In managed care and benefits, medical management has traditionally referred to care insurance providers and medical professionals working together to determine best practices and services to improve both quality and outcomes for plan members. However, over the last decade, medical management has been adapted to meet payers and medical professionals on their own terms in the evolving U.S. health system—and has come to mean anything from true utilization management (the purest definition), to pre- and post-claim submission, steerage or even the “gatekeeper” model.

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

Simultaneously, care costs and outcomes have never been more important, driving systemic health care conversations and increasing nontraditional health industry entrants.

For this reason, medical management should be considered by its purest definition—utilization management—a critical, but often overlooked, capability of benefit providers that enables health plans to more efficiently and effectively support members. And with eye health as a growing cost specialty—driving $102 billion in Medicare expenses—now is the time to integrate vision benefits into the conversation.

The overlooked benefits of vision benefits

As a natural part of routine eye coverage, members receive an eye exam and corrective wear, if needed. During this exam, the eye care professional may detect either an eye health or overall health concern. The eye care professional then enters their findings into the 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 across of all levels of care—allowing for ease of information to transfer across health care providers, while avoiding leakage and overspending.

While utilization management via managed vision care is great on paper, the proof really comes in the care and costs to members in a U.S. health care environment focused on integration and cost containment.

In addition to routine vision exam benefits, if an eye care professional detects an eye disease or chronic health condition, members whose health plans include utilization management through managed vision care experience no delays in medical care. This broadens access to medical vision care services, while minimizing the need for referrals and costly follow-up appointments. For plan members, this can drive the difference between receiving appropriate care and going undiagnosed.

Additionally, eye care professionals within the network of managed vision care companies with true utilization management capabilities see administrative advantages—including peer communication; coordination of seamless intra-practice care between optometrists and medical practitioners; and procedural consistency across managed care organizations.

Given the breadth of medical and health conditions that can be detected with a routine eye exam, the role of vision care in utilization 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, along with stroke, Alzheimer's disease, diabetes and heart disease, notes articles published by The Motley Fool and JAMA Ophthalmology.

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

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

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

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

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

This is particularly important with blood pressure, as uncontrolled high blood pressure (hypertension) is a leading risk factor for heart disease and stroke. Yet, one in five people with the condition are not even aware that they have it, according to a report from the American Heart Association. In fact, research shows that many people first learn of their risk for hypertension not from their cardiologist, but from their eye doctor. It's a similar story with diabetes. A study from Population Health Management shows that 20 percent of people first learn that they are diabetic as a result of an eye exam.

Vision for the future of utilization management

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

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

Dr. Mark Ruchman, MD, is the chief medical officer at Versant Health. Elizabeth Klunk, RN, BSN, CCM, 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.

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Redefining medical management with vision benefits

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