Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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6 Access to Clinical Vision Services: Workforce and Coverage
6 Access to Clinical Vision Services: Workforce and Coverage
Pages 271-324
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From page 271... ...
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)
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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.
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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.
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, 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.
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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.
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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)
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. 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
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. The need for eye care services was defined as "the level of eye-related pathology in the population that requires monitoring or medical treatment."
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. 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.
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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.
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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)
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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.
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. 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)
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. 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)
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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)
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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. COVERAGE FOR EYE AND VISION CARE SERVICES 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)
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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.
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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.
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Part C or Medicare Advantage (CMS, 2016k; Kaiser Family Foundation, 2016b)
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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)
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to correct refractive error eye examination with an intraocular • Annual eye examinations to assess for pressure measurement and either a diabetic retinopathy among individuals direct ophthalmoscopy examination or who are pre-diabetic or possess risk slit-lamp biomicroscopic examination) factors for diabetes for these high-risk individuals: Diabetes mellitus Family history of glaucoma African Americans ages 50 and older Hispanic Americans ages 65 and older • Hydrophilic contact lenses to prevent corneal abrasions • Intraocular photography • Cataract surgery • Ocular photodynamic therapy in con junction with verteporfin (a photosen sitive drug)
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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.
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. 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.
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. 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)
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. 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.
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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)
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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)
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. 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)
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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)
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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)
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, 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)
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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.
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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.
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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)
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contains the committee's definition for "corrective lenses." 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.
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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)
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. 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.
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. 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)
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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
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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.
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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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2015. A predictive screening tool to detect diabetic retinopathy or macular edema in primary health care: Construction, validation and implementation on a mobile application.
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2014. Tele ophthalmology screening for proliferative diabetic retinopathy in urban primary care of fices: An economic analysis.
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2012. Impact of geographic density of eye care professionals on eye care among adults with diabetes.
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2012. 1971–2011: Forty year history of scope expansion into medical eye care.
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2015. The geographic distribution of eye care providers in the United States: Implica tions for a national strategy to improve vision health.
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adults. http://www.vision expoeast.com/Press/Vision-Voice-Newsletter/MVC-Coverage-among-US-Adults (accessed April 7, 2016)
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2010. Access to and use of eye care services in rural Arkansas.
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2013. Vision insurance, eye care visits, and vision impairment among working-age adults in the United States.
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2009. National Rural Health Association policy brief: Workforce series: Primary eye care -- Recruitment and retention of quality health workforce in rural areas: A series of policy papers on the rural health careers pipeline.
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2009. Assessing the need for on-site eye care professionals in com munity health centers.
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Paper read at Second Meeting of the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health, Washington, DC. Staley, P., P
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2008b. Health insurance coverage and use of eye care services.
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