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Power Hour Optometry
AOA Leaders Take on Vision Benefit Managers: Legislation, Advocacy, and the Future of Eye Care
00:55:50
In this rare behind-the-scenes episode of Power Hour, host Eugene Shatsman is joined by an all-star panel from the American Optometric Association — Dr. Thomas A. Lucas, Jr. (Director of Advocacy, Texas Optometric Association), Dr. Jacqueline M....
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- [00:00]
Dr. Jackie Bowen
Foreign.
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Eugene Shotsman
Welcome to the Power Hour, Optometry's biggest and longest running show.
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Host/Moderator
We got a great show for you today.
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Eugene Shotsman
I'm your host, Eugene Shotsman and I've got an amazing panel of eye care leaders. So today's episode we're going to jump into something that just about every single practice owner deals with and gets frustrated with. And the topic of course is vision plans, or as the AOA calls, calls them, vision benefit managers. So that's a big focus of our episode today. And we've got an all star panel from the AOA. We've got Dr. Jackie Bowen, she's the AOA president. Got Dr. John Peterson, he's an AOA trustee. And then we've got Dr. Tommy Lucas, he is the director of advocacy at the Texas Optometric Association. And together they help talk about some of the things that the AOA is working on. But specifically we spend a lot of time this behind the scenes with this VBMS concept, the Vision Benefit Managers concept. What's changing, why it matters to your practice and your patience and profitability. We actually talk about what some of the recent legislation looks like and what impact it has or doesn't have on VBMs. And of course we cover the Texas playbook, some of the big changes in Texas over the last few years, including this most recent one which is called HB 30 to 11, and why states like Oklahoma, Arkansas and Illinois are following suit. There's this kind of hidden power of VBMS and how these vertically integrated companies have a chance to control pricing, supply chains, access and what the AOA is doing about that. And really we talk about what the federal level efforts look like for the aoa, including things like lab choice, bill and non covered service protections, but also scope expansion. They talk about some of the successes they've had in this area, including two states that increased scope this year. So perhaps most importantly, we also cover how to get involved even if you're busy, even if you've got a lot of things going on in your practice and you're not sure where to start. This is not just a policy episode. This is kind of a rare behind the scenes conversation at how the AOA is functioning, how the profession is trying to rebalance the power dynamic in eye care. And I definitely want your thoughts. Does it take, does it take an episode like this to help clarify the stakes? Are you seeing unfair VBM behavior in your state? Let me know. I posted some resources in the show notes as well, but of course you can drop me a line at Eugene shotsman.com or through the Power Hour website. Your stories and questions help shape the show for the future. So I absolutely look forward to hearing from you. Be sure to subscribe on YouTube, Spotify, Apple Podcasts or wherever you listen. And now let's jump into it.
- [02:50]
Host/Moderator
All right. Welcome to the Power Hour with another exciting panel from the aoa. I think we've got an amazing group. Jackie, John, Tommy, welcome to the show. And Jackie, you just took over the reins as the president of the AOA a few weeks ago and Optometry's meeting just happened and there were a lot of themes that were discussed and there are a lot of things that are on the go to. So just catch us up. What are the biggest kind of areas of focus for the aoa and what are the biggest areas of concern? Maybe for the members of the aoa?
- [03:29]
Dr. Jackie Bowen
Sure. First of all, we're happy with having hosted a very successful meeting with over 4,000 attendees, including doctors and students and para optometric staff. And for those of you who were able to attend, I hope you had a great experience and I want to put put a little thought in your head to consider attending Optometry's meeting in Phoenix next June. Certainly the House of Delegates is the highlight for me and for the board of the aoa. There are several sessions in the House of Delegates and we really honor the profession. We pay attention to what's happened so far and more importantly to what we need to be moving forward on. Chief among those priorities, of course, is the Vision Benefit Manager reform that we've been working on pretty significantly in the last several years. And we're going to hear a lot more about that, I know in our conversation here today. But we know that this impacts every optometrist in some way or another, that we have been impacted by reimbursement freezes and by just some unfair and sometimes unscrupulous tactics on the part of the Vision Benefit plan. So that's something constantly on the top of our priority list. Headlining everything that we message is reinforcing the importance of the doctor patient relationship, particularly on Capitol Hill in D.C. we are working with other organizations to make sure that contact lens sales are safe for patients and emphasize the needs for optometrists to oversee any kind of fitting and changes in contact lenses should not occur without that interaction. And we're looking to constantly preserve this current system, preventing loopholes that retailers are trying to exploit as laws are being made. Medicare physicians, as we are known, certainly are frustrated by annual cuts and we're constantly making changes at the end of every year, we have to send out an advocacy call to action to ask our lawmakers to prevent cuts in our pay. And we are looking to fix that so that that doesn't drive drain our time and resources at the end of every year. And then connected with that, the VA optometry concerns continue to rise to the top. In this past year, we made a major win in securing physician pay for VA optometrists. But within that system, there continues to be pushback against optometrists performing laser and minor surgical procedures. So these are some of the things that are constant and ongoing, and we're always looking to our membership to help support us and join the grassroots efforts to move those things along.
