In the beginning, before currency existed, men traded stuff. One person would trade some vegetables for some meat. Another would trade a service for some eggs or a goat. Everyone bartered services and products. Manhattan got traded for trinkets.

Some individuals had skills that others did not, so they traded those skills for products. These transactions didn’t cover everything, so an alternative trade currency was developed: money.

Fast forward to the 20th century.

How we got here: Vision plans enter eye care

Doctors, with very specific skill sets, traded their expertise for money—although I’ve heard numerous stories of patients bringing in everything from eggs to eclairs to trading lawnmowers. The doctor was paid by the patient and that was that. The transaction ended with a handshake. Enter third-party health insurances in the 1960s and 1970s: Doctors would join their panels and accept a 20% discount off their regular customary fees in exchange for seeing those patients. Sort of like joining a buying group.

That morphed into the “managed-care” model where the managed-care organizations dictated the reimbursements for certain procedures, usually at much larger discounts than 20%. They at times also mandated discounts on eyewear products. Once the patient joined the plan, the plan became the gatekeeper to refer patients to your office. This functioned to attract new patients to your office; something that was once handled by word of mouth, Yellow Pages, or advertising. So there was an expense to drive patients to your office. It was the cost of advertising or the 20% (or more) discount on fees for health plans.

It’s not insurance. It’s a discount plan

Enter third-party discount eyeglass plans in the 1980s and 1990s. They are not insurance companies. They are not health-care companies. They are discounters. They pay you a token service fee—a fee that has stagnated for over 20 years—for a refraction, although they may call it and infer that it is a “comprehensive exam” so eyeglasses or contact lenses can be ordered at a discount. The frame discount they offer is really your private-practice markup. They may also own the lab or even the frame company to keep prices very low, sometimes resulting in customers getting exactly what they pay for.

Because offering employees these no-risk discount plans is drastically cheaper for employers and benefits coordinators than real health plans, they flourished. Even real insurance companies realized that these non-medical discount eyeglass plans could offer cheaper products and services using the same offices as their flagship health plans. So they carved out eye care to the non-insurance discounters, who then became the gatekeepers for patients, now competing with the Walmarts and online vendors.

By offering minimal services, basic products and, in some cases, bypassing professional services altogether, prices and reimbursements were kept very low. So the expense for full-service optometry offices to participate with these discount plans was draconian, as each discount eyeglass plan customer displaced either a full fee-for-service patient or a managed-care plan patient.

Up to this point, we have had various third-party entities getting in between the patient and the doctor acting to “manage” that encounter from both a financial and gatekeeper perspective. Now we also have entities getting between the office itself and the doctor to “manage” the doctor. It may be a management group or private equity. It may be a third party supplying professional services to an office. It may be a corporation overseeing many offices or stores and many doctors. So now there is financial pressure on both the doctor and performance side; and the patient, customer and payer side, where previously there was none.

Third parties took the ‘care’ out of eye care

What we end up with is offices and stores having 10 to 15 patients or more per hour on the doctor’s side and aggressive opticals to make up the slack that the vision plans will not cover. We have burned out ODs and opticals, with neither the doctor nor the patient having an enjoyable experience. The ODs are becoming mercenaries, going into battle every day with rapid-encounter patients to generate optical sales. It’s no wonder that so many ODs are contract employees in futureless positions. No wonder that, for new grads, working in optometry is just a matter of signing on for the best deal until the next best deal comes along. Or they burn out and go into a different line of work entirely.

How many patients even remember their optometrist’s name? I believe this model is incompatible with the classic private-practice experience that many legacy patients so fondly remember.

Concierge care is a return to a better model

Enter concierge care: no more insurance companies or discount eyeglass plans. Just the private-practice model doctor and the patient interacting directly, and the transaction ending with a handshake and a smile. A couple patients per hour. ODs enjoying optometry and making a good living. Patients and their families enjoying their experiences with their optometrists and bonding for what will probably be their lifetimes.

There’s also modified concierge care. This, like modified monovision, taking the best attributes from each mode of practice. Still a couple of patients per hour, but with shorter, medical-care appointments interspersed to keep full scope of practice options available for everyone, payable by real insurance companies or Medicare.

The bottom line is to know what you’re worth. Years ago, I jokingly told my staff to move all of my discount-eyeglass-plan patients to one week, then cancel them all because I was going on vacation that week. That was a better use of my time. We have since dropped all of those plans except one.

Thank you to Dr. Kanevsky for her post. We should all know where we stand in our industry and our options. No one knows where private practice is going, but many of the other vision-care delivery models are benefiting corporate owners at the expense of employed ODs, which is why successful, established private practices are in such high demand today. Those owners may have to run a business in addition to their optometrist duties, but in the end, they reap all of the benefits of all of the revenue streams themselves.