Understanding Healthcare Reform in America

From the Affordable Care Act to HIPAA to MU, how will reform initiatives impact optometry?



Understanding Healthcare Reform in America

From the Affordable Care Act to HIPAA to MU, how will reform initiatives impact optometry?



Healthcare reform discussions seem to be omnipresent (on news channels, in medical offices, on airplanes, around the office and at the dinner table), but what effects will current reform initiatives have on you and your practice, and how will they impact healthcare administration and delivery on a local, regional and national level?

Here, we take an apolitical look at what has been achieved, needs to be accomplished and hurdles that remain.

Health Information Portability and Accountability Act (HIPAA)

The first step in the process of changing the American healthcare system is to provide security for valuable personal health information. This concept spawned HIPAA, which mandates O.D.s follow the rules of the CPT and ICD systems for medical record compliance. Further, HIPAA helps to deal with issues regarding fraud and abuse of federal programs.

As is true for many government programs, HIPAA’s original intent gets lost in the legislative and administrative process. It is up to us, as providers, to remember the need for and our part in protecting every patient’s privacy by being very careful of how we use, store and share health information. HIPAA makes and enforces very specific rules, and we must develop internal protocols that respect and protect patients’ privacy to completely comply with HIPAA.

Patient Quality Reporting System (PQRS)

In 2006, the Tax Relief and Health Care Act required the establishment of PQRS. Originally Patient Quality Reporting Incentives (PQRI), the program provided a small reimbursement entitlement to the providers who participated with this sampling method with the hope that the movement to EHRs and national reporting would gain momentum.

PQRS can be thought of as a peek into the future of health care. Insurers, including the government, have long felt that providers have not done a very good job of recognizing and applying “best practices” in the provision of care. PQRS provided a financial incentive for a few years and now a penalty to identify and encourage the use of some of those best practices.

It’s safe to assume that all healthcare providers will be measured based on their application of those best practices in insurers’ attempts to be sure they are getting what they are paying for. This concept is the basis of establishing criteria and protocols for the validation of the evidence-based medicine (EBM) outcomes, which will most likely lead to the establishment of clinical care protocol standards that demonstrate excellent patient outcomes corresponding with clinical processes. Those resultant processes may be the basis for carrier coverage in the future.

Foundations of Healthcare Reform

    ▸ HIPAA

    ▸ PQRS

    ▸ e-Rx

    ▸ EHR/Meaningful Use (MU)

    ▸ ICD-10

    ▸ ACA

Electronic prescribing (e-Rx)

This began as a process of controlling expenses, tracking drug utilization and designing the initial framework for a national healthcare database, and the national pharmacy database has done exactly that. The DEA’s Electronic Prescriptions for Controlled Substances rule took effect June 1, 2010 and allows authorized providers to voluntarily sign electronically and forward prescriptions to pharmacies. (e-Rx is also one of the 20 criteria outlined as part of the PQRS incentive payment criteria.) The ultimate goal is to save dollars and lives by preventing costly cross reactions, side effects and over-utilization of certain drugs without just cause.

On a practical level, e-Rx has positively affected the everyday duties of providers by creating a system that eliminates paper prescription blanks with unreadable abbreviations and signatures. Although it is still not perfect, e-Rx is a big step toward fewer misunderstandings between prescriber and provider of pharmaceuticals, better communication with patients about those drugs and healthier patients.

EHR/Meaningful Use (MU)

EHR is another step forward in healthcare delivery. Fifteen years ago, prior to the government getting involved with its programs to encourage the use of EHR, developers were free to innovate. EHR became faster, accurate and offered increased advantages to providers and the patients they served. Government regulations resulted in a significant shift of developers’ dollars toward compliance with those regulations, which left fewer dollars for creative improvements in the function of their programs.

To encourage adoption and utilization of EHRs, Congress set aside $19.2 billion as part of the American Recovery and Reinvestment Act (ARRA) to encourage doctors and hospitals to move quickly to adopt “qualified and meaningful use” systems.

EHR will play a vital role in EBM and, thus, in the healthcare reform process, as it allows for a far greater sampling than the PQRS initiative. Analyzing a large sampling size of data enables the comparison of certain risk factors, diagnostic devices and various effective treatment protocols to be developed. Whether it is the analysis of drug effectiveness or potential risk issues, we may be able to have greater information on certain drugs or the success rate of certain procedures across the general population. Also, EBM would eventually eliminate or penalize providers who order unnecessary tests or prescribe ineffective treatments.

Many eyecare EHR products are on the market in 2014 and will be very effective once developers can get back to concentrating on the needs of the doctors, staff and patients they really serve.


