Blind results: Will health care reform exclude the efficient providers?

Jesse Mermell is state director for the Massachusetts Association for the Blind and Visually Impaired, the oldest social service organization in the country that serves adults and elders who are blind or visually impaired.  But she is nervous about what might be an unintended consequence of health care reform.  She explained this to me recently.  Here’s a description of what her non-profit agency does.

“We are an extremely small direct service provider that works with individuals (mostly seniors) who are losing their vision and need to learn adaptive techniques to stay healthy and independent. Our services are provided by occupational therapists and optometrists who specialize in low vison, and are covered by virtually every insurance provider, including Medicare and Medicaid.”

A patient is referred to MAB when an eye doctor notes that the patient’s vision has deteriorated to the point that medical treatment is unable to reverse the damage.  At that point, the patient needs life counseling on how to adapt to forthcoming full or partial blindness, as well as certain skill training in mobility and accommodation to the new stage in his or her life.  Trained specialists can help make a home safer and recommend simple devices to make life with low vision easier.  The association is able to provide OT services to these patients at a very low cost.  This kind of supportive program makes it more likely that people are able to maintain healthy life styles.  For example, they learn how to continue to take required medications.  They also learn how to move about safely and avoid falls.

The Association offers part of its services in low vision clinics.  Low vision exams are different from your usual eye exam in that they are highly specialized and include eye charts and tools specifically developed to assess an individual’s remaining vision, and to determine if the client can benefit from optical devices.  They are held on a regular basis in regional locations.  For example, the Low Vision Clinic in Worcester runs weekly low vision clinics on Wednesdays.  MAB also offers an array of other services to help those with low vision, and so the assessment does not end in the clinic, but is taken into the home to help with activities of daily living.

For example, the Association might conduct a home safety assessment; evaluate lighting and eliminate glare; teach adaptive reading, writing and record-keeping techniques; reduce clutter and modify appliances with tape and markings; provide information about vision loss and community resources; help with healthcare routines and medication management; recommend adaptive aids and magnification devices.  And because many clients have diabetes, there is also a focus on offering strategies for adaptive diabetes management.

As Jesse notes, “What we do is 100% in line with the goals of payment reform: offering low-cost, preventive services that ultimately keep seniors out of expensive long-term care facilities.  We do this in partnership with respected community and medical groups to create high impact, cost effective services.”

But she is concerned.  “We are struggling to figure out how we survive in the fast-approaching global payment system. We are so small, that – hard as we try - we aren’t on anyone’s radar screen. We are desperately trying to connect to an ACO (accountable care organization) or even some sort of demonstration project, but with no luck. If we don’t find a place for ourselves in the new model, our referral sources will dry up and we will be forced to reexamine our whole operation, potentially severely limiting our services.” 

It occurred to me that the same concerns might exist for other small service providers who focus on particular segments of the population.

Why the concern?  Well, under capitated, or global, payment regimes, there is a strong incentive for medical provider groups (hospitals and doctors) to set up limited networks of service providers for their patients.  While, those networks could theoretically include organizations like MAB, the institutional framework for making clinical referrals will become more constrained and difficult.  We can envision that clients currently served by MAB would no longer get referrals to the Association, missing out on life-changing adaptations and support that currently keep them out of high-priced hospitals and nursing homes.

As the state Legislature considers changes to the law that will make this unintended result more likely, shouldn’t  they be considering steps that will help preserve these important services?