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As we look at the dawn of a new year, it is a great time to think about the future and consider changes that may affect our lives.
For health care providers, this can be a little frightening. If we use this time window to reflect backward, it is easy to see how the platforms of health care reform have changed our practice life.
For our practice, the change to electronic health records, just 5 years ago, has redirected our focus. Striving to make meaningful use has added items like the review of systems, medical reconciliation and the use of vital signs that has broadened our scope and made us aware of our critical role in primary health care. But what are the new challenges that will be ushered in by reforms and change to our practice life yet again?
I believe the next shoe to drop on the reform landscape is a change in the way we are paid for our services. We have heard much about “pay for performance,” “value-based programs” and “diagnosis-based global payments,” but where have we seen examples of these payment programs in eye care?
To date, these programs have not had an impact on our profession. The only risk-based contracts that I have seen that would seem practical in the eye care space is the global capitation of an integrated ophthalmic network, ophthalmic health system or regional eye care delivery system. These systems include optometrists, ophthalmologists and facilities that can “carve out” the entire body of eye care-related services with a single central capitation or payment on a per-member, per-month basis. These funds become available to each of the individual respective providers based on the eye care services that are delivered to the patient members during each month.
The payment for each service provided, be it an eye examination, cataract surgery, low vision consult or a retinal detachment procedure, is based on the overall efficiency of the total provider group. Better early diagnosis, patient education and early intervention on the front end will save dollars spent on complex restorative procedures and long-term rehabilitation on the back end. Providers must work as a team to maximize quality and, therefore, reimbursement. Rather than a reward for more services and procedures, the group is rewarded for better outcomes and fewer procedures.
Eye care providers in these systems must all adopt a “long view” in the care of their patients. This means preventive health care that includes a review of vital signs and family history with direct counseling and patient education. The risk pool is managed by an active committee structure of the optometrists and ophthalmologists that are providing the care. A quality assurance committee that develops protocols for the management of ocular disease is balanced by a utilization review committee that reviews care retrospectively and works to eliminate waste and duplication.
Part of the scope of services that may be an important new aspect of ophthalmic health systems are the preventive primary health care services that are provided to that subset of the health plan membership that have only refractive error as a health issue and seek their annual health care from an eye doctor. These services, which include the review of systems, family history, social habits and vital signs, may be the source of an increase in the global capitation rate that is paid to the ophthalmic health system.
Strong regionally based clinical eye care networks require an equally strong management services organization to seek out and negotiate comprehensive contracts. These progressive organizations will provide the management and disbursement of the capitation pool, data collection and analytics as well as group purchasing arrangements. Provider groups alone cannot manage these contracts and, likewise, management companies cannot negotiate provider risk contracts without strong network organizations. These new programs require a two-tiered approach.
Traditional insurance-based eye care delivery models, where a management company develops risk contracts and then pays the providers a reduced fee-for-service have only produced increased cost for the health plans and their subscribers and lower provider reimbursements. These programs will be phased out by health care reform long before they self-destruct on their well known “race to the bottom.”
A much deeper understanding of how risk contracts work and how providers need to play an active role is required by most optometrists for success with these new programs. These programs are in various stages of development in most areas of the country. Each of us should take a hard look at our own regional health care markets and get involved with these programs. Like the adaptation to electronic health records, the learning curve may be steep, but the rewards are dramatic.