Medicare’s glaucoma screening benefit a failure

After analyzing Medicare data on the 2002 glaucoma screening benefit, the authors of this editorial discovered that the benefit has essentially been unused. They offer suggestions as to why it has missed its target and how to re-focus the effort.

When the glaucoma screening benefit went into effect in January 2002, it was hailed a huge victory. It was the first time Medicare offered a screening benefit for an ocular disease. The benefit covers an annual dilated eye examination with an IOP measurement and direct ophthalmoscopy or slit-lamp biomicroscopic examination for individuals at high risk of glaucoma. Initially, high-risk individuals were defined as all African Americans aged 50 or older and individuals of any age or race/ethnicity with diabetes or a family history of glaucoma. In 2006, the benefit was expanded to cover Hispanics aged 65 and older.

To determine the actual impact the screening benefit has had on identifying persons with glaucoma, the authors analyzed publically available Medicare Part B National Summary Data and found that the code has been used only around 1,000 times annually, with utilization falling to just 405 claims in 2010. At the same time, they estimate that nearly 400,000 minorities with glaucoma remain undiagnosed in the United States each year.

“Not only is the benefit underutilized, but its use has declined over time: 2943 claims were billed in the first year, and the number dropped from 1205 in 2006 to 405 in 2010,” they write. “The screening benefit appears to have been a failure.”

They identify three reasons for the failure:

• Patients must present to an eye doctor to be screened. If a patient already has had a billed eye examination in the past 11 months, Medicare will not cover the benefit.
• The system provides a disincentive for eye doctors to bill under the screening code. The average reimbursement for screening was $46 in 2010, making reimbursement less than the amount doctors would receive for a routine eye examination (approximately $75).
• Medicare requires beneficiaries to pay 20 percent of the screening visit cost after the standard $162 annual deductible has been met. Individuals with limited financial resources who have not met the annual deductible may not be able to pay these costs.

They propose a broader screening approach that will bring additional older patients into eye care and keep them there. One option is to include a covered referral to an eye doctor for a complete eye examination by an eye doctor following the “Welcome to Medicare” initial preventive physical examination, and provide coverage for regular follow-up eye examinations.

They say this approach likely would lead to earlier detection of visual impairment and underlying causes before irreversible vision loss or blindness occurs, and therefore may reduce total Medicare costs.