June 10, 2025 • 24 mins
What if going to a restaurant worked like your insurance plan?
No menu.
No prices.
8 minutes with the waiter.
And a surprise bill three weeks later.
Sound ridiculous? That’s exactly how most vision insurance works.
In this episode, Dr. Kara Foster pulls back the curtain on how vision plans create confusion, drive up costs, and force rushed care—for both patients and doctors. We’ll unpack:
Why vision insurance isn’t true insurance
How patients end up overpaying (and don’t even know it)
The lab trap that puts profit over quality
A real patient receipt breakdown
What medical and vision providers really get paid
And why the system isn’t broken—it’s doing exactly what it was designed to do
Whether you’re a patient, provider, or someone who just wants care that makes sense—this episode will open your eyes.
Tune in now and share it with someone who needs to hear the truth.
#OptOutPodcast #DirectCare #VisionInsuranceExposed #EyeCareTruth #BreakTheMatrix
karafosterOD.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:01):
Hey everyone, welcome back to Opt Out, the podcast where we
call out the systems that are failing us and spotlight the
people building something better.
I'm Doctor Cara Foster, and today we're talking about a
system that most of us use everyyear, but almost no one
understands vision insurance. I want to add a little preface
(00:21):
for eye doctors and other providers that you can use to
share this with your patients. Please feel free to share it
directly. Post it in your office, play it
in your waiting room. e-mail it to people who ask, why don't you
take my insurance anymore? Because this conversation isn't
just about optometry. It's about truth.
It's about how a system built onpromises has turned into a
(00:43):
machine that profits off confusion, volume, and control.
The truth is that many Americansstill believe their health and
vision insurance are protecting them.
They think it saves some money. They think their plan covers
them and that they have to have insurance.
And they think doctors, especially the ones who don't
take their plan, are just in it for profit.
(01:03):
But here's the reality. The entire structure, from
pricing reimbursements to lab rules and coding games, wasn't
designed to benefit the doctor or the patient.
It was built to serve the middleman, the insurance companies,
the retail corporations. This is especially true in the
optical industry, the verticallyintegrated giants that own the
(01:25):
vision plans, the labs, the frames, offices.
And sometimes it feels like the care itself, it's not designed
for you or me or the patient in the chair.
I wanted to put together this episode so that we can help
share what practicing is really like working for the insurance
companies because it sounds responsible.
(01:46):
Vision insurance looks helpful on paper, but in reality it's
one of the most restrictive, misleading, and profit driven
tools in healthcare. And if you've ever asked
yourself, why doesn't my insurance cover that?
Why are my glasses so expensive even with insurance?
And why does my doctor seem to rush?
Well, this episode has your answer.
(02:07):
You've probably seen this analogy floating around the
Internet. It's something I like to call
the restaurant test, but it's based off an expanded version of
the restaurant analogy. It's simple, relatable, and this
pulls back the curtain on just how bizarre and broken our
healthcare system really is. So imagine this.
You walk into a restaurant, you're hungry, you're hopeful,
(02:30):
you're ready for a good meal. This is, like a lot of us often,
right? But instead of a menu, you're
handed a clipboard. You ask the host, what can I
order? And they say, well, that
depends, what insurance do you have?
You tell them. They squint.
OK, well, your plan covers a limited entree selection and
you'll need to sit with stick with the network special.
(02:51):
No substitutions. You try to ask about
ingredients, portions, prices, but the waiter is already
halfway back to the kitchen because they only have 8 minutes
per table. You eat the meal, kind of.
You're not sure what it was, or how much it cost, or if you even
liked it. 3 weeks later, a bill shows up in the mail and you owe
$87.00. Apparently the sauce wasn't
(03:12):
covered, your side salad was outof network, and you forgot to
pre authorize the bread. Ridiculous, right?
And yet, that's exactly how we've been conditioned to accept
medical care in this country. So let's zoom into vision care,
because here's the twist. We've dressed it up with fancy
words and clean storefronts and shiny insurance cards, but the
(03:34):
same dysfunctional rules still apply.
You think you're walking into your optometrist's office with
coverage. You think, great, I'll get a
free exam and money towards glasses.
But what you actually get is a short time limited visit based
on how much your plan allows. A-frame allowance that doesn't
cover most of the options that you like or need really.
(03:55):
Lens upgrades that aren't reallyupgrades, they're up cells and a
whole lot of confusion. When the final bill is more than
expected, we've normalized it. We've even trained people to
call and ask do you take my insurance?
As if that's the most important factor in choosing care.
But if I walked into a restaurant and asked, do you
take my dining plan, you'd laughbecause you'd want to know
(04:18):
what's on the menu, how fresh the ingredients are, and whether
the chef actually cares about the food.
The truth is insurance based healthcare and especially vision
plans have turned doctors into rushed wait staff patients, into
confused diners in meaningful care, into a commoditized
checklist. And here's the kicker.
