Vision impairment affects millions of people in the United States (Prevent Blindness, 2012), including approximately 6.4 million people who experience uncorrectable vision impairment and between 8.2 and 15.9 million people who have uncorrected refractive error (Varma et al., 2016; Wittenborn and Rein, 2016; Wittenborn et al., 2013). Different populations are higher risk for vision impairment from different types of conditions (see Chapter 2). For example, children are most commonly affected by amblyopia and strabismus, conditions that can lead to permanent vision loss without early intervention. Age-related diseases, such as glaucoma and cataract, are more prevalent in older population, but disease progression can be slowed with early and effective treatments. Diabetic retinopathy is a possible consequence of uncontrolled diabetes in almost any age group, but can be prevented if the underlying condition is controlled. For populations with uncorrectable vision impairment, access to rehabilitation services and appropriate accommodations can improve health and quality of life.
Although the etiologies of vision loss and the characteristics of affected populations differ, having access to appropriate care is a shared strategy to help mitigate the severity or impact of vision impairment. Combined with estimates of correctable and uncorrectable vision impairment, this prompts questions about broader conditions that may prevent access to existing eye and vision services. Access to health care services is influenced by numerous factors, such as income, distance from an eye care provider, wealth, and vision insurance coverage (Sloan et al., 2014; Zhang et al., 2008a). However, entry into the eye and vision care system is also affected by overaching social and policy barriers, including the availablity of trained eye and vision
care professionals (as well as primary care and public health practitioners familiar with eye and vision health) and payment policies that limit coverage for basic services and equipment, directly affecting populations who are most in need of assistance and likely to suffer from uncorrectable or uncorrected vision impairment.
This chapter focuses on two basic prerequisites to facilitate entry into the eye and vision care system: workforce adequacy and insurance coverage of eye and vision care services. Chapters 7 and 8 discuss strategies to improve care quality within the eye and vision care system and advance rehabilitation services and accessibility, respectively. The first section of this chapter explores the different types of providers, their distribution, and workforce diversity. The second section describes the status of insurance coverage for eye disease and vision impairment among both publicly subsidized and employment-based insurance providers and identifies policy options to expand coverage of specific eye and vision services. The final section highlights the importance of cost-effectiveness research to establish the value of specific policies and practices that can improve entry into the eye and vision care system for the most at-risk populations while maximizing health care resources and minimizing the downstream impacts of vision loss.
A variety of professionals provide eye and vision services in the United States and have different education and training. This results in fragmentation between different professional groups, which is compounded by differing provider and patient preferences, the suboptimal use of electronic medical records and low levels of interoperability and confidentiality within the health care information technology infrastructure, and different state laws and regulations that govern practices and professions in the medical and optometric communities (AAO, 2011; Hall and Schulman, 2010). Understanding who to see for what services is important not only in terms of public messaging, but also in terms of effective collaboration with the general medical establishment to promote eye and vision health through appropriate referrals and care coordination, which are discussed in Chapter 7.
Defining Eye and Vision Care Providers
Ophthalmologists and optometrists are the two professional groups most commonly associated with eye and vision care. Ophthalmologists are physicians, having completed either allopathic (M.D.) or osteopathic (D.O.) medical education after a baccalaureate degree, followed by a mandatory internship and residency training. According to the American Academy of
Ophthalmology, approximately 40 percent of ophthalmologists complete fellowship subspecialty training (AAO, 2011). Optometrists, on the other hand, have completed a doctor of optometry (O.D.) degree after a baccalaureate degree and may have completed a post-graduate residency or fellowship training. The distinction between ophthalmologists and optometrists may drive health care decisions in the United States, including some payment policies, and may impose barriers or create opportunities affecting access to preventive and follow-up eye care.
In addition to ophthalmologists and optometrists, a variety of additional health care professionals (e.g., occupational therapists, orthoptists, opticians, ophthalmic technicians, ophthalmic medical assistants, ophthalmic medical technologists, and ophthalmic surgical assistants) and educational specialists (e.g., low-vision therapists, orientation and mobility specialists, and vision rehabilitation therapists) play intricate and necessary roles in supporting the eye and vision health of populations. Vision specialists, occupational therapists, mobility specialists, and blind-rehabilitation specialists provide an important care component that is explored in greater detail in Chapter 8. Ophthalmic medical assistants, ophthalmic medical technologists, and ophthalmic surgical assistants support ophthalmologists and optometrists in the provision of patient care. Primary care physicians, physician assistants, nurse practitioners, nursing staff, and other primary care providers aid in the early detection of vision problems and serve as an entry point into the eye and vision care system. Appendix F describes the educational requirements and professional responsibilities of many of these providers.
State regulations govern scope of practice for both medical doctors, such as ophthalmologists, and optometrists. None of the 50 states has any restrictions on medical and surgical practice for ophthalmologists, and all 50 states allow optometrists to “diagnose” diseases of the eye and vision system and to use diagnostic pharmaceutical agents to facilitate examination and therapeutic pharmaceutical agents to treat diseases or conditions of the eye and related structures (Cooper, 2012).1 However, other aspects of eye and vision care for optometrists vary widely. For example, the legal authority to prescribe controlled narcotic substances, use injectables, or perform surgical and/or laser procedures varies state by state (Cooper, 2012). Kentucky and Oklahoma allow optometrists to perform all laser surgery procedures (with the exception of retina, laser in-situ keratomileusis, and cosmetic lid surgery in Oklahoma) (Webb, 2011). Other states, such as California and Colorado, explicitly prohibit optometrists from performing
1 Massachusetts is currently the only state where optometrists do not possess the authority to treat glaucoma.
surgery.2,3 Internal practice protocols and organizational barriers adopted by managed care organizations, as well as various other factors, may also affect the scope of practice (Soroka et al., 2000).
Although the committee was not constituted to define the appropriate scope of practice for each profession, the committee does find that differences in scope of practice can create confusion among members of the public and health care providers in general, hindering population health efforts to increase access to appropriate care. In addition, debates over scope of practice highlight tensions among eye and vision care providers, which can hamper efforts to create a unified advocacy platform from which to advance population eye and vision health.
Workforce Distribution and Projections
Healthy People 2020 identifies geographic location as a factor that affects an individual’s ability to achieve good health and that contributes to health disparities (ODPHP, 2016). The distribution of different types of eye care providers varies among and within states, which affects the delivery of preventive services and effective treatments for many populations, especially those already at risk for poor health. Analyzing the current workforce distribution is important to maintaining or expanding adequate access to appropriate care through sufficiently trained eye care and health care professionals. As the U.S. population ages and the prevalence of age-related eye diseases and conditions increase accordingly (Varma et al., 2016; Wittenborn and Rein, 2016), it will be important to ensure adequate workforce supply to respond to growing demand and the need to control costs.
The availability of eye care professionals affects rates of care, especially for specific types of eye diseases and conditions. For example, access to ophthalmologists is associated with whether an individual obtains medically related eye care for diabetes, age-related macular degeneration (AMD), and glaucoma (Chou et al., 2012; Gibson, 2014; Sloan et al., 2004, 2014). Yet, recent studies have noted an absence of eye care professionals in a substantial percentage of counties with diabetic populations. Chou and colleagues (2012), using 2006 Behavioral Risk Factor Surveillance System (BRFSS) and 2007 Area Resource File (ARF) data, estimated that 10 percent of BRFSS respondents with diabetes lived in counties with neither an ophthalmologist nor an optometrist. Alabama has a high and growing prevalence of type 2 diabetes, but almost 15 percent of the counties in Alabama have neither an ophthalmologist nor an optometrist (MacLennan et al., 2014; The State of Obesity, 2016). Similarly, a survey of 597 primary care pediatricians
2 S.B. 622 Optometry, 2015 Leg., Reg. Sess. (Cal. 2015).
3 S.B. 11-094, 68th Gen. Assemb., Reg. Sess. (Colo. 2011).
found that 67.6 percent and 38.5 percent of those located in rural and non-rural areas, respectively, reported shortages of pediatric ophthalmologists (Pletcher et al., 2010).
The Current and Projected Eye and Vision Care Workforce
Given predicted increases in the prevalence of age-related eye diseases and conditions (see Chapter 2), it will be important to determine whether the eye and vision workforce supply and distribution is adequate to meet the rising demand. In 2013, the Association of American Medical Colleges (AAMC) reported 18,317 active ophthalmologists in the United States, with about 95 percent reporting their major activity as patient care rather than teaching or research (AAMC, 2014). From 2008 to 2013, there was a 2.6 percent increase in the number of active ophthalmologists and a 1.6 percent decrease in the number of first-year Accreditation Council for Graduate Medical Education residents and fellows (AAMC, 2014). A report released by the U.S. Department of Health and Human Services in 2008 projected that, based on patterns of graduates, specialty choice, and practice behavior, there would be more than 20,000 active ophthalmologists by 2015 (HHS, 2008). The report also calculated “baseline physician requirement projections”4 from the number of ophthalmologists in 2000 and estimated that the need for ophthalmologists would grow by 28 percent by 2020 (HHS, 2008). This put ophthalmology third among all medical specialties, following closely behind estimated projected needs for cardiology (33 percent) and urology (30 percent) (HHS, 2008).
The Health Resources and Services Administration (HRSA) reports that, in 2013, an estimated 36,858 optometrists practices in the United States (HHS, 2013b).5 The number of graduates from optometry degree programs increased by approximately 20 percent from 2007 to 2014, according to the Association of Schools and Colleges of Optometry’s annual student data report (ASCO, 2009, 2015b). The number of new graduates per 100,000 in the population increased from 0.43 in 2007 to 0.49 in 2014 (ASCO, 2009, 2015b). The Bureau of Labor Statistics (BLS) (2015b) forecasts a faster-than-average growth over the next decade, with a projected 27 percent increase in the number of optometrists between 2014 and 2024.
The current distribution of different types of eye care providers varies among and within states, which can affect access to preventive services and
4 “The baseline projections take into account the growth and aging of the population, but are calculated on the assumption that the United States will provide the same level of care in the future” that it provided in 2000 (HHS, 2008, p. 56).
5 HRSA’s U.S. Health Workforce Chartbook, which provides detailed data on workforce supply but not supply adequacy, does not include data on ophthalmologists because they are categorized more generally under “physicians and surgeons” (HHS, 2013b).
effective treatments for many populations, especially those already at risk for poor health (Gibson, 2014, 2015; Kilmer et al., 2010). Figures 6-1 and 6-2 show the approximate distribution of ophthalmologists and optometrists in the United States, respectively. A substantial number of U.S. counties have neither an ophthalmologist nor an optometrist. Using practitioner data from the ARF, Gibson reported that 24 percent of the 3,143 counties in the United States had neither type of practitioner in 2011 (Gibson, 2015). Furthermore, 60.7 percent of these counties fell into one of the two lowest quartiles on the number of both specialists per capita. The author noted that there may be opportunities to leverage the use of optometrists in the 24.1 percent of counties with high availability of optometrists, but insufficient numbers of ophthalmologists.
