Choosing the right eye care provider – National Consumers League

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Choosing an eye care provider can be confusing! Optometrists, optometrists, opthalmalogists. It is important to understand the differences in education, training, credentials, and experience levels that distinguish one type of eye care provider from another – and what kind of services each specializes in.

Keep this in mind when selecting an eye care provider:

  • Know what your needs are when going to an eye care provider. If you don’t know what you need to have done, ask your primary care doctor.
  • Look for diplomas, licenses, and other qualifications and certifications displayed publicly at the office.
  • Ask the provider is he/she has sufficient training and experience to perform the procedure you need, especially when the procedure is more invasive than a regular office visit.
  • If your eye care needs include surgery or treatment with medications, ask your provider if he or she is trained and licensed to perform these services.  Ask how many times he or she has performed the service, and what kind of side effects and recovery time you can expect.
  • If you do not have access to or are unsure about the eye care provider you need, ask your primary care doctor for a recommendation to properly address your needs. 

What to ask yourself as you consider which eye care provider is right for you

What services do I need my eye-care provider to perform?

You should distinguish between the need for primary care (fitting of glasses and lenses), and more advanced care (serious conditions and diseases, surgery).

State laws and regulations specify what services an eye care provider is permitted to provide. While ophthalmologists, as medical doctors, can perform eye treatments including surgeries and prescribe medications, state laws and regulations vary for optometrists, who are not medical doctors. You should be aware of which services optometrists are authorized to provide in your state, and whether an optometrist is able to provide all aspects of treatment that is needed.

Visit the Association of Regulatory Boards of Optometry for a link to state optometry boards and information on the services an optometrist can provide in your state:

What credentials and qualifications does my eye care provider have?

Check to see whether diplomas, licenses and training credentials are posted clearly in office/waiting room. If this information is not posted, ask the practitioner if he or she is an optometrist (attended optometry school) or an ophthalmologist (attended medical school).

Terms used for eye care professionals can be confusing. For example, some optometrists refer to themselves and other optometrists as “optometric physicians.” Traditionally, only medical doctors or MDs are referred to as physicians. While optometrists offer valuable services, they are not medical doctors, and you should be aware of the difference in training and education.

Does my eye care provider have sufficient training and experience to provide the care I need?

While each member of the eye health care team is a professional with extensive training, you should know whether a provider has adequate training for and experience with the specific procedure or care that you need.

Questions to pose to an eye care provider might include: Is he/she on call if I have a problem at night or on the weekends? If not, who is available to deal with potential problems you might develop? Can he/she provide treatment in a hospital should that be required?

Does my eye care provider have sufficient training and experience performing surgery or prescribing medications?

Ask providers about their surgical training and the number of similar surgeries they have performed before making decisions regarding surgery.  Some questions you should ask include:  Where did they learn the procedure? How many times have they performed the procedure? What is the complication rate (the chance that a problem may occur) for the procedure?  What are the odds of success/failure?

Treatment of eye conditions and diseases often involves using prescription medication. The more prescriptions you receive, the greater your risk of drug interactions. Before prescribing, providers should ask you about other medications you are taking and any other medical conditions you may have. You should keep a personal medication list that includes all prescription medications, over-the-counter drugs (such as aspirin), vitamins and herbal supplements you are taking. Check this list with your provider to make sure there are no complications.

Do I have easy access to the eye care provider I need?

When considering access issues, you need to make sure that, in striving for convenience, you do not sacrifice quality. If you are seeking primary eye care, such as a vision check for glasses or contacts, the nearby optometrists could satisfy your patient care needs. If you are seeking advanced care, such as treatment for serious conditions and diseases, the extra time to access an ophthalmologist is likely worth the assurance of seeing a trained medical doctor.

Do I know how to report problems with my eye care provider to the proper regulatory authorities?

For optometrists, visit the Association of Regulatory Boards of Optometry.

