A flip of the coin

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• Paul B. Freeman, O.D.

In the health care community, January seems to be an especially economically stressful time, as patients begin the year with a new deductible or a higher copayment, or a new (and sometimes more confusing) insurance plan. For anyone who is in need of care, particularly those with chronic or ongoing health problems, there is often concern regarding out-of-pocket expenses. Given that at some point each of us will experience the role of being someone's patient (or perhaps we already are) the reality of these dollar-and-cents concerns affects everyone; for doctors it is the other side of the health care reimbursement coin. As a patient, I am shocked at the cost of care for a relatively healthy child or adult. It was with interest and by coincidence that I came across an article stating, “Economic theory and empirical evidence suggests that patients will use fewer health services when they have to pay more for them.”¹ And while this article identified the inverse relationship between increasing copayments and office visits, costs that might “deter patients from obtaining effective outpatient medical care, leading to greater offsetting use of acute care in the hospital,” I am particularly concerned about how this might impact patients who need to be monitored for vision-threatening conditions such as age-related macular degeneration, glaucoma, and diabetic retinopathy, to name but a few.

How did the system get to its current status? It is interesting to think about the evolution of this situation. When I first entered the profession in the mid-1970s, much of what we think of as eye care was an out-of-pocket expense; granted, in those days the scope of optometric practice was nowhere near what it is today and, for the most part, third-party payers were involved only in medical care. Then, an interesting thing happened: a major insurance carrier began covering traditional optometric services in the form of indemnification, where the insurance reimbursed a portion of the usual and customary fee that was charged for an eye exam, and the balance was paid by the patient as an “out-of-pocket” expense. As time went on, managed care programs also covered eye care fees, but most often without copays, creating a sense of “entitlement” for the services. Even with Medicare (which initially used usual and customary fees as the basis for reimbursement, and then ultimately applied relative values and formulas to determine what were considered appropriate fees), patients frequently had secondary insurers that covered those “copays” and often even the deductibles. Clearly, patients were still not yet incurring significant out-of-pocket expenses related to their care. However, over time, all of that slowly changed. Now, “in response to rapidly rising healthcare costs, many public and private insurers have increased the patient's share of the cost of ambulatory care.”¹

Optometry, for its part, fought to be included in the health care arena, inclusion that brings with it benefits as well as drawbacks. As much as any health care provider, we are acutely cognizant of the impact of these economic health care issues we now face, and will continue to face in the future, as they relate to the ongoing care of our patients. With all that we can do to help maintain the visual quality of life for our patients, this new fiscal concern can alter the timely interaction with some of our patients and can, in some instances, result in visually devastating consequences.

As is evident by the ongoing debate in Washington, the ever-increasing and complex costs associated with modern health care do not lend themselves to simple, obvious, or quick fixes. Knowing how the doctor and patient are on one and the same coin, however, I believe that our profession, through its leadership and volunteers, along with the other health care professions, are working to make it effective and fair for both sides of the health care coin.

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Reference 

1. Trivedi AN, Moloo H, Mor V. Increased ambulatory care copayments and hospitalizations among the elderly. N Engl J Med. 2010;362:320–328
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