In analyzing the number of ophthalmologists and optometrists by county, the committee notes that Gibson and colleagues (2015) used population-weighted quartiles6 that may lead to distortions in the presentation of the data. For example, in Alaska, the presence of one additional ophthalmologist or optometrist in one county of 1,000 residents could result in that county going from the lowest quartile to the highest quartile, which could be misleading. Another concern is that National Health and Nutrition Examination Survey (NHANES) data is not geographically representative of the entire country and could introduce selection bias that may affect the results. It is unclear if the ARF includes satellite offices that may be available in rural areas for ophthalmologists because there are not enough patients to support a full-time surgical practice. In addition, Gibson and co-authors did not take into account either the findings from the RAND group—that ophthalmologists are able to accommodate an approximately 30 percent greater patient load7 than optometrists—or the numbers of family physicians, pediatricians, nurse practitioners, and physician assistants who can provide select eye care services, including medical treatment and/or the use of screening telemedicine services (Lee et al., 2007). For these reasons, the county-level availability estimates of optometrists and the ophthalmologists in the figures and manuscript may be misleading about the actual workforce availability and needs.
6 “The definitions of population-weighted quartiles of the county-level number of ophthalmologists per 100,000 county residents are: low, ≤2.95; medium-low, >2.95 and ≤5.39; medium-high, >5.39 and ≤7.63; high, >7.63. The definitions of the population-weighted quartiles of the number of optometrists per 100,000 county residents are: low, ≤10.96; medium-low >10.96 and ≤14.09; medium-high >14.09 and ≤16.80; high, >16.80 (Gibson, 2015).
Challenges in Assessing Workforce Level
A number of challenges make it difficult to assess whether current workforce levels, distribution patterns, and projected trends will be sufficient to meet the growing demand for eye and vision care services as the U.S. population ages. Workforce projection studies produced by different advocacy groups vary substantially (see, e.g., AOA, 2013; Lee et al., 2007). Modeling projections make assumptions about the changing demographics of patient populations, the professional workforce, public health demand versus market demand, and the impact of new technologies and treatments on clinical practice, which can have substantial effects on projections (Higginbotham, 2012). For example, early projections from a RAND study found that whether ophthalmologists or optometrists were assumed to be primary eye care provider significantly affected whether models predicted an oversupply or no excess of ophthalmologists in the workforce (Lee et
al., 1995, 1998).8 A more recent study by Lee and colleagues (2007) predicted that ophthalmology would face “substantial manpower challenges by 2020 or 2030” after accounting for changes in ophthalmic practice, new therapeutic opportunities, more recent data on the optometric work effort, U.S. population growth, and the growth of the ophthalmologist workforce. Another modeling study predicted that growth in the general, diabetic, and insured populations in the United States will lead to increased eye care
8Lee and colleagues (1998) describe an optometry-first model as one in which “all care that optometrists are legally entitled to provide, exclusive of laser or incisional surgery, are provided by optometrists preferentially” (p. 918). By contrast, in an ophthalmology-first model, “ophthalmologists provide all the care that they can provide before any care is allocated to optometrists” (p. 918). Oversupply occurs when total full-time equivalents (defined as “the total number of hours, per year, in which eye care services can be provided and is a function of the number of hours worked per day and the number of weeks worked per year”) exceed the total need for eye care (Lee et al., 1995, pp. XIII–XV). The need for eye care services was defined as “the level of eye-related pathology in the population that requires monitoring or medical treatment.”
Changes in policy, payment practices, and referral patterns will also affect workforce patterns. For example, predictions must also account for the effect of the Patient Protection and Affordable Care Act (ACA) on demand for pediatric eye care services (see Chapter 7), renewed emphasis on population health, the emergence of the medical home, and the focus on team-based care (Higginbotham and Lippa, 2010). In the absence of trained eye care professionals or in response to evolving practice patterns, using public health practitioners and primary care providers to administer specific eye and vision care screenings or services will also affect demand.
More data could provide a more accurate, representative depiction of the workforce distribution for both optometrists and ophthalmologists. Research is also needed to fill existing knowledge gaps about workforce sufficiency, the likely impacts to care access and quality, and which workforce policies are best suited to addressing workforce capacity concerns.
Diversity in the eye and vision care workforce is important to address some of the inequities in eye and vision outcomes noted in Chapter 2. Komaromy and colleagues (1996) found that African American and Hispanic primary care physicians were much more likely than primary care physicians of other ethnicities to care for African American and Hispanic patients, respectively. African American and Hispanic patients also report receiving higher quality care from African American and Hispanic physicians, respectively, than from physicians of other races (Saha et al., 1999).10Komaromy and colleagues (1996) found that the physician-to-population ratio was lower in areas where African Americans and Hispanics made up higher proportions of the population and that African American and Hispanic physicians were more likely than non-Hispanic white and Asian physicians to practice in these areas. Although these findings were based on primary care practice, they suggest that a lack of diversity in the ophthalmologic and optometric workforce could limit care access and quality
9Lewin Group (2014) noted, “In the 2012 National Eye Care Survey of Optometrists, responding optometrists indicated that they could provide, on average, 32 percent more visits per year than they were currently providing.” Factoring in this excess capacity creates an excess in the supply of eye care for the period studied (2012 to 2025).
10 African American patients with African American physicians were more likely to rate their physicians as excellent and to report receiving preventative care and all needed medical care. Hispanic patients with Hispanic physicians were more likely to report being satisfied with their overall health care.
among minority patients, an implication that adds emphasis to efforts to increase the diversity and cultural competency of the eye and vision care workforce.
Despite advances in the overall diversity of medical student cohorts and medical school faculties, the lack of diversity in the schools and colleges of optometry and ophthalmology remains a significant issue for the vision care workforce. The 2015 AAMC faculty roster lists 2,902 faculty members working in departments of ophthalmology. Of these, 603 (20.8 percent) are Asian, 57 (2.0 percent) are African American, and 50 (1.7 percent) are Hispanic, Latino, or of Spanish origin (AAMC, 2015b, table 16). Not surprisingly, estimates of the ethnicities of practicing ophthalmologists reflect the lack of diversity in the academic pipeline and in academia. In a 2014 AAMC report on diversity in the physician workforce, ophthalmology was among the less diverse specialties: Among ophthalmologists, African Americans, Hispanics, American Indian/Native Alaskans, and Asians, respectively made up 2.4 percent, 3.0 percent, 0.2 percent, and 14.6 percent of the workforce, compared with 4.2 percent, 4.6 percent, 0.4 percent, and 12.5 percent in the larger physician workforce (AAMC, 2015a, table 8).
The lack of diversity in schools and colleges of optometry is also a substantial problem, with only modest increases in the diversity of student enrollment during the past 5 years. Between the academic years 2009–2010 and 2014–2015, African American student enrollments increased from 2.8 percent to 3.1 percent of total enrollments, while Hispanic students increased from 4.4 percent to 5.1 percent (ASCO, 2015b). Asian enrollment also saw a modest increase, but with a considerably higher representation, going from 27.5 percent to 29.1 percent in those same 5 years (ASCO, 2015b). Female enrollment increased to 66.1 percent in 2014–2015 from 64.0 percent in 2009–2010 (ASCO, 2015b). Of the 1,569 students graduating from regular and special O.D. programs in 2014, 2.4 percent were African American, 3.4 percent were Hispanic, and 30.1 percent were Asian (ASCO, 2015b). In 2014, female graduates accounted for 64.6 percent of graduates (ASCO, 2015b). The diversity of the faculty of O.D. programs is also limited. In academic year 2014–2015, African Americans, Hispanics, and Asians accounted for, respectively, 2.8 percent, 5.2 percent, and 15.7 percent of the fulltime faculty of O.D. programs (ASCO, 2015a). The optometrist workforce mirrors student enrollment, especially for African Americans and Hispanics. Using data from the 2010–2012 American Community Survey, the National Center for Health Workforce Analysis estimated the optometrist workforce to be 2.8 percent African American, 4.9 percent Hispanic, and 13.0 percent Asian, indicating a lack of diversity (HHS, 2015). Efforts to recruit more diverse student bodies in ophthalmology and optometry schools and colleges should be emphasized as a tool to improve access for minority and underserved populations.
Community and Rural Health Services
The literature demonstrates a high prevalence of unmet vision health needs in a substantial number of communities (Chou et al., 2014; Elam and Lee, 2014; Elliott et al., 2010; MacLennan et al., 2014). Disparities in vision health between rural and urban communities have been documented and observed, with long travel distances, limited provider availability, and lower income cited as significant obstacles to the provision of appropriate health care to people living in rural settings (Richardson et al., 2013; Tsui et al., 2015). Individuals living in rural areas are significantly more likely to self-identify as having diabetic retinopathy, and they are less likely to receive an annual dilated eye examination (Hale et al., 2010). Another study found that rural primary care physicians were significantly more likely to report shortages for pediatric specialties when referring patients (Pletcher et al., 2010). Approximately 19.3 percent of the U.S. population resides in rural areas (U.S. Census Bureau, 2015). This raises questions about how to better meet the eye and vision care needs of people living in rural communities.
For many underserved and low-income communities, federally funded community and rural health centers may be the only source of eye and vision care services. Federally qualified community health centers are required by statute to provide vision screening services for pediatric patients.11 Yet, in a survey administered by the George Washington University School of Public Health and Health Services, only 20 percent of health centers reported having an onsite optometrist or ophthalmologist who bills for comprehensive eye exams (Shin and Finnegan, 2009). Furthermore, in 2014, just 1.9 percent of health center patients used vision services from staff ophthalmologists and optometrists (HRSA, 2014). Another study found that approximately 72 percent of patients screened at a rural free community health clinic met the criteria for further ophthalmic evaluation12 (Tsui et al., 2015). Of those who received ophthalmic referrals, approximately 89 percent of the group kept their referral appointments (Tsui et al., 2015).
The National Rural Health Association released a policy brief advocating for increased efforts to incentivize optometrists to practice in rural areas, but noted that support of funding for the NHSC (National Health Service Corps) would be necessary to place optometrists in rural and frontier areas (NRHA, 2009). Similarly, the American Public Health Association
11 42 U.S.C. § 254b(b)(1)(A)(i)(III)(ff).