Although ICD-10 was delayed until Oct. 1, 2015, this does not mean these standards will never occur — ICD-10 is already the world standard. The United States is actually one of the last remaining countries to not operate on this standard, which is owned by the World Health Organization.

ICD-10 is the next viable step in the process toward EBM because successful healthcare reform will ultimately require an expansion of the diagnostic language to the world standard. Moving from the 19,000-code ICD-9 database to the 68,000-code, the ICD-10 database will significantly increase the specificity of various disease states as well as related morbidities. This will allow for more accurate diagnosis and treatment monitoring and expand the healthcare providers’ vocabulary by increasing the specificity of disease states involved. This coding system is required for all public and private health sector plans and will apply to all claims, not just electronic ones.

Utilization of the ICD-10 will be a change for healthcare providers and healthcare organizations in this country but not an insurmountable one. Providers will still look up each diagnosis in the index, then go to the section that contains the related codes and choose the closest matching code (five to seven characters) for each patient’s condition, very similar to proper use of ICD-9.

We expect most physicians will be using software or Internet-based solutions rather than manuals, which will make the process even better and easier, similar to learning a new and more precise dialect of the same language you have always known. ICD-10’s precision is the reason for more codes, so training will need to occur in the thought process and the medical record support behind the code, not the conversion from ICD-9 to an ICD-10.

Prepare Your Practice

▸ Ensure your HIPAA compliance. If you are not compliant or are unsure whether you are, review your office policies and processes.

▸ Enroll in e-Rx. If you are not already utilizing e-Rx, register with one of several trusted companies.

▸ Keep informed about ICD-10. Though these deadlines have been moved to Oct. 1, 2015, many EHR companies will be rolling out newer versions to comply with ICD-10 requirements.

▸ Adopt EHR, and achieve MU. Not only will EHR adoption make e-Rx and ICD-10 much easier, it is also essential to demonstrate MU.

▸ Enroll in local or regional Healthcare exchanges.

▸ Enroll in ACOs and marketplace panels, Medicare and Medicaid. Many of your state associates will have more information on state specific exchanges.

Keep in mind: The ICD-10 system is not used just for “billing & coding” — it is the basis for the medical record to capture everything about the patient/physician encounter. When used in conjunction with the Current Procedural Terminology (CPT), it will provide a precise description of what happened, why it happened, the clinical decision-making and the care plan going forward.

Patient Protection and Affordable Care Act (PPACA or ACA)

The ACA, signed into law on March 23, 2010, has several positives for our profession, including prohibiting discrimination against groups of providers, children’s vision care as an essential health benefit and the creation of state-based health insurance exchanges where consumers can shop for and purchase healthcare insurance.

Practice-Building Initiatives

▸ Improve efficiency. Evaluate the workflow processes present in your business. Analyze where you may be able to shave minutes or even seconds to enhance your efficiency.

▸ Review office processes. Is everyone in your office doing things the same way? Are they doing it the right way? Do you have written processes so everyone does and says the right things all the time? An office procedure manual may help with this and prevent many problems.

▸ Refocus on quality service. Are your consumers enjoying their experience? Do they want to return to you, and do they refer their friends? Think about how you could improve the quality of your service.

▸ Review treatment protocols. Are you consistently providing the standard of care for the various vision and medical conditions that present to the office? Written protocols for diagnosis, treatment and medical records management allow for greater consistency and correct management and financial processes associated with each exam.

▸ Expand your services. By enhancing and expanding the services you provide, you are more likely to increase your practice’s volume and diversity. Niche additives, such as children’s vision, sports vision, low vision and specialty contact lenses, add to your practice profile to both individuals and ACOs alike.

▸ Improve recall. Do you have a recall program in place? This will help capture lost patients so you can improve your volume.

▸ Train and delegate to staff. Take time to engage and educate your staff. Also, hand off some non-revenue-generating responsibilities or parts of the clinical examination to them. This allows you to do what you do best and lets other staff members perform their roles.

The intent of the ACA was to provide increased access to affordable, quality health insurance while controlling the skyrocketing costs of health care. The original misconception was that this would replace medical insurance. Rather, some of the basic concepts were to increase the “young and healthy” participant pool by allowing young adults to stay on their parents’ plans until the age of 26 (this was a positive for all).

Another major concept was to prevent pre-existing conditions from being a factor in determining eligibility, especially in children. Preventative services, such as health screenings, and physicians, are covered under all new plans, which has been instrumental for those who have serious health conditions to have the opportunity to obtain health insurance.