(04:39):
The entire thing is orchestratednot to improve your health, but
to extract value from you, from me, from the patient sitting in
the chair who just wanted to seeclearly.
So in this episode, we're going to break it all down.
What's really included in that vision benefit?
Why the frame allowance isn't the deal it appears to be, and
(05:00):
how providers are squeezed from both ends.
And why direct care isn't just afinancial one, it's a moral
model as well. Because once you see the
restaurant for what it is, you'll understand why so many of
us are walking out and opening something better.
So now that we've pulled apart how ridiculous the restaurant
version of healthcare sounds, let's get into the real story
(05:23):
behind insurance, starting with vision plans.
Here's the hard truth that most people don't know.
Vision insurance isn't actually insurance.
It's not there to protect you ina crisis.
It's not there to save you money.
It is a prepaid discount programthat limits what you get, where
you can go, and how much time your doctor can spend with you.
(05:44):
Most patients pay between 15 and$25.00 a month either on their
own or through their employer, which translates to about 180 to
$300 per year. And in return, here's what you
get. One basic eye exam if your
provider accepts the plan, A frame allowance, usually between
120 and $150.00, and a confusinglabyrinth of co-pays, add-ons
(06:10):
and exclusions for anything beyond the absolute basics.
So what happens when you walk inexpecting that great deal on
glasses? Well, by the time you pick a
frame that you actually like, add high index lenses, add anti
glare or blue light filters, andmaybe you need progressives or
transitions, you've spent another at least $300 out of
(06:32):
pocket easily. And here's the kicker, your
doctor didn't make any profit off of that.
In fact, in many cases they losemoney on the glasses just to
meet the plans requirements. And it gets worse.
Most vision plans require us to use their labs, which means we
lose control of the quality. The lenses come from massive
(06:53):
volume factories with minimal accountability.
And if something goes wrong, we're the ones explaining it,
not the plan. So you, the patient, walk away
frustrated. You're confused about what was
covered, You wonder why your benefits didn't feel like
benefits, and you may even thinkyour doctor was the one
(07:13):
overcharging you. But let's zoom out even further,
because this isn't just a visionproblem.
The entire healthcare system runs on a similar playbook.
Let's talk about how medical insurance works for a minute.
Because if you've ever sat in a waiting room for 45 minutes,
wondered why your provider seemsrushed or gotten a confusing
bill from a hospital weeks afteryour visit, then you felt the
(07:37):
pressure of this system too. And here's what most people
don't realize In medical care, insurance companies don't just
pay for services, they set the rules.
Most pricing is based on something called the Medicare
Fee Schedule. This tells doctors what they're
allowed to charge for each service, down to the penny.
(07:58):
And the spoiler alert, most of these fees haven't even kept
pace with inflation or cost of care.
Doctors are reimbursed based on CPT codes, little billing codes
tied to procedures, time spent, and diagnostic requirements.
If you forget the right modifier, if your notes don't
match the billing, if the patient's diagnosis doesn't
(08:19):
justify the visit, it gets denied, delayed, or underpaid.
And now the provider has to spend hours documenting, coding,
justifying, and resubmitting. That's not medicine.
That's bureaucratic gymnastics. So here's what that pressure
does to good providers. They start ordering more tests
(08:40):
to meet billing thresholds. They add extra diagnosis so that
the visit qualifies, and they shorten visit times to fit in
more patients. And they spend hours every night
catching up on charts instead ofsleeping, reading, or being with
their families. And you, the patient, feel that
in every rushed appointment, every time you're interrupted
(09:01):
mid sentence, and every time youleave with more tests but fewer
answers. And yet insurance companies
still send you a statement saying, look how much we saved
you because they want to look like the hero.
But let's be clear, that's not savings, it's sleight of hand
because while you're waiting forcare, while your doctor is
(09:21):
burning out and while your bill is growing more complicated, the
insurance company, it's doing great.
So what's the bottom line? Who's profiting?
United Healthcare made over $22 billion in profits last year.
Cigna, Aetna, billions more. VSP, the largest vision plan in
(09:43):
the country, which is a technically nonprofit, but it
owns several labs, frame companies and retail chains, and
its CEO earns 7 figures annually.
So just to recap, the patient pays monthly premiums, then pays
again at the point of care. The doctor gets underpaid,
(10:04):
overburdened and blamed, and theinsurance company walks away
with record profits. Sound backwards?
That's because it is. And the worst part is that most
Americans think this is the onlyoption.
But it's not. And that's what we're going to
explore in the next segment. Because while the system isn't
broken, it's functioning exactlyas it was designed.
(10:27):
We don't have to play along. We can opt out of the tangled
web of red tape. We can choose transparency, time
and trust, and we can build something better.
All right, so let's go behind the curtain now, because if
you're wondering why so many doctors seemed rushed, burned
out, or hesitant to go off script during your visits, it's
(10:50):
not because they don't care. It's because they're trapped
inside a system that wasn't built for real care.
