Medicare Coverage of Vision Assistive Equipment for Low Vision Patients
Article
by Alan Morse
Deficits in visual perception have been associated with loss of independence in self-care, while improved ability to function independently can result in decreased dependence. For example, patients with diabetes and vision impairment who learn to self-monitor their glucose levels and independently administer insulin through rehabilitation and diabetes self-management education may reduce the need for home health care or clinic visits for medication management. Enhancing functional vision through rehabilitation decreases disability and increases functional ability by improving a patient’s ability to perform essential life functions (ADLs and IADLs), which can reduce the cost of subsequent Medicare-covered health care services.
The CMS position of providing coverage for rehabilitation services but not for the necessary equipment (VAE) is paradoxical; a beneficiary may receive VR care and be successfully rehabilitated and able to perform ADLs and IADLs necessary for reasonable self-sufficiency but if VAE is not provided, beneficiaries are unable to perform these tasks and are relegated to an unnecessarily dependent status. This is akin to providing a wheelchair and a home attendant to an individual with an amputated limb, while denying coverage for a lower extremity prosthesis that would allow for safe independent ambulation. Medicare beneficiaries with vision loss who qualify for Medicare-covered rehabilitation services should also qualify for VAE necessary to implement their rehabilitation care plan and to enable them to use the skills and techniques that have been acquired through the rehabilitation process.
Because of the substantial increase in prevalence of cognitive impairment with aging, a substantial number of new Medicare enrollees aged 65 years, and increasing with each year aging thereafter, would be unable to benefit from VR or VAE. Among Medicare beneficiaries under the age of 65, many qualify for Medicare because of traumatic brain injury or congenital, developmental, multiple, or other acquired disabilities, and it is likely that a significant number of these individuals also may be unable to benefit from VR and VAE. We estimated that in 2008, there were 256,000 new beneficiaries with low vision or blindness and, considering the above, between 50%-75% may qualify for and be able to benefit from VR and VAE. However, because of the necessary intensity of the therapy and training visits required for effective rehabilitation, we anticipate that only about half of those who begin VR will actually complete a plan of care that includes VAE.
To determine which Medicare recipients would be appropriate for vision rehabilitation and VAE, We developed a flow chart algorithm to facilitate clinical decision-making. The decision points in the flow chart ask the following questions:
- Does the beneficiary have a vision limitation that significantly impairs his or her ability to participate in 1 or more ADLs?
- Can the functional vision deficit be sufficiently resolved by correcting the beneficiary’s refractive error?
- Are the enhancements provided by a VAE needed to allow the beneficiary to participate in 1 or more ADLs?
- Are there other conditions that limit the beneficiary’s ability to participate in ADLs at home? For these beneficiaries, even with VAE, they might not be able to participate in ADLs if the other conditions prevent effective use of the VAE or allow reasonable completion of the tasks even with VAE. Some examples are significant impairment of cognition or judgment and neurologic or orthopedic impairment.
- If other limitations or comorbidities exist, can they be ameliorated or compensated sufficiently such that the provision of VAE will be reasonably expected to significantly enhance and improve the beneficiary’s ability to perform or use assistance to participate in ADLs?
- Does the beneficiary demonstrate the capability and willingness to use VAE safely and consistently?
Although many practitioners might prefer a “try and see if it works” approach, this is neither desirable nor appropriate. Patients who qualify for low vision rehabilitation under coverage provided in accordance with the Program Memorandum should be able to successfully meet the conditions of the algorithm: if they cannot, the appropriateness of vision rehabilitation should be reconsidered. To illustrate use of the flow chart, we developed case examples demonstrating where vision rehabilitation and VAE is appropriate, and where it is not. A PDF of these cases is available here.
Current Medicare policies relating to vision assistive equipment and devices should be modified to provide coverage for (1) prescribed by a Medicare approved physician in conjunction with Medicare approved vision rehabilitation services, (2) for purposes other than correcting the refractive state of the eye, (3) to a beneficiary receiving Medicare approved vision rehabilitation services, (4) consistent with, and on the same basis as, Medicare coverage provided to beneficiaries receiving durable medical equipment (DME) related to other Medicare covered rehabilitation services. Medicare coverage of vision assistive equipment should be determined using the criteria above, to allow beneficiaries with vision loss to benefit fully from Medicare-covered rehabilitation to achieve the proven outcomes and cost-effective results of these services.
Archives of Ophthalmology article: click here
Medicare Coverage of Low Vision Rehabilitation - Another View
by Ken BradleyI applaud Mr. Morse for furthering the discussion of the need for and benefits of vision rehabilitation for the visually impaired. The flow-chart algorithm proposed is a novel new way of screening visually impaired candidates for prospective third-party reimbursement of services and equipment.
Some of the stakeholders in the value-chain that delivers services and equipment to the visually impaired may disagree that Medicare coverage of assistive equipment for the visually impaired would result in a better long-run system for providing care to the visually impaired. Single and dominant-payer public systems, in an effort to efficiently allocate taxpayer resources, consistently seek low cost providers in both service provision and equipment supply and this can have a detrimental effect on the visually impaired.
Many physicians and service providers have witnessed the impact of a dominant-payer system on the provision of other eye care and rehabilitation services over the past decade and in many cases had to discontinue some services due to annual declines in the rates of reimbursement from Medicare making these services financially unviable. The prospect of a financial return through service fees generated and product margins earned serves as a key incentive for many eye care professionals to provide low vision care. The possibility that the impact of a single or dominant-payer’s squeezing of margins at the clinical level is real and should not be overlooked. The pressure that can be brought to bear on prices in single and dominant-payer systems squelches innovation and eliminates the financial motive for service providers including both private health care professionals as well as not-for-profit service providers.