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Host/Moderator
Yeah, and you know, I'll turn over to John because, you know, in your role with the aoa and maybe you can talk a little bit about what that role is. You have really tried to push really hard for this concept of VBM reform. So maybe just explain it to listeners who are not so tuned in to exactly what that means.
- [06:31]
Dr. John Peterson
Yeah, thanks. So I guess defining my role, I'm on the Board of Trustees, and that's a new role. My previous role was within the State Government Relations Committee. SGRC for AOA is the arm of AOA that helps states pass legislation, whether that's VBM reform, scope of practice, children's vision, and so forth. So I chaired and was served on that committee for the last many years before going on to the Board of trustees. When you look at VBM reform, which is the kind of the topic du jour today, Tommy and I have been working a lot through a whole bunch of different avenues with a whole bunch of different states and a whole bunch of different national organizations looking to make this VVM reform meaningful, make it effective. There are between 20 and 30 states that have some sort of VBM laws on the books. And unfortunately, some of the problem is the VBMs ignore these laws, find loopholes through these laws, work around these laws, do all of the nefarious things that we know about. So, Tommy, the SGRC team, myself, we've all worked to try to create really good language to help states pass meaningful legislation that really trickles down into benefits to the practitioners. You know, right now there's 200 million plus covered lives that covered lives for the VBMs. Most markets, there are two plans that have around 85% of the share. These markets, they control supply chains, they control practices, they control, you know, low reimbursement, they control where patients are steered to. They Control how doctors are tiered and appear before their patients. And so I think looking at reform, that creates a level playing field and gives practitioners and the patients the kind of the relationship that we all prefer to work with.
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Host/Moderator
Yeah. And, you know, I think maybe, Tommy, you can elaborate on that a little bit, because you guys just passed House Bill 3211, right. So talk about where that fits. And then you guys had some other momentum in 2023.
- [08:56]
Eugene Shotsman
So how does all this fit together?
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Dr. Tommy Lucas
Yeah, you know. You know, I work as the director of advocacy for the toa and the AOA and the state affiliates are partners, you know, in all endeavors, legislative and regulatory matters. And on the state level, here in Texas, you know, we've been working on VBM reform since 2011 when we passed our first bill, you know, in this arena. So it's been an ongoing project, you know, for over a decade now. And most recently, just a couple months ago, we passed House Bill 3211, which is a concept that is most commonly referred to as any willing provider, which means that any doctor who meets the credentialing criteria of the plan and who is willing to sign the contractual terms is allowed to become a in network doctor for that plan. So this was a critical, you know, situation in Texas for two reasons. One, because historically, you know, Texas optometrists have faced discrimination, usually depending on where they work. So if an optometrist happened to work in a certain retail setting or a certain group setting, they were either allowed or not allowed to enter into certain plans, as in network providers for the vision plans. So obviously, the toa, you know, hears from our membership, we're reactive to our membership, and we decided that we needed to take action on this so that all doctors could join plans and treat the patients and their communities where they practice, to help with patient access, make sure patients get the care that they need. So House Bill 32, House Bill 3211 was a big fight. Of course, the BBMs didn't want it to pass, but thankfully, it passed unanimously in Texas, meaning that every single legislator voted for it. And that's an uncommon feat in politics. But it underscores the, you know, importance of the policy where, you know, obviously legislators act on behalf of their constituents, and they decided that, hey, our constituents need access to eye care, and, hey, we don't necessarily want these VBMs restricting that career for. For profit reasons.
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Host/Moderator
What was the argument that the VBMs gave against the. The bill?
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Dr. Tommy Lucas
Yeah, usually it would all boil down to cost of premiums. Would go up. And, you know, we debunk, debunked that successfully. Obviously, premiums for vision care have gone down historically every single year, because the vision care market itself is competitive. You know, there's 15 or 20 plans total, but of course, two plans dominate, you know, 80% of the marketplace. So there is that competition that's been driving down those premiums over time. And legislators looked at that and, you know, knew that passing these reforms would simply allow better access without raising premium costs on consumers or patients. And the way, you know, vision plans are constructed, you know, so much of that interaction is financially the covered benefit, but a large chunk of it is the non covered benefit, the, the things that the plan doesn't cover. So the VBM's try to play games with their plan design, you know, to benefit themselves based on the covered part versus the uncovered part. And, you know, that's where we find ourselves trying to deal with this financial situation that the VVMS force onto, you know, small business optometrists.
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Host/Moderator
Yeah. And Tommy, remind everybody what the bill was that Texas passed in 2023.
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Dr. Tommy Lucas
Yeah, in 2023. We've been very active in this space. Obviously in Texas, you know, we're the second biggest state and, you know, have a lot of, you know, doctors. There's over 5,000 doctors in Texas. In 2023, we passed another, you know, kind of groundbreaking state law that kind of reined in some of the unscrupulous practices of VBMs. Most prominently, it dealt with chargebacks where a plan could not apply, improper chargebacks when they're not providing the services or goods that that patient's receiving. It's still a practice, unfortunately, that they're doing and not complying with the law. It also addressed the steering of patients to cell phoned locations. And that is a very, you know, big ongoing fight, you know, addressing the steering of patients and then also the tiering of doctors. So VBMs would tier doctors based on things that are inappropriate, of course, how much product they buy, that that VBM owns, things like that. So that bill addressed all of these things in a novel way for the first time. And since that time, other states have followed that lead, including Oklahoma, Arkansas, Illinois, Nevada. So there's kind of a movement among the states now to deal with these unfortunate practices by the BBMs.