Let's start with vision plans. Most of these plans reimburse
about $45.00 for a full comprehensive exam.
Not a quick check, but a comprehensive medical assessment
of one of the most complex organs in the body.
(11:10):
We're expected to screen for glaucoma, check for macular
degeneration, evaluate eye muscle coordination, educate the
patient, and document every detail in under 20 minutes.
And that's pushing it. If that sounds impossible,
that's because it is. So let's talk glasses.
If you use your vision plan benefits, The lab is chosen for
(11:33):
us and it's usually owned by theinsurance company itself.
We have to follow their billing codes exactly, and if we don't
follow the frame allowance rulesto the letter, then we eat the
cost. So maybe, maybe we make 20 to
$40 profit on glasses and that doesn't come close to covering
the time it takes to fit, addressed, troubleshoot, or redo
(11:55):
the order. Now factor in rising rent,
equipment cost, salaries for staff, and all the continuing
education that we're required todo.
That $45.00 reimbursement doesn't even touch it.
So what do practices do? We shorten exams, we double
book, we hire scribes to speed up charting, we bring on extra
(12:15):
text so we can squeeze in more patients, and we hire full time
insurance builders to chase the money that we've already earned
and still often don't receive. And here's what patients don't
hear. Vision plans haven't raised
reimbursements in over 15 years,not even for inflation.
Meanwhile, the cost of doing business, just like everything
(12:36):
else, has skyrocketed. So instead of rewarding good
care, the system rewards a volume.
But this isn't just vision. It's a medical, too.
Let's zoom out to the broader healthcare system for a moment.
Medical insurance uses a model based off the Medicare fee
schedule. That means Medicare sets a price
for every service down to the penny.
(12:59):
Private insurers usually pay a percentage of that rate.
And here's the kicker. In order to be in network with
those plans, doctors often have to agree to accept 60 to 80% of
Medicare's allowed amount. Let that sink in.
You're not allowed to set your own pricing.
You have to agree to a discounted rate before you even
(13:21):
see the patient. So when the provider signs a
contract with an insurance company, they're often locking
themselves into accepting less than what it costs to do the
work. And if you want to stay on that
panel, you can't charge patientsmore, even if it could cover the
difference. It's like running a restaurant
where the health department not only tells you what you're
(13:43):
allowed to charge for spaghetti,but also says you can't use
better ingredients unless you eat the cost.
So let me pull back the curtain just a little bit further
because this part is one of the most frustrating, dehumanizing
aspects of insurance based care.You come in for your annual exam
and you say, oh, by the way, I've been seeing some weird
(14:05):
flashes in my vision lately. Guess what I have to say?
Well, we'll need to schedule a separate medical visit for that.
Why? Because your vision plan only
covers Wellness screenings. If I evaluate a medical issue
during that visit, your vision plan won't pay and neither will
your health insurance because the visit was already coded as
(14:25):
routine. The same thing happens in
primary care. You show up for your annual
Wellness exam and you mention your knee has been hurting or
your anxiety is worse, and your doctor sighs and says we'll have
to book another visit to discussthat.
It's not that we don't want to help, it's that the insurance
company literally won't pay if we go off script.
(14:48):
And what's worse, they might deny both visits if we
accidentally cross code them. So we're left walking a
tightrope. Code it wrong and we don't get
paid. Code too much and we risk
audits. Code it honestly and the patient
gets a surprise bill. It's a lose, lose lose situation
and it's not care, it's a billing exercise.
(15:10):
So to summarize, vision plans pay below cost, haven't raised
their rates in over a decade, and control everything from labs
to frames to fees. Medical plans restrict how and
when we can talk to you. Pricing is rigged behind the
scenes based on Medicare's outdated tables.
(15:30):
And the more care we try to provide, the harder it is to get
paid. That's why so many doctors are
exhausted. That's why care feels rushed.
And that's why you can't just have a conversation without
wondering what's billable. And that's why so many of us are
choosing to opt out. Because we didn't go into
medicine to play games with coding software.
(15:50):
We went into it to help people. And somewhere along the way that
got buried in spreadsheets and policies and fine print.
But here's the good news. There is another way and that's
what we're building together. So just to recap, let me tell
you a true story that literally just happened to last week.
(16:11):
It perfectly illustrates why this conversation matters so
much. A patient came into my office
with a receipt. She had recently purchased
glasses through an in network provider locally using her great
vision insurance plan. But she had a feeling that
something didn't quite add up. So she asked me, can you tell me
what these would have cost at your office?
(16:32):
Here's what was on her receipt. A designer frame for $225
premium progressive lenses $325 and the add-ons, UV protection,
edge Polish, anti glare coating about $400.00.
The total listed value was over $1000.
And here's the kicker. After her insurance discounts,
(16:54):
she paid $699 out of pocket. Not to the average person, that
might seem like a deal. Look at all these adjustments.
