The year 2015 may go down as one of the most tumultuous in terms of health care reform changes. Optometrists have found themselves feeling a bit like Smokey the Bear, putting out fires and trying to maintain control. Let’s look back at a few of the issues that have made the biggest impact.

In January, we were once again dealing with Medicare’s flawed sustainable growth rate (SGR) formula and a 21% decrease in reimbursements. Also in January, the Centers for Medicare and Medicaid Services (CMS) released its goal of moving from a traditional fee-for-service system based on volume to a system based on quality or value through alternative payment models such as ACOs or bundled payment arrangements—with the hope of obtaining 85% of all payments by 2016 and 90% by 2018.

In April, the Supreme Court ruled that health care providers cannot sue to increase Medicaid reimbursements. Specifically, it said “neither the Constitution nor federal law authorizes doctors and other health-care providers to go to court to enforce the law’s directive that the reimbursement rates set by states be ‘sufficient to enlist enough providers so that care and services are available’ to Medicaid recipients just as they are to the general population.” 

April also brought us a fix for the flawed SGR, and the bill blocked a 21% cut in payments due to take effect that month. It also provided financial incentives for physicians to bill Medicare patients for their overall care, not individual office visits—again, a move to value not volume.

With the summer heat of July and August came legislation tying future payments to quality outcomes, as well as studies showing that consumer health care spending is accelerating faster than the past decade due to the Affordable Care Act (ACA) and an improving economy. Health insurance companies also began filing for premium increases across the country, with some as high as 58% year over year. We also learned that as individual income rose, fewer were actually purchasing insurance; many were more willing to pay the tax penalty.

The summer was also merger mania. Aetna merged with Humana and Anthem agreed to buy Cigna, effectively reduced the big Five to the big Three. 

Of course, October brought ICD-10, which came out with more of a whimper than a bang. Studies were also released indicating that health insurance deductibles are growing six times faster than wages. IBM and CVS partnered to provide automated solutions for chronic disease care delivery, and CMS announced a $585 million grant to develop a system to provide higher quality outcomes for less cost. More recently, some high profile insurance carriers such as Highmark and UnitedHealthcare have suggested they may not offer ACA plans due to increasing costs and lower profits. 

Optometry Updates
Our industry was also reshaped by a number of significant events:

  • Essilor’s acquisition of Vision Source and PERC/IVA. 
  • VSP opening up VSP-branded clinics on company campuses and partnering with CVS.
  • Luxottica partnering with Macy’s to put 500 LensCrafters into prominent Macy’s locations around the country.
  • More private equity money coming into optometry and acquiring practices nationwide.

Health care reform will be a primary focus in 2016 as the employer mandate rolls out, Meaningful Use stage 3 becomes more refined and we begin to learn new acronyms such as VBM (value-based modifier) and MIPS (merit incentive-based payment system). So as you ring in the New Year, don’t forget that, in our dynamic environment, change is the rule, not the exception. In order to thrive, you must be aware of your market and nimble enough to change your paradigm. Next year’s Coding Connection column will highlight the issues shaping our health care system and discuss how to safely implement changes into your practice.

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