effective in securing key victories to provide optometrists opportunities for an increased role in the nation’s changing health care system,” Dr. Hopping said. “However, many reform provisions will be implemented at the state level. It is now up to affiliates and individual optometrists to act on these new opportunities to provide quality eye and vision care to a growing number of Americans.”
Dr. Hopping suggests practicing optometrists monitor closely the following reform-related developments.
Health insurance exchanges
Health insurance exchanges, offering standardized health care plans for individuals and small businesses, must be operational in all states by Jan.1, 2014. In states that do not establish their own exchanges, the federal government will operate a federally facilitated exchange or coordinate a partnership exchange with the state.
Optometrists and their state optometric associations should carefully monitor the development of the exchanges that will serve their areas, begin familiarizing themselves with the plans to be offered through the exchanges, and seek appointments to governing boards for the exchanges.
The AOA-backed Harkin Amendment applies to health plans operating inside the new exchanges, and ODs should monitor plan compliance with this federal non-discrimination safeguard. The AOA-backed pediatric eye care benefit also applies to plans being offered through the exchanges and affiliates and ODs should make preparations for an expected influx of new pediatric patients.
The federal reform law will increase the number of patients enrolled in Medicaid by expanding eligibility criteria for state Medicaid programs. While the planned Medicaid expansion has been limited by a Supreme Court ruling and could be in further jeopardy as the result of ongoing federal budget negotiations, optometrists should be aware of a potential increase in Medicaid patients seeking care.
Optometrists should explore recognition by state Medicaid agencies as providers of physician services (medical eye care) as a means of ensuring both full participation in expanded Medicaid programs and the option to participate in Medicaid electronic health record (EHR) incentive programs (see below). ODs should join the AOA in working to advance federal legislation to fully recognize ODs under Medicaid, Dr. Hopping said.
Employer-based health plans
The ACA’s Harkin Amendment, beginning in 2014, will bar arbitrary discrimination against health care providers by insurance plan administrators. Such discrimination has been common among large employer-based health plans, organized under the federal Employee Retirement Income Security Act (ERISA), which are considered by some to be exempt from state provider nondiscrimination and access-to-care laws.
Over recent years, the AOA and its affiliates have worked to convince some of the nation’s largest employers to open their health benefit plan provider panels to optometrists as a way of increasing both cost-efficiency and access to care for employees. Optometrists should reach out now to any employee health plans that do not reimburse optometrists for medical eye care services and explain how the utilization of optometric practices for eye care services is not only advantageous to their employees but complies with new federal law. At the same time, ODs and affiliates should monitor health plan implementation of the Harkin Amendment and report any non-compliance issues to the AOA.
New care models
New health insurance plans created under the reform law, as well as existing public and private insurance programs, are expected to move toward emerging coordinated care models – such as accountable care organizations (ACOs) and possibly medical or health homes – over the coming years. The health reform law includes several provisions to encourage the development of such new care delivery and payment models. Medicare has already authorized the startup of ACOs across the nation for its beneficiaries.
Optometrists who have not already done so should become familiar with the organizational structures of such new care models and monitor the development of ACOs and medical or health homes in their areas. For its part, the AOA will continue to monitor the moves of the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation, which was created under the ACA to develop and test new payment and delivery models.
Quality reporting and new payment models
Health plans are also moving rapidly beyond traditional fee-for-service reimbursement and managed care programs, Dr. Hopping said. Notable among these new alternative reimbursement systems is “value-based” payment, which rewards practitioners for adherence to quality-of-care standards and successful outcomes. Many private-sector health plans have implemented clinical quality measure (CQM) reporting programs. Medicare is transforming its voluntary Physician Quality Reporting System (PQRS) from rewarding doctors who participate to punishing doctors who do not, including penalties in 2015 for doctors who do not attempt to report measures for PQRS in 2013. The CMS is also implementing a value-based payment modifier for large groups of 100 or more physicians in 2015, again primarily based on performance on PQRS in 2013. Medicaid value-based reimbursement programs are under development.
Eventually demonstrating adherence to widely accepted, evidence-based practice guidelines is expected to be required of practitioners in virtually all public and private-sector health insurance programs. Optometrists who have not already done so should begin participating in voluntary CQM reporting programs such as the Medicare PQRS. In an effort to ensure optometrists help set the standards for primary eye and vision care under such quality measurement programs, the AOA is developing evidence-based practice guidelines, in line with new Institute of Medicine (IOM) criteria. Optometrists should also become familiar with other emerging payment models such as “bundled payment.”
Health information exchanges
Participation in new coordinated care models and quality reporting-based payment systems will require health care practitioners to have interconnected health information technology (HIT).
The AOA has worked hard over the past few years to secure opportunities for ODs to receive incentives for adopting health information technology, such as up to $44,000 under Medicare and potentially $64,000 through the Medicaid EHR incentive program, and many of our members have already benefitted financially from these programs. Now government reports find many optometrists have implemented EHR systems in their practices and are participating in government EHR incentive programs. The Medicare EHR incentive program’s Stage 2 utilization criteria, beginning in 2014, will require the electronic exchange of patient information using those EHR systems. Ultimately Stage 3 criteria might require the use of EHRs to produce documented improvements in patient health.
Dr. Hopping urges optometrists to monitor the development of health information exchanges, which are designed to provide interconnectivity among health practitioner EHR systems. For optometrists who do not have access to such systems, AOAExcel™ plans to introduce its XNetwork interconnectivity service in March 2013.
“The Affordable Care Act (ACA) and other federal health care legislation will mean revolutionary and substantial changes in the U.S. health care system over the not-too-distant future,” Dr. Hopping said. “Already health reforms are creating important opportunities. Optometrists and their state optometric associations should act now to ensure their patients benefit and our profession is treated fairly under these reforms. As always, the AOA is here to help our members adapt and succeed in our changing world.”