- [13:52]
Host/Moderator
Yeah. And I want to come back to other states in a moment. And John, kind of back to you in now that you've transitioned to a more, I guess, national role with the aoa, how do you help other states Take the momentum that for example, Texas is experiencing and get into, get into the fight or help help advocate for this.
- [14:19]
Dr. John Peterson
So the first thing I would say, whether it's BVM reform, whether it's scope of practice or anything else, it ultimately optometry wins through grassroots. And I think anyone who is listening here, who has concerns about VBMs, who has concerns about their scope of practice, who has concerns about anything related to their profession, getting involved with your state association with the aoa, getting involved particularly legislatively, meeting legislators in your that represent you in your district, where you live, where you work, ultimately that's how we win these battles. I think more nuanced, it's educating, it's finding the right legislators that understand a very, very complex issue. So VVM benefits are intentionally incredibly confusing. They are burdensome to the practitioner, they.
- [15:16]
Host/Moderator
Are.
- [15:18]
Dr. John Peterson
Not clearly understood by the consumer being the patient. And of course all of that is intentional. And so when you try to take a citizen legislator and explain what's going on in this market, you have to find the right people. And that's what we work with states with. So as we help them build up their grassroots, we look for good champions of these bills. And so, you know, with Dr. Lucas in Texas, they had the help of the physician who understood this. In Arkansas, it was a pharmacist who was able to understand this. When you have, sit down and have a conversation and you are able to coherently explain how these plans work to a person who sits down and pays attention and gets the details of this, they're astonished. And turning that person into a champion for, for this cause is really easy once you get through the understanding part I and, and so I think at.
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Host/Moderator
The state level, what are they astonished most at? John? The, the fact that these companies are so vertically integrated is that the vertical.
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Dr. John Peterson
Integration is, is absolutely stunning when you look at it at plans that own the insurance, the retail outlets, the product products, the clinics, the all, all things supplied side, you know, you really look at these, these VBMs, there's, there's no other form of coverage in the healthcare market where the provider of the so called insurance actually profits from utilization of, of that insurance. Right. You know, so if you're a medical insurer, you're trying to decrease the amount of cost and exposure you have with the patients. If you are a VVM that owns everything along the way and you can have for the nominal fee of paying the doctor to do the service and you can sell your products all the way up and down, I think Legislators are completely baffled that this system exists.
- [17:28]
Dr. Jackie Bowen
If I can just dovetail onto what John was saying, AOA kind of has defined our approach into what we call seven pronged approach. And so in addition to what he's talking about, we've also had opportunity, many opportunities to have what we call top to top discussions. So the CEOs of these vision plans and AOA and our, you know, our partners will sit down and for two years I've had opportunity to be in on those things. We also make our AOE resources available to every state. Tommy is one of those resources. People who are experts, who've been through the paces. We really want to make sure that each state that has gone through or is thinking about going through this kind of legislation avails themselves of what others have already done and best practices that we know of. Tommy kind of mentioned the statement that DSP made that they would have to increase premiums. And for me, an astonishing response when we talk to these CEOs of these companies is their response to the thing that we really want. We really want, well, many things, but certainly importantly, we want to get paid more. We want that reimbursement to increase. And that's one of my pain points every single day when I'm seeing patients is recognizing the increasing value of the comprehensive exam, but the not increasing reimbursement. And the response to that is, well, you know, that's, if we do that, then we have a difficulty in competing in the market and we won't be able to get all these plans that work so well for you and draw these patients into your practice. So I just, I was astonished by that and I continue to be astonished by that response. But I want to let everyone know that we're not backing down. We're continuing to send that message along with all the other ones. And you know, on the AOA board's comprised of optometrists. We all are doing the same things that our members are doing every day. And, and we get it. And we're continuing to try to make things better little by little.
- [19:35]
Host/Moderator
Well, and what do you say to people when they, when they say to you that, well, but yeah, the reason you accept these plans is because it is a marketing tool and it brings a patient in. And usually if you do a good job with capture rates in your practice, you are going to make that, that, that visit wildly profitable for your practice. Come on, what are you trying to accomplish here?
- [19:57]
Dr. Jackie Bowen
Right? And we often talk about that as a marketing plan. You need to think of Vision benefit plans as marketing opportunities. And there are, there are resources. The plans themselves are willing to help you figure out how to use the plan and use the best products in order to maximize your profitability. And what's important to recognize is this is not an employment contract. We all voluntarily are providers on these plans, but I think it's where we're failing is just unawareness. So many optometrists don't read the contracts, and I'm guilty of that too. It's hard to commit to reading those contracts as they change and just a lack of awareness of how much each patient encounter is costing relative to what we're being paid. So, you know, I would admonish anybody who is a vision plan provider to look at your conduct and really understand what you are agreeing to in there and make a plan for change if that's your goal. And from real early in your career, understand what it means to be a provider on these plans and how that impacts your community and how it impacts your bottom line and your general happiness of practicing optometry. So as you sign these contracts and go into them, recognize what you're committing to and figure out how that's going to work best for your practice. Bottom line.