For ophthalmologists, visit the Federation of State Medical Boards.

 

Eye care 101 – National Consumers League

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Consumers have many choices of eye care providers: opticians, optometrists, and ophthalmologists. How do you know which kind of provider is right for your needs?

Eye care providers serve a broad range of patient needs, from fitting eyeglasses to performing invasive surgery, and all have different levels of education and training. Depending on the services you need, one type of provider may be more appropriate than another. In addition to the usual considerations of convenience, cost and established relationship, you should make a point to learn about the credentials, education, training, and experience of all eye care providers.

Meet the members of your eye care team

Here is a listing of the various members of the eye care provider team, what they do and their credentials. Opticians provide the most limited amount of service while ophthalmologists provide all services within the eye care continuum.

Opticians fit eyeglasses and contact lenses, following prescriptions written by optometrists or ophthalmologists. They measure patients’ eyes, recommend eyeglass frames and lenses based on the patient’s needs and can reshape eyeglass frames to fit properly.  When licensed to do so, opticians also can fit contact lenses.

Credentials:

  • They are licensed (required in twenty-one states) after they have earned either an associate opticianry degree (one- to two-year program), or after they have apprenticed for at least two years.
  • They must pass a licensing examination and some apply to the American Board of Opticianry for certification.  Certification is awarded after passing an exam, and must be renewed every three years.
  • In some states, opticians must pass the National Contact Lens Examination to dispense contact lenses.

Optometrists provide routine, primary vision care.They examine eyes to detect vision problems such as nearsightedness, farsightedness and astigmatism, and diagnose eye diseases such as glaucoma. They also test patients’ depth and color perception, as well as their ability to focus and coordinate eye function.  Opticians prescribe eyeglasses and contact lenses, and in some states administer and prescribe medications to help diagnose vision problems and treat certain eye disease.

Credentials:

  • All states require optometrists to be licensed.
  • Optometrists must have a Doctor of Optometry degree that requires a minimum of three years of undergraduate studies at a college or university, followed by four years at an accredited optometry school.
  • They must pass both a written and clinical state optometric board exam in order to receive a license, required by all states.
  • They are regulated at the state level, and must report to a state board of optometry for their license renewal (usually every three years). 

Ophthalmologists are medical doctors who specialize in all aspects of eye health. They provide primary eye care services including eye exams and prescribe medications and perform surgical procedures, such as laser surgery and lens replacement. Using both surgical and non-invasive techniques, ophthalmologists diagnose and manage eye diseases, conditions, and disorders, and treat and repair eye injuries.

Credentials:

  • All states require ophthalmologists to be licensed.
  • Ophthalmologists must have a college degree (or minimum of three years of college), four years of medical school, a one-year internship, and at least three years of an ophthalmology residency (hospital-based training). They must then pass a licensing examination.
  • As medical doctors, ophthalmologists are regulated by state medical boards

Speak the language of your drug coverage plan – National Consumers League

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If you’re facing the opportunity to choose a new drug coverage plan for you and your family, you need to speak the language in order to weigh the costs and benefits.

Brand name (drug): A one-of-a-kind drug that is still protected by a patent.

Co-pay (or co-payment): A fixed amount, for example $10, that an insured individual pays for health services, regardless of the actual cost of that service.

Co-insurance: A percentage of the cost of a health service, usually 20%, paid by the insured individual.

Deductible: An amount an insured individual must pay for health services before their insurance plan begins to pay any benefits. For example, the individual may be required to pay the first $500 before the insurance company will pay for subsequent services.

Formulary:A list established by a health plan or PBM to indicate which drugs they cover or which tier drugs are in.

Generic drug: A drug that is no longer patent protected, so that many companies can copy and manufacture the drug with the same active ingredient as the original inventor.

Mail Order: Prescriptions that are received in the mail.

Out-of-Pocket Maximum: An upper limit on how much an individual or family must pay in a year for health services. Once the limit is reached, co-insurance and sometimes co-payments do not have to be paid.

