By Carla Gasparini, OD
April 10, 2019
A practice of high-income patients, capable of purchasing multiple pairs of luxury eyewear, is one way to build a practice. Another way to build a practice is by serving a wider swath of the community, one that includes patients who are financially struggling.
My 13-year-old and 12-year-old practices, which operate independently within Walmarts in Austin, Texas, do just that. Here’s how I am able to profitably serve low-income patients.
Defining “Low Income”
Low-income working families earn less than twice the federal poverty threshold to meet their household expenses, according to statistics from the U.S. Census Bureau. That equals out to an average of $48,678 annually for a family of four (assuming an average two children) per household. The low-income threshold can be much higher than you would expect. For instance, the low-income threshold in New Jersey is $68,000 for a family of four since the median income in that state is $91,200.
According to the National Center for Children in Poverty 2016 survey, 48 percent of children in Texas under the age of 18 are considered low income. Nationally, 41 percent of children younger than 18 are from low-income families. These children live in single/dual parent households with either parent working full- or part-time.
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At one of my independent practices, I am at about 46 percent low-income patients, and at the other I am at about 30 percent low-income patients. One of my locations is in a more rural setting where people are moving to escape the high cost of living in Austin. Cost-of-living increases affect lower-income people faster, so they are moving into the outskirts of the city at a higher percentage than other income groups.
Struggling to Fulfill Doctor’s Prescribed Treatment
In a lower-income population there is less follow through with health care. For instance, I will routinely tell a parent that their amblyopic child needs patching and possible vision therapy. Because of lack of resources they usually forgo the vision therapy in lieu of patching with mixed results.
Low-income people often fall through the cracks in maintaining their overall health. Most have not had a physical in years, and do not remember the last time their blood pressure was checked. The level of understanding of preventative medicine is drastically different than in a higher-income population in which doctors for all aspects of health are regularly seen.
Preference for In-Person Rather Than Online Service
We average 1.5 to two years between visits for all patients, including those on Medicaid. The adverse impact of online refraction has been the more significant among our middle-income Millennial population than those with low income. Our younger Medicaid, and Children’s Health Insurance Program (CHIP), patients are more likely to opt for in-person care.
I do not see a tendency for lower-income people to forgo care if they have insurance. It is more of a question of whether they can get to their appointment. It’s the working lower-middle-class families with no safety net, which make above the minimum poverty-line threshold, that tend to go longer without appointments.
Medicaid Compensation About Same as Private Vision Insurance
Medicaid patients do not usually have a co-pay, and for those on CHIP who do, it is between $5-$20. Compensation for care given to my low-income patients is comparable to private vision plans in Texas, so I am making about the same for a Medicaid patient as I do for a Spectera patient, for example.
Tips for Getting Medicaid Reimbursements
We typically file all of our vision plans the same day service is provided, or the next day. You should verify benefits before or on the same day as the appointment because patient eligibility can change. Some Medicaid plans have subcontracted the vision portion to a vision plan like Superior or Davis Vision (BCBS Medicaid). Traditional Medicaid is farmed out to the vision plans after one month. Make no mistakes in how you file for Medicaid reimbursement since trying to get payment after the fact is much harder.
Give Patients Many Options to Buy Eyewear
I try to offer all patients choices of where to buy their eyewear since their insurance may not work with all optical retailers. Having Walmart subleases has allowed me to grow my Medicaid business since its selection of eyewear is lower in cost than boutique opticals.
Find Doctors to Refer Patients to With Systemic Conditions
Lower-income patients, who do not have a primary care physician, and are sick with diabetes, hypertension, or another condition, pose a special challenge. I keep a list of doctors’ business cards who serve Medicaid patients. Low-cost doctors and clinics provide a profound resource for low-income patients, so educating them on where to go for other medical needs is important.
Offer Financing Options
We don’t yet offer CareCredit, but we offer our own payment plans to those who pay in check/cash since monthly installments might be easier to handle than a lump sum.
Fortunately, most of our patients do not require financing, as I keep my prices reasonable for the area that I am located in.
Bring In Whole Families of Patients
Usually the children are the first ones to get their eyes checked in lower-income families. Providing care to these children is a gateway for my office to talk to the parents, or caregivers, about eye health, diabetic eyecare and other ocular conditions. Once you provide care for one child, the rest of the family often will follow.
Serving low-income patients has been a great practice-builder for me. I do not shy away from caring for these patients.