- [21:20]
Host/Moderator
Tommy, looks like you wanted to jump in.
- [21:23]
Dr. Tommy Lucas
Yeah. You know, with VBMs, it's, you know, a lot of their messaging kind of, you know, falls on deaf ears with us optometrists. Like we understand that we're the product, you know, that they're selling every day. And when they tell us, you know, we can't raise your reimbursements, you know, $5 or $10 or $20, but then we see them, you know, make a nine figure acquisition or a billion dollar acquisition, which they're doing, you know, every year. You know, we, we look at ourselves and like, geez, okay, we see, you know, the value that these companies are placing on us and it's not very much. So that's what's got to change ultimately is a kind of a reset of how the VBMs think about the optometrists that are integral and, and key to their entire business model. So we hope to see these VBMs respond in a positive way soon.
- [22:12]
Host/Moderator
Yeah, and I mean, you're right to some extent, Jackie, when you said that it's a, it's not an employment contract, it's a voluntary decision to accept these plans. And I think that there are some practices, I know we have some clients who have said, yeah, you know, just not going to do it. I'm going to start dropping My lowest. The division benefit plan that is least profitable for my practice, that may be bringing me the wrong kind of patients and isn't working as a marketing tool for me. And I don't know if you're seeing more of that as well, John, so.
- [22:44]
Dr. John Peterson
I'll have a comment on that. And so, yes, we voluntarily sign these contracts. There's a legal term called contract of adhesion. That's really where these VBMs fall into. So I think these. These practices who are fortunate enough to be able to drop vision plans, I think they fit not the criteria that is the large swath of optometrists. They can be rural practices or niche practices or practices that have kind of subspecialties, you know, away from that. I think for the primary urban, suburban practices, contract of adhesion means that really everything is on the side of the contractor. And so when the. When the VBMs give you this contract, it is not a negotiable contract. It is the rates. You cannot negotiate your rates. You cannot negotiate fees, you know, associated with products or services. And they are really take it or leave it contracts. And when you have two plans really monopolizing to or monopolizing your market, your ability to function as a kind of a traditional optometry practice in that market without taking those plans is really limited. So I think that is something that also resonates because that's something that the plans always say they don't have to sign the contract, and then the legislators hear that. So when you explain to them that the ability to practice how we are wanting to practice and not sign that contract in most markets is probably not reasonable.
- [24:24]
Host/Moderator
Mm. So I think that makes an interesting point. I think that I guess I would ask you all to comment, and I don't know who wants to go first, but where are we headed as an industry in relationship to these? And I noticed you using the language vbm, which stands for vision Benefit Managers. Right. Patients refer to these things as insurance. I think you all have made a deliberate distinction between insurance and vision benefit management. And it kind of seems like there's maybe some conflicting political headwinds that, you know, maybe want to give them some power or maybe want to take some power away from the. From these large organizations. So if you had. If you had to talk about the. Of course, there's. What are the states doing? What's the way doing? And we've covered some of that. But what do you think is going to continue to happen? What is the trend going to look like over the course of the Next two to three years when it comes to vision benefit managers.
- [25:26]
Dr. Tommy Lucas
Yeah, I can speak to that, you know, for a minute. You know, we just keep seeing the number of covered lives by VBMs increase, you know, over the years and over these last few decades. Right. So, you know, over 200 million Americans are covered by a VBM now. That's about, you know, almost 2/3 of the country has a VBM. We see the VBMs moving into the different markets that exist, like Medicare Advantage, the exchange plans, Medicaid in every state. So, you know, as these large companies, you know, pursue their, their business goals, you know, they're trying to gain as many covered lives as possible. And that's going to be in every aspect of the healthcare marketplace. Traditionally it was mainly employer based insurance where you would see these, these vision plans attached. But now they've become ubiquitous. So, you know, I think over the next 10, 20 years, you're only going to see more Americans covered by these vision plans, which is why this issue is so important to the AOA and to the states to fight for fairness. I don't see it going any other way at this point.
- [26:29]
Host/Moderator
Yeah, that makes a lot of sense. And I think that. And, and do you feel like, and this is maybe moving into this, we're taping this episode right between Optometry's meeting and AOA and Capitol Hill. And it seems like, you know, that that is your big advocacy event. So Jackie, I'll ask you, obviously this is going to come up. Do you, how is the AOA really received on Capitol Hill? And you know, what, what is the positioning that AOA has in our nation's capital and whether it's in relationship to these VBMs or anything else, we're positioned very well.