12 Criteria included: (1) two or more positive responses to a set of eight screening questions regarding past medical history; (2) less than 20/30 distance acuity despite pinhole, or less than 20/40 near acuity; (3) any distortions, blind spots, or irregularities with Amsler grid testing; (4) any abnormality of extraocular movements in the cardinal positions of gaze; and (5) any visual field defect on confrontation visual field testing.
has recommended that the U.S. Congress improve access to primary eye and vision care in medically underserved communities by “reinstating doctors of optometry in the National Health Service Corps” and by including “optometry as a named primary health care discipline in CHCs [community health centers]” (APHA, 2009).
In the absence of optometrists and ophthalmologists, primary care physicians, nurse practitioners, physician assistants, and other primary care providers can provide vision screenings at community and rural health centers. More research is needed to better understand how to use the existing infrastructure of community health organizations and established relationships with underserved and low-income communities. This research could better assess the capacity of community health centers to deliver comprehensive eye examinations, identify factors that influence whether screening programs lead to improved eye and vision health, and explore policy and funding strategies to expand the role of community health centers to improve access to eye and vision care services.
To ensure that populations, especially underserved and at-risk populations, have access to timely and high-quality eye and vision care, new strategies will be needed to expand access to eye and vision care services—beyond the offices of eye and vision care specialist. In some cases, population health efforts may have the most impact if resources are focused on geographic areas or populations that are defined in terms of eye care professional supply.
Emerging Technologies to Expand Access
With the focus on increasing value in health care, alternative technologies to expand access to providers have been explored as keys to improve access to eye and vision care. Technology options include telemedicine for the screening, evaluation, and diagnosis of eye disease and Internet technologies for patients and their families to take a greater role in the monitoring of their chronic disease conditions, thus reducing the need for more frequent follow-up visits. These technologies cannot replace key clinical services, such as in-person or comprehensive eye examinations and patient counseling, as a whole. Rather they complement existing services and can be a tool for bringing high-risk populations into the eye and vision care system.
Telemedicine is “the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status” (ATA, 2016). Telescreening of eye disease, which is a type of
telemedicine, offers a way to provide diagnostic services to populations that do not have access to adequate local eye care services. In many telescreening programs, screenings are provided in a community setting, such as a federally qualified health center, and the results are forwarded electronically to a diagnostic referral center for interpretation by an eye care provider. Patients receive a diagnosis and are referred, as necessary, for follow-up care.
Telescreening has the potential to improve population vision health and the performance of the vision care system by promoting the early detection of select eye diseases and conditions, minimizing personnel and overhead costs to the health care system, and reducing transportation and time costs to the patient (Brady et al., 2014; Li et al., 2012; Phan et al., 2014). For example, a randomized, controlled trial found that adult diabetic patients who received diabetic retinopathy telescreening in a primary care setting were significantly more likely to have a follow-up eye examination in the first 18 months of the study than patients who only received referrals for eye examinations from community eye care providers (Mansberger et al., 2013). Over 5 years of follow-up, the severity of diabetic retinopathy remained generally stable in more than 90 percent of the study’s participants. In a systematic review and meta-analysis, Shi and colleagues (2015) found that the pooled sensitivity and specificity of telescreening exceeded 70 percent and 90 percent, respectively, for the detection of absence of most forms of diabetic retinopathy and macular edema.13 A number of studies suggest that telescreening for open-angle glaucoma is effective at reducing costs, lowering barriers to access, and promoting the early detection of glaucoma among remote and medically underserved populations (Arora et al., 2014b; Thomas et al., 2014, 2015; Verma et al., 2014). A few studies have also concluded that telescreening may be used to accurately diagnose retinopathy of prematurity (Lorenz et al., 2009; Wang et al., 2015; Weaver, 2013). However, professional organizations, such as the American Academy of Ophthalmology, the American Academy of Pediatrics, and the American Association of Certified Orthoptists have stated that telemedicine-based remote digital fundus imaging cannot replace bedside binocular indirect ophthalmoscopy, despite moderate-quality evidence to support its use in
13 Sensitivity for the detection of absence of diabetic retinopathy, 86 percent; mild nonproliferative diabetic retinopathy, 76 percent; moderate non-proliferative diabetic retinopathy, 72 percent; severe non-proliferative diabetic retinopathy, 53 percent; low-risk proliferative diabetic retinopathy, 84 percent; high-risk proliferative diabetic retinopathy, 81 percent; diabetic macular edema, 76 percent; and clinically significant macular edema, 75 percent. Specificity for detection of the absence of diabetic retinopathy, 95 percent, mild non-proliferative diabetic retinopathy, 89 percent; moderate non-proliferative diabetic retinopathy, 94 percent; severe non-proliferative diabetic retinopathy, 99 percent; low-risk proliferative diabetic retinopathy, 98 percent; high-risk proliferative diabetic retinopathy, 99 percent; diabetic macular edema, 95 percent; and clinically significant macular edema, 97 percent.
the identification of certain patients with clinically significant or referral-warranted retinopathy of prematurity (Fierson et al., 2015).
Telescreening programs also have the potential to reduce health care expenditures when compared to traditional eye examinations for select populations. Several studies suggest that telescreening for diabetic retinopathy can be a cost-effective means of screening some populations with diabetes. A study on diabetic patients receiving digital retinal imaging versus a standard ophthalmologic examination at a federally qualified health center found that the total per-patient costs14 of teleretinopathy screening were $40.40, compared with $77.80 for a conventional examination. Even including the cost of a follow-up eye examination for the 12.3 percent of telescreened patients who screened positive with clinically significant disease, average per-patient costs were lower under the telescreening protocol ($49.95 versus $77.80) (Li et al., 2012). Kirkizlar and colleagues found that a telescreening program to detect diabetic retinopathy was a cost-effective (i.e., ≤$50,000/quality-adjusted life year [QALY] gained) means of screening diabetic populations that were larger than 3,500 people or whose members were younger than 80 years of age. The program was cost-saving when screened patients were younger than 50 years of age (Kirkizlar et al., 2013). In a modeling study, biennial eye exams were found to be more cost-effective than telescreening or annual eye exams at reducing visual morbidity in a hypothetical population of patients with diabetes and a low risk of progression, when it was assumed that exams could detect diabetic retinopathy, early and advanced AMD, glaucoma, and uncorrected refractive error, and that telescreening could detect diabetic retinopathy and AMD.15 On the other hand, when the model assumed that telescreening could detect 25 percent to 75 percent of uncorrected refractive error, it was found to offer more QALYs at a lower cost than biennial exams (Rein et al., 2011). However, the high cost of imaging equipment may negatively affect return on investment, especially for short-term telescreening initiatives (Phan et al., 2014).
There are several challenges to implementing a telescreening program. First, covering equipment and facility costs, contracting with eye care
14 The primary cost for digital retinal imaging per patient was the sum of costs for a medical assistant ($3.80), ophthalmologist ($15.00), capital cost of equipment and training ($17.60), equipment maintenance ($1.50), and transportation fee ($2.50). The primary direct cost for a standard examination per patient was the sum of costs for round-trip transportation ($8.70), Medicaid Physician Fee Schedule allowable for bilateral eye examination ($65.30), and medical assistant personnel ($3.80). The cost of a follow-up examination per patient was an additional $9.55 (Li et al., 2012).
15 Low-risk individuals were defined as those who were ages 30 and older with diagnosed type 2 diabetes, had no diabetic retinopathy or only retinal microaneurysms, and visited a primary care physician in the previous 12 months.
providers, and training local caregivers to perform telescreenings all entail significant costs that some communities or clinics may have difficulty affording (Thomas et al., 2014, 2015). Second, imaging technologies may lack sufficient diagnostic sensitivity and specificity, the methods to encrypt patient data may not meet security needs or may obstruct data sharing, and training of screeners may be inadequate (Heaven et al., 1993). Furthermore, care providers must be appropriately trained and quality metrics will have to be clarified in order to create a program that provides optimal care (Li, 1999). A study that polled ophthalmologists and optometrists found that 82 percent reported that they were willing or extremely willing to participate in consultations or to interpret photographs, though the majority (71 percent) indicated they were not currently participating in any telemedicine initiatives (Woodward et al., 2015). However, 59 percent indicated that they had low confidence in making decisions for care, and 68 percent were not comfortable basing care solely on remote evaluations (Woodward et al., 2015).
The public and policy makers must be aware of the limitations of telescreenings for eye and vision health. Comprehensive eye exams, patient–provider interactions, surgical procedures, and in-patient treatments for eye disease cannot be provided through telescreening, which “does not replace optometrists or ophthalmologists, but instead complements their contribution” (Ng et al., 2009). These challenges are as relevant for public health practice as they are for clinical eye and vision care. Public health departments share similar concerns over the cost and cost-effectiveness of telescreening programs and the sensitivity and specificity of new screening technologies. Future research on telescreening will need to account for the capacity, training, and resource limitations of public health departments and other public health actors.
Other Emerging Technologies
In addition to telescreening, a number of other innovative, developing technologies may prove useful in tracking and diagnosing poor eye health or vision impairment in the future. More than two out of every three Americans owned a smartphone in 2015 (Pew Research Center, 2015). Recent studies of software and hardware designed to enable smartphones to perform some vision screening tests found that these technologies can accurately measure visual acuity and produce optic nerve images comparable in quality to those produced by desktop retinal cameras (Bastawrous et al., 2015, 2016). Similar tools currently in development may one day provide effective testing for diabetic retinopathy, macular edema, retinopathy of prematurity, and other eye diseases (Azrak et al., 2015; Ettore Giardini, 2015; Oluleye et al., 2016). Currently available applications for
smartphones offer tests of visual acuity, astigmatism, and color vision, in addition to providing information on eye health and making it possible to locate nearby eye care services (Rocktime, 2016). Given the ubiquity, portability, innate connectivity, and comparatively low cost of smartphones, these innovations hold the potential to expand the availability of vision screenings and diagnostic and monitoring services in remote and medically underserved communities. Similarly, the use of specially designed video games makes it possible to quickly test threshold visual acuity in children, without the aid of medically trained examiners, and the results have been shown to concur with examinations by pediatric ophthalmologists in 87.5 percent of cases (Trivedi et al., 2010).
However, technological innovations come with their own set of challenges. Data protection is a particularly important issue. For example, researchers in the United Kingdom conducted a cross-sectional, systematic assessment of 79 mobile phone health applications certified by the National Health Service Health Apps Library. In order for an application to be featured, it must be ensured as clinically safe and compliant with the data protection principles of the United Kingdom’s Data Protection Act of 1998 (Huckvale et al., 2015). The applications varied in function, scope, and breadth of information. Ninety-two percent of the applications had unencrypted data storage of some kind, with 53 percent of the applications storing unencrypted personal or sensitive information on the device (Huckvale et al., 2015). Of the sample, 89 percent of the applications transmitted the data through the Internet. Half of the applications transmitted information with strong identifiers, and of these, 66 percent of the applications sent this sensitive data without encryption (Huckvale et al., 2015).