Additionally, in the market for equipment for the visually impaired, the greatest numbers of new product innovations over the past decade have been introduced by the manufacturers that occupy higher-tiered price positions. Price pressure on low vision equipment would limit the margin earned by manufacturers, driving market volume to low cost manufacturers and harming those producers that have invested in new products and technology for the end-user. This will eventually result in poorer patient outcomes and declines in consumer satisfaction with the low vision care received. Low vision device manufacturers enjoy lower rates of return on research & development expenditures than most other industries even when new products are successful due to the small size of the market being served. Speaking for a leading manufacturer of equipment for the visually impaired, I know first-hand that decreased future manufacturing margins on low vision equipment would be compensated for in reduced service levels for low vision care providers and a reduction in research and development into better and more effective devices.
I encourage stakeholders in the field of low vision rehabilitation to take a pragmatic view of the political and economic environment and pursue agendas to improve and expand the availability of low vision rehabilitation that have the greatest potential for success and benefit. Unfortunately, on the heels of a Low Vision Demonstration Project that can be characterized as an abject failure and the lack of a long-term (20-year) study that shows the cost-effectiveness of low vision rehabilitation in the overall health-care economy, it is unlikely to expect that expanded coverage will be available through Medicare when this program is already under scrutiny for reform and benefits reductions.
It is the position of some that maintaining a strong, unregulated, private-pay economy for low vision rehabilitation services and equipment for the non-handicapped visually impaired represents the best way to ensure the overall health of the delivery system and the availability of the greatest number of options for low vision rehabilitation for the visually impaired in the future.
Ken Bradley
President
Eschenbach Optik of America, Inc.
Medicare Coverage of VAE
by Bill Mattingly“Medicare Coverage of Vision Assistive Equipment for Low Vision Patients” by Alan Morse is a well thought-out, balanced and simple presentation of an algorithm that should strengthen the argument and confidence for congressional action and CMS changes to include VAE as part of rehabilitation of those with visual impairments. It is a well-defined methodology that would prevent unnecessary services, which would likely receive across-the-board acceptance.
Observations:
1. The approach includes refraction a necessary prerequisite, or component of, a low vision examination, yet distinguishes refractive changes from VAEs.
2. The scope of rehabilitation services goes way beyond the use of VAE as a cure-all, strengthening the multi-disciplinary model of vision rehabilitation.
3. The case studies refer to the importance of contrast sensitivity assessment and treatment.
4. The importance of scotomas is found in the case studies; however, this is still a developing area of low vision rehabilitation. Most practitioners do not have the equipment to plot the size, shape and number of scotomas, as well as how they interfere with ADLs and respond to illumination.
5. The importance of using a variety of VAE is necessary, avoiding a “one device fits all” paradigm.
Suggestions:
1. Further discuss the importance of contrast sensitivity measurement. Suggest assessment tools including inexpensive, effective tests such as the Colenbrader Mixed Contrast Card.
2. Further discuss the need for mapping scotomas and understanding how they affect ADLs. Suggest assessment tools including inexpensive tests such as The California Central Visual Field Test and SKRead.
3. Discuss the importance of PRL training as part of a comprehensive rehabilitation plan. Poor PRL use could be masked by other complaints such as “this device is too difficult to use”.
Bill Mattingly, President
Mattingly Low Vision, Inc.
2361 Bear Rock Glen
Escondido, CA 92026
P 888.642.0842
F 706.888.4955
Medicare Coverage of VAE
by Roy Cole, ODAs Bill Mattingly points out, contrast sensitivity, scotomas and PRL are all of critical importance in understanding vision loss, assessing patients, and providing rehabilitation training. Our goal was to set out a framework that facilitates CMS recognition specifically of equipment and devices as integral to the rehabilitation process. Reimbursement has already been approved for the medical examination and rehabilitation training components. We are trying to encourage Medicare’s reimbursement of equipment and devices. Certainly the use of tools and procedures Mattingly cited are useful in providing comprehensive care, but a complete discussion of low vision was far beyond our intent. Our goal was, and is, to underscore that proper use of VAE is essential for effective vision rehabilitation.
Addressing Mattingly’s specific suggestions:
1. Further discuss the importance of contrast sensitivity measurement. Suggest assessment tools including inexpensive, effective tests such as the Colenbrader Mixed Contrast Card.
It is well recognized within the field that contrast sensitivity is an important measure, and can explain why patients are having problems that are unaccounted for by reduced visual acuity or field loss. It also guides us in setting up appropriate interventions. Ideally, it would be desirable to be able to certify the need for services based on a specific reduction in contrast sensitivity. The problem we face is that there is no accepted value. Ideally, reduced contrast sensitivity would be added to visual acuity and field loss criteria to qualify someone for services. Until the research is done and the professions and government agree, this will not be the case.
2. Further discuss the need for mapping scotomas and understanding how they affect ADLs. Suggest assessment tools including inexpensive tests such as The California Central Visual Field Test and SKRead.
Mapping scotomas is already covered by Medicare and other insurances. It is part of the medical workup of a patient. The testing equipment itself is not covered by Medicare. This discussion would not be appropriate for the discussion of VAE in this paper.
3. Discuss the importance of PRL training as part of a comprehensive rehabilitation plan. Poor PRL use could be masked by other complaints such as “this device is too difficult to use”.
PRL training is also already covered by Medicare for licensed Medicare providers such as occupational therapists. If a patient cannot use a device because of central scotomas or poor PRL use, that would be a reason not to prescribe the device. If the skill is developed by PRL or visual skills training and the patient can subsequently use the device, then it should qualify for coverage.
Roy Gordon Cole, OD, FAAO
Director of Vision Program Development
The Jewish Guild for the Blind