- [27:07]
Dr. Jackie Bowen
For many, many years. We've had great staff who's able to line up a lot of meetings. And that AOA on Capitol Hill event is just exciting to be a part of. Just to kind of give an example, we're about a third the size in membership of the ada and we have more of an ear by the lawmakers and their staffers. So we have a lot of punching power when we're on the Hill and our lobbyists are consistently recognized in awards and publications as being some of the top in the country. So we're certainly really proud of that. We very specifically use the term VBMs because PBMs is something that legislators really understand as pharmacy benefit managers. And it's a bit villainous maybe. And I can tell you that the vision plans don't like that term very much. It makes them uncomfortable because they know what kind of implication that has. But it truly is very similar to PBMs. And so, you know, we don't feel, we don't feel uncomfortable about using that term. And in my office, and I imagine in many of our offices, we've really tried to not use the word insurance. Right. Because patients think I have insurance, then I pay a copay and everything else is covered. And we know that that's not the case. So the way that we talk about vision plans to our patients, I think is very important just as much as the way we talk about vision plans to legislators. There's a lot of keywords that we use very purposely to try to send our message that these contracts of adhes, for example, are like contracts with credit card companies. There's not that many credit card companies. And so you just don't have negotiating power. And that seems to be an analogy that, that helps them to understand where we're at with this.
- [28:55]
Host/Moderator
Yeah, that makes a lot of sense. My when you think about obviously what you're doing in your office and then also what's happening on Capitol Hill, I think it is so important to have power in relationship to the, to the VBMs. But you know, is it. Are states following in the footsteps of Texas quickly enough? Is there more that can be done? What do you all think, John?
- [29:23]
Dr. John Peterson
Yeah, so they are following, you know, I think since Texas, you had Oklahoma, which had a very robust lot, and you had Arkansas, that had a very robust law, we have a whole bunch of other states teeing up to go. I think based on the successes or now known loopholes in some of these laws, we continue to adapt and we continue to come forward with stronger and stronger bills. Ultimately, the legislators are on our side. Like the momentum is on our side. The money is not on our side. We will always be swimming uphill with these battles and these groups have tremendous amounts of money that they throw. So it is up to us to play the long game, work with the legislators and keep chipping away at this one state at a time. Going back to AOA and Capitol Hill without going into the nuances of the overall vision benefit manager market. You can't fix this just at the state because of ERISA plans. You're going to have to fix this at a national level too, so that the state level, the AOA level, in order to make this work. It's a two pronged approach.
- [30:40]
Dr. Tommy Lucas
Yeah. A comment to follow up on John there. He's exactly Right. In Texas, you know, we, we put, you know, a lot of effort and a lot of work into these state based bills. But what the truth is now only 11% of plan types in Texas are regulated by the Texas Department of Insurance. The rest of those are regulated by the federal government at this point, whether it's Medicare, Medicare Advantage exchange plans, Medicaid, partnership with the states. So, you know, when the regulation of these plans and who enforces these fairness clauses that pass, you know, becomes the responsibility of the federal government. That's the importance of the AOA. We have to have that, that solid representation in D.C. to fight for our profession there and our patients there. So yeah, the regulation and oversight, you know, that's goes into enforcing these bills. A lot of that is moving towards DC as time goes on.
- [31:39]
Dr. Jackie Bowen
What we're learning in the paradigm shift that we're dealing with is, you know, we're pretty good at passing bills and we really understand the grassroots effort and how to make that legislation happen. The implementation is just as, or oftentimes more, Tommy will probably agree, arduous and expensive than the actual passage of the legislation. So that's the reality of the landscape right now that we have to project.
- [32:06]
Host/Moderator
And I think you're probably also getting some support when you were talking about the money, would you consider that private equity is on your side in this particular fight? I mean they want greater reimbursements? No.
- [32:22]
Dr. Jackie Bowen
Yeah, we, we are definitely working with some of the larger private equity groups for a couple of years now. We have been, we established the Advocacy Roundtable which is a forum designed to talk about everything advocacy related. And I my eye, Dr. Kepler Eye care Partners and Elevate are all part of the Advocacy Roundtable. So they, they are, they pay to play, they're, they're participants in the discussions. They really appreciate the information that we have to offer and they're definitely on our side. There are many, many private equity groups, so I can't speak for all of them, but we're certainly have, we have our eyes on all of them and we want to bring them around because the reality is now Our membership is 2/3 employ doctors and that's a significant shift from where it was, you know, even 10 years ago, certainly 20 years ago. So regardless of mode of practice or who your employer is, we're all impacted by all these things. And most employee doctors have a production based pay scale, you know, so it matters to not just the whole company, but individual practitioners, even if you're not the practice owner.
- [33:34]
Host/Moderator
Yeah. So let's talk A little bit more about some of the other. It says some of the other things that are going on from an advocacy standpoint. And I'm also really curious because obviously we just passed this new big bill that happened in just a few months ago and I think that there's trepidations and some people thought it impacted optometry in some ways. Some people think it doesn't impact optometry in some ways. Can John, maybe you can speak to that and talk a little bit about what the impact of that legislation has had. And then also there's also other acts that are on the go, right?