Investing in research to speed the development of new screening tools and models of care that are Web based or carried out via smartphones have the potential to expand screening services with increasing diagnostic specificity and sensitivity at a lower cost to patients and the health care system. However, appropriate care must be taken to ensure mechanisms are in place to protect patient privacy and health information as these emerging technologies continue to evolve.
A lack of insurance coverage, poor access to services, and unaffordable costs are identified as major barriers to obtaining eye and vision care (CDC, 2011; Chou et al., 2014; DeVoe et al., 2007; Fudemberg et al., 2016; Levin et al., 2013; Zhang et al., 2008b). This is consistent across racial groups, with one survey reporting that approximately one-third of African Americans, Hispanics, Asians, and non-Hispanic whites having eye exams less frequently than they would like because of their insurance
status (Research!America, 2014). An analysis of the 2006–2011 BRFSS data found that costs and a lack of insurance were cited by 32.3 percent of diabetic patients as the reason they did not seek an annual eye exam, with rates higher among those individuals with annual incomes less than $35,000 (Chou et al., 2014). A few studies have also described cost as a barrier to obtaining eyeglasses (Berry et al., 2012; Hodges and Berk, 1999). Data from NHANES revealed that in 2008, 16.0 percent of non-Hispanic whites, 15.3 percent of African Americans, and 26.7 percent of Hispanic adults could not afford eyeglasses when needed (Zhang et al., 2012).
A number of studies have also found that insurance coverage is an independent predictor of vision health, with a lack of insurance associated with a higher incidence of vision loss and an older mean age of diagnosis for the degenerative diseases of glaucoma and cataracts (Chan et al., 2014; Jin et al., 2013). Age-adjusted rates of service utilization are highest among those with private insurance16 (67 percent) and lower for those with public (55 percent) or no health insurance (42 percent) (Li et al., 2013; Zhang et al., 2008b). The problems associated with the relative high cost of care, lack of insurance, and poor eye health are exacerbated by the lower income levels and education status typical for the blind and visually impaired population (Erickson et al., 2014; Kraus, 2015).
Current payment policies create access barriers for entry into and referrals within the eye and vision health system. More generally, divisions between optometry and ophthalmology or the medical establishment contributed to the development of separate insurance systems and payment policies for each profession, which continue to function largely independently. As a result, eye and vision care is bifurcated. General health insurance plans—whether public or employer-based17—typically offer limited or no coverage of routine and preventive eye health and vision care services and supplies (such as regular comprehensive eye examinations, eyeglasses, or contact lenses) in the absence of diagnosed risk factors for specific eye diseases or conditions, leaving beneficiaries to purchase supplemental or stand-alone vision insurance plans. In 2009, three-quarters of adults with vision insurance obtained coverage through stand-alone plans, with the rest obtaining coverage through general medical insurance (AOA, 2013). This
16 Private insurance is used interchangeably in this instance alone with “employment-based” coverage to maintain consistency with the discussion from Zhang et al. (2008b). The rest of the chapter will use “employment-based” coverage to describe insurance providers from the private sector.
17 For purposes of this report, “public insurance” is an umbrella term used to describe coverage gained as a result of eligibility for Medicare, Medicaid, or Children’s Health Insurance Plan (CHIP), and may include possession of private plans as a supplement to the publicly subsidized coverage. The term “employment-based” is used to describe private insurance providers whose plans are procured through employer benefits.
practice results in additional procedural and financial burdens, especially for those populations that already experience poor health status and lower socioeconomic position—that is, for those who generally need more care but are less able to obtain it.
Overview of Costs and Coverage
In the United States, the costs of eye and vision care are typically shouldered by public programs, private insurance companies, and individuals, including patients and families. Since passage of the ACA, the size of the uninsured population in the United States has decreased and more children have access to eye and vision services, but approximately 32 million nonelderly Americans still did not have health insurance in 2014 (Kaiser Family Foundation, 2015). Those without health insurance are far less likely to have vision insurance (Zhang et al., 2008b).
A large proportion of adults in the United States do not have vision insurance that covers comprehensive eye examinations, eyeglasses, and contact lenses. The Vision Council’s U.S. Optical Industry Report Card, which details the industry trends associated with vision correction usage, stated in 2015 that 76.2 percent of the adult population reported wearing some form of vision correction18 (Vision Council, 2015, 2016). However, one 2012 survey found that 48 percent of the adults reported that they were not enrolled in any type of vision insurance plan, and another 5 percent were not sure if they were enrolled (Jobson Optical Research, 2012). This is not for lack of want: A consumer survey found that 92.9 percent of respondents identified vision coverage benefits as somewhat or very important, just slightly less than that for general medical insurance (94.5 percent) (NAVCP, 2013).
The next few sections discuss coverage of eye and vision care services through Medicare, Medicaid, and CHIP, and employer-based insurance. The purpose it to highlight inconsistencies in policies and opportunities to consider coverage decisions that can better serve a population health approach to eye and vision care, by enabling populations to access eye and vision care services that can modify or correct vision impairment, especially for underserved and low-income communities. These sections also highlight the numbers of people who would immediately be impacted by changes in payment policies governing provision of eye and vision services.
18 “Vision correction” includes prescription eyeglasses, prescription sunglasses, plano sunglasses, contact lenses, and over-the-counter readers.
In general, Medicare eligibility extends to adults over the age of 65 and to individuals with certain disabilities and diseases. In 2013, there were approximately 52.3 million Medicare part A and/or Medicare part B beneficiaries. Of these, approximately 42.5 million were eligible for Medicare on the basis of age, and 9.8 million were eligible because of disability (CMS, 2014c). Various stipulations involving Social Security benefits or disability pension eligibility qualify beneficiaries to sign up for Medicare Part A at no cost. In most cases, eligibility for social security disability benefits is a prerequisite for disability-based eligibility in Medicare.
Some Medicare beneficiaries are also dually eligible for Medicaid. The Kaiser Family Foundation estimates that approximately 9 million beneficiaries are “dual eligible,” meaning they are covered by both Medicare (Parts A and B) and Medicaid or receive some assistance with Medicare cost sharing or premiums through a specific Medicare Savings Program category (CMS, 2016a; Kaiser Family Foundation, 2016a). Of these 9 million beneficiaries, an estimated 5.5 million are low-income seniors, and 3.4 million are people with disabilities under the age of 65 (Kaiser Family Foundation, 2011). All services received by dual-eligible beneficiaries are covered and paid for first by Medicare, with Medicaid seen as the “payer of last resort” (CMS, 2016a).
Overview of Medicare Coverage
Medicare benefits include four categories of medical services and supplies. These include (1) those medically necessary to treat a disease or condition in hospitals, nursing facilities, nursing homes, hospice, or through home care (Part A); (2) preventive and medically necessary inpatient and outpatient services such as clinical research, ambulance services, durable medical equipment, inpatient or outpatient hospitalization related to a condition or disease, a second opinion prior to surgery, and some prescription medications (Part B) (CMS, 2016k,m). These two parts comprise what is often referred to as traditional Medicare19 (Kaiser Family Foundation, 2016b). Traditional Medicare benefits, or the medical services and supplies covered by Parts A and B, can alternatively be provided through a private health plan called (3) Part C or Medicare Advantage (CMS, 2016k; Kaiser Family Foundation, 2016b). Finally, (4) coverage of outpatient prescription drugs (Part D) is received through private plans that contract with Medicare, supplementing traditional Medicare (CMS, 2016d,m; Kaiser Family
Foundation, 2016b). Generally, Part D benefits are included in the Part C benefits package (Kaiser Family Foundation, 2016b). For those enrolled in traditional Medicare and not Part C, Medigap policies sold through private companies offer additional, supplemental coverage for copayments, coinsurance, and deductibles (CMS, 2016j).
Because Medicare Part A covers in-hospital services, medically necessary inpatient procedures to treat eye injuries, conditions, and diseases are generally covered by Medicare (CMS, 2016d,l). Federal statutes explicitly prohibit Medicare from covering expenses “for routine physical checkups, eyeglasses (other than eyewear described in section 1861(s)(8)) or eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, procedures performed (during the course of any eye examination) to determine the refractive state of the eyes,” along with hearing aids or examinations and immunizations, unless otherwise noted (42 U.S.C. § 1862(a)(1)(A); 42 U.S.C. § 1395y; see also CMS, 2016b). CMS has interpreted this as prohibiting coverage of any device containing a lens (including low vision optical devices, electronic magnifiers, eyeglasses, or contact lenses). Some individual preventive services are allowed by statute, including screenings associated with diabetes and personalized prevention plan services (42 U.S.C. § 1862(a) (1)(M),(K)&(L)), but there are no statutory allowances for preventive services for eye and vision health. In essence, Medicare pays only for corrective lenses implanted in the eye, with the exception of one pair of eyeglasses or one set of contact lenses following a cataract surgery that implants an intraocular lens (CMS, 2016c). Comprehensive eye exams are covered only after a specific diagnosis or identification of qualifying risk factors (CMS, 2015d). Although other congressional statutes, such as the Medicare Modernization Act (2003) and the ACA (2010), have expanded eligibility and medical services, payment for preventive or rehabilitative services specifically for eye and vision health remains limited (Blumenthal et al., 2015a,b). Table 6-1 lists examples of covered and noncovered vision services.
In 2015, there were about 17 million beneficiaries enrolled in Medicare Advantage plans (Jacobson et al., 2015). Medicare Advantage plans generally offer additional benefits, such as vision, dental, and hearing services. In the case of vision, this may include routine, yearly eye exams and eyeglasses or contact lenses every 24 months (CMS, 2015d). Alternatively, Medicare beneficiaries who enroll in supplemental Medicare insurance, may obtain additional vision benefits, though the policies vary. Medigap can cover an individual’s share of the cost for Medicare-covered vision services, copayments, and deductibles. Most Medicare beneficiaries have coverage for several different vision services, but are required to pay an annual deductible, and are usually responsible for 20 percent of Medicare-approved costs for covered services (CMS, 2015d; Curtis et al., 2012). Again, these policies are only available to Medicare beneficiaries who can afford to purchase
TABLE 6-1 Examples of Covered and Noncovered Eye and Vision Items and Services Under Medicare Parts A and B
|Covered Services||Noncovered Services|
supplemental insurance, which leaves many beneficiaries without coverage for basic eye and vision care or corrective lenses.
