BLOG: But who is going to pay for that screening test?
Those of us who have been in eye care for more than 25 years remember how hard we tried to look at the retina.
Detecting a subtle epiretinal membrane, macular thickening from diabetes or a nerve fiber layer defect required a high-resolution binocular view and a lot of experience differentiating normal from abnormal. Color fundus photographs were used to document known exam findings but were feeble at picking up these subtleties if a human couldn’t. That all changed with OCT. Overnight, we gained three-dimensional sectional images down to the cellular level. Identifying microscopic threats to vision became effortless, and examination became truly secondary. Does it really matter that you can see macular thickening if it’s perfectly documented on the OCT?
In this issue’s cover story, we explore the next phase of optical methods for disease detection. Advanced fundus imaging coupled with population-based artificial intelligence analysis is allowing risk stratification for important chronic diseases. Worried about developing dementia like grandma? Retinal nerve fiber analysis and OCT angiography may soon tell you just how likely that will be. (Perhaps a more important question I asked in 2013 is if you really want to know.) Curious about your risk for cardiac disease? Forget the CT scan of your chest. Fundus photos can now predict your coronary calcium score more accurately.
But who is going to pay for these tests? Currently, routine screening eye tests like OCTs and fundus photos cannot be covered by Medicare and other third-party payers. To cover the cost of a test, carriers require an exam by a doctor leading to the suspicion of a finding. An imaging study is then ordered and performed to determine whether that finding is present. This makes perfect sense when a patient comes in with signs and symptoms of a stroke and an MRI is ordered. But when vision (or life) can be threatened by highly common ailments that have few or nebulous early symptoms and exam findings that are challenging or impossible to detect, we should use screening tests if they are available. That’s why we do TB tests, and it’s the same reason there needs to be a reimbursement mechanism for screening tests in eye care offices.
Some practices offer screening diagnostic tests as an out-of-pocket value-added service. That makes sense for some, but if a simple picture can give us earlier detection of common serious illnesses like heart disease, isn’t that a service that everyone deserves?
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