- [34:17]
Dr. John Peterson
Sure. I guess in I assume we're talking about the one big beautiful bill. And so I think the kind of the couple things with that is we were able to avoid the Medicare cuts and would that get a 2.2.5% pay increase. Some of the other things that come with that are pass through taxes for practice owners that are maintained. Unfortunately, one thing that did not get in through the latest reconciliation was there was PBM reform that's in there and we're going to look follow that as maybe something comes up towards the end of the year. I think the other thing we're going to have to really watch are the Medicaid changes that will be coming down to each state. So you know, Medicaid has this big federal umbrella and then it has all of the states doing kind of the managing of these benefits along with their state dollars. Every state is a little different on how strong their Medicaid system is. As Tommy mentioned, you have VBMs getting involved in the Medicaid market, but ultimately having Medicaid having good reimbursement for ICE services through Medicaid increases access. Colorado is a good example of that. We had a very stagnant Medicare or Medicaid reimbursement rate that was going on for 40 years. We were able to change that around 2014 significantly. That brought the Medicaid rate up much more on par with Medicare. We saw an almost fourfold enrollment of providers who are now Medicaid providers in Colorado. And that reached out throughout the state into all the rural areas, all the underserved areas, which is what they're looking for.
- [36:13]
Host/Moderator
So you're saying that there are some things to watch. Can you explain that a little bit more as what are we watching for future legislation and what what impacted us a little bit negatively, maybe even in the big beautiful bill that you know, you mentioned, PBMs were not in there and PBM reform was not in there. So Explain that a little bit for listeners who don't quite get the connection.
- [36:35]
Dr. John Peterson
So the PBM reform is really a few years ahead of us. It's been around in the states for a few more years than, than the VBM reforms. And so I think you have legislators that have a keener ear to that. I think you have legislators that have a greater understanding of PBMs. And so the more that PBM reform happens on a state, national level, the more that we have kind of an easier entry into explaining the similarities and the same problems that we have with VBMs. So the more that we're able to get these, you know, kind of support getting these included in these federal bills, the better.
- [37:15]
Host/Moderator
Got it, Tommy?
- [37:18]
Dr. Tommy Lucas
Yeah. And, you know, with this reconciliation package, you know, PBM reform, I believe was in the House version, got stripped out of the Senate version, if I remember correctly, and now it's passed. So, you know, the next opportunity for something to occur will probably be later this fall when, you know, potentially another package moves through Congress. So that's typically how these things go in Congress. They, you know, set many initiatives, get rolled up into one either appropriations bill or reconciliation bill, because not a lot of individual bills pass through Congress every session these days. So, you know, the AOA is, you know, looking at opportunities to have its, its bills addressed. And I know, John, can, you know, describe those, those bills that are introduced right now on the federal level, and hopefully we'll see those initiatives put into a package this fall.
- [38:16]
Host/Moderator
Yeah. And this, this PBM reform, is that like trying to break it up, the. Break up the vertical integration? What, what's the, what was the reform that got passed by one but not the other?
- [38:29]
Dr. Tommy Lucas
Yeah. Pb, PBM reform was slated to be passed, and it would have addressed, you know, some of the unfair practices where these PBMs that are owned by the insurance companies, you know, harming independent pharmacists, you know, making cost structures that don't make sense where, you know, a patient can get a medication for cheaper by paying cash than paying the insured price, a lot of different intricate things in the pharmacy market, and they're very analogous to what's going on in the vision space. It's a lot of intricacies with these vision plans where patients kind of don't understand what their benefit covers and doesn't cover. So it's similar in that respect. But federally, there are two bills that are introduced right now that, that deal with the VBM marketplace.
- [39:17]
Host/Moderator
And.
- [39:19]
Dr. Tommy Lucas
Those are the bills that we're, you know, advocating for gaining Traction on gaining co sponsors on and hopefully we'll be able to pass this fall.
- [39:25]
Host/Moderator
Okay, John, you want to cover what those two are?
- [39:28]
Dr. John Peterson
Yeah, I think the broad one that has been around for a while. Federal legislation moves at a slow pace. It's just a reality. And so doc access and kind of what we refer to as doc access light are really co initiatives that we are doing with the Dental association and they really aim to hit the kind of the core things that we look at with VBM, reflection form, lab choice, different negotiating powers with contracts. So there's like a take one take all type clause. And so I think when you dental has some of the same problems with the little dental vision companies and they're not probably little, I can't speak to their market. So I think co tailing with them and which actually they're probably co tailing with us more as, as Jackie mentioned, we're kind of the stronger organization on the hill. Just adds more visibility and weight to those issues.
- [40:38]
Host/Moderator
Got it. And the, and lab choice explained that too.
- [40:42]
Dr. John Peterson
Tommy, do you want to.
- [40:43]
Dr. Tommy Lucas
Yeah, sure. Yeah. So, you know, lab choice is kind of a concept that came up through the states and now was put into, you know, the AOA's, you know, federal package. And you know, lab choice is simply where an optometrist can decide what lab to use for their patients that is in the best interest of that. That patient. So it may be a lab that produces a better quality product. In your doctor opinion, it may be a lab that's closer. It may be a lab that can get the glass is made in a quicker time for that patient versus the required lab of a vbm. And you know, that lab could be anywhere, you know, from Texas here, it could be in Pennsylvania or the Northwest. And it may take 14 days to get the job back where, you know, obviously as a small business owner, I can find ways that are better for the patient to get the glasses back in three days or five days, you know, and that benefits that patient. So that's the underpinnings of lab choice. Also in the doc access bill is the concept of non covered services. And this is the concept also from the states, you know, passed in dozens of states at this point that VBMs or vision plans should not be able to dictate, you know, a small business's prices for things that the vision plan doesn't cover. So and that's kind of common sense when you think about it. You know, you're signing a contract, you're accepting a reduced rate for access to that patient population for a defined set of services that you agree to provide. But when that company has the leverage on you because of, you know, market power, contracts of adhesion to dictate rates and prices on things that they don't even cover that aren't in their, you know, actuarial science for deciding what their premiums are, that is unjust and unfair. You know, and we feel that as small business owners, every day, you know, when, when a VBM is telling you to give this discount or charge this price for something they're not covering.