OTC Drugs: Over-the-counter (OTC) drugs can be purchased without a prescription and are generally not covered by insurance.

Pharmacy Benefit Manager (PBM): A company that administers a pharmacy benefit plan. They aren’t insurance companies; but are often subcontracted by health insurers or employers to manage the prescription drug portion of the health plan.

Prior authorization:A requirement that a physician obtains approval from the health plan or PBM in order to get the medicine covered.

Step therapy: A requirement of the health plan or PBM to try a less expensive drug first. If that drug fails to work on the patient, the health plan or PBM will then approve the use of a more expensive drug.

Therapeutic substitution: The process of switching an existing prescription to one that is less expensive and chemically different, but has the same expected clinical effect.

Tiered co-pay (co-payments): A co-payment that is determined by which tier the drug is assigned to by the health plan or PBM. There may be a few tiers, each with a different co-payment amount. This design is intended to encourage the use of drugs that are in the less expensive tiers.

Questions for choosing an Rx drug plan – National Consumers League

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Before you decide on a prescription drug benefit plan, get the facts you need.

1. Will I be able to get the medicine that my doctor and I think is best for me?

Find out if the health plan or PBM has a limited list of medicines it will cover (known as a formulary). If someone in your family takes medication for a chronic illness, such as high blood pressure, asthma, or high cholesterol, make sure that medicine is on the formulary before you select that plan. If it isn’t, and you choose that plan, you will be expected to switch to a different medication or pay for it out-of-pocket. This is a discussion you should have with your doctor — to make sure you are taking the drug that is best for you.

Find out if the health plan has to pre-approve certain medicines before you can fill the prescription. Many plans require your doctor to get “prior authorization” of high cost medications before you can get coverage for them. That means your doctor or pharmacist must call the health plan or PBM for permission to give you a prescription for these medications. Some plans also require you to try a less expensive medicine first — before they will cover the one your doctor recommends. Check with your plan to understand their authorization process and restrictions to avoid a surprise when you get to the pharmacy. And be sure to learn how to appeal these requirements and decisions if you feel it is important.

Find out how often your health plan or PBM changes its formulary. Be aware that, in most states, even though your medications may be covered at the time you choose your health plan, the health plan or PBM may change its list of approved medicines at any time throughout the year. If they choose to take your medication off the formulary, you will be expected to pay out-of-pocket or switch to a medication the health plan prefers. Check to see what sort of notification you will get so you can discuss changes with your doctor.

2. How much will I have to pay for my prescriptions?

Find out about the co-payments. Most plans require you to pay a co-payment for each prescription. Some plans have just one co-pay amount, for example $10.00, for any prescription. But many plans have different levels of co-payments (known as tiered co-pays) for different medicines. If the plan you are considering has tiers, you should find out what medicines are in each tier and what the co-pay amount is for each. Note that the health plans and PBMs can move your medication from one tier to another at any time. If the amount you will have to pay is more than you can afford because your medication is in the highest tier, you may want to ask your doctor if there are other drugs on a lower tier that is appropriate for you. Also ask about how you will be notified if your plan makes tier changes.

Find out if there is a limit on how much you have to pay each year. Many health plans try to protect individuals from catastrophic costs by having “out-of-pocket limits.” You don’t have to pay co-insurance on medical services once you reach that limit. But prescription medications are often not included in the protection. So you may still have to pay your co-payments for medicines even after you reach the out-of-pocket limit.

Find out if the health plan offers or requires you to get your medicines through a mail order service. Some plans offer a mail order service for medicines and offer incentives like lower co-payments to encourage you to use it. Other plans have mandatory mail order services and require you to order your long-term medications through the mail. The plan will not pay for them if you get them at a local pharmacy.

