Medicare Policy Issues Related to Low Vision Rehabilitation

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Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore MD
Dec 18 2009
rmassof's picture

Approximately 80% of the U.S. low vision population is over age 65.1 Consequently, Medicare coverage policies have a large impact on the types and levels of low vision rehabilitation services provided by the health care system and on the choice of health care professionals who provide those services. Medicare policies relevant to low vision rehabilitation have undergone significant revisions over the past several years and are expected to evolve with the Center for Medicare and Medicaid Services (CMS) 5-year Medicare Low Vision Rehabilitation Demonstration Project. The low vision rehabilitation service delivery model currently recognized and covered by Medicare is the rehabilitation medicine team approach.2-3 In that model, evaluation and management services are provided by a physician (optometrist or ophthalmologist) and rehabilitation services are provided in the office, at the patient’s home, or in the community by an occupational therapist under a physician-approved plan of care. The 5-year Medicare demonstration project is evaluating the feasibility of covering services provided by unlicensed vision rehabilitation professionals (low vision therapists, vision teachers, and orientation and mobility instructors) incident to and under the general supervision of a physician.4

 

Low Vision Rehabilitation is Effective. It is widely assumed that the provision of rehabilitation services is better than doing nothing, but there is a paucity of formal studies to support that assumption. A recently completed, two-center, randomized controlled trial (RCT), the Veterans Affairs (VA) Low Vision Intervention Trial (LOVIT), provided the first compelling evidence that low vision rehabilitation is effective.5 Although LOVIT overwhelmingly confirmed the prior assumptions of the community, generalizing LOVIT results to real world practice is limited because VA health care policies and the demographics of the VA patient population differ from those in the private sector. Perhaps most salient, the VA system covers the costs of most prescribed low vision devices, including CCTVs, whereas Medicare does not cover any low vision device costs.

 

Medicare Coverage of Low Vision Rehabiliation Services. Currently, Medicare covers evaluation and management services provided to low vision patients by ophthalmologists and optometrists and of rehabilitation therapy provided to low vision patients in the clinic, patient’s home, or patient’s community by occupational therapists (with medical necessity based on visual impairment ICD-9-CM codes). With the exception of six regions of the country, low vision rehabilitation services provided by Certified Low Vision Therapists (CLVTs), Certified Vision Rehabilitation Therapists (CVRTs), and Certified Orientation and Mobility Specialists (COMSs), who are not trained occupational therapists, are not covered by Medicare, even if those services are incident to the physician’s services and provided under the direct supervision of a physician. However, the passage of the amendment to the Labor, Health and Human Services, and Education Appropriations Bill in 2005 mandated a 5-year Medicare Low Vision Rehabilitation Demonstration Project that began in April, 2006. The project is limited to the states of New Hampshire, North Carolina, Washington, and Kansas, to the city of Atlanta and all five Burroughs of New York City and was subsequently expanded to several more NY counties, and enables unlicensed CLVTs, CVRTs, and COMSs to be reimbursed by Medicare for up to twelve hours of low vision rehabilitation services per patient for services provided in the clinic, patient’s home, or community, incident to and under the general supervision of, a Medicare-defined physician (including optometrists).6 The demonstration project is not looking at patient outcomes, rather it is designed to study the feasibility and impact on the Medicare budget of covering the services of certified unlicensed vision rehabilitation professionals.

 

Disappointing Results in the Low Vision Rehabilitation Demonstration Project. Utilization of CLVT, CVRT, and COMS services has been disappointingly low in the Medicare demonstration project. Low utilization of CLVT and CVRT services might be expected because they duplicate services offered by OTs. However, COMS services are not offered by any other service provider and as of the end of 2008, after 2.5 years since the start of the project, COMS claims had been filed for services that represented a total of 49 hours of O&M instruction per year across all six demonstration project areas. This figure is even more astonishing when considering that 83% of the claims were submitted by a single vision rehabilitation agency. The total CLVT claims across all six demonstration areas averaged 268 hours of service per year while total CVRT claims averaged 86 hours per year. If this trend continues, CMS will be forced to conclude that the services of these vision rehabilitation professionals are not needed by low vision patients and should not be covered by Medicare.

 

There is an alternative explanation for low service utilization. The low vision demonstration project requires physicians to file claims with Medicare under their own provider numbers on behalf of the CLVT, CVRT or COMS who provided the service, which means there must be an employment or contractual relationship between the parties. Such a relationship is likely to incur liability and overhead costs for the physician since the vision rehabilitation professional must provide services under the physician’s supervision and, in effect, practice under the physician’s license. Add these barriers to the current shortage of vision rehabilitation professionals and a low rate of claims is inevitable.

 

Medicare Does Not Cover Visual Assistive Equipment for Low Vision Patients. Medicare Part B covers a wide range of medical equipment prescribed by a physician to be used in the patient’s home. To qualify for Medicare coverage, the physician must complete and sign a Certificate of Medical Necessity that is sent to and approved by Medicare. If the equipment is purchased from an enrolled Medicare supplier, then the supplier must accept Medicare’s approved amount for the equipment as payment in full. The patient must pay 20% (co-insurance) of the Medicare approved amount (plus any remaining deductibles) and Medicare pays the balance. If the supplier is not enrolled and does not accept Medicare’s assignment, then the patient must pay the supplier the asking price and accept reimbursement from Medicare of Medicare’s portion of the approved amount. Medicare prohibits physicians from making a profit or financially benefiting from the sale of Medicare-covered medical equipment that they prescribe.

