Month: June 2013

by Mark Ridenour, OOA Consultant

Medicare Advantage Plans

Medicare Advantage (MA) plans are growing in popularity (from 26% of Ohio Medicare eligibles in 2008 to 36% in 2012), and if you are a participating provider you have become even more valuable to MA plans. Medicare pays private insurance companies a capitated amount to provide hospitalization, professional, and prescription drug benefits as MA products to those eligible for Medicare. This is an alternative for beneficiaries to taking traditional Medicare benefits from the federal government.

MA plans are approved for sales to beneficiaries by county. There are now 28 plans available in Ohio with 8 of those being Special Needs Plans (SNPs), specifically those in long-term institutions or dually eligible for both Medicaid and Medicare. MA payers include large insurers like United HealthCare, Anthem, Aetna, Kaiser and Humana and many local or regional carriers such as SummaCare, MediGold, and CareSource.

The Affordable Care Act (ACA) has modified the plan payment formulas to reward quality measures. Performance on these are represented by a 5 Star system which was originally designed to help consumers choose high quality plans, but now carries the greater weight of increased funding and more liberal enrollment parameters for the insurers. Of the current 37 metrics used to rate all MA plans, Glaucoma Testing and Diabetic Eye Exam are included. In addition, #22 is Fall Prevention where a vision exam is recommended, and others measure customer satisfaction (e.g., Getting Appointments and Care Quickly) which could include members’ perception of their Optometrist. This focus on quality Stars should increase your leverage with the plans and lead to outcome-based bonus payment and/or increased volumes to your practice.

If you find your practice is excluded from a Medicare Advantage product and the plan seems unwilling or unable to add you to their network, please take the following steps:

1. Contact the ophthalmologist(s) you generally refer patients in this MA plan to solicit their support for continuing to receive referrals.

2. Encourage your patient to contact the MA plan as a member to your practice be added.

3. Inform OOA.

Medicaid Managed Care

The Medicaid Managed Care Plans for all regions of Ohio starting July 1, 2013 are:

Buckeye

CareSource

Molina

Paramount

United HealthCare

The AOA has made the elimination of barriers to OD participation in Accountable Care Organizations (ACOs) a top priority. The result has been important gains for the profession that are reflected in the regulation implementing the new health care law and new opportunities being explored by optometrists related to value-based care models and pioneering partnerships with other providers.

As was first reported in the May 24 AOA First Look, a volunteer workgroup coordinated by the AOA’s Third Party Center is now working to develop a resource toolkit and practical guide for optometrists who are interested in exploring ACO participation. The workgroup is nearing completion of its product – a toolkit of education materials and other resources that detail what optometrists need to know and what to do when engaging with ACOs. The first article, entitled “What Optometrists Need to Know about ACOs”, can be found here. The workgroup’s latest installment, “What Optometrists Need to Do about ACOs”, can be found here. The AOA’s overarching goal is to help its member optometrists gain full access to these new ACOs and other value-based care delivery models.

To be sure, current national health policy and major sections of the Affordable Care Act support a shift toward integrated, coordinated, and accountable care. Many ACOs have already been formed and are operational, and many more are currently being formed. Market penetration of ACO coverage is expected to increase considerably over the next few years. Right now, approximately 250 ACOs are accountable for the cost and quality of care for more than four million Medicare beneficiaries (roughly 10 percent), with more Medicare ACOs expected to come online next year. Additionally, more than 400 ACOs are ACO-like private entities that are engaged in value-based contacting activities with commercial insurers and large employer-based health plans are thought to be involved in thousands of private contractual arrangements covering more than 30 million Americans, or approximately ten percent of the U.S. population.

Ultimately, gaining ACO inclusion in most cases will be up to the local optometrist. For its part, though, the AOA will continue to advocate for ODs to be included in these and other value-based care models in a way that allows ODs to practice at the full scope of their license. At the same time, the AOA will keep its focus on the integration of eye health and vision care in all health plans that work with ACO-like entities in value-based insurance arrangements, and will continue working to make organizations, groups and associations involved in ACO developments and management aware of OD interest and the potential role of ODs in ACOs, ensuring that those organizations turn to the AOA and state affiliates for help with attempting to involve ODs. Meanwhile, AOA’s wholly-owned subsidiary, AOA Excel will continue implementing a plan to provide related information technology and connectivity tool that will support various models of OD integration into ACOs.

Look for more articles on this important topic leading up to Optometry’s Meeting. Questions about the ACO workgroup and the coming ACO Toolkit for Optometrists should be directed to [email protected].