Policy Solutions to Mitigate Gaps in Retina Care Access

Many individuals living in the United States of America do not have access to care provided by a fellowship-trained vitreoretinal physician.^1,2 With the rising rate of metabolic syndrome and heart disease, there will be a continued increase in demand for retina medical and surgical services to manage diabetic retinopathy and other complications secondary to advanced cardiovascular disease. Beyond vasculopathic disease burden, there is a projected increase in the prevalence of other conditions relevant to the retina, such as age-related macular degeneration.^3,4

Similar to the overall physician shortage that has been well characterized,⁵ equitable access to subspecialty retina care is a challenge for policymakers, retina physicians, and the eyecare community. Patients may face greater travel burdens to retina care, particularly those who are elderly, live in rural areas, come from a low-income socioeconomic status or have less than bachelor’s degree education.^1,2

This is especially difficult for patients who require monthly treatment for various retinal diseases (e.g., intravitreal injections for macular degeneration or diabetes). Distributional issues of retina services exist even when accounting for hybrid providers (e.g., general ophthalmologists) who may provide some, but limited, medical retina services such as intravitreal injections and retina laser therapies.^1,2

Disparities in access to medical and surgical retina care extend to clinical trials for patients from communities with higher disease burdens. These patients are not adequately represented, nor do clinical trials tend to occur in more rural communities with more advanced diseases.^6,7 While there are many policy approaches to address this issue, we discuss three potential growth areas, targeting various stakeholders and areas within the healthcare system to help mitigate gaps in access to medical and surgical retina care.

Proposed Policy Solutions

1) More competitive Medicare reimbursement models

A significant proportion of patients seen by ophthalmologists, including retina specialists, fall under Medicare eligibility and thus, Medicare represents a substantial payer for retina and ophthalmological services.⁸ In recent years, The Centers for Medicare & Medicaid Services (CMS) has taken an approach of reimbursement cuts for various surgical subspecialists, including retina specialists.⁹

With frequent reimbursement cuts for examination and procedural codes by CMS, retina specialists are often pressured to see more patients with shorter face-to-face examination times. This results in greater wait times for patients and the potential for suboptimal clinical care to keep up with overhead costs and prior total reimbursement levels.

Part of the issue with CMS fee schedule alterations involves reallocating funds between disciplines of medicine. While increasing reimbursement for primary care fields is critical to maximizing public health, it should not come at the expense of surgical subspecialties. The decline in payments to surgical subspecialties has directly affected the availability of retina specialists and other ophthalmological specialists in underserved areas.

We previously found that the cost to maintain ophthalmology graduate training programs was too burdensome for some training hospitals and systems in underserved areas. For these institutions, primary care programs were maintained, but surgical subspecialty training was not. Any such institution should not have to make such a decision, as primary and surgical care access are critical to optimal public health.

Medicare must reconsider its “single pie” approach to reimbursing physician specialties; rather than allocating percentage reimbursements to specialties at the expense of others, the size of the pie itself should expand, at minimum, to match inflation. This holds especially true, given that physician salary accounts for a meager 8% of US health expenditures. As discussed below, reimbursement models offered by Medicare often do not even cover basic costs for retina services.¹⁰

Some may believe academic centers and affiliate retina fellowships may fill the gap in access to retina care through establishing programs and clinical sites in high need areas due to the nature of graduate medical education (GME) funding and the perceived financial security from federal funding. Academic departments, however, still must meet financial benchmarks for sustainability. An analysis conducted by Berkowitz et al. found that routine vitrectomy procedures’ cost was significantly higher than the maximum allowable Medicare reimbursement (i.e.,>$2000).¹¹

Reimbursement for vitrectomy cases could not cover the total cost per patient unless the cases were completed in less than 27 minutes, overhead reduction by over 50%, or increased reimbursement by 40%.¹¹

Such a model is not financially sustainable and stifles the potentially strong avenue of mitigating gaps in access through academic institutions and GME.

2) Expand Teaching Health Center Graduate Medical Education (THCGME) and Public Service Loan Forgiveness (PSLF)

Physicians often stay and practice where they train for residency.¹² The establishment of GME programs in underserved settings and community-based ambulatory care centers through the Teaching Health Center Graduate Medical Education (THCGME) program has effectively retained physicians in under-resourced areas. However, this program has focused mainly on primary care positions in light of the national shift in emphasizing the importance of health prevention through primary care. In recent years, this program has expanded to include surgical subspecialties such as obstetrics and gynecology. These developments can be used as a model to expand retina training sites and fellowships in high-demand settings.

Debt burden affects most medical students in the United States, affecting over 75% of medical graduates and producing an average loan debt of 200,000 USD. These numbers are even higher for those attending private medical schools.¹³ Declaring bankruptcy on student loans, including medical student loans, is uniquely burdensome due to higher standards and extra legwork compared to filing bankruptcy for business debt, mortgages, etc.¹⁴

Public Service Loan Forgiveness (PSLF) is another program that provides a mechanism to provide debt relief to physicians and surgeons in exchange for their practice in a high need setting. To be eligible, one must be employed full-time by a non-profit or governmental employer and make 120 on-time monthly payments (i.e., 10-years).

However, too often, PSLF funding is threatened rather than expanded.

A targeted expansion of PSLF represents a high yield, high return investment for legislators as maximizing health outcomes leads to exponentially improved productivity.

This return in productivity is even higher when examining improved productivity from preserved vision.