Opportunities for Action
The field of vision and eye health affords prime opportunities for value-driven initiatives that will facilitate patient-centered population health improvements in care. In particular, many opportunities exist to use payment policies as a mechanism to expand access to eye and vision care. This section explores a few of these opportunities.
Changing Medicare statute Historically, insurance coverage was designed to cover catastrophic injury and acute conditions rather than chronic conditions and prevention, which led to the exclusion of services that are essential to improving the metrics of population health. Lack of coverage contributes to out-of-pocket costs, but it also makes tracking utilization, cost by payer, and eye health outcome data difficult, not only across provider type, but also across a patient’s lifespan and episodes of care. Although the costs of a comprehensive eye examination and eyeglasses to correct deficits in visual acuity may not be great in comparison to the costs of treating chronic vision impairment from conditions such as glaucoma or cataract, these expenses need to be viewed from the perspective of the patient and the potential to reduce harm to the beneficiary. This is not unique to the field, because the same divisions exist in the field of oral health.
Moreover, advances in medical treatments and technologies have greatly expanded both the cost and scope of treatment applications for lens-containing devices, and the underlying principles of insurance coverage have shifted from an indemnity system to cover large expenses to a coverage system intended to assure delivery of essential services. Because of their high cost, many Medicare beneficiaries may be unable to afford either the procedure or many types of vision assistive equipment without financial assistance in the form of insurance coverage. Under these conditions, arguments for excluding certain eye examinations related to prescription lenses, however they are defined, may no longer be valid. This is significant considering that vision impairment is highly concentrated in the Medicare population, with prevalence rates rising from 1.49 percent for 65- to 69-year-olds to 25.66 percent for individuals ages 80 and older (NEI, 2016).
CMS policies governing who is qualified to bill for specific services also restrict provision of low vision rehabilitation services. Current policy states that licensed vision rehabilitation personnel can only include ophthalmologists, optometrists, occupational/physical therapists, or social workers
(AHRQ, 2004).20 The 2003 Medicare Prescription Drug, Improvement, and Modernization Act authorized the Medicare Low Vision Rehabilitation Demonstration Project, which was designed to “document coverage mechanisms for services provided by alternative vision rehabilitation providers,” including low vision therapists, orientation and mobility specialists, and vision rehabilitation therapists (Coan, n.d.). Evaluation of the project found that the professionals were significantly underutilized, but did not make any recommendations about Medicare coverage of low vision services (Bishop et al., 2010). Some experts criticized the project design, including a lack of data necessary to identify all beneficiaries eligible for vision rehabilitation services, lack of vision rehabilitation services in some demonstration areas, and lack of “specificity, with respect to variables, data analysis, and quantitative analysis, required to pass the peer review process that is required for other federally funded research protocols” (Mogk et al., 2008). Future demonstration projects related to coverage of vision assistive equipment and to expand the definition of Medicare-approved providers working in vision rehabilitation will need to account for these issues.
Evidence-based guidelines can help inform specific payment policies related to “routine” eye examinations and corrective lenses, as well as qualified providers for rehabilitation services. As discussed in Chapter 7, professional societies for both ophthalmologists and optometrists release evidence-based guidelines as a tool to implement efficient and consistent care based on an established evidence base, though there are differences between the guidelines. Many health plans use these guidelines to make coverage decisions, which can become problematic when evidence is lacking or misinterpreted (Garber, 2001; Woolf et al., 1999). A unified set of evidence-based guidelines would be helpful to guide changes to CMS payment policies, especially those related to comprehensive eye examinations for asymptomatic patients, corrective lenses, and rehabilitation services.
“Welcome to Medicare” and the annual wellness visit Inclusion of eye and vision health as a measure of overall health is a logical fit for regular wellness examinations, preventive care, and chronic disease management already offered through the Medicare program. As defined in the Code of Federal Regulations, the initial preventive physical exam (IPPE), among other services, includes a visual acuity screen.21Gower and colleagues (2013) noted that broader inclusion of eye and vision care in the IPPE could lead to earlier detection of high-cost, irreversible eye diseases because
20 The U.S. Code defines doctors of optometry as physicians with respect to the provision of certain items or services related to the Medicare and Medicaid programs (42 U.S.C. 1395x).
21 Initial Preventive Physical Examination: Conditions for and Limitations on Coverage, 42 C.F.R. § 410.16 (2008).
Medicare claims show that the uptake for certain services on their own, such as glaucoma screening, is low among beneficiaries. The first visit should, in addition to the visual acuity screen, also establish a “list of risk factors and conditions for which primary, secondary or tertiary interventions are recommended or are underway for the individual, including . . . any such risk factors or conditions that have been identified through an initial preventive physical examination.”22 Under these definitions, conditions that relate to deficits in visual acuity could be included on the patient’s list of risk factors and conditions.
After the first IPPE, the ACA (§ 4103) authorizes an annual wellness visit (AWV), which does not explicitly include another visual acuity test.23 As part of the AWV, a health care provider must include a health risk assessment (HRA). The HRA allows a physician to evaluate the health status and risk of an individual through a personal prevention plan that also includes counseling, coaching, and behavior change interventions (Staley et al., 2011). Among other functions, the HRA may be used to identify chronic diseases, injury risks, modifiable risk factors, and the urgent health needs of an individual through encounters with a health care professional or community-based prevention programs (CDC, 2015b). A loss of vision is associated with negative health outcomes beyond vision impairment, including reduced quality of life, higher likelihood of falls, increased odds of nursing home placement, and unintentional mortality (Dhital et al., 2010; Klein et al., 2003; Lee et al., 2002).
Incorporating questions regarding visual function would be an appropriate short-term solution, as the questions relate to the review and potential update on functional ability and level of safety (which at a minimum includes hearing impairment, activities of daily living, falls risk, and home safety). CMS has not officially announced what the HRA must include. The sample HRA that CMS provided asks about exercise, tobacco use, alcohol use, nutrition, seat belt use, anxiety, high stress, social support, pain, depression, general support, activities of daily living, sleep, blood pressure, cholesterol, blood glucose, and height and weight (CVFP, 2016). The sample HRA does not include any questions related to the social determinants of health beyond social or emotional support, nor are there questions specific to vision, but the goals of the program parallel those goals laid out by the committee in Chapter 1 to advance a population health approach that will improve eye health in the United States (CVFP, 2016; Loeppke, 2011). The sample is not meant to be a prototype; questions included in the HRA should be prioritized, but providers should ask questions with a “capability to tailor and drill down
22 Annual Wellness Visits Providing Personalized Prevention Plan Services: Conditions for and Limitations on Coverage, 42 C.F.R. § 410.15 (2011).
with additional queries depending upon patients’ responses” (Goetzel et al., 2011, p. 22). Emerging technologies have also demonstrated an initial promise for making possible rapid and portable tests for visual acuity, but these methods should be appropriately validated and tested before being widely adopted for use in the AWV (Arora et al., 2014a).
Although inclusion of vision-specific questions during the AWV would be a relatively straightforward way to incorporate eye and vision health into existing health policy without requiring statutory changes, it is limited by utilization of the benefit in general. Although the number of Medicare beneficiaries receiving an IPPE or an AWV has been increasing (CMS, 2011, 2014a, 2015b), a survey found that only 2.8 percent of eligible individuals had an IPPE and 63 percent were unaware of the benefit (Petroski and Regan, 2009). Another study found that about 96 percent of primary care physicians surveyed were aware of the AWV benefit, yet two-thirds of those physicians conducted fewer than 10 AWV visits per month (Hurley et al., 2016). Thus, the impact of the AWV on eye and vision health among Medicare beneficiaries would turn, in part, on efforts to expand utilization of the IPPE and AWV benefit.
Payment for telemedicine An Institute of Medicine (IOM) workshop on “The Role of Telehealth in an Evolving Health Care Environment” discussed the potential for telemedicine to expand access through “creating better reimbursement models” but it would be important to consider how to “remov[e] barriers for providers to take advantage of those models” (IOM, 2012, p. 38). Provider payment will be an important variable affecting the degree of accessibility to telemedicine. Literature suggests that providers may be skeptical or hesitant to adopt telemedicine technology because of a multitude of factors, one of which is difficulty procuring what providers perceive as insufficient payment for services (Brooks et al., 2013; Shimizu and Chorneau, 2009). For example, in a policy statement released by the American Academy of Pediatrics, “inadequate payment for services” is addressed as a barrier to telemedicine expansion (Burke et al., 2015).
Medicare’s current payment policy has been described as “restrictive” (Horton et al., 2014, p. 196; Neufeld et al., 2015). To qualify for telemedicine payment, authorized originating sites must either fall outside a metropolitan area or be in a geographic “health professional shortage area” (HRSA, 2016). Counseling for smoking cessation and the AWV are two reimbursable telehealth services for 2016 (CMS, 2015c). In addition, Medicare Part B limits the services that can be provided, and telescreening for eye disease is not explicitly covered (CMS, 2015c). Medicare will only cover services that “mimic normal face-to-face interactions” but does not cover
store-and-forward applications,24 which are utilized in teleophthalmology and teleoptometry for retinal imaging (Horton et al., 2014; HRSA, 2016). Similar to the variations observed in scope and coverage for in-person eye and vision care services, Medicaid reimbursement is dependent on the state (CCHP, 2014). More than 40 of the individual states perform some type of reimbursement for telehealth (Quashie, 2012). California is one state that has expanded Medicaid to cover teleophthalmology for eligible beneficiaries (CDHCS, 2016).
Demonstration projects aimed at evaluating the impact of telemedicine on health care delivery, especially in the context of “high-value purchasing strategies, market power, payment reform, and benefit design,” could allow for more widespread adoption across the nation, especially for ophthalmologic and optometric services (Delbanco and Tessitore, 2016). The Congressional Budget Office noted that the “results of a demonstration project conducted in the fee-for-service Medicare program could be especially valuable in light of particular challenges of controlling spending on new benefits in that program” (Housman et al., 2015). While the committee acknowledges that there are reservations regarding full substitution of telehealth services for in-person care delivery, a demonstration project to examine the cost-effectiveness and vision outcomes could serve to advise policy makers on budget considerations for the expansion of teleophthalmology and teleoptometry services for populations that may need this care the most.
At present, Medicare spending on telehealth is below projections. An analysis of Medicare spending in 2012 found that total telemedicine-related expenditures were about $5 million, or only 65.2 percent of the total budget allocated to telemedicine for that year (Neufeld and Doarn, 2015). The annual cost to each Medicare beneficiary was just $0.09, indicating that actual telemedicine expenditures have been significantly below earlier budget projections (Neufeld and Doarn, 2015). The Medicare Telehealth Parity Act of 201525 was introduced to the House Energy and Commerce Committee in July 2015, but was last referred to the House Subcommittee on Health with no further action. This bill, among other things, would extend qualified sites for telehealth payments to include any federally qualified health center, rural health clinic, and home telehealth sites; authorize additional telehealth providers; and develop additional payment methods. Medicare and Medicaid’s payment policies have broader implications on the larger health insurance market; the responses from one 2012 survey
24 “Store-and-Forward Telehealth involves the acquisition and storing of clinical information (e.g., data, image, sound, video) that is then forwarded to (or retrieved by) another site for clinical evaluation” (VA, 2015).
