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Impact on Vision Providers
November 2010
National Healthcare Reform
Reform in Review
President signed H.R. 3590 into law on March 23rd. (Patient Protection and Affordable Care Act - PPACA)
President signed H.R. 4872 into law on March 30th. (Healthcare and Education Reconciliation Act)
Parts of legislation scheduled to roll out yearly between 2010 and 2019.
Reform in Review
• What is included– Coverage Expansion
• Coverage expansion to 32M additional Americans @ $940B est.• Individual Mandate
• Requires all citizens have health insurance beginning 2014• Employer Responsibilities
• No employer mandate for employer w/under 200 employees but…• Employers w/+50 employees assessed a penalty if any employees
receive premium credit through an exchange• Must auto enroll employees who do not select or opt out
– Delivery System Reforms– Revenue Provisions
• What is not included– Cost containment– Employer Mandates– Tort Reform/Liability Protection
Coverage Expansions
Public Program Expansions Medicaid eligibility up to 133% of FPL
States prohibited from reducing current benefit levels to offset cost of additional members
High risk pools Medicare “Improvements”
Plug donut hole in Part D
State Exchanges
State Exchanges
Stand alone vision not a mandated inclusion Probable that they may be included at state’s
option Separate exchanges for individuals and
employer groups Administration must be self sustaining thru
state “assessments” Standard sets of benefits
Delivery System Reforms Requirements for Transparency
Healthcare costs Medical loss ratio
85% for large group/80% for small group and individual Reporting begins 2010/Rebates begin 2011
Premium review
Administrative simplification Development and use of uniform explanation of coverage
documents Development of standardized definitions
Delivery System Reforms Consumer protections
Choice of primary care provider Mandatory coverage of ER visits w/out prior
authorization Federally defined “minimum qualified” coverage
(Sept. 2010 provisions) No cost sharing for preventive services No denial of coverage based on pre-existing conditions No life time or annual limits Extend dependent coverage to age 26
Revenue Provisions Reduce pharma payments & increase access to generics Reduce Medicare/Medicaid fraud Reduce hospital readmissions through bundled payments under Medicare Assessments on RX drug manufacturers, medical device manufactures,
health insurance companies, and diagnostic labs Expand P4P programs Excise tax on “Cadillac” health plans (2018) Medicare surtax on “upper income” citizens (2013) Additional penalties on non-medical HSA/HRA withdrawals (2011) Increase threshold for itemized medical deductions from 7.5% to 10% of
income (2013) Sin taxes (indoor tanning 2010) Reduce Medicare Advantage funding
Revenue Provisions
Impact on Vision
Provider non-discrimination provision (Section 2706)
Enhanced vision coverage through “pediatric vision exam requirement” (2014) Vision exam but not eyewear will be a mandate
coverage for children under 18 2.3% medical device tax beginning 2013
Specifically excludes eyeglass and contact lenses
Value of stand alone vision plans not included in calculation of “Cadillac” coverage (2018)
Dilate optometric scope of practice
Impact on Vision OTC products no longer an allowable expense for HSA or FSA
spending (2011) Contact lenses, solutions, readers, and refractive surgery still allowed
Limit on FSA contribution (2013) SCHIP programs maintained thru 2019
Exchanges and “Cadillac” tax likely to accelerate adoption of HDHPs HDHP members w/ HSA, HRA or limited FSA show
higher than average rate of vision care use Accelerated health plan consolidation
Reduced vision coverage under Medicare Advantage plans
Medicare Advantage Enhancements
Share of Medicare Advantage Plans with Selected Extra Benefits 2010
Vision exams - 86% Hearing tests - 65%
Worldwide coverage - 62% Preventive dental - 55%
Extra podiatry benefits - 47% Extra chiropractic benefits - 34%
Some transportation - 14% Part B premium rebate - 6%
Source: Medicare Advantage 2010 Data Spotlight, Kaiser Family Foundation
Accountable Care Organizations
Medicare demo project In 2012 providers will be allowed to
organized as ACOs Must be led by physicians or hospitals Must manage full spectrum of care “Accountable” for the overall cost and quality of care
for a defined patient population Must follow clinical guidelines and have quality
measured continuously Must provide care across all care settings
Accountable Care Organizations
Four organization models Network Organized Medical Group Hospital Collaborative
Two reimbursement models Total risk model Shared savings model
Accountable Care Organizations
Key strategies Integrate care management and engage patient Identify preventable events Reconfigure care to reduce, waste, and harm to patient
Anticipate impacts include Accelerate hospitals’ employment of physicians Accelerate clinical integration Reduce private practice delivery options
Impact on ECP as Small Employer
Small Business Tax Credit 35% tax credit of health care premiums
Fewer than 25 employees Average wages of less than $50K Employer must pay 50% or greater of employee only premium cost Can include cost of dental and vision premiums Available 2010 thru 2013 Advise to talk with a benefits consultant
Wellness Program Grants Fewer than 100 employees Program must not have existed prior to 3/23/10
Impact on ECP as Small Employer
Exchanges (2014) Small Business Health Options Program (SHOP) Run by state Available to employers with up to 100 FT
employees After 2017 may also be opened to larger
employers
Impact on ECP as Small Employer
1099 Filing Requirement (2012) Must file a 1099 form with IRS for any
vendor from whom you purchase property or services worth $600 or more during the calendar year
What Next? – Implementation! Varying interpretations Promulgation of rules through multiple agencies Stakeholder advocacy will continue at federal
and state agency level Public comment periods Question of agency authority to address
Items beyond agency authority will require additional legislation to fix
Compliance enforcement
2010 Elections Impact? Total repeal unlikely
Obama veto power Portions already enacted
Federal Level Action Require multiple hearings Stall funding Adjustments
1099 requirement Definition of grandfathered plans Delay Medicare Advantage cuts
State Level Action Limit scope of exchanges Impede expansion of Medicaid
Drop out of Federal Medicaid/SCHIP program Join legal challenges
Prepare Now!