The ACA also protects individuals by preventing annual limits to the 10 Essential Benefits. (See “ACA Essential Benefits,” page 31.) There is no distinction regarding the rates that patients might have to pay, but they cannot be turned down.

The downside is that someone has to pay for all of these services, which comes in the form of taxes on high earners, large businesses and the healthcare industry itself. Also, tax credits subsidies were enacted to help low- and middle-income Americans, as were individual mandates stating that families have a deadline to obtain health insurance.

In addition, tax credits were added for small businesses with fewer than 50 employees that cover more than 50% of the full-time employees’ premiums. (Find out more at

As of the writing of this article, about 8 million Americans had at least enrolled in the various insurance marketplaces.

What will it take for real healthcare reform?

Many challenges lie ahead for the ACA and any subsequent healthcare reform initiatives, and there are no easy solutions.

The ACA is a classic example of a policy designed by many committees that are populated by legislators with limited knowledge of healthcare delivery and heavily influenced by lobbyists for people who know a lot about the business of health care (insurance companies, health systems, large hospitals, large clinics, etc.). The result is a program that has been poorly understood, implemented and utilized.

We need real reform of the healthcare system, not just reform on the payment side or what is acceptable to insurance companies. This occurs when both sides of the equation are addressed (providers and payers), which will probably require a revision or replacement of the fee-for-service system.

It may take generations to achieve true healthcare reform, and we are off to a slow start. Some of the pending challenges of real, long-lasting reform include increased personal responsibility, tort reform, control of big industry activities, governmental changes, continued technological innovation and utilization by the masses. These hurdles will not be achieved easily. Road maps for these processes are starting to form, but many adversaries are ahead.

The impact on healthcare delivery and vision care

The verdict is still out on how the ACA or recent healthcare reform initiatives have affected healthcare delivery.

Many argue that initiatives, such as e-Rx and increased informational exchange, have shortened times between visits, improved inter-specialty communication and saved lives. Others claim that the increased operational demands placed on the systems have created an environment where healthcare providers are spending more time clicking buttons than taking care of patients.

Likewise, the real effect on vision care is mixed. We have seen an increasing trend toward managed medical plans having an embedded vision benefit. In most of these instances, there is no associated material benefit, which has caused some beneficiaries to become confused or question how their plan has changed.

ACA Essential Benefits

    1. Ambulatory Patient Services

    2. Emergency Services

    3. Hospitalization

    4. Laboratory Services

    5. Mental and Substance Use Disorder Services

    6. Newborn and Maternity Care

    7. Pediatric Services (including vision)

    8. Prescription Drugs

    9. Preventative and Wellness Services

    10. Rehabilitative and Habilitative Services

The future of stand-alone vision plans is still a mystery. It is yet to be seen whether our country will move toward more of a self-directed managed care plan (cash) like the Canadian model for all citizens between ges 19 and 65 or move to the opposite end of the spectrum toward true single-payer healthcare with embedded eye care.

One of the big game changers for the embedded plans was the ACA initiative stating that managed medical plans must have a pediatric vision benefit. The anticipated influx of pediatric patients has yet to materialize in most practices, and the long-term success is impossible to predict at this point.

The change in dependent care coverage extending until the age of 26 has positively affected the managed vision care utilization of many young people who might previously have foregone vision exams due to a lack of coverage.

In addition, the more than 30 million people who would have been seeking care under the new healthcare reform initiatives has failed to materialize. Some practices have seen an increase, while many other areas of the country have not experienced an uptick in eye-related visits.

A positive that may come out of the ACA is the formation of Accountable Care Organizations (ACOs) to provide patients with the right care, at the right time and in the right place. The participation of O.D.s in ACOs will help to make their services much more mainstream in the medical care delivery system. It is important that every O.D. do a detailed market analysis of their individual marketplace and how ACOs may change the O.D.’s participation in providing medical eye care to those consumers whose care is directed by the ACO.

For additional management tips, see “Practice Building Initiatives” on page 30.

The future of our profession

Eye care will not be the same in 2020 as it was in 2010. We’ve been through immense challenges/opportunities through the past 10 years. We’ve had doubters and even some enemies, but the members of the profession have always risen to challenges, seized opportunities and thrived.

The profession of optometry will remain strong and financially viable as we navigate healthcare reform. OM

Dr. Brownlow provides billing and coding consulting services through PMI, LLC. E-mail him at

Dr. Morris is the director of Eye Consultants of Colorado and Morris Education & Consulting Associates. E-mail him at

Dr. Rumpakis is founder, president and CEO of Practice Resource Management, Inc., a consulting, appraisal and management firm for healthcare professionals. E-mail him at, or send comments to