The plan made it appear as if they were saving her hundreds.
The receipt even included language like insurance discount
and patient responsibility. But let's break this down first.
What she didn't know was the provider had no choice but to
(17:16):
use the insurance company lab. That lab is owned by the same
company that owns the vision plan.
Let me say that again. The insurance company made the
rules, set the prices, owns the lab and takes a cut of the sale.
Even though they paid nothing towards the glasses themselves,
the provider, they're legally required to collect those
(17:39):
co-pays exactly as dictated or they risk being audited or
accused of insurance fraud. So not only did the insurance
plan not contribute any actual money towards her glasses, they
profited from the transaction. How?
By forcing the provider to send the order to their own lab and
then charging them for it while still dictating what the patient
(18:01):
paid. So where did that $699 goes go?
Part went to the lab that the insurance company owns, Part
went to the frame manufacturer that the insurance company owns,
and the sliver of it went to theprovider who is now stuck
waiting weeks to get paid, hoping nothing gets denied or
adjusted. And let's talk about those labs
(18:22):
for a second. They're high volume insurance
labs designed to prioritize speed, scale, and profit, not
quality. I can't tell you how many times
I've seen lenses arrived with warping, anti reflective
coatings that peel off early, prescription slightly off
because of lab error, or frames improperly aligned with no way
to fix it unless we reorder. And even that's a hassle.
(18:45):
And if something does go wrong, good luck.
These labs are so big, so disconnected, and so buried
behind 1800 numbers that gettinga remake feels like begging for
a favor. Now let me contrast that with
what we do in direct care. When I looked at her receipt and
matched up each piece with the products ioffer, I said that
(19:06):
exact same pair of glasses wouldhave cost about the same here,
maybe even less. But here's what would have been
different. We use a small, trusted lab with
incredible customer service. We choose the best lenses, not
the ones that are allowed, and we bundle our premium coatings,
materials and lens designs so there's no surprise up charges.
(19:28):
And we include A2 year warranty because we believe in standing
behind the products that we sell.
And if something's not right, wefix it and quickly because your
glasses have our name on them. She was stunned.
Not because of the price difference, because there wasn't
much of 1, but because of the transparency, quality, and
respect for her time and trust. So let me say it plainly, we're
(19:51):
not more expensive, we're just more honest.
We're not using trick receipts or manufacture discounts to make
it look like we're saving you money.
We're actually giving you value.And we're not answering to a
corporation. We are only accountable to you.
So you've ever walked out of an optical with a bill that made no
sense? If you've ever been told that
(20:12):
you had a benefit only to feel like it barely covered anything,
if you've ever wondered why yourlenses took three weeks and came
back wrong, now you know. Because the truth is, your
insurance didn't pay for those glasses.
You did. And the people profiting from
the transaction aren't the ones looking at you in the eye when
(20:33):
you pick them up. This is why I opted out, because
I became a doctor to help peoplenot decode CPT codes, not spend
my weekends resubmitting claims,and definitely not to explain
why $120.00 frame allowance won't cover a $225 frame in
(20:53):
direct care. I set clear prices, I take my
time, I build relationships, andI get to practice the way I was
trained to. And my patients?
They're not confused, they're not rushed, and they're not
wondering why their vision benefit feels like anything but
they're empowered. So what's the answer?
(21:14):
First, we had to stop pretendingthat the system is broken,
because it's not. It's doing exactly what it was
designed to do. Maximize profits, minimize
payouts, shift the blame. It's not a glitch, it's the
business model. But here's the good news.
There are places in the world and right here in the US, where
(21:37):
healthcare actually works, wherepeople live longer, healthier
lives, where Wellness is prioritized, not postponed,
where doctors have time to listen and patients feel seen.
They're called the Blue Zones. These are regions, both globally
and its small corners of America, where people live well
into their 90s without chronic disease, where communities are
(22:00):
walkable, food is whole and local, and connection is a form
of medicine. And here's what's exciting
Direct care models are gaining ground in these very same
places. Next week, we're going to
explore the connection between direct care and Blue Zones and
how we can start creating our own pockets of health in a
system that desperately needs healing.
(22:22):
But I want to leave you with onemore thing today.
If this episode made something click for you, if you found
yourself nodding along or thinking, wait, why didn't I
know this before, then I want toask you a favor.
Please share this. Send it to your friends, your
family, your coworkers, your doctor, your patients.
Because the only way we change this system is together.
(22:46):
Every time someone hears the truth about health insurance and
vision insurance and how they really work, the illusion starts
to break, the confusion lifts, and the frustration starts to
make sense, and the path forwardgets clearer.
When we stop playing along with a system that was designed to
extract value instead of create health, we start building
(23:08):
something better in its place. A system where doctors are paid
fairly to give you their time, where patients understand what
they're paying for, Where Wellness isn't a luxury, it's a
right. And care becomes personal, not
transactional. That's what direct care is, Not
just a model, a movement, one that reconnects patients and
(23:31):
providers, rebuilds trust, and returns healthcare to its
original purpose, helping peoplelive better, longer lives.