3. Does the health plan allow me to appeal for coverage of prescriptions they have denied?

Find out about any exceptions or appeal processes offered by the health plan or PBM. If you really need a medication because of a valid medical reason, you can often get it covered. But you must go through whatever exception or appeal process the plan may have, and they have to agree that you really need the medication you want, based on information your doctor will be expected to provide. If you can’t wait for the process to finish, you may need to pay for the drug yourself and then file an appeal to be reimbursed by the plan later.

You should be aware that you will not be notified of your right to appeal when you are denied coverage because your medication isn’t on the formulary. So you must become familiar with how to file an appeal on your own initiative.

You should also know that most plans do not allow you to appeal for a lower co-pay level, even if the only medication that works for you is in the most expensive tier.

Get the answers!

The following resources can help you get answers to these questions:

  • Materials that the health plans or PBMs give you
  • The Web site for the health plan or PBM (look for general benefit information and plan requirements, as well as information on their current formulary)
  • A sales representative from the plan (they are often available at your worksite during the time of year when you must make decisions about your plan for the coming year)
  • The benefits department in your employer’s human resources division
  • The state Department of Insurance or, if your state has one, the Managed Care Ombudsman

Choosing a prescription drug coverage plan – National Consumers League

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When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing that your doctor is in the network.

Most health plans cover prescription medicines, but the rules may be different than those for other medical services. In addition, pharmacy benefits may not be administered by the same company as the physician and hospital benefits, but rather by a separate company, called a PBM.

Before you decide on a prescription drug benefit plan, get the facts you need:

Find out if the health plan or PBM has a limited list of drugs it will cover. This is known as a formulary. If someone in your family takes medications for a chronic illness, such as high blood pressure, asthma, or diabetes, be sure those medicines are on the formulary before you select that plan. If they aren’t, you will be expected to switch to different medications or pay for them without insurance.

Find out how to file an appeal if the medicine you need is not covered by your insurance. If the medicine you need is not on the formulary, you usually can file an appeal with the health plan to request that they cover it anyway. You will not be notified of your right to appeal when you are denied coverage, so it is important to find how to file an appeal on your own. Your doctor will need to provide the information to explain why you need that specific medicine.

Find out how much you have to pay when you fill a prescription. Most plans require a co-payment for each prescription. Many plans have three or even four levels, or tiers, of co-payments that apply to different medicines. Find out what co-payment level applies to the medications you are taking. If it is more than you can afford, you may want to ask your doctor if there are other medicines on a lower tier that would be appropriate for you.

Find out if the health plan has to pre-approve certain drugs before you can fill the prescription. Many plans require your doctor to have “prior authorization” for some medicines before it will pay for them. That means your physician or pharmacist must call for permission to prescribe these medications. Some plans also require you to try a less expensive medicine before it will pay for the one your doctor might otherwise recommend. If you need a certain medication for a valid medical reason, you can often get it covered by filing an appeal. If you can’t wait for the appeal process to finish, you may need to pay for the medicine yourself and then file an appeal to be reimbursed by the plan.

Find out if the health plan offers a mail order option. Some plans offer a mail order service for medicines and offer incentives like lower co-payments to encourage you to use it. Other plans have mandatory mail order services and require you to order your long-term medications through the mail. The plan will not pay for them if you try to obtain them at a local pharmacy.

When choosing a health plan, making sure the medicines you take regularly are covered is just as important as knowing that your doctor is in the network. Knowing how to select the right prescription drug coverage for you and your family is important to maintaining and restoring your health.

While most insurance includes coverage for prescription medicines, the rules for pharmacy benefits are often different than for medical. For example, your prescription claims may be handled by a pharmacy benefit manager, or PBM (a company that administers a health plan or employer’s drug benefits).

Asking the right questions is key to getting the most appropriate medicines for you and your family and in limiting your costs. When making decisions, always look at the potential impact of your health plan choice on the medicines that members of your family are currently taking for a serious condition or chronic illness.

