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Glaucoma detection to be new Medicare benefit
Recently passed legislation will allow patients with risk factors for glaucoma more accessibility to ophthalmic medical care.
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WASHINGTON — Medicare-eligible patients who may be at risk for glaucoma will be able to obtain a glaucoma detection exam starting in January 2002.
The new law has the potential to ease access to care by providing glaucoma detection exams to patients most at risk for the disease: those with a family history of glaucoma, African-Americans and others determined to be at high risk by the Health Care Financing Administration (HCFA). Exact eligibility determinations have yet to be made.
Eligible patients are to receive a glaucoma screening exam at minimum once every 2 years.
First blindness prevention act
This is the first law that actually seeks to prevent blindness, said Carrie Kovar, a public health specialist with the American Academy of Ophthalmology (AAO). This new law will allow Medicare beneficiaries to receive an exam at least once every 2 years.
"That's important because we know that a lot of our seniors aren't getting access to the exams they need," she said. "Right now there is no covered benefit, so it has to come out of their own pocket, which for some is not a feasible alternative. This brings people into the system who might otherwise not have been seen."
According to Ms. Kovar, exact eligibility requirements will be determined through the regulatory process by HCFA.
"For now, we assume that African-Americans and those with a family history will be covered," she said.
There could be an age-defined group that would be eligible for the benefit, but that remains to be determined as well, she added.
The Medicare Glaucoma Detection Act, (part of a larger appropriation act contained in H.R. 4577), was signed into law in December 2000 by President Clinton.
The new Medicare law is the culmination of a 3-year effort spearheaded by the AAO, congressional members and political organizations such as the Congressional Black Caucus. Reps. John Lewis, D-Ga., and Mark Foley, R-Fla., co-authored the legislation.
It is estimated to cost potentially as much as $400 million over 5 years for screening and diagnostic tests, a study by the Lewin Group has determined.
Politics, science and society
The debate over the cost-benefit ratio of glaucoma screenings has been ongoing, according to Eve Higginbotham, MD, professor of ophthalmology and department chair at the University of Maryland School of Medicine in Baltimore. She said studies in the early 1980s and 1990s seemed to demonstrate that the cost of large-scale glaucoma screenings outweighed the benefit to society.
To some degree, she said, the current bill may have been passed more due to political pressures than to the crucible of hard medical science. But in light of newer diagnostic tools that may detect glaucoma earlier, evolving methods for performing rapid visual field assessment and the evolving paradigm shift regarding the nature of the disease, the concept of glaucoma screening can potentially be transformed. Older studies may no longer be relevant, she suggested. Furthermore, if one targets high-risk groups, then the rate of return on screening efforts is certainly higher.
One benefit that can be realized immediately is an increased public awareness of the importance of detecting a serious disease like glaucoma in its earliest stages, she added. This legislation, and its preceding debate, have "definitely elevated this issue in the mind of Congress, the public and the insurance carriers," Dr. Higginbotham said.
Departure from past
Under the previous plan, a patient "had to have something wrong with their eyes, or a specific medical complaint, in order to see an eye doctor and have that visit paid through Medicare," said Heather Freeland, a Medicare reimbursement consultant with Rose and Associates. "This is essentially a 'well-patient benefit,' where you don't have to have anything wrong with your eyes, or have to provide a certain type of chief complaint, in order for Medicare to pay.
"HCFA rules about ophthalmic examinations are very clear, and they're very strict. Medicare states (the determination of) whether a visit is billable is dependent on the patient's complaint, as defined by Medicare, and has nothing to do with the final outcome of the examination," Ms. Freeland said.
That was a problem in the past, she continued, because often patients would not state a medical eye complaint as defined under Medicare. These patients would subsequently be held responsible for their eye care bill.
Patient information and reimbursement
The AAO hopes to work with HCFA on a direct mail campaign to beneficiaries so patients will learn about the new glaucoma detection benefit, Ms. Kovar said. Direct mail has been used with other Medicare early-detection programs such as mammography and colorectal cancer screenings.
The AAO will also approach the Office of Minority Health at the Department of Health and Human Services to provide assistance in getting the word out. The AAO will conduct its own public education campaign as well, she said.
The Glaucoma Foundation and the Glaucoma Research Foundation — two groups with "substantial constituencies" – also will be working hard to increase awareness and get patients in to be seen, she added.
The details of reimbursement for screening exams have not yet been worked out, according to Kim Colman, a specialist with the AAO on Medicare reimbursement issues.
"Right now we have a covered benefit, but the method for getting it paid has not been set out yet. We're waiting for HCFA to give us some direction as to how payment will be documented and determined — whether they will come out with a new ICD-9 code to indicate that the patient is eligible for the benefit or if there will be a new CPT code."
For Your Information:
- Eve Higginbotham, MD, can be reached at the University of Maryland School of Medicine, department of ophthalmology, 419 W. Redwood, Ste. 580, Baltimore, MD 21201; (410) 328-5929; fax: (410) 328-6346; e-mail: fcwejh6786@aol.com.
- Carrie Kovar and Kim Colman are with the American Academy of Ophthalmology's Federal Affairs Office and can reached at 1101 Vermont Ave. NW, Ste. 700, Washington, DC 20005; (202) 737-6662; fax: (202) 737-7061; e-mail: ckovar@aaadc.org. kcolman@aaodc.org.
- Heather Freeland is a health care consultant who can be reached at Rose and Associates, 402 West Wheatland, Ste. 150, Duncanville, TX 75116; (800) 720-9667; fax: (972) 780-8546; e-mail: hfreeland@roseandassociates.com.