So if this episode helped you see things more clearly,
literally or figuratively, please share it.
Because the more people who opt out of this broken system, the
more we all opt into something better.
(23:53):
More health, more trust, more time, more life.
Thank you for listening and I'llsee you next time where we talk
about what's really possible when we stop waiting for someone
else to fix it and start building the future ourself.
Hey everyone, welcome back to Opt Out, the podcast where we
call out the systems that are failing us and spotlight the
people building something better.
I'm Doctor Cara Foster, and today we're talking about a
system that most of us use everyyear, but almost no one
understands vision insurance. I want to add a little preface
(00:21):
for eye doctors and other providers that you can use to
share this with your patients. Please feel free to share it
directly. Post it in your office, play it
in your waiting room. e-mail it to people who ask, why don't you
take my insurance anymore? Because this conversation isn't
just about optometry. It's about truth.
It's about how a system built onpromises has turned into a
(00:43):
machine that profits off confusion, volume, and control.
The truth is that many Americansstill believe their health and
vision insurance are protecting them.
They think it saves some money. They think their plan covers
them and that they have to have insurance.
And they think doctors, especially the ones who don't
take their plan, are just in it for profit.
(01:03):
But here's the reality. The entire structure, from
pricing reimbursements to lab rules and coding games, wasn't
designed to benefit the doctor or the patient.
It was built to serve the middleman, the insurance companies,
the retail corporations. This is especially true in the
optical industry, the verticallyintegrated giants that own the
(01:25):
vision plans, the labs, the frames, offices.
And sometimes it feels like the care itself, it's not designed
for you or me or the patient in the chair.
I wanted to put together this episode so that we can help
share what practicing is really like working for the insurance
companies because it sounds responsible.
(01:46):
Vision insurance looks helpful on paper, but in reality it's
one of the most restrictive, misleading, and profit driven
tools in healthcare. And if you've ever asked
yourself, why doesn't my insurance cover that?
Why are my glasses so expensive even with insurance?
And why does my doctor seem to rush?
Well, this episode has your answer.
(02:07):
You've probably seen this analogy floating around the
Internet. It's something I like to call
the restaurant test, but it's based off an expanded version of
the restaurant analogy. It's simple, relatable, and this
pulls back the curtain on just how bizarre and broken our
healthcare system really is. So imagine this.
You walk into a restaurant, you're hungry, you're hopeful,
(02:30):
you're ready for a good meal. This is, like a lot of us often,
right? But instead of a menu, you're
handed a clipboard. You ask the host, what can I
order? And they say, well, that
depends, what insurance do you have?
You tell them. They squint.
OK, well, your plan covers a limited entree selection and
you'll need to sit with stick with the network special.
(02:51):
No substitutions. You try to ask about
ingredients, portions, prices, but the waiter is already
halfway back to the kitchen because they only have 8 minutes
per table. You eat the meal, kind of.
You're not sure what it was, or how much it cost, or if you even
liked it. 3 weeks later, a bill shows up in the mail and you owe
$87.00. Apparently the sauce wasn't
(03:12):
covered, your side salad was outof network, and you forgot to
pre authorize the bread. Ridiculous, right?
And yet, that's exactly how we've been conditioned to accept
medical care in this country. So let's zoom into vision care,
because here's the twist. We've dressed it up with fancy
words and clean storefronts and shiny insurance cards, but the
(03:34):
same dysfunctional rules still apply.
You think you're walking into your optometrist's office with
coverage. You think, great, I'll get a
free exam and money towards glasses.
But what you actually get is a short time limited visit based
on how much your plan allows. A-frame allowance that doesn't
cover most of the options that you like or need really.
(03:55):
Lens upgrades that aren't reallyupgrades, they're up cells and a
whole lot of confusion. When the final bill is more than
expected, we've normalized it. We've even trained people to
call and ask do you take my insurance?
As if that's the most important factor in choosing care.
But if I walked into a restaurant and asked, do you
take my dining plan, you'd laughbecause you'd want to know
(04:18):
what's on the menu, how fresh the ingredients are, and whether
the chef actually cares about the food.
The truth is insurance based healthcare and especially vision
plans have turned doctors into rushed wait staff patients, into
confused diners in meaningful care, into a commoditized
checklist. And here's the kicker.
(04:39):
The entire thing is orchestratednot to improve your health, but
to extract value from you, from me, from the patient sitting in
the chair who just wanted to seeclearly.
So in this episode, we're going to break it all down.
What's really included in that vision benefit?
Why the frame allowance isn't the deal it appears to be, and
(05:00):
how providers are squeezed from both ends.
And why direct care isn't just afinancial one, it's a moral
model as well. Because once you see the
restaurant for what it is, you'll understand why so many of
us are walking out and opening something better.
