Managed Care

Major Implications of Health Care Reform–for Independent ODs

By ROB Editors

Vision Source commissioned Review of Optometric Business to create the “Navigation Guide to Health Care Reform for Independent Optometrists,” a report summarizing important trends in US health care delivery and what they mean for independent optometrists. Included in the report are strategy imperatives and action plans. This article is the first in a three-part series.

CLICK HERE or on the image to the left to download the full report,published in April 2014.

Major Implications of Health Care Reform

Increased government regulation of health care
A major consequence of the 2010 Affordable Care Act (ACA) will inevitably be greater government control of health care delivery. The federal government will enforce a standardization of services provided to insured patients, and through a combination of penalties and incentives, will dictate administrative procedures and standards of care that providers must adopt.

It will become imperative for independents to keep current on the administrative requirements mandated by the government to maintain accreditation and patient access, assure rapid reimbursement and to reduce audit risk.

Consolidation of medical insurance companies
The federal government’s increasing role in health care is likely to stimulate consolidation within the insurance industry. The ACA defines national standards for health insurance plans, which has the effect of making insurance a commodity. In commodity markets, larger firms are better able to reduce costs through economies of scale and thus gain market share. Commodity markets tend to be dominated by a few large companies.

Larger insurers have greater capacity and expertise to manage risks and to deal with government agencies. Larger companies can be more effective in organizing and maintaining provider networks and in marketing plans to employers and consumers. Larger insurers have greater bargaining power with hospitals and providers. Government is likely to consider larger insurers “too big to fail” and provide financial protection against unforeseen negative consequences of healthcare regulation.

A result of consolidation is to increase the leverage of the large companies over both providers and consumers. It will become increasingly difficult
for independent OD practices to negotiate successfully with large insurers. To maintain access to patients, it will be necessary for ODs to comply with insurer credentialing and administrative requirements.

Universal adoption of digital record-keeping and electronic connectivity with other providers
Very soon no health care provider will be able to rely on paper records or be incapable of electronic sharing of patient records and imaging with other
providers. Failure to adopt EHR and to achieve Meaningful Use standards will result in financial penalties, loss of accreditation, loss of access to insured patients and reduction in the market value of a medical practice.

Action Plan

Adopt EHR and satisfy Meaningful Use requirements

This should be the first priority for an optometric practice because the financial consequences of non-adoption will soon be debilitating. There are many continuing education programs outlining the steps toward EHR adoption and Meaningful Use. As EHR systems are selected, it is critical that a system enables automatic data transmission from testing instrumentation to patient records and permits effortless data sharing with other providers.

Make systems compliant with government regulations to avoid reimbursement penalties.
Starting in 2012, CMS began lowering reimbursement to practices that did not comply with government initiatives such as e-prescribing. In 2015, more practices will incur penalties if they fail to show Meaningful Use with electronic health records and reporting PQRS. Focus on service quality. Third parties want happy patients. Practices with large numbers of unhappy patients are not attractive to third parties. A practice can assess its current level of service quality by visiting doctor rating web sites such as Yelp, HealthGrades and Angie’s List. A practice must keep current on what patients are saying because that is what the third parties will do. On HealthGrades, a practice is rated on a scale of 1- 5 for the following areas:

• Ease of scheduling urgent appointments
• Office environment: cleanliness, comfort
• Staff friendliness and courtesy
• Total wait time
• Level of trust in provider’s decisions
• How well provider explains medical conditions
• How well provider listens and answers questions
• Spends appropriate amount of time with patients
• Likelihood of recommending the doctor to family and friends

If deficiencies are noted, the problem areas should be addressed now

Medicare patients will be directed by the Centers for Medicare and Medicaid Services to visit the Physician Compare Website as they choose medical and eyecare providers. At this time it is possible to compare group practices on Physician Compare, and in the future, to compare individual physicians and other health care professionals. ODs should check their current listing on the site. OD practices will soon be listed according to board certification, participation in Meaningful Use and your PQRS data.

Challenges and Opportunities in the Future of Independent Optometry

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