25 H.R. 2948, 114th Congress (2015–2016), July 7, 2015.
of insurance providers demonstrated government rules for telemedicine payment were highly influential for determining payment policies for other insurance providers (Antoniotti et al., 2014). This compounds the need for CMS to update telemedicine payment policies to reflect the most current evidence and emerging technological capabilities.
Medicaid and the Children’s Health Insurance Program
Medicaid is the largest health insurance provider in the United States, covering approximately 62 million people, or one in five Americans and one in three children (Kaiser Family Foundation, 2013). It covers low-income families, children, pregnant women, parents, seniors, people with severe disabilities, and low-income Medicare beneficiaries (Kaiser Family Foundation, 2013; Medicaid, 2016c). CHIP provides insurance coverage for children under age 19 in families with incomes too high to qualify for Medicaid (Medicaid, 2016c). CHIP operates as a distinct entity from Medicaid, an expansion of a state’s Medicaid program, or as some combination of the two program types, depending on the state (Medicaid, 2016d).
In 2015, the average monthly enrollment in Medicaid among beneficiaries receiving coverage because of blindness, vision impairment, or disability was 10 million, or about 16 percent of the total Medicaid beneficiary population. By 2025, this number is projected to increase to 11 million enrollees (CBO, 2016). The unduplicated annual enrollment of blind or disabled Medicaid and CHIP beneficiaries was 10.7 million out of 72.8 million total enrollees in 2013, up from 6.5 million out of 43.3 million total enrollees in 1995 (HHS, 2013a). In 2011, individuals with vision difficulties comprised 5.8 percent of the total population of U.S. adults over age 18 who were receiving income-based government assistance through programs such as Medicaid (Boursiquot and Brault, 2013).
Overview of Medicaid and the Children’s Health Insurance Program Coverage
Medicaid programs are managed individually by the states, but are jointly funded by the state and federal governments. Each state’s Medicaid program must operate within federal guidelines, but the state has leeway to “determine the type, amount, duration, and scope of services within federal guidelines” (Medicaid, 2016a). As a precondition for federal funding, federal law requires state Medicaid programs to extend coverage to certain populations and allows states to individually determine whether additional populations will be covered under the program (Medicaid, 2016c). Similarly, state Medicaid programs are required to offer specific mandatory
services in exchange for federal support dollars, but may expand coverage benefits to include optional services.
Mandatory vision-related services All plans that cover children and adolescents must provide basic eye care services and treatment under the early and periodic screening, diagnostic, and treatment (EPSDT) benefit (CMS, 2014b). This requirement guarantees comprehensive and preventive health care services for Medicaid-enrolled children under age 21, including the diagnosis and treatment of vision conditions or diseases as well as the provision of eyeglasses as necessary (Medicaid, 2016b). States that designate CHIP as part of the Medicaid expansion program must ensure EPSDT coverage for all CHIP beneficiaries (Medicaid, 2016a). States that operate CHIP as a separate program have the option to pick coverage options that similarly meet all federal requirements (Medicaid, 2016a). At a minimum, the vision screening component in each state must include diagnosis and treatment for vision defects. These screenings occur at “regular intervals,” which may be determined by the state but should be based on current practices of pediatric care and must be reviewed by the state to ensure that the periodicity schedule reflects best practices (AAP, 2016).26 When vision screening results require further evaluation, diagnostic services must be provided, and “necessary referrals should be made without delay and there should be follow-up to ensure the enrollee receives a complete diagnostic evaluation” (Medicaid, 2016b). Each state determines how frequently these services are provided (Medicaid, 2016b). Medically necessary services to correct problems found during vision screenings, including eyeglasses and their replacement if lost, stolen, or broken, are covered. EPSDT also includes medically necessary screenings outside of the state’s screening schedule, if there is a change in the child’s condition that warrants examination.
Optional vision-related services Individual states determine which optional benefits to offer under Medicaid, and those benefits may include the provision of eyeglasses and optometric, diagnostic, screening, preventive, and rehabilitative services, as well as prescription drugs, dental care, physical and occupational therapy, and podiatric services, among others (Medicaid, 2016a). As of 2012, Medicaid programs in all states and the District of
26 CMS recommends Bright Futures of the American Academy of Pediatrics (AAP) as a reasonable and current periodicity schedule. Currently, AAP’s vision schedule includes “risk assessments to be performed with appropriate action to follow, if positive” at regular intervals until age 3. Assessments should be performed at ages 3–6, 8, 10, 12, 15, and 18, with risk assessments at all other ages until 21 (AAP, 2016).
Columbia covered optometric services and 41 states and the District of Columbia covered the cost of eyeglasses (Kaiser Family Foundation, 2012a, 2012b). To better understand the differences in vision-related coverage under state Medicaid programs, the committee collected information from state websites and other sources to catalogue the types and scope of vision-related services offered by states for adults and for children beyond the mandatory essential health benefits (see Appendix G).27,28
There are wide variations among states in Medicaid coverage for vision benefits. Most states provide coverage to those over age 21 for some eye care services, including optometric examinations, eyeglasses and contact lenses, cataract surgery, and emergency medical procedures. Although many states cover periodic vision examinations for all or most adult beneficiaries (usually between every 1 and 3 years), fewer states cover eyeglasses for that same population.
Of the states that do cover eyeglasses, many cover them only for a specific population, typically post-op cataract patients, pregnant women, and long-term residents of nursing or other types of facilities. For example, Delaware, a state that has expanded Medicaid coverage, does not cover routine eye care or corrective lenses for adults, unless these supplies and services are incident to cataract surgery (DMAP, 2016; Kaiser Family Foundation, 2016c). Similarly Arkansas, a state that also has expanded coverage, limits the Medicaid benefit to “a total of twelve (12) office visits allowed per fiscal year for any combination of the following: certified nurse midwife, nurse practitioner, physician, medical services provided by a dentist, medical services furnished by an optometrist and Rural Health Clinics” (Arkansas DHS, 2012, p. 7; Kaiser Family Foundation, 2016c). Conversely, Iowa will cover routine eye examinations once every year, nonroutine eye examinations when presented with a complaint or injury, and corrective lenses (Iowa DHS, 2014). The state of Washington will cover eye examinations for asymptomatic adults every 2 years, and additionally covers vision therapy with prior authorization, including lenses,
27 The committee found it difficult to locate and, sometimes, to access current information on Medicaid vision benefits, including a description of what services or benefits are covered, by whom, and how often. Some states provided a list enumerating noncovered items or services, but not all states provided such a clear-cut list. Although EPSDT services are explicitly required for state Medicaid programs, many states do not make information readily available to consumers. Similarly, some states do provide a list of covered vision benefits for adults, but the benefits listed are often vague. One state in particular listed more than 100 Current Procedural Terminology (CPT) codes as “covered services,” without describing the procedure to which the codes referred (Cabinet for Health and Family Services, 2007).
28 Individual state Medicaid offices were asked to confirm the data. States that replied are identified in the appendix.
prisms, filters, occlusion or patching, and orthoptic and pleoptic training (WSHCA, 2016).
Expanding Medicaid coverage The Omnibus Budget Reconciliation Act of 1989 expanded EPSDT benefits to encompass codified, inter-periodic screening;0 vision, dental, and hearing coverage; and all services and supplies allowable under the definition of “medical assistance,”29 regardless of eligibility for adult coverage (Naylor, 2013; Rosenbaum and Wise, 2007). Improvements in various clinical and financial outcomes have been associated with the utilization of EPSDT benefits, including a lower rate of emergency department visits, increased care utilization in rural counties, improved navigation of the health care system, and better school readiness (Pittard et al., 2007; Schor et al., 2007; Snowden et al., 2008).
These opportunities should not be unique to children and adolescents. Individuals with an annual income of less than $20,000 are more than twice as likely as individuals with incomes above $55,000 to be visually impaired (Salman and Shirey, 2002). Compared to working-age adults without disabilities, those with vision impairment exhibit lower rates of full-time employment (26.4 percent versus 56.8 percent), lower median annual earnings ($35,300 versus $43,300), and lower median annual household income ($36,500 versus $62,000) (Erickson et al., 2014; Kraus, 2015). This restricts their opportunities for enrolling in employment-based vision plans. One study from the dental field demonstrated that Massachusetts’ Medicaid expansion of dental benefits to all adults ages 19 to 64 who were below the federal poverty level increased care utilization by 11 percent; when coverage for dental services was eliminated, the state saved less than 1 percent of total MassHealth spending (Nasseh and Vujicic, 2013). State Medicaid programs do provide some coverage for adult eye and vision health services and supplies, but the scope of coverage varies considerably (see Appendix G). In addition, states face challenges balancing growing demand with decreasing budgets. However, when debating coverage determinations and qualifying individuals, states should consider the impact that improved eye and vision care services could have not only on reduced vision impairment but also on downstream health consequences (see Chapter 3).
The exclusion of stand-alone plans from the exchange As mentioned, the exclusion of vision benefits from general health insurance plans is similar to the coverage limitations for dental benefits. Although both the dental
29 Defined as all items and services medically necessary to correct and ameliorate physical and mental conditions and illnesses.
and vision fields have progressed toward better coverage through Medicaid expansion and pediatric oral and vision coverage, both are similarly limited through regulatory restrictions for Medicare.30 However, more Americans have access to some form of dental insurance coverage than have access to vision coverage, with an average of 47 percent of civilian workers reporting access to dental plans versus 26 percent for vision plans (BLS, 2015a).
As written, the ACA does not allow stand-alone vision plans to be featured on the government exchange, while dental plans are featured as either part of a bundled benefit or as a stand-alone plan (Kirkner, 2011; Tozzi, 2014). Stand-alone vision plan companies may enter the exchange only under contracts with ACA-recognized qualified health plans to provide the vision benefits in a bundled benefit package (AOA, 2014). The American Dental Association, Delta Dental Plans Association, and the National Association of Dental Plans were able to successfully advocate for the inclusion of stand-alone dental plans in the federal exchange, arguing that bundling of medical and dental benefits without stand-alone dental plans as an option would raise costs by splitting family policies to remain compliant with the ACA mandate for pediatric dental benefits (Kirkner, 2011).
