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Roxann Mayros headshotBy Roxann Mayros, President & CEO, VisionServe Alliance

In my blog posted on May 21st, I provided background information to help explain why professional services provided to people with vision loss by vision rehabilitation therapists, orientation and mobility specialists, and low vision therapists are not reimbursed by Medicare or medical insurance (third-party payers).  Even though the effort to see these professionals reimbursed began in 1990, and there was a five-year Demonstration Project to prove the efficacy of these professionals, they still do not qualify for reimbursement in 2018. We learned many lessons during the very expensive and decades long effort.  We hope that the following “lessons learned” will guide future endeavors to see this very important category of nationally certified professionals recognized and reimbursed by third-party payers.

  • University degree programs must move. Medicare is a medical model – it does not recognize, nor does it reimburse professionals with special education degrees.  University programs providing degrees in vision rehabilitation therapies with a focus on adults, must be housed in the Department of Allied Health Professions and provide degrees in Orientation & Mobility, or Vision Rehabilitation Therapy, or Low Vision Therapy, and not special education.
  • The current system for referrals must change. Most referrals currently come from State Agencies for the Blind, and they are not reimbursable by third-party payers.  Referrals from Ophthalmologists, Optometrists, or other medical doctors are reimbursable.  Medicare and other third-party payers require that the patient be under the care of a physician while therapies are being administered.  The physician must certify the patient’s need for services, and sign-off on the plan of care and follow-up that includes evidence-based outcomes that include written progress notes and a summary.
  • Ophthalmologists, Optometrists, and even Occupational Therapists, must “buy-in” and be supportive. Legislators know the organizations representing these medical professions and they will ask if they are in support.  During the early days of our campaign, we did not seek their involvement or understanding, so they literally advocated against reimbursement for vision rehabilitation professionals.  In the last campaign before the Medicare Demonstration Project, we were far more inclusive, asking for advice, bringing representatives on visits with us to legislative offices, and more.  It wasn’t easy – it took a lot of convincing that there would be a benefit to their professions before they came out in support.
  • Medicare recognizes State licensing which they believe assures “quality” of the service providers (medicarenow.org). It took a lot of lobbying and negotiating with the Centers for Medicare and Medicaid (CMS) – and it will again – to recognize ACVREP certification during the Demonstration Project. We are still the only profession that has ever received reimbursement based on national certification instead of State licensing.
  • The legislative process is long, expensive, and arduous. It will take several attempts and several years to find a champion/s to support the bill, bi-partisan support, a good lobbyist to shepherd and advise, traversing the review and hearings process by appropriate (sub)committees of both the House and Senate, and to bring enough advocates together to make an impact.  And you better hope that your champion is re-elected, or you will start all over from the beginning.
  • Cost savings must be proven, so studies are necessary. Experts sanctioned by Congress must be hired to study the impact and cost of reimbursing vision rehabilitation professionals, and to produce recommendations and/or administrative actions to legislative (sub)committees.  These studies have been impacted in the past by the lack of data and evidence-based outcomes in relation to vision rehabilitation.
  • Lobbyists are a necessity. No lay-man, grass-roots advocate, or vision rehabilitation professional has the necessary connections at the Federal level, nor the knowledge required, to “get meetings with the right people,” or to initiate and move a Bill through Congress.  Lobbyists know the system, and they know how to make it work.  They know how to write appropriate language for a Bill, how to get it filed and numbered, who in Congress works with whom, how committees work, and more.  Even though expensive, they are an absolute necessity!
  • It requires “boots on the ground.” Getting a bill passed cannot be done by writing letters, leaving messages, or visiting a legislator once.  It has to be done in person in legislators’ offices in Washington, D.C.  Advocacy must be done frequently, with urgency, and by more than a small cadre of devotees.
  • It takes a dedicated and full-time staff. As explained above, it is necessary and time consuming to find enough money for studies and lobbyists, getting the right people on the bus, using a data base to track progress or next steps, organizing on-site advocacy days/meetings, seeking support from allied health professionals, meeting with legislators and their aids, organizing policy forums and Congressional updates, producing written materials, understanding the legislative process, writing press releases or journal articles, attending (hundreds if not thousands) of meetings, and shepherding a bill through Congress.  None of this can be accomplished without one or more full-time staff positions.

The bottom line is that it is morally and professionally “right” to reimburse Master degreed and nationally certified Vision Rehabilitation Therapists who teach people how to live independently, Orientation and Mobility Specialists who teach travel skills using a white cane or guide dog, and Low Vision Therapists who teach how to use remaining vision and specialized tools to remain independent.  I end this by challenging University programs to move degree programs from Education to Allied Health, current leaders to develop national standards and evidence-based outcomes, and to all of you to successfully shepherd a bill through Congress that will order CMS to amend Medicare law to add a new category of services provided by vision rehabilitation professionals!

