Optometrists Must Prove Their Value to ACOs

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With reducing costs while improving care among ACO’s tenets, optometrists who contribute to these goals are better positioned to join them. One way to achieve this is by showing that they can raise patient quality measurement scores.

For example, the Physician Quality Reporting System (PQRS) combines incentive payments and payment adjustments for reporting information such as e-prescribing, exchanging health information, implementing electronic health records, and tracking results through clinical data registries. Beginning in 2015, the program penalizes those who do not satisfactorily report data on quality measures.

“The performance of an ACO-like system indicates the importance of the ECP in helping achieve improved quality of care and the awarding of millions of dollars in shared savings and PQRS incentives,” stated the KDD white paper on Emerging Models in the Reform of Healthcare commissioned by Essilor. “ECPs participating within a network of over 600 physicians in a 2005 Physician Group Practice Demonstration Project involving Medicare fee-for-service beneficiaries at St. John’s Health System (now Mercy Clinic) in Springfield, Mo., identified early symptoms of diabetic retinopathy and other disease in otherwise asymptomatic patients. The organization did not achieve its threshold for savings in the first two years of service but did record 100 percent of its quality measures in the same period. Since then it has achieved millions in CMS shared savings each year while significantly improving patient satisfaction scores.”


Another quality measurement system, Star ratings determine patient outcomes and are tied to Medicare reimbursement. The Star rating program reimburses some Medicare plans at a higher rate, depending on how many stars they reach on a scale of five stars. In 2014, those with three to five stars will receive bonuses up to 5 percent, but only those with four or five stars in 2015 will receive bonuses.

One component of the Stars rating system is the Healthcare Effectiveness Data and Information Set (HEDIS), which includes 76 quality measures across five realms of care—effectiveness, access, utilization, descriptive information, and experience.

Because of optometrists’ ability to influence the diagnosis and continuing care of certain chronic diseases, such as glaucoma, diabetes, hypertension, and others, optometrists can contribute to the elevation of these important Star, HEDIS, and other measures. “There are several quality metrics that ECPs are in a unique position to help with ACOs,” said 4PatientCare’s Guterman, citing diabetes, glaucoma and hypertension among them.

“Early detection of diabetics results in higher HEDIS scores, which translates into enhanced reimbursement,” agreed Davis Vision’s Burns.

Glaucoma and diabetic scores are typically always very low, according to OD Excellence’s Sude. “When an optometrist is part of a coordinated team, how diabetics and glaucoma patients are handled figure into Star ratings and how and whether they will be paid,” said Sude. “To be part of a coordinated care team, many things have to be incorporated into your practice that may be foreign. One is sending detailed reports directly to the primary care physician, not in the mail or faxed, for every patient 65 or over on the results of their glaucoma screen. This is part of Stars, but very few optometrists are doing this.”

The AOA’s Third Party Center has also determined a way optometrists can show value by reducing health care costs. After analyzing four years of paid claims data encompassing over 161 million member months from 2006 to 2009, an AOA study determined the role of optometry in diverting emergency services from hospital settings. The study revealed that diverting eyecare services from the emergency room or primary care physicians to ECPs in an outpatient setting, benefits realized included improved clinical outcomes and a potential cost savings of $0.18 per member per month.

“Optometrists must understand these systems are being formed around big ticket items such as hospital stays,” said the AOA’s Third Party Center’s Montaquila, “but at about 1 to 2 percent of the total health care spend, eyecare is way down the list. It’s important to show this cost savings that results from emergency room diversion.” ■