Stay alert to developments nationally and locally Contact local ASOs and other integrated care
organizations for inclusion Express opinions and concerns to your elected
representatives Work with industry advocacy groups
Advocacy is Key to Promote Quality Vision Care
If you don’t tell your story,
someone else will tell it for you!
Prepare Now!
Consult with your business professionals Accountant Benefits consultant
Update your practice Delegate to staff so you can practice to the full scope of
licensure Adopt an EHR Develop an effective, professional web site
Align with strong business partners such as Essilor
The Essilor Partnership
Essilor and IHMS Commitment - Supporting the Eye Care Professional Grow Your Business
Employer strategy Other strategies
Run Your Business Provide Managed Care expertise
CO
NS
UM
ER
S
LABECPs
/Retailers
LENS FRAMES
Essilor’s Traditional Focus
Large Self-Funded
EMPLOYER/PURCHASER
Medium/Small(Broker)
GovernmentBusiness Coalition/Affiliations
Co
ns
um
ers: M
emb
ers & W
ork
ers
Health Insurers( HMO / PPO )
Vision Plan Dental/Vision Plan Combo
LAB ECPs
LENS FRAMES
Expanded View
The IHMS TeamSteve Nussbaumer
VP IHMS
Barbara Heffez-PiperDirector - Cross-Channel
Operations
Terri NesrstaRegional
Director- Central
Gail TarantinoRegional
Director- West
Jessica SumnerAssistant
Colleen GelbPlan Specialist
•Optum Health•Superior Vision•Opticare
Mike MonacoRegional
Director- East
Maria BarnwellDirector-Business
Development
Raphael VarisellaPlan Specialist
•VSP•CompBenefits
Christelle BroizeProject Manager
Alyssa BakerPlan Specialist
•EyeMed•Avesis•VBA
• EyeMed
• Humana (CompBenefits)
• VBA
• Advantica
• Medicare / Medicaid
• VSP
• Superior Vision
• Anthem BCBS (WellPoint)
• Optum Health (Spectera)
• Davis Vision
• Avesis Vision
• NVA
• Opticare
• Medicare / Medicaid
• Military
• Kaiser
• Employer initiatives
• Strategic Accounts
Red SoloskoDirector-Marketing
Matt WoodMarketingAssociate
Kristie MillerMarketing Manager
Steven FalesMarketing ssociate
Employer Program
What They Want? Reduced healthcare costs
99.4% of top decision makers are concerned with the impact of health care costs (2010 UBA Employer Opinion Survey)
Tactics employed Minimize employee health risk Shift costs to employee 80% will spend money on health promotion and wellness in
2011 Majority express frustration with the ROI Desire to increase employee engagement rates
So What? Opportunity to leverage Vision Care as a program that:
Increases employee engagement, Improves health outcomes Reduces healthcare utilization
What is the Employer Program?
A strategy that ties the eye exam to reduced health care costs and risks
Provides frequent and direct messaging to large pools of people
Grows utilization of eye exam and hardware
Health Fair Program
2008-2009 100 Events Attended 200k+ Employees Impacted 10 Trade Shows Attended 100K
Vision Wellness BrochuresWhat:
A set of 6 topical (vision-related) information sheets you can use to build interest and initiate a dialogue on vision coverage with a target employer
Topics:
1. Vision & the Aging Workforce
2. Vision for a Healthy Workplace
3. Eye Safety at Work and Play
4. The Road to Better Health
5. Vision Disorders in Children
6. Computer Vision Syndrome
VisionSavesMoney.com
CUSTOMLogo
Think About Your Eyes Direct to consumer messaging – importance of
comprehensive eye exams TV, radio, online and social media
communications 2 year campaign
Focused on nine cities – New York, Los Angeles, Chicago, Denver, Atlanta, Houston, Sacramento, Cincinnati, and Portland
To date has generated more than 213.5 million impressions.
Think About Your Eyes Events
New York – May 24-30, 2010
Chicago – July 19-25, 2010
Essilor Vision Foundation A public charity whose mission is to eliminate poor vision and its
lifelong consequences starting with children Provides free eye exams and new prescription eyewear through in-
school and partnership programs to children who cannot get them otherwise
Educates parents, teachers, caregivers, and community leaders to be aware of the implications of poor vision and watch for signs of vision problems in children
Educates children on importance of vision care and proper care for eyewear
Hot Off the Presses
“A Path to Wellness” – A white paper by KDD Health Solutions
Analyzed 3 years of medical claims for a company of 10,000 employees & dependents
62% higher
Strategies For Sustainable Environment
Assistance to Run Your Business thru: Managed Care Plan Expertise Webinar Training
Run Your Business Practice Assessment Development to:
Increase Capture Rate and Traffic Reaching out to new customers Internet presence Retaining current customers
Increase Practice Profitability Dispensing techniques Staff training on plans Pricing strategy Frame board optimization
Report Trend Analysis
Conclusion
Managed care will continue to be highly important to independent optometry
Healthcare reform will keep things “exciting” for the foreseeable future
Recommendation: Find the right advisors to partner with during this turbulent time, and STICK WITH THEM.
Terri [email protected](214) 496-4846
For more information please contact your Essilor Sales Rep or:
Ken [email protected](801) 589-6539
Matt SwartzDistrict Sales [email protected](480)387-4705
