While utilization management viamanaged vision care is great on paper, the proof really comes inthe care and costs to members in a U.S. health care environmentfocused on integration and cost containment. (Photo:Shutterstock)

In managed care and benefits, medical management hastraditionally referred to care insurance providers and medicalprofessionals working together to determine best practices andservices to improve both quality and outcomes for plan members. However,over the last decade, medical management has been adapted to meetpayers and medical professionals on their own terms in the evolvingU.S. health system—and has come to mean anything from trueutilization management (the purest definition), to pre- andpost-claim submission, steerage or even the “gatekeeper” model.

The result is a very common term that no longer lives up to itsoriginal definition.

Simultaneously, care costs and outcomes have never been moreimportant, driving systemic health care conversations andincreasing nontraditional health industry entrants.

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For this reason, medical management should be considered by itspurest definition—utilization management—a critical, but oftenoverlooked, capability of benefit providers that enables healthplans to more efficiently and effectively support members. And witheye health as a growing cost specialty—driving $102 billion inMedicare expenses—now is the time to integrate vision benefits intothe conversation.

The overlooked benefits of vision benefits

As a natural part of routine eye coverage, members receive aneye exam and corrective wear, if needed. During this exam, the eyecare professional may detect either an eye health or overall healthconcern. The eye care professional then enters their findings intothe medical claims review system—and this is where utilization management kicks in.

Through this continuum of care that starts with vision benefits,the member care experience is improved via integrated claims acrossof all levels of care—allowing for ease of information to transferacross health care providers, while avoiding leakage andoverspending.

While utilization management via managed vision care is great onpaper, the proof really comes in the care and costs to members in aU.S. health care environment focused on integration and costcontainment.

In addition to routine vision exam benefits, if an eye careprofessional detects an eye disease or chronic health condition, members whose healthplans include utilization management through managed vision careexperience no delays in medical care. This broadens access tomedical vision care services, while minimizing the need forreferrals and costly follow-up appointments. For plan members, thiscan drive the difference between receiving appropriate care andgoing undiagnosed.

Additionally, eye care professionals within the network ofmanaged vision care companies with true utilization managementcapabilities see administrative advantages—including peercommunication; coordination of seamless intra-practice care betweenoptometrists and medical practitioners; and procedural consistencyacross managed care organizations.

Given the breadth of medical and health conditions that can bedetected with a routine eye exam, the role of vision care inutilization management is a critical one.

Managed eye care contributes to overall health

We all appreciate the advantages of good vision. In fact,blindness ranks as one of the top fears of aging Americans, alongwith stroke, Alzheimer's disease, diabetes and heart disease, notesarticles published by The Motley Fool and JAMA Ophthalmology.

While most people recognize the importance of a routine annualphysical to either prevent or detect many of these conditions, farfewer understand that an annual eye exam has long-reaching benefitsbeyond just vision correction, glasses and contacts.

The reality is a routine exam is not only an early detectionstrategy for eye health, but overall health as well—playing acritical role in the diagnosis of both the leading causes ofblindness and chronic medical conditions.

Vision health issues such as glaucoma, cataracts, maculardegeneration and diabetic retinopathy can be downright devastating,profoundly impacting the quality of members' lives and the lives oftheir loved ones. In all four cases, a routine eye exam can detectthe signs and symptoms of each of these eye conditions in the earlystages—but that's just the beginning.

Research shows that a regular eye exam can identify many medicalconditions before the patient even knows they have the disease. Infact, more than 25 chronic diseases can be detected with an eyeexam, often before systemic symptoms are noticed—from diabetes toGraves' disease, high cholesterol to Crohn's disease, and manymore.

In fact, in one study published in Population Health Management,a routine eye exam detected signs of chronic disease long beforeany other health professional had noted the condition—finding signsof high cholesterol 65 percent of the time, high blood pressure 30percent of the time and diabetes 20 percent of the time.

This is particularly important with blood pressure, asuncontrolled high blood pressure (hypertension) is a leading riskfactor for heart disease and stroke. Yet, one in five people withthe condition are not even aware that they have it, according to areport from the American Heart Association. In fact, research showsthat many people first learn of their risk for hypertension notfrom their cardiologist, but from their eye doctor. It's a similarstory with diabetes. A study from Population Health Managementshows that 20 percent of people first learn that they are diabeticas a result of an eye exam.

Vision for the future of utilization management

There is no doubt that utilization management is a best practicewhen it comes to health outcomes and costs, and now is the time toconsider the role of managed vision care and benefits in improvingthose factors for members in the scrutinized care landscape.

In a world where fewer members are entering the care systemthrough primary care physicians, vision care offers an inside,integrated, non-invasive look at overall health that can drivesmarter, more connected member outcomes at controlled costs.

Dr. Mark Ruchman, MD, is the chief medicalofficer at Versant Health. Elizabeth Klunk, RN,BSN, CCM, is the senior vice president of medical management atVersant Health, a managed vision care company focused on creatingan integrated and seamless experience for health plans, members andeye care professionals across the total eye health valuechain.

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