January 25, 2008
6 min read

Low vision patients present unique challenge to Medicare system

Ophthalmology advocates call for more aggressive preventative action on the part of the CMS.

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Population at Risk:  Low Vision Patients

Despite making notable strides in recent years in an effort to address low vision patients and their related health problems, the Medicare system continues to struggle to effectively meet the needs of this unique, yet loosely defined, patient population, according to experts in this arena.

A study published last year in Ophthalmology, led by Jonathan C. Javitt, MD, MPH, determined that about 90% of Medicare costs associated with low vision between 1999 and 2003 were non-eye related. Non-eye related conditions associated with low vision cost Medicare more than $2 million annually, according to Dr. Javitt and his co-authors, Zhiyuan Zhou, PhD, and Richard J. Wilke, PhD.

According to Dr. Javitt, the study’s findings could help Medicare officials to view blindness prevention as a money-saving strategy and not as just an obligation.

Jonathan C. Javitt, MD, MPH
Jonathan C. Javitt

“Unfortunately, when you talk about Medicare and low vision, a lot of what’s needed in terms of low vision rehabilitation, to my understanding, is not paid for in Medicare,” Dr. Javitt told Ocular Surgery News in a telephone interview. “You spend money in order to keep people seeing because the Medicare program obligates the government to pay for medically necessary care. But nobody in the policy shop has ever particularly viewed preventing blindness as something that saves Medicare money.”

Dr. Javitt and other advocates for low vision rehabilitation efforts hope the tide might be changing. The belief is that blindness prevention efforts will begin to attract the same resources and attention as forestalling hip fractures in the elderly, which is largely recognized to decrease hospitalizations and reduce related health care costs.

“All of a sudden, we’re able to show that if you are able to prevent blindness and visual impairment, not only does that have a very beneficial effect on the patient, it also has a very significant financial effect on the Medicare program,” Dr. Javitt said.

Study specifics

The retrospective cohort study included 5% of Medicare beneficiaries (about 1.5 million people) enrolled continuously from 1999 to 2003.

Non-eye related costs rose in tandem with advancing vision loss. Patients with moderate loss, severe loss and blindness had annual non-eye related medical costs of $2,193, $3,301 and $4,443, respectively. Those patients had high rates of depression and injury, and often required nursing home care, the study showed.

More than half of low vision cases stemmed from age-related macular degeneration and glaucoma. A significant number of cases were attributed to cataracts that had not been surgically removed, the data showed.

The study is an impetus for the Centers for Medicare and Medicaid Services to build on the new Medicare Glaucoma Detection benefit passed in 2001, according to the American Academy of Ophthalmology. The CMS could also improve the number of diabetics receiving eye exams, another benefit that began in 1998, the AAO said.

Low vision rehabilitation demo

The CMS has taken steps to counteract rising costs related to low vision.

In April 2006, the CMS launched a program called the Low Vision Rehabilitation Demonstration. The implementation of the program, designed to assess the financial impact of home-based rehabilitation services, has been touted by the CMS as having the potential to improve patients’ access to low vision rehabilitation services and enhance their independence

The demo program is expected to last for 5 years, ending in March 2011. It is being conducted at six sites: New York City, Atlanta, Kansas, New Hampshire, North Carolina and Washington state, according to the CMS.

Eligible participants must be diagnosed with moderate to severe visual impairment that cannot be corrected by conventional treatment or surgery, according to a CMS news release.

However, AAO officials have voiced concerns that the program’s limitations – small size and low reimbursement rates – could discourage physicians and patients from participating.

Catherine Cohen
Catherine Cohen

Rehabilitation services must be completed within 90 days and are limited to a lifetime maximum of 9 hours prescribed by an ophthalmologist or optometrist.

In a conference call with OSN, AAO Executive Vice President H. Dunbar Hoskins, MD, and Catherine Cohen, AAO vice president for governmental affairs, said the demonstration may be too limited and poorly designed.

“Having a limit on it makes sense, but having to have it all delivered within a 90-day period doesn’t make any sense at all,” Dr. Hoskins said. “Elderly folks forget. They can get worse in terms of vision.”

The program’s viability depends on reorganization and an adequate number of participants, Ms. Cohen said.

“We are reviewing CMS criteria for analysis of the demonstration to decide if we will support or call for an end to the demo. If the criteria [are] so stacked against any possible recommended Medicare coverage of vision rehab at the end of this, there is no reason to continue,” she said.

Dr. Hoskins said he feels the demonstration project has “basically failed.”