3) Incentivize modernization of diabetic eye screenings

Telehealth, in particular tele-retina, is a rapidly expanding field. Technological innovation allows for a more primary care-friendly, streamlined, and comprehensive diabetic eye screening. While it may not be possible to provide a retina specialist in every high-demand region, the primary care physician can have an expanded role to help bridge gaps. The Remidio FOP NM10 camera, for example, captures retinal images through a non-mydriatic (non-pharmacologically dilated) eye with a 45-degree field of view.

This technology can screen for diabetic retinopathy using an algorithm that takes 10 seconds and has been validated as high quality in multiple peer-reviewed journals.^14-17 However, potential barriers to access exist, namely the cost of this device and user training required.

To hasten implementation and widespread use of such modern tools, reimbursement models must incorporate the cost of purchasing and maintaining such equipment.

Conclusions

In summary, in this article, we outline three evidence- and data-based areas to potentially target stakeholders to bridge gaps in access to retina care. Swift and impactful action must be taken to offset an already high and increasing demand for retina services, especially in areas that currently lack retina care. For those interested in pursuing these policy goals, it is recommended to join your local county and state ophthalmological and medical societies, support political action committees such as OPHTHPAC, and attend state and federal legislation days hosted by organizations such as the American Academy of Ophthalmology (AAO) and American Medical Association (AMA).

References

Ravi Pandit, Turner D Wibbelsman, Thomas Jenkins, David Xu, Anthony Obeid, Allen C Ho; Factors predicting distribution and practice patterns of retina providers across the United States (US). Invest. Ophthalmol. Vis. Sci. 2019;60(9):3961.
Ravi R. Pandit, Turner D. Wibbelsman, Sean P. Considine, Thomas L. Jenkins, David Xu, Hannah J. Levin, Anthony Obeid, Allen C. Ho. Distribution and Practice Patterns of Retina Providers in the United States,Ophthalmology, Volume 127, Issue 11,2020, Pages 1580-1581, ISSN 0161-6420, https://doi.org/10.1016/j.ophtha.2020.04.016.
The Eye Diseases Prevalence Research Group. Prevalence of Age-Related Macular Degeneration in the United States. Arch Ophthalmol. 2004;122(4):564–572. doi:10.1001/archopht.122.4.564
National Eye Institute. Age-Related Macular Degeneration (AMD) Data and Statistics | National Eye Institute (nih.gov)
Ahmed H, Carmody JB. On the Looming Physician Shortage and Strategic Expansion of Graduate Medical Education. Cureus. 2020 Jul 15;12(7):e9216. doi: 10.7759/cureus.9216. PMID: 32821567; PMCID: PMC7430533.
Rebecca R. Soares, Devayu Parikh, Charlotte N. Shields, Travis Peck, Anand Gopal, James Sharpe, Yoshihiro Yonekawa, Geographic Access Disparities to Clinical Trials in Diabetic Eye Disease in the United States,Ophthalmology Retina, Volume 5, Issue 9, 2021, Pages 879-887, ISSN 2468-6530 https://doi.org/10.1016/j.oret.2020.12.006.
Soares RR, Gopal AD, Parikh D, Shields CN, Patel S, Hinkle J, Sharpe J, Ho AC, Regillo CD, Haller J, Yonekawa Y. Geographic Access Disparities of Clinical Trials in Neovascular Age-Related Macular Degeneration in the United States. Am J Ophthalmol. 2021 Apr 20;229:160-168. doi: 10.1016/j.ajo.2021.04.001. Epub ahead of print. PMID: 33848533.
Juarez DT, Guimaraes A, Seto B, Davis JW. Medicare reimbursement to ophthalmologists: a comparison of Hawai'i to other states. Hawaii J Med Public Health. 2015;74(5):169-173.
Centers for Medicare and Medicaid Services Annual Fee Schedule 2022. CMS-1751-F | CMS
Becker Hospital Review Staff. Physician Pay Accounts for 8.6% of Total Healthcare Expenses Becker Hospital Review. 2012
Berkowitz ST, Sternberg P Jr, Patel S. Cost Analysis of Routine Vitrectomy Surgery. Ophthalmol Retina. 2021 Jun;5(6):496-502. doi: 10.1016/j.oret.2021.02.003. Epub 2021 Feb 12. PMID: 33588067.
Association of American Medical Colleges. Physician Retention in State of Residency Training Table C4. Physician Retention in State of Residency Training, by Last Completed GME Specialty | AAMC
Association of American Medical Colleges. Medical School Debt. 2020. https://www.aamc.org/news-insights/7-ways-reduce-medical-school-debt
Forbes. Can you File Bankruptcy on Student Loans. 2021. https://www.forbes.com/advisor/student-loans/can-you-file-bankruptcy-on-student-loans/
Chhablani J, Kaja S, Shah VA. Smartphones in ophthalmology. Indian J Ophthalmol. 2012;60(2):127–31.
Sosale B, Aravind SR, Murthy H, Narayana S, Sharma U, Gowda SGV, et al. Simple, Mobile-based Artificial Intelligence Algo r ithm in the detection of Diabetic Retinopathy (SMART) study. BMJ Open Diabetes Res Care. 2020 Jan;8(1):e000892.
Natarajan S, Jain A, Krishnan R, Rogye A, Sivaprasad S. Diagnostic Accuracy of Community-Based Diabetic Retinopathy Screening With an Offline Artificial Intelligence System on a Smartphone. JAMA Ophthalmol. 2019 Oct 1;137(10):1182–8.
Sengupta S, Sindal MD, Baskaran P, Pan U, Venkatesh R. Sensitivity and Specificity of Smartphone-Based Retinal Imaging for Diabetic Retinopathy. Ophthalmol Retina. 2019 Feb;3(2):146–53.