So now that we've pulled apart how ridiculous the restaurant
version of healthcare sounds, let's get into the real story
(05:23):
behind insurance, starting with vision plans.
Here's the hard truth that most people don't know.
Vision insurance isn't actually insurance.
It's not there to protect you ina crisis.
It's not there to save you money.
It is a prepaid discount programthat limits what you get, where
you can go, and how much time your doctor can spend with you.
(05:44):
Most patients pay between 15 and$25.00 a month either on their
own or through their employer, which translates to about 180 to
$300 per year. And in return, here's what you
get. One basic eye exam if your
provider accepts the plan, A frame allowance, usually between
120 and $150.00, and a confusinglabyrinth of co-pays, add-ons
(06:10):
and exclusions for anything beyond the absolute basics.
So what happens when you walk inexpecting that great deal on
glasses? Well, by the time you pick a
frame that you actually like, add high index lenses, add anti
glare or blue light filters, andmaybe you need progressives or
transitions, you've spent another at least $300 out of
(06:32):
pocket easily. And here's the kicker, your
doctor didn't make any profit off of that.
In fact, in many cases they losemoney on the glasses just to
meet the plans requirements. And it gets worse.
Most vision plans require us to use their labs, which means we
lose control of the quality. The lenses come from massive
(06:53):
volume factories with minimal accountability.
And if something goes wrong, we're the ones explaining it,
not the plan. So you, the patient, walk away
frustrated. You're confused about what was
covered, You wonder why your benefits didn't feel like
benefits, and you may even thinkyour doctor was the one
(07:13):
overcharging you. But let's zoom out even further,
because this isn't just a visionproblem.
The entire healthcare system runs on a similar playbook.
Let's talk about how medical insurance works for a minute.
Because if you've ever sat in a waiting room for 45 minutes,
wondered why your provider seemsrushed or gotten a confusing
bill from a hospital weeks afteryour visit, then you felt the
(07:37):
pressure of this system too. And here's what most people
don't realize In medical care, insurance companies don't just
pay for services, they set the rules.
Most pricing is based on something called the Medicare
Fee Schedule. This tells doctors what they're
allowed to charge for each service, down to the penny.
(07:58):
And the spoiler alert, most of these fees haven't even kept
pace with inflation or cost of care.
Doctors are reimbursed based on CPT codes, little billing codes
tied to procedures, time spent, and diagnostic requirements.
If you forget the right modifier, if your notes don't
match the billing, if the patient's diagnosis doesn't
(08:19):
justify the visit, it gets denied, delayed, or underpaid.
And now the provider has to spend hours documenting, coding,
justifying, and resubmitting. That's not medicine.
That's bureaucratic gymnastics. So here's what that pressure
does to good providers. They start ordering more tests
(08:40):
to meet billing thresholds. They add extra diagnosis so that
the visit qualifies, and they shorten visit times to fit in
more patients. And they spend hours every night
catching up on charts instead ofsleeping, reading, or being with
their families. And you, the patient, feel that
in every rushed appointment, every time you're interrupted
(09:01):
mid sentence, and every time youleave with more tests but fewer
answers. And yet insurance companies
still send you a statement saying, look how much we saved
you because they want to look like the hero.
But let's be clear, that's not savings, it's sleight of hand
because while you're waiting forcare, while your doctor is
(09:21):
burning out and while your bill is growing more complicated, the
insurance company, it's doing great.
So what's the bottom line? Who's profiting?
United Healthcare made over $22 billion in profits last year.
Cigna, Aetna, billions more. VSP, the largest vision plan in
(09:43):
the country, which is a technically nonprofit, but it
owns several labs, frame companies and retail chains, and
its CEO earns 7 figures annually.
So just to recap, the patient pays monthly premiums, then pays
again at the point of care. The doctor gets underpaid,
(10:04):
overburdened and blamed, and theinsurance company walks away
with record profits. Sound backwards?
That's because it is. And the worst part is that most
Americans think this is the onlyoption.
But it's not. And that's what we're going to
explore in the next segment. Because while the system isn't
broken, it's functioning exactlyas it was designed.
(10:27):
We don't have to play along. We can opt out of the tangled
web of red tape. We can choose transparency, time
and trust, and we can build something better.
All right, so let's go behind the curtain now, because if
you're wondering why so many doctors seemed rushed, burned
out, or hesitant to go off script during your visits, it's
(10:50):
not because they don't care. It's because they're trapped
inside a system that wasn't built for real care.
Let's start with vision plans. Most of these plans reimburse
about $45.00 for a full comprehensive exam.
Not a quick check, but a comprehensive medical assessment
of one of the most complex organs in the body.
(11:10):
We're expected to screen for glaucoma, check for macular
degeneration, evaluate eye muscle coordination, educate the
patient, and document every detail in under 20 minutes.
And that's pushing it. If that sounds impossible,
that's because it is. So let's talk glasses.
