BLOG: Do you provide preventive health care?

ByScott A. Edmonds, OD, FAAO

To prepare for this blog, I reviewed the piece entitled, “Implementing Health Reform: House Can Sue Administration Over ACA Cost-Sharing Reduction Payments,” by Timothy Jost.

This was the lead story in the Health Affairs Blog, a great place to follow topical issues in health care reform. This article covers the latest attempt by the House of Representatives to overturn the Affordable Care Act (ACA) and deals with tax credits and other measures that have been used by the Administration to lower the cost sharing of health care services for the poor.

Many of the health insurance marketplace products feature significant cost sharing requirements that defeat the purpose of the ACA. In spite of some legal standing for many of these legal actions against the ACA and affordable health care for all Americans, the Supreme Court has been consistent in upholding the intent of the new law.

In reviewing this information, I took a close look at how eye care and optometry fit into this picture. When eye care services for children were included as an essential service, many of us expected to see a wave of young people at our doors. As the health exchange products rolled out however, we soon learned that we were often a big part of the cost sharing aspect of the most common bronze and silver products. This amounted to little or no actual coverage for the eye exam and glasses as the costs were applied to co-pays and deductibles, all of which the patient could not afford.

The problem for us lies in the interpretation and execution of the ACA by the states and insurance companies. And a big part of the interpretation problem lies with optometry and our traditional mindset of being “vision and eyeglass providers” and part of the ancillary benefit package rather than primary care health providers and part of the front line of primary care.

In the 10 essential health benefits of the ACA, we are listed as number 10 and titled “pediatric services-dental and vision care for kids.” Because these services have been traditionally ancillary benefits, it was easy for insurance companies to package these outside of primary care services and build in significant co-pays or make the entire body of services applicable to the deductible.

Where we belong in the essential services list is at number nine: “preventive services including counseling, screenings and vaccines to keep you healthy and care for managing a chronic disease.” These services are fully covered in virtually all of the product lines and seldom require co-pays or deductibles. If we drill down into the list of specific services included in this category, you will find:

Blood pressure screening;
Diabetes screening;
Diet counseling;
Obesity screening and counseling;
Tobacco use screening; and
Immunization vaccines.

The first five are the very items that I have identified as optometry’s primary care data points and in upgrading your eye exam to primary care. The sixth point is part of the legislative initiative in California and should be part of every state’s expanded scope legislation.

Preventive health services are the key element of moving our health care system away from a focus on sickness, procedures and treatments and into one of wellness, prevention and health. There are not enough primary care physicians in America to meet this challenge. There is not a mindset among young Americans to seek this type of care. Alternate pathways for wellness care must be established, and we can be a big part of this movement.

We must be the source of this paradigm shift for optometry. The schools must emphasize this to our students, and optometry practices must emphasize this as part of the eye examination. Our state associations and the American Optometric Association must educate legislators, insurance companies and managed care plans of this critical role for our profession. Integrated ophthalmic networks must carve primary health care services into eye care contracts.

Health care reform is a moving target. Just because the current insurance-based product design relegated us to an unfunded ancillary benefit does not mean that this is where we must remain. Our training and background as health care providers and our wide distribution across the country makes our position for prevention-based health care services logical and achievable. It is up to us to make this happen.

Reference:

Jost T. Implementing health reform: House can sue Administration over ACA cost-sharing reduction payments. Health Affairs Blog. Posted September 10, 2015. Accessed September 14, 2015.