As health care costs continue to rise and employers can't continue to afford to provide health care and ancillary benefits, it increases the possibility that fewer employees will have the opportunity to obtain vision care insurance. This creates a vicious cycle, as the eyes are the gateway to the body.

Since the eye has a direct connection to the brain and is made up of muscles, nerves and blood vessels, "a disease that compromises these systems in any part of the body can affect those components of the visual system as well," according to a UnitedHealthcare white paper.

Therefore, a routine eye exam even for healthy patients can catch diabetes before it becomes widespread, also glaucoma, hypertension and hypertensive retinopathy, among other diseases [see chart p. 36].


The impact on millions

Most small employers do not offer vision care insurance. According to LIMRA, of the 98% of U.S. businesses that have less than 100 employees, just 21% provide vision insurance as an employee benefit.

It's an issue that affects millions, with possibly millions more who do have coverage going untreated. According to the American Academy of Ophthalmology, cataracts affect more than 24.4 million adults age 40 and older, with more than half of all Americans having one by age 80.

As for diabetes, the Centers for Disease Control and Prevention say that 26 million Americans have the disease, with 27% of those - 7 million people - not realizing they have diabetes. According to VSP Vision Care, diabetes can sometimes be seen in the eye as early as seven years before a patient becomesymptomatic.

With an early identification of the disease, the person can move on to a proper diet and lifestyle changes, and get treatment before it becomes more expensive. Further, the longer one has diabetes, the more likely they are to develop diabetic retinopathy. These are all diseases visions exams are likely to catch early.


ACA changes ahead

Meanwhile, the Affordable Care Act may be detrimental to adults due to the fact that vision care for them was not explicitly covered by the health reform legislation. This means paying out of pocket for these exams or for insurance, says Dr. Gene Sherman, senior vice president of business development and professional relations at AlwaysCare Benefits in Baton Rouge, La.

"It will lead to a delay in diagnosis of systemic diseases. ... That becomes a burden on the health care system because the more advanced they get the more expensive it is to treat them. ... When it's discretionary spending, you try to put it off," he says.

It is incumbent on all health care providers to educate the population, and with the ACA some of that responsibility also falls on the exchanges, Sherman says. A trade group did a statistical analysis on some of the carriers and found that people are much more likely to have an annual eye exam when they have a standalone vision plan that when it is embedded on a medical plan, he says. "That signals a shortcoming of the ACA because Congress and regulators have made it so only standalone vision plans can't provide benefits within the exchange. ... As a result, I think that there will be less utilization of the exam."

The Vision Council of America estimates that just less than half of the population in the United States has an eye exam annually.

While there is no question that the Affordable Care Act will help pediatric patients get preventive eye exams, as it is now covered as part of the ACA's Essential Health Benefits, the impact on adults is still not clear, some say. Many in the industry believe there will be less people purchasing the coverage, and as a result less annual eye exams. The thinking is as more employers give employees a sum of money to spend as they see fit on medical, dental, vision, long-term and short-term disability, travel assistance, vacation and everything else, vision may be left behind, says Tim Falanga, executive vice president of Managing Agency Group, a division of AmWINS Group Benefits, in Shelton, Conn.

"From the carrier side, every time you have an employee making a choice to participate in the plan or not you are faced with adverse selection," he explains. "A person who has [perfect] vision is not interested in spending money on vision care. They say, 'I don't need it, I'm not going to take it.'"

It is also bad for the carriers, Falanga says, as it is difficult to make a profit when everybody who buys your plan is going to use it. When you are on the employee-pay-all side, you will find more restrictive contracts because carriers need to remain profitable," he says.

But Susan Egbert, director of eye health strategies at VSP Vision Care in Rancho Cordova, Calif., says that there are still many decisions to be made about vision care in regard to health reform, especially on the exchanges mandated under the law.

"We are committed to help exchanges find simple solutions so everyone can get eye care they need inside or outside the exchanges," she says. "We know it will continue to be an important benefit and I think that as more health plans and people understand how eye care can save on overall health care cost, it will be viewed as more important."

It's too early to tell if people will gain or lose coverage under the ACA, she concludes.

Dr. Linda Chous, chief eye care officer at UnitedHealthcare Vision, agrees. It is difficult to say with any certainty the overall impact of the ACA on vision, she says. "But we do believe that the inclusion of pediatric vision in the essential benefits coverage will draw attention to the importance of eye health and its relationship to overall health and wellbeing for both children and adults."



The case for vision care insurance is made in the numbers, says AlwaysCare Benefits' Sherman. "When you think about it, for just 36 cents on average per day someone can cover themselves for exam and vision correction," he says. "That is really not a lot of money in the scheme of things, the cost of a vision plan per family is probably less than one eye exam out of pocket. ... We've seen eye exams anywhere from $50 up to $180-$200, depending on the type of practitioner and the geographic location," he adds.

Vision is relatively low cost but highly valued and utilized by employees, according to Griff Bailey, second vice president of dental for The Standard in Portland, Ore. "It is a benefit that businesses and employees both cite as wanting to see as part of their own employee benefits package," he says. "Vision, along with dental insurance, provides brokers with an opportunity to help their clients expand their offerings beyond health insurance."


Broker's role

A broker plays a role in making sure employees get eye exams, and in the long-term that keeps overall medical plan costs down.

"Brokers will continue to play a critical role in helping clients manage their health coverage, including vision care. Specially, brokers will play an important role in reviewing the vision needs of their customers, both for embedded features in medical coverage and what wrap-around vision coverage options should be considered," says UnitedHealthcare Vision's Chous. "During those evaluations, brokers should pay particular attention to product design and network access. "Brokers also need to recognize that the plan designs for children could be substantially different than the plan design for adults," she adds. "If clients do not have a vision plan, brokers can educate them on the benefits of vision coverage, which in most cases can be offered on a fully voluntary basis and no additional cost to the employer."

According to Bailey, many times that is being done through bundling - often with dental - which simplifies the buying process and administration for employers and brokers alike. "Linking the products together provides a win-win. Employers who were previously unable to offer vision benefits may have vision within their reach due to the lower combined cost and easier administration of more benefits," he says. "This also elevates the status of the employer in recruiting and retaining talent, as they can offer a more robust benefits package to their workforce.

"Plus it's a win for employees because they get access to these two distinct, but important, benefits that are instrumental in the overall health of them and their families," he adds.

Brokers can also help their clients by helping with account administrative burdens, Bailey says. "Many businesses that are considering adding vision benefits are smaller," he explains. "They may not have the resources to manage an array of benefits, so providing streamlined administration with other popular benefits, like dental insurance, can make it convenient for employees to add to these important benefits."





With the eyes being the gateway to the body, many diseases can be detected through routine eye exams. According to UnitedHealthcare's "Integrating eye care with disease management" white paper, below are some of the diseases that can be detected.

They are classified by the ability of the detection by an eye care provider:

Early - the first to diagnose or identity early signs of the disease

Advanced - can diagnose, but usually when disease is advanced

Late - the provider is primarily involved in monitoring of the condition.

Also included is the average annual medical and biological pharmaceutical claims data for 2011, excluding pharmacy costs, from UnitedHealthcare data.

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