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New delivery models for primary care optometry
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I have been a careful student of the new models for the delivery of primary health care. Most of us are familiar with the patient-centered medical home, but there are other models known as accountable care organizations. These groups are made up of physicians, hospitals and other health care providers that come together on a voluntary basis to provide coordinated health care for Medicare or Medicaid patients.
These models are particularly interested in improving care for patients with chronic medical problems. When the accountable care organizations (ACOs) are successful, the providers share in the savings for the Medicare or Medicaid programs.
The Medicare program currently offers three programs. The Medicare Shared Savings Program is for fee-for-service beneficiaries to improve quality and reduce unnecessary costs. This program is based on primary health care and does not involve optometry services at this point in time.
The Advanced Payment model is for physician-based programs and rural providers, with selected participants receiving upfront payments.
The Pioneer model is an advanced model designed for providers with experience in coordinated care. There are currently 23 participating programs, and this model is closed to new applicants.
Of the current Medicare programs, none have evolved to the level of comprehensive care that would include optometry services. However, readers of this blog have learned many ways that optometrists can participate in primary medical care, offer expanded coverage and reduce the duplication of care.
With eye care electronic health records (EHRs), optometrists can coordinate care in a way that will save money for the ACOs, thereby increasing dollars available for sharing. Optometrists who are horizontally integrated in independent practice associations (IPAs) are in a position to approach existing ACOs and develop expanded programs that would include optometric care. The IPA would need to require that each optometrist use a qualified EHR and establish a vehicle to transfer data in a manner that is compliant with the Health Information Portability and Accountability Act to the ACO. To win these contracts, the IPA will need to demonstrate the quality improvement and the cost saving with the addition of optometry services.
To date, the ACO movement has been limited to the Medicare program. Recently, however, there has been significant movement by several states to institute ACOs for the Medicaid program. Of note, New Jersey, Utah, Colorado, Oklahoma and Oregon have initiated some type of Medicaid ACO program. The movement into the ACO programs has been fueled by the success of managed care organizations to produce cost savings for state Medicaid budgets. Medicaid programs should be fertile ground for optometrists to be well positioned for primary care, because the optometrist may be the only contact many younger patients have with the health care system.
Jan. 1, 2014, will see the beginnings of the phase of the Affordable Care Act that includes eye care services for children. With this act, routine eye examinations and some level of vision correction will be core benefits for any health plan. This fundamental change in basic health care will require all plans to include optometric services. This program elevates the optometrist to a member of the primary health care team and should pave the way for the profession’s direct involvement in the ACO movement.
As optometrists, we should take the time to learn more about ACOs and find out which ones are operating in our local areas. In addition, we need to learn more about the eye care IPAs that are organized to some level of evolution in most states. We need to encourage our IPA leadership to actively pursue the ACO movement.
Even though some ACO programs are already established for Medicare, with several years of operation, many are struggling to develop successful programs. The Medicaid-based programs may be more successful, but all of these organizations are still in their infancy. Whether these programs are an evolutionary phase or a stepping stone to better programs, ACOs are a vital piece of health care reform and one where optometry can play a major role.