Capitol building in Washington DC

Roxann Mayros headshotBy Roxann Mayros, President & CEO, VisionServe Alliance

Did you know that vision rehabilitation therapists are the only medical/rehabilitative professionals NOT reimbursed by Medicare or insurance companies (third-party payers)?  Here is why this is important.  Think about the person who has a stroke.  They lose their ability to use their right arm to brush their teeth. An occupational therapist is paid by Medicare or insurance to provide needed therapies.  That stroke also caused the person to lose the ability to speak clearly.  Medicare or an insurance company pays for speech therapy.  That stroke also caused a severe balance issue.  You guessed it, Medicare or insurance pays for a physical therapist.  BUT, if that same stroke victim, also loses some or all of their eyesight, no insurance company or Medicare will pay for important therapies provided by a specialized and nationally certified vision rehabilitation therapist, low vision therapist, or orientation and mobility specialist.

There are many reasons for this disparity and no easy solutions.  Due to my long-time tenure in the blindness and low vision field, being involved in and leading previous attempts to seek third-party payment, and my quickly approaching retirement, I have been asked to document why vision rehabilitation professionals are not currently reimbursed by Medicare or medical insurance.

Background

From 1990 through 2012, nonprofit organizations providing vision rehabilitation therapies and services to people with vision loss underwrote the expensive cost of, and spent untold hours leading, a national effort to secure third-party reimbursement for vision rehabilitation therapists to teach independent living skills, low vision therapists to teach the use of remaining vision as aided by magnification devices and techniques, and orientation and mobility specialists who teach safe movement and travel skills using a white cane or guide dog.

Why did it take so long?  Because it literally took an Act of Congress!    Medicare law must be amended by Congress to add a new category of services for which Medicare will provide reimbursement, i.e., establish coverage.  Congress must authorize the Secretary of Health and Human Services to establish rules, assign codes, and provide reimbursement.  Once these rules and codes are established and Medicare begins to reimburse for vision rehabilitation therapies, then other third-party payers (medical insurance companies) will begin to reimburse.  Congress doesn’t normally do this out of the goodness of their hearts, but only after intense and protracted advocacy from their constituents.

This decades-long and very expensive process produced four separate bills (none were ever brought to the floor for vote) and the only study at the time about the rate and cost of vision loss (The Lewin Report).  Our biggest champions were Congressman Michael Capuano of Massachusetts (his mother had lost her vision due to macular degeneration and was not referred for vision rehabilitation therapies by her medical doctor) and Senator John E. Sununu of New Hampshire.

Congressman Michael Capuano of Massachusetts
Congressman Michael Capuano of Massachusetts
Senator John E. Sununu of New Hampshire
Senator John E. Sununu of New Hampshire

Senator Sununu was most especially important because his vote was needed to pass legislation that created Part D (prescription drug coverage) under the Medicare Modernization Act of 2003. When asked by President George W. Bush to enter his deciding vote in favor of establishing prescription drug coverage, Senator Sununu boldly asked the President to support Medicare reimbursement for vision rehabilitation professionals.  Negotiations resulted in a Congressional order to the Centers for Medicare and Medicaid Services (CMS) to create and oversee a Five-Year Demonstration Project in the states of North Carolina, Kansas, New Hampshire, and Washington; and in the five boroughs of New York City and specific zip codes in the city of Atlanta.

US Department of Health & Human Services building
Washington, UNITED STATES: The US Department of Health and Human Services building is shown in Washington, DC, 21 July 2007. The department, which began operations in 1980, has more than 67,000 employees. SAUL LOEB/AFP/Getty Images

It was in 2005, as the new Executive Director of VisionServe Alliance (a consortium of nonprofits providing vision rehabilitation services) that I was assigned the task of working with CMS to implement and oversee the “Demonstration Project.”  CMS had experience in developing demonstration projects for established and traditional medical providers (Diabetic Educators, for example), but they were inexperienced in establishing a demonstration project for non-medical providers like vision rehabilitation therapists who earn their Master’s degrees through University Departments of Education and not Departments of Allied Health as physical or speech therapists do, and are traditionally employed by nonprofit agencies, the Veterans Administration, or State Agencies for the Blind.

The Demonstration Project was not successful for several reasons, including 1) how CMS designed the project – patients were required to live in the same New York borough or Atlanta zip code as the doctor’s office; 2) CMS assumed that vision rehabilitation professionals worked in physicians’ offices (which they didn’t); 3) that referrals for services came solely from physicians; and 4) by placing demonstration sites in low population or rural states like New Hampshire. The Project was also negatively impacted by the lack of standardized reporting, outcome measurements, and physician referrals within the field of vision rehabilitation.  These issues resulted in only one participant in each Demonstration State – nonprofit agencies already performing vision rehabilitation therapies.  Neither Optometrists nor Ophthalmologists participated because they did not (and would not) employ vision rehabilitation professionals. The lack of participation resulted in very low patient numbers, thereby not creating enough data to determine if the Demonstration Project proved the need for this professional category (vision rehabilitation) to be reimbursed by Medicare.

Those of us who had our “boots on the ground” advocating for reimbursement and the nonprofit agencies who participated in the Demonstration Project learned many lessons that should impact future endeavors seeking third-party reimbursements.  Watch for our next installment of Lessons Learned from the Vision Rehabilitation Demonstration Project 2006-2011.