If you use your vision plan benefits, The lab is chosen for
(11:33):
us and it's usually owned by theinsurance company itself.
We have to follow their billing codes exactly, and if we don't
follow the frame allowance rulesto the letter, then we eat the
cost. So maybe, maybe we make 20 to
$40 profit on glasses and that doesn't come close to covering
the time it takes to fit, addressed, troubleshoot, or redo
(11:55):
the order. Now factor in rising rent,
equipment cost, salaries for staff, and all the continuing
education that we're required todo.
That $45.00 reimbursement doesn't even touch it.
So what do practices do? We shorten exams, we double
book, we hire scribes to speed up charting, we bring on extra
(12:15):
text so we can squeeze in more patients, and we hire full time
insurance builders to chase the money that we've already earned
and still often don't receive. And here's what patients don't
hear. Vision plans haven't raised
reimbursements in over 15 years,not even for inflation.
Meanwhile, the cost of doing business, just like everything
(12:36):
else, has skyrocketed. So instead of rewarding good
care, the system rewards a volume.
But this isn't just vision. It's a medical, too.
Let's zoom out to the broader healthcare system for a moment.
Medical insurance uses a model based off the Medicare fee
schedule. That means Medicare sets a price
for every service down to the penny.
(12:59):
Private insurers usually pay a percentage of that rate.
And here's the kicker. In order to be in network with
those plans, doctors often have to agree to accept 60 to 80% of
Medicare's allowed amount. Let that sink in.
You're not allowed to set your own pricing.
You have to agree to a discounted rate before you even
(13:21):
see the patient. So when the provider signs a
contract with an insurance company, they're often locking
themselves into accepting less than what it costs to do the
work. And if you want to stay on that
panel, you can't charge patientsmore, even if it could cover the
difference. It's like running a restaurant
where the health department not only tells you what you're
(13:43):
allowed to charge for spaghetti,but also says you can't use
better ingredients unless you eat the cost.
So let me pull back the curtain just a little bit further
because this part is one of the most frustrating, dehumanizing
aspects of insurance based care.You come in for your annual exam
and you say, oh, by the way, I've been seeing some weird
(14:05):
flashes in my vision lately. Guess what I have to say?
Well, we'll need to schedule a separate medical visit for that.
Why? Because your vision plan only
covers Wellness screenings. If I evaluate a medical issue
during that visit, your vision plan won't pay and neither will
your health insurance because the visit was already coded as
(14:25):
routine. The same thing happens in
primary care. You show up for your annual
Wellness exam and you mention your knee has been hurting or
your anxiety is worse, and your doctor sighs and says we'll have
to book another visit to discussthat.
It's not that we don't want to help, it's that the insurance
company literally won't pay if we go off script.
(14:48):
And what's worse, they might deny both visits if we
accidentally cross code them. So we're left walking a
tightrope. Code it wrong and we don't get
paid. Code too much and we risk
audits. Code it honestly and the patient
gets a surprise bill. It's a lose, lose lose situation
and it's not care, it's a billing exercise.
(15:10):
So to summarize, vision plans pay below cost, haven't raised
their rates in over a decade, and control everything from labs
to frames to fees. Medical plans restrict how and
when we can talk to you. Pricing is rigged behind the
scenes based on Medicare's outdated tables.
(15:30):
And the more care we try to provide, the harder it is to get
paid. That's why so many doctors are
exhausted. That's why care feels rushed.
And that's why you can't just have a conversation without
wondering what's billable. And that's why so many of us are
choosing to opt out. Because we didn't go into
medicine to play games with coding software.
(15:50):
We went into it to help people. And somewhere along the way that
got buried in spreadsheets and policies and fine print.
But here's the good news. There is another way and that's
what we're building together. So just to recap, let me tell
you a true story that literally just happened to last week.
(16:11):
It perfectly illustrates why this conversation matters so
much. A patient came into my office
with a receipt. She had recently purchased
glasses through an in network provider locally using her great
vision insurance plan. But she had a feeling that
something didn't quite add up. So she asked me, can you tell me
what these would have cost at your office?
(16:32):
Here's what was on her receipt. A designer frame for $225
premium progressive lenses $325 and the add-ons, UV protection,
edge Polish, anti glare coating about $400.00.
The total listed value was over $1000.
And here's the kicker. After her insurance discounts,
(16:54):
she paid $699 out of pocket. Not to the average person, that
might seem like a deal. Look at all these adjustments.
The plan made it appear as if they were saving her hundreds.
The receipt even included language like insurance discount
and patient responsibility. But let's break this down first.
What she didn't know was the provider had no choice but to
(17:16):
use the insurance company lab. That lab is owned by the same
company that owns the vision plan.
Let me say that again. The insurance company made the
rules, set the prices, owns the lab and takes a cut of the sale.