Before you decide on a prescription drug benefit plan, get the facts you need.

Health IT: growing interests and concerns – National Consumers League

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Many assume that the health care system in the United States is the best in the world — at least for those who are able to access it. The reality for many people is that our system often fails to deliver quality care, misses many people who need care the most, and suffers from significant inefficiencies that lead to high costs. Even according to conservative estimates, hospital errors are the nation’s eighth leading cause of death — ahead of breast cancer, AIDS and motor vehicle accidents combined.

Preventable medical errors include a wide variety of examples: misidentification of patients; misreading of tests; medication errors, equipment failures; and hospital-acquired infections. Researchers have estimated that your chance of getting the right care at the right time is only slightly more than 50 percent — and it’s worse for women and minorities!

Unfortunately, low-quality health care means high-priced consequences. The combination of overuse, misuse, and underuse accounts for up to 30 percent of our national health care expenditures. Improving the quality of care would make Americans healthier and help us address the skyrocketing costs. With that goal in mind, many policy makers, businesses, health care providers, and provider institutions (such as hospitals) are looking to health information technology (HIT) as a way to improve health care quality.

HIT represents a transition from paper-based to computer-based transactions for health care services. For patients, it can mean that doctors use computers to keep track of patient health information, rather than traditional paper charts. These electronic medical records can help health care providers stay organized and make better clinical decisions. Much of the real value to patients and providers is seen only when multiple providers (and ideally the patient) are able to share medical information electronically whenever and wherever it is needed. This concept is often referred to as health information exchange, or HIE.

Appropriately implemented, HIE has the potential to provide consumers with information to make better decisions about their own health care and the care of their loved ones. An electronic health record that could be accessed by authorized parties would mean that health care providers would be able to access the information they need (medications, lab results, allergies) to make better health care decisions.

While all of this is possible, there are potential risks. Understandably, many consumers are afraid that broader sharing of their personal health information will only make it more vulnerable to unwanted and unintended exposure, which could have significant life-long consequences for their personal, social, and financial wellbeing. While NCL is very supportive of moving forward with health information technology and exchange systems, these initiatives will only succeed if all consumers can be confident that their personal health information is being handled in a secure, appropriate, and confidential manner.

NCL is part of a growing consumer coalition dedicated to seeing that these and other essential conditions are built in to systems emerging across the country. This is a critical time for consumer involvement, as efforts to promote nationwide adoption of health information technology are proceeding rapidly. There is a significant need for strong consumer voices at all levels of this effort — voices that strongly support the promise of health information technology to improve our healthcare system, but that will work to ensure adequate consumer protections. 

 

Trends in medicine: What is evidence-based medicine? – National Consumers League

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Doctors and health care professionals are attempting to help patients make sense of the overload of health information by gathering, evaluating, and sharing well–tested, proven medical research. This process of bringing the best available evidence from scientific research to patient care is known as evidence-based medicine (EBM).

The emphasis with EBM is on applying research to medical care: when there is evidence that a treatment works and benefits the patient, it is practiced; where there is evidence that a treatment has not benefited the patient, is ineffective, or harmful, it is not practiced; and where there is not enough evidence, healthcare professionals should proceed carefully.

Many patients are educating themselves about their health, self-diagnosing, and pursuing care on their own.

Some patients are using health information to self-diagnose their conditions and asking doctors to prescribe treatments based on their own research, others are confused by the overload of health information.  To improve health outcomes, doctors and patients should share the responsibility for making health care decisions.

