“In the Year 2525” was a Billboard #1 hit song in 1969, just four years after HR 6675 – a.k.a. the Medicare Act – was signed into law by President Johnson. In the year 2017, a recent JAMA editorial argues for consideration of ‘Medicare coverage of vision, dental and hearing services under Medicare’. Attention should be paid to this long-recognized national need, as witnessed by the continued battle for expanded CMS coverage observed throughout my entire professional career. In reading this viewpoint, however, several things struck me – primarily statements and assumptions made that framed recommendations, and, as still too often seen, the lack of included data and information related to eye and vision care as compared to that for oral health and other sensory systems like hearing.
To begin with some context, a new infographic from Axios gives the breakdown of where insurance coverage comes from for Americans. Kaiser Family Foundation data shows that Medicare covers 43.3 million people, including older individuals and individuals with disabilities:
(NOTE: it’s also interesting that the JAMA authors claim 56 million covered by Medicare, but they do not provide a reference for their statistic).
The first sentence of this viewpoint encountered by the readership states that “Medicare explicitly excludes coverage of dental, vision, and hearing services as a core benefit, leaving beneficiaries responsible for paying for these services on their own or for finding alternative supplemental coverage.” As is, this leading statement is problematic and deserves some attention, especially to fully appreciate where eye and vision care coverage correctly stands in 2017 for Medicare beneficiaries.
Let’s first ask this: what specifically do the authors mean when they say “vision services” and “core benefit”? What message regarding eye and vision care are they trying to convey to the reader? How are they defining these concepts? Only two of ten references listed by the authors mention ‘vision care’ in their titles, and if one were to dig deeper and review them both, one would find both are lacking in accurately representing the current state of eye and vision care in the US:And while the authors include reference a 2016 National Academies of Science, Engineering, and Medicine (NASEM) report on hearing health care , there is no mention of the landmark NASEM report “Making Eye Health a Population Health Imperative” from that same year, nor are any references made to the myriad of evidence-based findings from that report. The authors include information from the American Dental Association, but none from the American Optometric Association (AOA) or other professional eye care entity. This leads me to question how thorough the assumptions were made in this piece regarding eye care and if evidence supports them.
Next, we come across yet another example of framing eye care as “vision services”. What differentiates the continuum of eye and vision care into “services”? What is perceived as a “service”? What separates eye care from other health care into “services”? Is oncology, cardiology, orthopedic, neurological, or pediatric care routinely described as a “service”? Is primary care understood as “primary services”? How do the authors and editors perceive “vision services” relative to population health? Is their perception based on clinical factors like setting, care provider, treatment option, or health insurance coverage? Or is it relative to the writers’ training and background? Aside from wanting honest answers to these questions, my point here is that words – and messaging – matter. They matter to everyone. Language remains critically important in health policy and health care delivery. Language choices persist in the health care literature that continue to frame and misrepresent eye care as ‘less than’ other types of medical care – some words like ‘services’ can be more subtle, some like ‘screening’ are more overt, but all are nonetheless harmful to the importance of comprehensive eye care and awareness by the health care community, patients & their stakeholders, and to public health.
But wait – there’s more! While the overarching statement in principle is correct in that Medicare does not universally cover “routine” or “preventive” eye examination for beneficiaries, the assumptions based on this statement do not accurately reflect the Medicare beneficiary eye and vision care continuum. Along with many fellow eye doctors, over time my patient census has included large numbers of Medicare beneficiaries – primarily because my care focused on the diagnosis and treatment of chronic visual impairment. Eye doctors across the country continue to provide a great deal of needed eye care to individuals that are covered by Medicare, even though “vision” as stated here is not a “core benefit”. In actuality, Medicare does not routinely cover comprehensive eye examination unless a patient has already been diagnosed with a specific medical condition or has a complaint or symptom of an eye problem caused by illness or injury. More specifically, Medicare does not routinely cover refraction procedures, and does not cover optical treatment (i.e., eyeglasses or contact lens prescriptions) except for once following cataract removal. Medicare does provide coverage for care from an eye doctor for people with diabetes, those at high risk for glaucoma, and for some beneficiaries with age-related macular degeneration . For patients with diagnosed vision impairment and other conditions/diseases, Medicare does provide coverage for appropriate rehabilitation therapy and other, but not all, selected treatment options. And, since 1987, care provided by doctors that is covered by Medicare includes doctors of optometry, as optometrists are considered physicians and have parity with physicians as recognized by Centers for Medicare and Medicaid Services (CMS). The information below from the Medicare.gov website is even a bit confusing linguistically, mixing “refraction” (a procedure conducted as part of an eye examination that allows for the diagnosis of refractive error and determines its prescriptive correction) with “eye exams” (also note their use of ‘routine’ vs. ‘preventive and diagnostic’):
At the very end, the authors remark that “Continuing to exclude dental, vision, and hearing services from the covered services under Medicare fails to acknowledge that all these health services and the systems that provide them are interconnected.” This is an important statement as it harkens to the continuum of comprehensive health care that includes coverage for all aspects of care required to provide optimum population health. Medicare doesn’t cover 100% of needed care, and coverage doesn’t extend to “routine” care. From the mountain top view, there is no argument. However, I do question how well the authors understand the aspects of our current U.S. eye care delivery system and the ground game especially at the provider/beneficiary level, and how that perspective connected them to factors leading to the development and specificity of higher-level recommendations and projected economic numbers presented by the authors and editors to the readership.
From the recent NASEM report on eye health alone (in addition to the AOA, American Public Health Association Vision Care Section (APHA-VCS), CDC, NEI-NEHEP, and other sources) we know that there is an across-the-board national lack of awareness by other health care professionals, decision makers, and the public regarding the value, scope, delivery, and population health benefits of comprehensive eye and vision care – in addition to the negative personal, societal, and economic impacts of chronic vision impairment resulting from a lack of accessing available care. Current evidence makes clear that eye and vision care deserves its place as a critical component of our nation’s health continuum, and optometry has uniquely demonstrated this through the provision of years of quality, comprehensive care. What is truly needed is further recognition and integration of eye care by the house of medicine and decision makers, and greater awareness of the eye care spectrum and its value by the public. While quality eye and vision care remains available, it is not yet fully accessible. Continued framing of eye and vision care positioned as separate ‘services’ directly opposes a systematic approach to coordinated care and hinders care integration that evidence shows improves population health.
An ongoing challenge remains in overcoming barriers to those outside of optometry and the eye care community in fully embracing eye care’s importance to overall health. Doctors of optometry well understand the nuances and caveats to caring for Medicare beneficiaries, but as the JAMA piece demonstrates, valid concerns still remain regarding perspectives within the very health care arena in which we work that impact forward progress. How do others view and understand eye care, and care relative to CMS beneficiaries today? Where do our colleagues get their information and how do they evaluate and integrate it? How do other health professionals learn what eye doctors live every day – that as we strive to improve health by maneuvering head-on through a fragmented and constantly changing system of health coverage to effectively care for CMS beneficiaries, eye doctors still face exclusion from the mainstream, misrepresented and essentially dismissed from the getgo with relative ease – just like in the very first sentence of this opinion piece, as if eye care was an estranged relative rarely invited to the health care family table. Join me in the continued good fight for our seats at the table – we need to dine with others & help them also recognize the tremendous value we bring to the family discussions.