“Since there’s a shortage of ophthalmic technicians anyway, providing them for low vision services for half of what they can get paid in other areas doesn’t make a lot of sense,” Dr. Hoskins said.

In addition, the program is hampered by a lack of measurement criteria, Dr. Hoskins said.

“They don’t really have any way of measuring [its success], and we’d like to see a way to measure it,” he said.

The program needs significant restructuring to gain momentum, Ms. Cohen said.

“Right now, even CMS will tell you that the demo is not working, that practitioners aren’t participating, patients don’t know about it,” Ms. Cohen said.

Yet CMS is making a renewed effort to step up outreach for the demonstration, “a big push on their part because the first year hasn’t gone as expected,” Ms. Cohen said.

No statistics on physician participation or patient enrollment were available.

Researchers receive $6 million grant to develop low vision aids

Researchers at the University of Southern California have received a $6 million National Institutes of Health grant to develop visual aids for senior citizens with severe vision loss.

Norberto Grzywacz, PhD, professor of biomedical engineering at USC’s Viterbi School of Engineering and director of the USC Center for Vision Science and Technology, will serve as principal investigator for the 5-year project.

The USC team will collaborate with researchers at Harvard Medical School and the University of Houston School of Optometry. The teams will focus on low vision problems posed by age-related macular degeneration and other retinal diseases. They will also study neural malfunction associated with low vision, according to a USC news release.

“Aging, injuries and diseases all cause low vision, but the leading causes among older adults and the elderly are impairments such as age-related macular degeneration,” Dr. Grzywacz said in the release. “Our dream is to build devices like intelligent glasses or intelligent television displays that can improve these people’s lives.”

The research teams will develop displays with region-specific contrast enhancement, work to outline and simplify objects to make them more recognizable, and develop tests to assess the effectiveness of the visual display systems. Patients will be trained to use the devices effectively, the release said.

Engineering faculty at USC will work to enhance video contrast, reduce video background “noise” and enhance the outlines of objects to make them more visible to those with low vision, the release said.

Other Medicare initiatives

The Glaucoma Detection benefit passed in 2001 allowed Medicare to cover annual glaucoma screening exams for Medicare Part B beneficiaries deemed at high risk of glaucoma. Medicare covers 80% of the screening exam fee. Beneficiaries must pay out of pocket or use supplemental health insurance to pay the 20% fee balance and deductible, according to CMS.

A glaucoma screening includes a dilated eye exam with IOP measurement and direct ophthalmoscopy exam or slit lamp biomicroscopic exam, the CMS said.

Medicare recipients considered at risk of glaucoma are those with diabetes or a family history of glaucoma, African Americans older than 50 years and Hispanics older than 65 years. Diabetics have almost double the risk of developing glaucoma compared with non-diabetics.

Additionally, the Medicare Modernization Act of 2003 authorized coverage of a “Welcome to Medicare” physical examination for new beneficiaries, which includes functional assessments such as vision, and referral for glaucoma screening. Beneficiaries, however, must undergo the physical exam within 6 months of enrollment in Medicare Part B, according to the CMS.

Dr. Javitt, while praising the “Welcome to Medicare” benefit, said that educating the public on who should be screened remains among the greatest challenges.

“I think the Medicare screening benefit was a very positive step in the right direction, but I also think it needs to be accompanied by some mechanism for increasing utilization of the benefit,” Dr. Javitt said. “For instance, Medicare could send notices to beneficiaries who haven’t been screened. It’s the same thing with diabetes. It would be nothing for the administrator of Medicare to send a note to every diabetic who hasn’t had an eye exam, saying, ‘Here’s why we think routine eye exams are critically important for people with diabetes.’”

For more information:
  • Catherine Cohen can be reached at 1101 Vermont Ave. NW, Suite 700, Washington, DC 20005; 202-737-6662; fax: 202-737-7061; e-mail: cgcohen@aaodc.org.
  • H. Dunbar Hoskins, MD, can be reached at 655 Beach St., San Francisco, CA 94109; 415-561-8510; 415-561-8526; e-mail: dhoskins@aao.org.
  • Jonathan C. Javitt, MD, MPH, can be reached at 1700 Pennsylvania Ave., Suite 400, Washington, DC 20006; e-mail: jjavitt@healthdirections.net.
  • Javitt JC, Zhou Z, Wilke RJ. Association between vision loss and higher medical care costs in Medicare beneficiaries: Costs are greater for those with progressive vision loss. Ophthalmology. 2007;114:238-245.
  • Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.