The role of networks in the new health care delivery models

ByScott A. Edmonds, OD, FAAO

The entry point for optometrists to accountable care organizations, health care exchanges and other new delivery models will largely be through some form of network. There are many types of networks, and optometrists need a better understanding of how they work and which are the best to support them for the future of their practice.

The most common form of an optometry network is the vision plan. By contracting to be a provider for a vision plan, you become a member of their network. Most vision plans are focused on ophthalmic materials, and some are even vertically integrated, owning frame companies and optical labs to better enable these programs to offer low pricing for materials. These plans were designed for employer-based contracting, however, where the emphasis was placed on the materials benefit. Although they will be offering their programs to the accountable care organizations (ACOs) and other new programs, their philosophy will stay based on low-cost optical goods and not the primary care services that these new plans will be seeking,

Another form of network is the vision and eye care plan, or primary eye care plan. These plans often include ophthalmologists also and contract mostly to health plans for vision and eye care services. The plans often include routine and primary medical eye care. Primary medical eye care is defined as: “medical care within the scope of practice of an optometrist.” The scope of services will vary from state to state, based on the optometry laws in each. Because these plans include medical eye care, they are in a better position to contract with the new programs.

Some optometrists have been able to contract directly with health plans. These providers are then a member of the health plans network. Many optometrists believe that this is the most desirable way to participate, expecting to be able to bill directly and be paid straight “fee for service” for all medical care. Although that can happen, it is the exception rather than the rule. Most managed care plans require a referral or have precertifications that severely limit optometric care. Many plans also contract with some type of vision or eye care plan and expect all optometrists to access the plan through that vehicle rather than the direct relationship.

The last type of network is one that has great potential in the new health care environment. This network is commonly called an eye care independent practice association or eye care IPA. Many states or regions have an IPA. Some were formed in the late 1980s or early 1990s to gear up for the original wave of managed care while others have formed more recently. Some IPAs include both optometrists and ophthalmologists while others are limited to optometrists. These networks are owned and operated by their members and are often funded by strategic vendor partners. One of the key advantages of these networks is their local focus and management. This allows each IPA to study the evolution of the new health care environment in their region and roll out a strategy to develop local contracts with the key players. Many of the individual eye care IPAs are backed by a national association formally known as the National Coalition of Eye Care IPAs but now reorganized as Independent Eye Care Professionals. The national organization is owned by the member IPAs and operates the administrative hardware, software and staff to execute local, regional or national contracts.

It is critical for each optometrist to understand their network relationships and become more involved with the programs that he or she prefers to support. It is important for doctors to follow the literature, attend meetings and pay close attention to what is happening in your local health care market. Optometrists that fail to do these things may find that their comfortable independent practices that have always seemed insulated from the complicated health care systems will become separated from their own patient base.