Conversely, the American Academy of Ophthalmology and the American Optometric Association opposed the inclusion of stand-alone vision plans in federal exchanges (Kirkner, 2011). The organizations argued that “stand-alone vision plan companies aim to turn back the clock by continuing to segment vision from eye health, and seeking to impose misguided limits on the care that our patients—especially children—receive. Such plans are routinely mislabeled as complete or comprehensive . . . any expansion of stand-alone vision plans through health care reform would result in a continuation of non-responsive action and fractured and uncoordinated care” (AAO/AOA, 2009). The National Association of Vision Care Plans (NAVCP), which represents 17 different private plans, countered with the argument that stand-alone plans are better fit to address the barriers to eye care access and utilization (Kirkner, 2011).
A study conducted among 10 managed vision care plans submitting claims data for more than 86 million beneficiaries found individuals enrolled in stand-alone plans were twice as likely to receive an eye examination than those with bundled plans (NAVCP, 2010). The study was published by the NACVP and was not peer-reviewed. Furthermore, this association may not be causal, because intuitively beneficiaries who prioritize the purchase of a stand-alone plan would likely self-select as a group that would be more likely to use this particular benefit than beneficiaries who have access to eye care as part of a bundled plan. However, Li and colleagues (2013) found
30 Limitations on Services of a Doctor of Dental Surgery or Dental Medicine, 42 C.F.R. § 410.24 (1991).
that individuals with vision insurance (as an add-on benefit) were twice as likely to have had an eye care visit in the previous year than those without, further noting that “having general health insurance was not a significant predictor of an eye care visit once vision insurance was included in the model” (p. 501).
The committee acknowledges that the provision of stand-alone vision plans on the exchange may extend access and coverage at the expense of propagating fractured and bifurcated vision and medical care; however, the better access to plans could also increase rates of care utilization and decreased financial barriers to care (see Nasseh and Vujicic, 2013; and Vujicic et al., 2014, for general examples of policies to increase coverage and utilization in oral health). However, significant consideration should be given to weighing the benefits and harms of such a decision, because further fragmenting the field in favor of suboptimal coverage lies in direct opposition to the ACA’s push toward integrated and coordinated care. Opportunities to improve access through other, more preferable means should be identified.
Employment-based insurance is a major source of coverage for services and supplies related to eye care for working age adults under age 65. Unfortunately, comprehensive information detailing employment-based insurance coverage for eye and vision care in the peer-reviewed literature is limited. In 2012, 17 vision insurance companies offered their products in the U.S. marketplace (AOA, 2013). Yet recent surveys suggest that about only half of American adults have some form of vision coverage through various employer-based plans (International Vision Expo East, 2015; Jobson Optical Research, 2012). Among U.S. adults ages 18 and older who had vision problems, 74.7 percent and 17.1 percent had employment-based insurance or public health insurance, respectively, whereas 8.2 percent had no general health insurance coverage (Zhang et al., 2008b). Of individuals with employment-based insurance, 58 percent also had vision insurance, compared with 44 percent of those with public insurance and 4 percent of those without health insurance (Zhang et al., 2008b).
In the United States, populations may purchase either medical or vision insurance or both to help cover expenses related to eye and vision care. A detailed breakdown of expenditures by payer can be found in Chapter 3. Employment-based vision insurance can be offered as a stand-alone insurance plan or as an add-on benefit to general health insurance plans. Most individuals, whether they have employment-based or public medical insurance, must pay additional monthly premiums for general eye examinations and corrective lenses or purchase of stand-alone vision insurance.
Yet employees may be “much more price sensitive to the out-of-pocket premium for fringe benefits other than health insurance” including vision insurance (Royalty and Hagens, 2005, p. 97). Of individuals with vision insurance in 2009, approximately 72 percent were enrolled in a stand-alone vision plan (AOA, 2013). The frequent exclusion of comprehensive vision benefits from general health insurance plans is mirrored by similar coverage limitations for dental benefits. Results from the National Compensation Survey in 2015 suggested that, if vision benefits were offered, they would be well utilized: the survey found a 79 percent take-up rate for employees offered vision care (BLS, 2015a).
Employment-based medical insurance typically covers medical payments for eye injury and various eye diseases such as cataract, glaucoma, and diabetic retinopathy as well as for related corrective lenses (Bihari, 2014; UnitedHealthcare, 2016). In some cases, elective laser surgery for vision correction may also be covered. Most employment-based medical insurance plans do not include any vision benefits related to asymptomatic eye examinations or corrective lenses absent documented risk factors for specific diseases or conditions. Similarly, health insurance exchanges established under the ACA do not cover these services for adults, although vision benefits for families and for children under age 19, as well as small group markets, are required to offer this coverage benefit. The singling out of small group markets in the ACA may reflect historical data suggesting that larger employers are more likely to provide vision insurance for their employees (Spahr, 2015).
The cost and services covered by employment-based vision insurance vary between plans. For example, the Federal Employees Dental and Vision Insurance Program (FEDVIP) offers vision insurance plans through Aetna, Blue Cross Blue Shield, UnitedHealthcare, and Vision Service Plan (VSP). The monthly rates for these plans range from $6.31 to $8.30, and copays range from $0 to $10 per eye exam. See Table 6-2 below for details. The coverage of eye exams under private vision insurance plans available to the general public is similar. For example, three private vision insurance plans offered by VSP all require beneficiaries to pay a $15 copayment for coverage of an annual comprehensive eye exam, and three plans offered by EyeMed either provide full coverage or require a $10 copay for an annual eye exam with dilation as necessary (EyeMed, 2016; VSP, 2016a,b,c). Although these rates may seem relatively low compared to medical insurance, these additional costs to people with few financial resources can serve as a barrier to critical care, especially in at-risk populations.
Employers are an important source of the provision of medical and vision insurance, though benefits vary by plan in terms of the type of coverage and the costs. A 2014 Kaiser Family Foundation survey of employers
TABLE 6-2 Costs and Coverage of Employment-Based Vision Insurance Plans
|Plan Profile||Aetna Vision-Standard||FEP BlueVision-Standard||UnitedHealthcare Vision-Standard||VSP-Standard|
|Family Plan Benefits||$21.32||$24.87||$18.35||$23.86|
|Vision Exam||Every 12 months||Every 12 months||Every 12 months||Every 12 months|
|Vision Lenses Only||Every 12 months||Every 12 months||Every 12 months||Every 12 months|
|Frames Copay (in-network)||Every 24 months||Every 24 months||Every 12 months||Every 12 months|
|$10 lenses/$0 exam, materials||0||$10 exam/$25 materials||$10 exam, $20 eyeglasses|
|Additional Features||Additional lens options, retinal imaging, second pair of eyeglasses, laser vision correction discount||Breakage warranty; choose eyeglasses or contact lenses; laser vision correction discount, low vision coverage||Low vision, prosthetic eye, vision therapy; choose eyeglasses or contact lenses; laser vision correction discount||Prescription eyewear, choose eyeglasses or contact lenses; laser vision correction discount|
NOTES: a Rates are for DC area beneficiaries. Rates may vary by locality.
FEP = federal employee program; VSP = Vision Service Plan.
SOURCE: Adapted from OPM, 2016.
found that only 63 percent of large companies (defined as having 200 or more employees) and 34 percent of small companies (under 200 employees) offered stand-alone vision benefits (Claxton et al., 2014). Cost was cited as the primary reason that companies did not offer ancillary health coverage. The BLS data corroborated this trend, indicating that larger companies were more likely to offer vision benefits: Forty-two percent of companies with 500 employees or more offered vision care benefits, while only 17 percent of companies with under 49 employees offered vision benefits (BLS, 2015a).
Health savings accounts (HSAs) and flexible spending accounts (FSAs) are also offered as a benefit accompanying general medical insurance plans and are often used by consumers to cover vision and eye care expenditures (NAVCP, 2013). Consumer participation is affected by plan type, coverage, and deductibles, and available funds must be spread across competing expenses, such as prescription drugs and copayments (Konrad, 2010). Although these mechanisms are useful for increasing vision and eye care
utilization, they do not substitute for general vision and eye care coverage, because FSAs and HSAs are subject to annual limits (IRS, 2016). Individuals are also responsible for most, if not all, contributions to FSA and HSAs. Given the limitation of consumers having to self-finance these accounts, these benefits may have limited value to low-income individuals (Blumberg, 2008).
The decision to subsidize medical costs and not vision costs poses an additional barrier to parity between general medical care and eye and vision care. Voluntary plans allow employers to provide ancillary benefits without significant investment, because employees pay up to the full premium at a group rate (Aetna, 2016). About 60 percent of benefit advisers identified vision insurance as a voluntary benefit plan of high interest to employers, including the federal government (Bradley, 2016). Federal enrollees are responsible for 100 percent of the premiums for the FEDVIP, in contrast to medical insurance, which was subsidized by up to 75 percent by the federal government in 2014 (Cornell, 2015). Thus, employers often subsidize care for eye diseases and conditions that affect older populations, such as glaucoma and cataract, but do not provide equal subsidies for services that are more likely to impact children and young adults, such as detection of refractive error and correction of subsequent vision impairment with eyeglasses or corrective lenses.
The committee was not able to identify robust literature documenting the potential impact of expanding employer-based medical insurance to cover comprehensive eye examinations for asymptomatic patients or corrective lenses on the cost of coverage, the number of insured people, or on access to timely and appropriate eye and vision care. The committee was not able to find any peer-reviewed literature that documents the average cost (both to the insurer and average out-of-pocket costs) for corrective lenses31 and examinations in the private sector, although various independent sources are available that indicate variation in pricing based on a variety of factors (e.g., Aetna, 2016; Blue Cross Blue Shield, 2016; CMS, 2014b; OkCopay, 201632; UnitedHealthcare, 2016; VSP, 2016d). However, basic economic theory states that reducing the cost to consumers will increase participation in insurance plans. To better understand the impacts of various coverage decisions on total health expenditure and health outcomes, especially on a national scale, it will be important for insurers and health care providers to be more transparent in the costs associated with eye and vision care. More research is needed to guide evidence-based policies
32 OkCopay provides free information on health care costs and is unaffiliated with insurance providers or health care providers. Data on eye exam cost is compiled from surveys of eye care providers performed by OkCopay, publicly available claims data, and provider websites.
that ensure higher rates of insurance coverage for comprehensive eye examinations and corrective lenses in employment-based insurance markets. This will likely include a more robust literature on the cost-effectiveness and comparative effectiveness of particular services and equipment or devices.
