The historical definition of medical management has been co-opted over the last decade or so. What once referred to insurers and medical professionals collaborating to determine services that drive better member outcomes and costs is now being adapted to mean anything from pre- and post-claim submission, to the “gatekeeper” model—depending on the specific needs of individual payers and doctors.
So while care outcomes and costs have never been more important, the term “medical management” has become muddled and, often, doesn’t live up to its original definition.
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Elizabeth Klunk Elizabeth Klunk is the Senior Vice President of Medical Management at Versant Health , a managed vision care company focused on creating an integrated and seamless experience for health plans, members, and eye care professionals across the total eye health value chain.
To truly be impactful, medical management should be considered by its purest definition—utilization management. And with eye health as both a growing care cost-driving more than $100 billion in Medicare expenses—and a non-invasive method of looking at total health, now is the time for managed vision care to lead the conversation.
What is Comprehensive Vision Care?
During routine eye exams, patients typically receive a thorough look at their eye health and any necessary corrective vision wear, but during that exam, the eye care professional may detect a larger issue—either eye health or overall health concern. And in fact, this is a common, but often undervalued, occurrence, as routine eye exams are likely to detect signs of chronic disease long before other health professionals note the condition, such as high cholesterol, high blood pressure and diabetes, shows research by Population Health Management.
This is where comprehensive managed vision care adds value. Once the eye care professional enters their findings into the medical claims review system, managed vision care providers—that practice true utilization management—improve the member care experience by integrating claims across all levels of care. This eases information transfer across healthcare providers to allow members to better access the medical vision care services they need while minimizing referrals and costly follow-up appointments. To add, this can help avoid leakage and overspending in a healthcare environment focused on cost containment.
Thus, the practice of utilization management in collaboration with a managed vision care provider can mean the difference between members receiving a diagnosis and appropriate care or going unseen by a professional—a critical factor to the health of the aging U.S. population.
A Deep-dive Into Specialty Pharma
A specialty drug is a class of prescription medications used to treat complex, chronic or rare medical conditions. Although this classification was originally intended to define the treatment of rare, also termed “orphan” diseases, affecting fewer than 200,000 people in the US, more recently, specialty drugs have emerged as the cornerstone of treatment for chronic and complex diseases such as cancer, autoimmune conditions, diabetes, hepatitis C, and HIV/AIDS.
Managing the Health of an Aging Population
According to the AARP, there are nearly 109 million Americans age 50+, with this same demographic growing over the next decade to 19 million (as compared to a growth of just six million in the 18-49 age group). Among aging Americans, blindness ranks as a top fear, along with stroke, Alzheimer’s disease, diabetes and heart disease, according to The Motley Fool and JAMA Ophthalmology. These fears may be founded in fact—as people age, so do their risks for blindness and chronic diseases.
The Alzheimer’s Association notes that 5.6 million Americans age 65 and older are living with Alzheimer’s dementia. Additionally, a study from JAMA Ophthalmology found that seniors with visual impairment were up to 2.8 times more likely to have cognitive dysfunction or dementia.
The story is similar for diabetes, with a study from Diabetes Care showing that more than 25 percent of Americans age 65 and older have the disease. This then increases the risk for diabetes-related blindness, as diabetes is the leading cause of preventable blindness in adults.
Not only do these diseases take a toll on members’ health and vision, but also on total health costs. The American Diabetes Association estimates that diabetes’ costs total an estimated $327 billion annually, with $237 billion coming from direct medical costs and $90 billion coming from decreased productivity.
And when you look at Medicare reimbursement, Alzheimer’s leads the pack. According to the Alzheimer’s Association, one in every five Medicare dollars goes to someone with the disease. More specifically, in 2018 alone, Medicare and Medicaid spent $186 billion caring for someone with Alzheimer’s/dementia.
While eye disease costs are relatively low comparatively, the CMS, Department of Health and Human Services Administration on Aging, shows that ophthalmology and optometry are the second-highest cost specialty for Medicare expenditures. More directly, eye-related costs drive 7.2 percent of total Medicare expenses, and as a whole, eye care costs have been growing three times faster rate than total Medicare costs.
Given this, the importance of understanding the true definition of utilization management and what it is intended to provide—consistent cost reductions while keeping member outcomes as the target goal—is abundantly clear.
The Future of Vision Care and Utilization Management
The reality is that a routine exam should be seen as a preventative care strategy for not only eye health, but overall health as well—playing a major role in the diagnosis of both the leading causes of blindness and chronic medical conditions.
More than 25 chronic diseases can be detected with an eye exam, often before symptoms are noticed—from Graves’ disease to Crohn’s disease. In fact, research shows that many people first learn of their risk for hypertension, a leading risk factor for heart disease and stroke, from their eye doctor, rather than a cardiologist.
As U.S. healthcare continues to evolve, and the methods by which patients enter the medical care system change, understanding true utilization management is critical now more than ever and managed vision care serves as an opportunity for an integrated, cost-effective, non-invasive look at overall health that drives better utilization—it’s time pay attention.
Photo: Jay_Zynism, Getty Images
Elizabeth Klunk is the Senior Vice President of Medical Management at Versant Health , a managed vision care company focused on creating an integrated and seamless experience for health plans, members, and eye care professionals across the total eye health value chain.
