Few eyecare offices today in the United State are without at least some involvement with managed vision care. In California, for example, more than half of all refractions are paid for by someone other than the patient.

Managed vision care may not have made the inroads in other states that it has established in California, but third part eyecare is nonetheless growing in every state. Many eyecare providers are, in fact, keeping an eye on California with the assumption that the situation there may reflect the future of eyecare in this country.

When it comes to managed care, doctors and dispensers often share a common misconception: They assume the controlling factor in managed care is to simply provide those patient with what their plan will pay for. This is why so many offices prepare for managed care's presence by limiting much of their frame inventory to those frames that fall within the plan's limitations.

Unfortunately, most managed care patients make the same assumption...initially, anyway. When employees learn their employer is providing vision care for the company, it means just one thing to them -- free glasses. As a result, this is their usual state-of-mind when they first visit an eyecare office as a managed care recipient.

It's important to note that the eyecare professionals are unique among healthcare providers because their professional services usually involve materials -- that is, lenses and frames -- that are as much cosmetic as medical. This fact is, however, precisely what makes it possible for managed care to be a profitable part of an eyecare practice. Here's how this works out:

Vive La Difference

Managed care organizations (MCOs) base their plans on a central premise. They expect to pay less than the usual and customary fees for professional services (refractions, for instance). They rationalize this concept in two ways: they assume they are producing additional patients for the doctor's practice, and this helps the doctor keep the exam chair filled for more hours each day. If that doesn't encourage a particular doctor to become a provider, they know there are always others who will sign up. Fear of losing existing patients probably motivates more eyecare professionals to sign up as providers than any other single fact.

Because a product6 (spectacles) is usually required in providing vision care, most plans include a pair of glasses in their coverage. Most set specific limits on the price of frames and lenses they cover. Even the most liberal managed care plans are finding it necessary to reduce benefits as competition among plans heat up. As a result, few plans will pay for the more desirable frames and lenses currently available.

There is, however, a bright side to many current managed care plans. It's all about selling up.

Selling Up

Most vision care plans permit recipients to pay extra for frames and lenses that provide additional benefits to those covered by the basic plan. This makes it possible to generate meaningful profits under managed care. Fortunately, encouraging a patient to spend some of his own money along with what the plan covers is not difficult when done under the right conditions.

Eyecare professionals are aided by two circumstances. The first is the profusion of new and exciting lens technology. The other comes from the continuing advancements in frame designs and fashions. With the proper office routine, it is not difficult to entice consumers to spend extra to enjoy the benefits provided by the more advanced lenses and frames. By spending a little of their own money, managed care patients can enjoy the most modern eyewear available instead of the more basic eyewear authorized under most plans.

Developing A Strategy

To take advantage of this "loophole" in managed vision care requires establishing a strategy for handling managed care patients. The Optical Laboratories Association (OLA) recently published the most definitive handbook covering the subject of managed vision care. Titled Making Managed Care Work For You, the book outlines the importance of joining only managed care plans that allow recipients to pay extra to upgrade frames and lenses ordered under the plan. The book explains how to train the office staff in important aspects of handling managed care patients. This useful book can be used as a "cookbook" for creating a personal recipe for dealing profitably with managed care.

Two categories of modern lenses are particularly suited for encouraging managed care recipients to upgrade lenses ordered under managed care. Those categories are progressive action lenses (PALs) and photochromic lenses.

One basic fact influences every dispensing transaction covered by managed care: When a recipient opts to order only what their plan covers, profits for the provider from that transaction will be minimal.

Profits aside, managed care patients who only order lenses provided by their plan are probably not enjoying all the visual benefits that modern lenses have to offer.

To start, it is critical that managed care recipients fully realize that they are not limited only to lenses and frames covered by their plan. This seems pretty basic, but don't expect the managed care organization to remind the recipients to use their benefits as an "allowance" toward whatever they want. It is up to you, the eyecare provider, to make sure your managed care patients understand this important distinction. The following advice from the OLA handbook points out a simple but effective way to accomplish this.

Your first task is to dispel the managed care patient's perception that managed vision care means free glasses. This important task starts when the managed care recipient first calls or visits the office. The entire office staff must be fully informed about all the plans the office accepts. A simple managed care reference file covering plans accepted by the practice makes this task easy.

When a caller states they are covered by a managed care plan, the prepared receptionist first determines if the plan permits upgrading (avoid accepting plans that don't). The receptionist's response should then be, "You have a very good plan. It provides an allowance covering the basic costs of your new eyewear. By spending a little extra, you can end up with the finest eyewear possible." The most important job is to dispel that "free glasses" concept encouraged under most managed care plans.

Positioning PALs

The following information refers specifically to PALs and photochromic lenses, but the techniques discussed here will work with any category of modern ophthalmic lenses. Keep in mind that the basic approach with managed care patients is to provide them the same opportunity to enjoy the benefits of advanced premium lenses that are offered to private patients. The basic difference with managed care patients is that someone else is paying for the basic costs of a frame and lenses in their new eyewear. This gives them an even greater incentive to order "the best" since someone else is covering the basics.

As presbyopes have come to accept and even demand PALs, many plans now cover progressives but require some sort of co-payment by the recipient. The more advanced progressive designs usually require higher co-pay.

The key to encouraging managed care patients to spend some of their own money to enjoy the benefits of these modern PALs is no different than with private-pay patients. Be prepared to explain and demonstrate why more advanced designs are better lenses, and how they enhance vision. It requires a keen knowledge of progressive designs and an understanding of the technology involved to effectively encourage patients to spend a little more to get the newest progressives. Deciding which progressive will work best for the patient is best determined by the refractionist during the eye exam; explaining and demonstrating the progressive design recommended by the doctor is the responsibility of the dispensing staff.

Often, convincing a managed care patient to pay extra for a modern progressive is easier than convincing a private-pay patient. Why? Because with a decent managed care vision program, the recipient pays only a fraction of what their progressives would cost without coverage. The key is to encourage managed care patients to view coverage as "an allowance" that pays a major portion of their new eyewear. Once the patient understands this, upgrading them to whatever premium lens the doctor recommends is relatively easy.

Photochromics and Managed Care

Another lens enhancement that is seldom paid in full by managed care plans is photochromic lenses. Much like PALs, the job of encouraging patients to upgrade to photochromic lenses is made easier through consumer awareness due to the heavy advertising of these lenses.

Because of their universal appeal and well-communicated benefits, photochromic lenses are an effective tool for weaning managed care patients away from that expectation of free glasses. For this reason, photochromic lenses should be actively discussed with every managed care patient.

The Refractionist's Role

The Vision Council of America (VICA) recently published a valuable set of training tapes on the important role of the doctor for recommending which lenses will be best for the patient. Ideally, this is done during the refraction. The VICA videos point out how important the doctor's recommendation is in influencing the entire dispensing process.

If the doctor has recommended progressives or photochromics, even patient anticipating free glasses will consider spending a little extra for what their doctor believes to be the best lens for them. Doctor recommendations encourage a more effective dispensing process -- particularly important in overcoming that free glasses syndrome.

Contrary to the bad rap managed vision care has acquired, there can be genuine opportunities for reasonable profits and substantial practice growth from third party eyecare. All it takes is planning and structuring an appropriate office routine and a concerted effort by the staff. EB