In Improving the Nation’s Vision Health: A Coordinated Public Health Approach, the Centers for Disease Control and Prevention (CDC) stated that “cost-effectiveness information is . . . needed to establish that expenditures for prevention and treatment interventions are justified” (CDC, 2009, p. 24). Cost-effectiveness research has the potential to inform payment policy for eye and vision health broadly, although the existing cost-effectiveness literature related to eye and vision health tends to focus on the detection, treatment, and management of a singular eye disease or condition. For example, Brown and colleagues (2013) analyzed the cost-utility of cataract surgery and found that third-party insurer and overall societal per-QALY costs for unilateral cataract surgery were $1,636/QALY and $74,759/QALY respectively, indicating cost-effectiveness. The study also found that the 13-year return on investment for a 1-year cohort of cataract surgery patients equated to $36.4 in savings for Medicare and $48.6 billion in savings for patients (Brown et al., 2013), although aspects of the study’s methodology have drawn criticism (Lee and Kymes, 2015). A modeling study of patients ages 65 and older with cataract and astigmatism found that those who received astigmatism-correcting toric intraocular lenses (IOLs), as compared to conventional IOLs with or without intraoperative refractive correction, were more likely to achieve uncorrected visual acuity of 20/25 or better (Ochoa et al., 2014). Toric IOLs were also associated with lifetime cost savings of $34 per patient and $349/QALY compared to conventional IOLs. Rein and colleagues (2009) used computer models to determine that office-based identification of glaucoma through routine eye examinations and subsequent American Academy of Ophthalmology (AAO)-recommended treatment of glaucoma is cost-effective at $28,000 to $46,000 per QALY gained compared to no treatment, depending on the assumed efficacy of treatment. The cost per QALY dropped to $11,000 to $20,000, depending on assumed efficacy of treatment, when the costs of eye examinations (which include tests and procedures unrelated to detection of glaucoma) were excluded. The probability that routine eye examination followed by recommended treatment would be cost-effective was greater than 99 percent for a willingness to pay of $14,000 per QALY (assuming high treatment efficacy and excluding examination costs) to $64,000 per QALY (assuming low treatment efficacy and including examination costs) (Rein et al., 2009).
Despite some studies finding specific instances of cost-effectiveness, overall the literature on cost-effectiveness or risk-benefit for eye and vision health remains insufficient, especially in the context of vision screenings. For instance, the U.S. Preventive Services Task Force found an inadequacy of direct evidence on the benefits and harms of glaucoma screening (Moyer, 2013; USPSTF, 2013). The Agency for Healthcare Research and Quality (AHRQ) was unable to identify studies addressing five of these six key questions when attempting to determine the predictive value and harms of glaucoma screening programs (AHRQ, 2012). Evidence on the predictive value of glaucoma screening tests was identified, but “the lack of a definitive diagnostic reference standard for glaucoma and heterogeneity in the design and conduct of the studies” prevented a coherent synthesis of the data (AHRQ, 2012, p. 15). Another systematic review found that available cost-effectiveness research was insufficient for developing glaucoma screening recommendations (Hernandez et al., 2008). Because glaucoma disproportionately impacts African Americans, the paucity of research to guide development of effective and cost-effective glaucoma screening programs may have the adverse impact of perpetuating disparities in eye and vision health. The application of some cost-effectiveness research may be further limited by a lack of generalizability to the U.S. population (Tamura et al., 2015).
Cost-effectiveness may be influenced by many factors, including the eye disease and vision impairment risk profile of the targeted population, the screening interval, the diagnostic accuracy of screening tools, the staffing models used in a screening program, the rate of follow-up after abnormal screening results, the efficacy of available clinical treatments, and numerous other factors. One review found significant variation in the cost-effectiveness of different diabetic retinopathy screening efforts, noting the influence of differences in the size and age of the screened population, whether a program employed a systematic or opportunistic model of screening, the extent of centralization of the screening processes, and the screening interval on the cost-effectiveness of the screening efforts (Jones and Edwards, 2010). Whether a particular screening is found to be cost-effective can also be influenced by whether the screening occurs alone or in combination with other treatments (e.g., Chan et al., 2015; Rein et al., 2012b). Assumptions about patients’ willingness to pay also affect the range in which specific screenings are determined to be cost-effective (Rein et al., 2012a). Blumberg and colleagues (2014) found that the costs of specific types of glaucoma screening (i.e., spectral-domain optical coherence tomography), as well as its effect on visual field loss, were sensitive to assumed rates of follow-up care, suggesting that efforts to promote patient and provider adherence to follow-up and referral guidelines could improve the effectiveness and cost-effectiveness of glaucoma screening.
Cost-effectiveness may also turn on prevalence of a specific disease. For example, Burr and colleagues (2007) performed a systematic review and economic evaluation to determine the cost-effectiveness of glaucoma screening in the United Kingdom and found that the prevalence of glaucoma among adults age 40 was 0.3 percent, but would have to be approximately 3 percent to 4 percent for screening to approach cost-effectiveness. Targeted screenings of high-risk populations may be more clinically effective and cost-effective (Blumberg et al., 2014; Burr et al., 2007; Ladapo et al., 2012). Research on these and other issues is needed, but remains limited (Azuara-Blanco et al., 2016; Blumberg et al., 2014; Burr et al., 2007; Ladapo et al., 2012).
There are several government-funded initiatives to encourage cost-effectiveness research, but these are generally discrete efforts from individual agencies. For example, the CDC developed a discrete simulation model called the CDC and Research Triangle Institute (RTI) Multiple Eye Disease Simulation (CR-MEDS) to estimate the combined economic impact of major adult eye and vision disorders in the United States (CDC, 2015a). Models for diabetes, amblyopia, and comprehensive eye examinations are similarly being studied (CDC, 2015a; Hoerger et al., 2009, p. 9). Similarly, insurance providers can also participate in cost-effectiveness research, especially research that examines the impact of expanding coverage of preventive services or corrective lenses on long-term costs associated with chronic vision impairment, as part of ongoing continuous quality improvement programs (see Chapter 7). The recent passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)33 is a recent example of efforts to promote value-driven care through, for example, the creation of the quality payment program. The impact of the law cannot be assessed because its provisions are being gradually phased in through 2021, but the committee is optimistic about its potential impact for providers and patients.
Several databases exist to catalog cost-effectiveness research studies. These include the AHRQ Clinical Economics Research Database and the Cost-Effectiveness Analysis Registry (CEA Registry) (NICHSR, 2016). Two other databases have lost funding: The National Health Service (NHS) Economic Evaluation Database (EED) lost funding in early 2015, though the information can still be accessed (Cochrane Community Archive, 2015). Similarly, the Health Economic Evaluations Database ceased publication in 2014, though the articles can be accessed through the publisher (John Wiley & Sons, Inc., 2016). The databases vary in the features that they include; for example, the NHS EED includes a critical appraisal by health economists, while the others do not (NICHSR, 2016). Similarly, the CEA Registry
33 P.L. 114-10, 114th Congress, April 16, 2015.
only catalogues studies that use the QALY metric (NICHSR, 2016). The AHRQ Clinical Economics Research Database is limited to publications funded by the government and only includes studies published from 1997 to 2001 (AHRQ, 2014). Unlike the Cochrane Database, the databases centered on economic evaluation do not use catalogued information to generate systematic reviews, with one exception. The CEA Registry does facilitate such studies, but they are hugely limited. For example, in 2015 only five studies were published from CEA Registry data across all subjects (CEA Registry, 2015). While these databases are critical to facilitating research and encouraging collaborative studies, they are limited in their scope by the lack of sustainable funding.
More research is needed to accurately characterize the factors affecting, and effectiveness of, different treatments and screening techniques for different eye diseases and conditions. Research should include the cost-effectiveness of vision screenings versus comprehensive eye examinations (including rates of follow-up care), the validity and reliability of the methodological techniques used to assess screening, the effectiveness and cost-effectiveness of screening models that have the capacity to detect multiple eye diseases, and what resources are necessary to facilitate access to the appropriate services. Moreover, a research program with sustainable funding sources that evaluates the cost-effectiveness of vision and eye health prevention, treatment, and management could support the development of evidence-based guidelines (see Chapter 7), value-based payment policies, and coverage determinations that better promote value-based eye and vision care.
Access to clinical services is only one determinant of eye and vision health and 1 of 10 essential public health services (see Chapter 1) that comprise an overarching population health approach to reduce the impact of vision loss and impairment in the United States. However, given the number of people at risk for and affected by uncorrectable and correctable vision impairment, especially in the context of an aging population and the long-term effects of uncorrected vision impairment in childhood, appropriate entry into the eye and vision care system becomes an elevated concern. Overarching social and political barriers, including the availablity of trained eye and vision care professionals, existing payment policies, and the availability of vision insurance, have direct implications for populations who are most in need of assistance and likely to suffer from uncorrectable or uncorrected vision impairment.
Understanding the roles of traditional eye and vision care providers can help policy makers assess the adequacy of the workforce to address growing
demands and determine how best to reach underserved populations through emerging technologies, including telemedicine and telescreening, as complementary services to critical in-person examinations and treatments. It will also be important for the eye and vision field to establish clear messaging about the roles of eye and vision care professionals to communicate effectively with other health care providers and the public. Ensuring diversity within the eye and vision health workforce can help address observed inequities in vision impairment prevalence and severity among different populations. A comprehensive understanding of the distribution and needs of the workforce could help clarify the directions that policy makers should take to mitigate these disparities.
Payment policies have the ability to not only expand coverage of evidence-based services to at-risk populations, but also incorporate eye and vision health into national policy discussions about chronic conditions and how eye and vision health can help promote function and overall quality of life. Unfortunately, the bifurcation of coverage for eye and vision services between traditional health insurance and separate vision insurance exacerbates inequities in eye and vision care and reflects historical decisions and distinctions that no longer reflect available evidence and trends in payment policies for other similarly placed services. A number of currently
reimbursable services could incorporate elements related to eye and vision health into existing platforms in order to improve the health and well-being of Medicare beneficiaries. There are additional opportunities to reexamine broader Medicare, Medicaid, and private coverage decisions and policies related to eye and vision care that could help reduce the impact of vision impairment (e.g., allowing Medicare to cover routine eye examinations, corrective lenses, and certain rehabilitation services, as well as expanding or reducing state variability in Medicaid benefits). These opportunities involve varying degrees of regulatory, procedural, or economic hurdles and should account for the different populations at risk for different etiologies of vision loss.
Changes in payment policies should reflect the best available evidence, including evidence-based guidelines (see Chapter 7). To better inform decision makers, additional research related to the eye and vision care workforce and payment policies is needed. Box 6-1 includes key research gaps identified in this chapter. Investment in cost-effectiveness research may help identify opportunities to reduce or shift the economic costs associated with vision impairment and strengthen clinical practice guidelines.
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