Even though they paid nothing towards the glasses themselves,
the provider, they're legally required to collect those
(17:39):
co-pays exactly as dictated or they risk being audited or
accused of insurance fraud. So not only did the insurance
plan not contribute any actual money towards her glasses, they
profited from the transaction. How?
By forcing the provider to send the order to their own lab and
then charging them for it while still dictating what the patient
(18:01):
paid. So where did that $699 goes go?
Part went to the lab that the insurance company owns, Part
went to the frame manufacturer that the insurance company owns,
and the sliver of it went to theprovider who is now stuck
waiting weeks to get paid, hoping nothing gets denied or
adjusted. And let's talk about those labs
(18:22):
for a second. They're high volume insurance
labs designed to prioritize speed, scale, and profit, not
quality. I can't tell you how many times
I've seen lenses arrived with warping, anti reflective
coatings that peel off early, prescription slightly off
because of lab error, or frames improperly aligned with no way
to fix it unless we reorder. And even that's a hassle.
(18:45):
And if something does go wrong, good luck.
These labs are so big, so disconnected, and so buried
behind 1800 numbers that gettinga remake feels like begging for
a favor. Now let me contrast that with
what we do in direct care. When I looked at her receipt and
matched up each piece with the products ioffer, I said that
(19:06):
exact same pair of glasses wouldhave cost about the same here,
maybe even less. But here's what would have been
different. We use a small, trusted lab with
incredible customer service. We choose the best lenses, not
the ones that are allowed, and we bundle our premium coatings,
materials and lens designs so there's no surprise up charges.
(19:28):
And we include A2 year warranty because we believe in standing
behind the products that we sell.
And if something's not right, wefix it and quickly because your
glasses have our name on them. She was stunned.
Not because of the price difference, because there wasn't
much of 1, but because of the transparency, quality, and
respect for her time and trust. So let me say it plainly, we're
(19:51):
not more expensive, we're just more honest.
We're not using trick receipts or manufacture discounts to make
it look like we're saving you money.
We're actually giving you value.And we're not answering to a
corporation. We are only accountable to you.
So you've ever walked out of an optical with a bill that made no
sense? If you've ever been told that
(20:12):
you had a benefit only to feel like it barely covered anything,
if you've ever wondered why yourlenses took three weeks and came
back wrong, now you know. Because the truth is, your
insurance didn't pay for those glasses.
You did. And the people profiting from
the transaction aren't the ones looking at you in the eye when
(20:33):
you pick them up. This is why I opted out, because
I became a doctor to help peoplenot decode CPT codes, not spend
my weekends resubmitting claims,and definitely not to explain
why $120.00 frame allowance won't cover a $225 frame in
(20:53):
direct care. I set clear prices, I take my
time, I build relationships, andI get to practice the way I was
trained to. And my patients?
They're not confused, they're not rushed, and they're not
wondering why their vision benefit feels like anything but
they're empowered. So what's the answer?
(21:14):
First, we had to stop pretendingthat the system is broken,
because it's not. It's doing exactly what it was
designed to do. Maximize profits, minimize
payouts, shift the blame. It's not a glitch, it's the
business model. But here's the good news.
There are places in the world and right here in the US, where
(21:37):
healthcare actually works, wherepeople live longer, healthier
lives, where Wellness is prioritized, not postponed,
where doctors have time to listen and patients feel seen.
They're called the Blue Zones. These are regions, both globally
and its small corners of America, where people live well
into their 90s without chronic disease, where communities are
(22:00):
walkable, food is whole and local, and connection is a form
of medicine. And here's what's exciting
Direct care models are gaining ground in these very same
places. Next week, we're going to
explore the connection between direct care and Blue Zones and
how we can start creating our own pockets of health in a
system that desperately needs healing.
(22:22):
But I want to leave you with onemore thing today.
If this episode made something click for you, if you found
yourself nodding along or thinking, wait, why didn't I
know this before, then I want toask you a favor.
Please share this. Send it to your friends, your
family, your coworkers, your doctor, your patients.
Because the only way we change this system is together.
(22:46):
Every time someone hears the truth about health insurance and
vision insurance and how they really work, the illusion starts
to break, the confusion lifts, and the frustration starts to
make sense, and the path forwardgets clearer.
When we stop playing along with a system that was designed to
extract value instead of create health, we start building
(23:08):
something better in its place. A system where doctors are paid
fairly to give you their time, where patients understand what
they're paying for, Where Wellness isn't a luxury, it's a
right. And care becomes personal, not
transactional. That's what direct care is, Not
just a model, a movement, one that reconnects patients and
(23:31):
providers, rebuilds trust, and returns healthcare to its
original purpose, helping peoplelive better, longer lives.
So if this episode helped you see things more clearly,
literally or figuratively, please share it.
Because the more people who opt out of this broken system, the
more we all opt into something better.
(23:53):
More health, more trust, more time, more life.
Thank you for listening and I'llsee you next time where we talk
about what's really possible when we stop waiting for someone
else to fix it and start building the future ourself.
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