  • Patients are bringing in articles and ads and self-diagnosing specific conditions. This presents an opportunity for doctors and patients to discuss the patient’s actual situation and make appropriate decisions based on shared information.
    • Pharmaceutical ads are a major source of tension because they tell patients to ask the doctor for certain prescriptions by name without knowing if it’s appropriate. Doctors should take the time to explain to patients why the drug is or is not appropriate for them and then discuss other treatment options as well.
  • Doctors can start the dialogue to help patients sort out their questions and concerns.
  • Learning about medical treatments from friends, family and co-workers is a significant source of information that is credible to patients.
  • Often times, patients feel they know what is wrong before seeing a doctor and the challenge is communicating this knowledge to the doctor.
  • Doctors who disagree with their patients’ diagnosis or do not provide them with the desired treatment are often criticized. Shared decision making helps avoid disagreements and leads to successful patient outcomes.

All of the health information now available to consumers is changing the patient/doctor relationship.

Patients’ increased access to medical information is changing the relationship between patient and health care professional.

  • Patients have access to more medical information than ever before through magazine articles, advertisements and online searches, and health care professionals can play a critical role in helping patients differentiate the good from the bad.
  • More patients are taking more responsibility for their own care and want doctors to be partners, not bosses, in this relationship.
  • As America becomes more diverse, we need to pay special attention to cultural, linguistic, and economic barriers that may inhibit consumers from getting the information they need to make appropriate health care decisions.

To help doctors and patients make treatment decisions, it is necessary to sort through health information and find the best medical treatment based on what has been proven to work and is effective

Many doctors and other health care professionals are attempting to help patients make sense of the overload of health information by gathering, evaluating, and sharing well-tested, proven, medical research.  With this research, the health care professional and patient make treatment decisions together based on what works and is effective.

  • Health care systems are working towards a decision-making process incorporating medical research evaluation along with good stewardship – if there is evidence a treatment works and benefits the patient, it is practiced; if there is evidence a treatment has no benefit or may harm the patient, it is not done.  In cases where there is insufficient evidence about a treatment or if evidence doesn’t exist, a consensus is developed among health care professionals and they proceed carefully.  It is a shared decision-making process between patient and doctor.
  • Your doctor uses clinical judgment, incorporating the best research, his/her knowledge and experience, to present you with treatment options.
  • Making decisions based on what has been proven to work helps ensure that you and your health professional choose the most effective and beneficial treatment for you.  Understanding what works most effectively helps spend your health care resources wisely and benefits everyone.

Ask your doctor or other health care professional about how you can decide together what is the best medical treatment for you.

Patients and doctors need to engage in a dialogue about making the best medical treatment decisions.

  • Health care providers are working at bringing together the best available information about health care practices to create and implement programs that help people live healthier lives.
  • Health care providers have created specific care management programs for many diseases, including diabetes, asthma, congestive heart failure, coronary artery disease and depression.
    • Health care professionals stay up-to-date by using a computer system of well-tested medical research that can be used right in your doctor’s office.

Additional Resources about Evidence Based Medicine

To learn more about making health care decisions based on the best medical evidence, check the following resources for quality health information:

Cochrane Consumer Network.  This Web site is part of the Cochrane Collaboration, an international organization that aims to review all healthcare evidence and publishes the reviews electronically. The consumer network website summarizes the reviews for consumers.

MEDLINEplus at www.medlineplus.gov has extensive health information for consumers from the National Library of Medicine and the National Institutes of Health.

The National Committee for Quality Assurance (NCQA) consumer Web site at www.healthchoices.org explains how to choose a health plan based on quality. Includes a Health Plan Report Card.

Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) website at www.jcaho.org has information on the quality of care at your local health care facility.  JCAHO evaluates the quality and safety of care for health care organizations.

Kaiser Permanente’s Care Management Institute, www.kpcmi.org, establishes care management programs for patients based on the best available evidence.

To learn more about evidence-based health care and how healthcare professionals are making treatment decisions, Check out the online course developed by CUE (Consumers United for Evidence Based Health Care) on Understanding Evidence Based Healthcare: A Foundation for Action.

About this Web page

These messages were developed by the NCL, in partnership with Kaiser Permanente, to educate consumers about the concept of Evidence-Based Medicine. For more information, contact NCL’s health policy team.