- [42:44]
Host/Moderator
Yeah. And it's, I think that makes perfect sense. So you're expecting both of these bills to be addressed relatively soon.
- [42:51]
Dr. Tommy Lucas
Yeah, both of those concepts are included in one bill together called the Doc Access Bill. And also the other key feature of that bill is limiting the length of these contracts so that they can be readdressed, renegotiated on a, on a more frequent basis so that the contracts just don't go on into perpetuity. And those, those are the major concepts of the Doc Access Bill.
- [43:15]
Host/Moderator
That makes sense. Okay, perfect. So when we come back from the break, I'm going to ask you all how people can, number one, get involved with some of these initiatives and also some of the things that are also on the go from a legislative standpoint in other states. We'll be right back on the Power Hour. All right, back on the Power Hour, John Peterson, Jackie Bowen, Tommy Lucas, excited to have you on the show. I think we're having a really interesting conversation about some of the advocacy work that's being done. I think we talked a lot about VBMs, but we haven't talked about some of the other initiatives or even some successes that the AOA and your affiliates have had this year. So, Jackie, I'll turn it over to you. Talk a little bit about some of the other things that are going on and maybe some of the wins that we've seen or some of the things that are on the go.
- [44:04]
Dr. Jackie Bowen
Sure. Establishing contemporary optometry, we coined that term that has long been a priority and will continue to be. And that sort of refers to the fact that we want every optometrist to be able to practice at the top level of their expertise and training as they want to in every state. So that kind of translates into scope expansion or, or scope modernization is probably a more appropriate term. So we are at 14 states now where they are able to perform minor surgeries and use lasers for yag, slt, and lpi. And the big wins this year were In West Virginia and in Montana. So it's great when we can have a year like that where we have double states. We hope to have more in the future. And the more states that we have, the more we're looking forward to an increase in that domino effect. If you look at the map right now of the United States where those procedures can be performed, there's a great opportunity to fill in the middle. And then we've got, you know, the coasts are. And the bigger states are definitely harder to move the needle on. Some states, lots of states went for a scope expansion, scope modernization this year. New Mexico passed in both chambers, but it unfortunately got vetoed by the governor at the last minute. It was very discouraging, but a learning opportunity. And certainly our successes and the not quite so successful efforts that we make are something that's shared, you know, in a couple of weeks. And then again in the fall, we have a state government relations regional meeting program planned where it's a really great opportunity for state leaders to share. Here's what went down, here's what went right, here's what went wrong. And so as the strength of everybody's experience builds, we're going to see more successes from state to state. So that also kind of plays into concerns that we have about workforce and the increase in eye care that we know is going to happen in the next decade or two, the not quite as fast increase in optometry students entering the field, and the flatline or even decline of ophthalmology entering the field of ophthalmology. So as more and more ODs are able to perform these procedures, it behooves us to look more carefully at where we're referring. If an optometrist in your area performs those procedures and you don't send them to the optometrist and let them know about what you do that they can refer back to. So in this year in my presidency, that's something I'm really interested in raising awareness about is OD to OD referrals. Because there are so many areas of emphases and you can't possibly be an expert in everything optometry because it is so broad. So it's exciting as. As more and more states acquire more and more privileges, we're going to be able to take care of more of our patients.
- [46:59]
Host/Moderator
Yeah. And I think it's interesting because you highlight two important parts, which is that it's more interesting, it's more exciting to practice optometry when you can perform at the top of your training Right. And then it's also, I guess, easier to recruit students into practices that have, I guess we would call it a more sophisticated scope of practice. And so then you've got a, you, you've got kind of a double whammy in states where you don't have that scope expansion or scope modernization as you call the Jackie. So you know what, what else is from, from both of those areas? What is the AOA working on and then what are the states individually working on when we think about that and even in states that aren't necessarily going for scope expansion, what are they doing to prepare? John, you have any comments on that?
- [47:57]
Dr. John Peterson
Yeah. So any state that has anything on the horizon is right away working on building up their grassroots network. And I think that comes through for people who are in any state that's getting involved with your state association, getting involved with the aoa, getting involved at your state capital day that your state optometry association is putting on. Ultimately there are a lot of players that want to influence, you had mentioned, say private equity or industry or even VBMs that get involved sometimes in these, these various pieces of legislation. This, your, your state association and the AOA are kind of the only ones that are, they're advocating just purely for optometry. And so we have partners, but partners we all, we always keep our partners at a fair arms length away because we, their interests, if they ever vary, are going to sometimes not be 100% aligned with us. And we AOA, in my case, Colorado, COA, we are 100% focused on what's best for our members and practicing docs. And I can't imagine that would ever change.
- [49:17]
Dr. Tommy Lucas
Yeah, I mean, that's right. You know, any of us optometrists or, or Eugene, you, you, you see that the future is coming at us all fast these days, right? So, you know, that leads to discussions about technology, what consumers want, you know, what is the future of optometry? And you know, that's kind of an open ended question. And when we look at that, you know, all we can really do is look at ourselves and say, hey, who's going to represent us and who's going to fight for us in this, you know, new frontier that, you know, we're all living and experiencing every day. And obviously the answer to that is the AOA and the state affiliates and you know, for, for doctors that are not members of the aoa. I would ask why? Because, you know, the membership in your, in your professional association is all we have. It's your professional insurance policy. We all carry dozens of different insurance policies to insure different things in our life. But why would you not want to insure the, the one thing that is actually fighting for your career and your profession? So it doesn't make a lot of sense to me. I know there's factors out there that, that, you know, limit people from joining, but, you know, making that sacrifice, joining up with your peers will only make us, you know, stronger and able to navigate the waters of the future. So, you know, thank you to, you know, all the members that are out there. They give us the strength to pass state laws like we do in Texas and John does in Colorado. And they give us the financial resources to play the political game because it costs money. And, you know, we learn a lot from each other. We learn how to take care of patients better every day. And those are the, you know, fundamental pillars of, of being in a profession versus being in a job. Right. So, you know, we are, you know, constantly trying to make sure this profession has a future and making sure that the students that are getting out of school have the potential for a 30 year career versus some other future where technology or consumerism changes.
- [51:25]
Dr. Jackie Bowen
That's supposed to be 30 years. Is that what you said? Wait a minute, no one told me that.
- [51:35]
Host/Moderator
And Jackie, to wrap it up, I guess I think both John and Tommy made an excellent point about why somebody should both be a member and maybe an active member. But if I'm listening and I'm busy and I'm seeing patients and I have lots of things going out of my practice, I got my own turnover to deal with, I've got my own headaches and I got the patients coming in and just lots and lots of headaches. What in particular are the small actions I can take that could help the AOA achieve some of the things that we're talking about today?
- [52:12]
Dr. Jackie Bowen
I'd say take the opportunity to tell your story. We try to make that easy in if you subscribe to AOA first look, which is the email that comes with your box Monday through Friday. I know we have plenty of emails, but if you, if all you do is look at the headlines, that's going to keep your awareness level up as to what's going on in the country. Sometimes outside of the eye care industry that's impacting us. There is also every single day a little red box that you can click if you need help reconciling a problem with a VBM or a medical plan. And that is something we really encourage because it doesn't matter how small your concern is we want to get you straight to the people that can help you resolve any kind of an issue. And so that plus you can also go to Stop plan abuse or stopplanabusesoa.org I think is the website. And these guys will correct me if I'm wrong. But if it's 35 bucks or 75, I'm going to tell you in less than two years those little amounts have gone up to over seven and a half million dollars that we have recovered and put back into optometric practices. So just do yourself the favor of taking advantage of that little member benefit. And there are seasons in life when you know you're raising a family, you're growing a practice where you can't engage heavily, but make it a point to decide. If someone asks you or perceives that there's an opportunity for you to fill or sit on a committee, just say y. You will never have the time and money to volunteer to your professional organization. Just do it anyway. I promise you the rewards are going to far outweigh anything that you're giving to it. And all of us on this call have many, many years of experiencing that. And Eugene, if I can just kind of talk about AOA on Capitol Hill a little bit, historically we have gathered leaders in Washington D.C. in April and we shifted that cadence a little bit. And I want to credit the volunteers and the AOA staff who recogn that we can have a little bit more impact if we space that differently. So at the end of September, we have an AOA on Capitol Hill event. And if we had done that in April, I don't think our message would have been heard. There's so much going on since the election and I think September is going to position us a lot better to talk with key staff and with some legislators in particular. And then we're going to do one, two, punch and go there again in March of 2026. So that real close together messaging opportunity is going to be critical for us. And it's not just for the state leaders. Every member can contact your association and say, hey, I want to learn a little bit about this. They will be thrilled, thrilled to hear from you. So if anyone is interested in being a part of that, it's not hard. We won't make you do anything and there's a lot of listening and networking opportunities. I promise you you're going to like it.
- [55:08]
Host/Moderator
Yeah, that's great and thank you. And we'll post some information in the show notes about that, that event and what's coming up thank you all for everything that you do for the profession, but also for spending some time with us on the Power Hour today. I think you guys have done an amazing job kind of summarizing some of the issues and some of the initiatives that are that the AoA is so deeply engaged in currently. So thank you all for spending some time. Jackie, Tommy, John, appreciate you being on the Power Hour.
- [55:37]
Dr. Jackie Bowen
Thank you, Eugene.
- [55:38]
Dr. Tommy Lucas
Bye, Eugene.
- [55:39]
Dr. John Peterson
Thank you.