 

Medicare has a history of refusing to cover the costs of visual assistive equipment (i.e., low vision devices), although they do cover the costs of intraocular lenses, glasses, and contact lenses for patients who have had cataract surgery. In the new proposed rules for durable medical equipment procurement, Medicare made its reason for excluding low vision devices clear. Despite three U.S district court rulings to the contrary, CMS interprets the eyeglasses exclusion from Medicare coverage by section 1862(a)(7) of the Social Security Act as including “all devices irrespective of their size, form, or technological features that use one or more lens to aid vision or provide magnification of images for impaired vision.”7 Thus, besides conventional optical low vision aids, CMS argues that CCTVs and other electronic magnifiers must be excluded from coverage because they contain lenses.

 

In sharp contrast to Medicare, the Department of Veterans Affairs Veterans Health Administration (VA) classifies low vision aids, including CCTV magnifiers, as prosthetics and purchases those devices and issues them to qualified veterans. The VA employs a bidding and contract purchase process whereby low vision device vendors sell their products directly to the VA, well below retail price, and the VA then issues the devices to qualified patients.

 

What Should Be Done Next? There is a clear dichotomy in the coverage of low vision rehabilitation services between the VA health care system and the portion of the private sector health care system that is financed by Medicare, although there is little difference in the clinical characteristics of their respective patient populations. Both Medicare and the VA cover the costs of low vision rehabilitation services provided by therapists (occupational therapists in the case of Medicare and unlicensed vision rehabilitation professionals in the case of the VA). Unlike the VA, Medicare does not cover the costs of low vision devices and, outside of the Low Vision Rehabilitation Demonstration Project, Medicare does not cover the costs of services provided by orientation and mobility specialists.

 

There is some evidence that abandonment rates of certain low vision devices are relatively high for VA beneficiaries (14% for hand held telescopes, 21% for hand and stand magnifiers, 23% for spectacle-mounted telescopes, 32% for spectacle magnifiers, and 43% for field expansion devices, compared to about 30% for other types of assistive and medical devices).8 High abandonment rates suggest the possibility of unnecessary prescriptions or inadequate training. It is likely that some of the rehabilitation services offered and some of the prescribed low vision devices, although proven efficacious in the clinic, do not provide real benefit to low vision patients in their daily lives. Thus, using the VA data alone would result in an overestimate of the potential utilization and cost of low vision services and devices.

 

The standard of care in the U.S. for low vision rehabilitation outside of the VA is defined by clinical guidelines of professional societies, including the American Academy of Ophthalmology, the American Optometric Association, the American Occupational Therapy Association, and the Academy for Certification of Vision Rehabilitation and Education Professionals.  However, in the private health care sector, clinical practice is largely driven by Medicare coverage policies. While low vision rehabilitation has been established as effective in the VA, and is within the practice guidelines of ophthalmology and optometry, and of occupational therapy, current Medicare policy continues to erect substantial barriers to its delivery.

 

A clinical trial is warranted when there is disagreement within the field over best practices (equipoise), the public health problem to be addressed is significant, and the conduct of the trial is feasible. The current dissonance of best practices in low vision rehabilitation creates an urgent need to establish evidence of best practices and to reconcile the evidence from the VA with the failure of Medicare to cover such services and devices.

 

Upon completion of the Medicare Low Vision Rehabilitation Demonstration Project, Congress will have to make a decision about Medicare coverage of services provided by unlicensed certified vision rehabilitation professionals. The most likely choices are 1) continue the present policy outside of the demonstration project and not cover the services, 2) cover the services, but at the expense of occupational therapy services (e.g., not exclude them from the occupational therapy cap), or 3) cover the services as independent of occupational therapy services (e.g., excluded from the occupational therapy cap). Other issues such as whether to permit such services to be provided by unlicensed vision rehabilitation professionals, and if so, how, also need to be addressed. Each of these policies undoubtedly will have an impact on the amount and quality of services provided to Medicare beneficiaries.

 

To inform policy it is essential to determine which, if any low vision patients need and derive benefit from the services offered by the various vision rehabilitation professionals as well as which low vision devices are most appropriate. Most low vision devices magnify and many devices are designed to perform essentially the same function, but often at widely discrepant prices. We do not know which devices are optimal for which patients and we do not know what impact third party coverage would have on device prescription, purchase, and abandonment decisions. CMS’s interpretation of the eyeglasses exclusion clause in the Social Security Act to apply to all devices used to enhance vision is a distortion of the intent, if not the common sense understanding of the clause. In today’s economic climate, changing Medicare policy law will require persuasive arguments backed by evidence. The time has come to ask the uncomfortable and challenging questions about current low vision practices and to conduct serious clinical research that measures and compares patient outcomes of different practices and coverage policies.

 


References

  1. Massof RW. A model of the prevalence and incidence of low vision and blindness among adults in the U.S. Optometry and Vision Science, 79: 31-38, 2002.
  2. Massof RW, Dagnelie G, Deremeik JT, DeRose JL, Alibhai SS, Glasner NM. Low vision rehabilitation in the U.S. health care system. J Vis Rehabil. 1995;9:3-31. [reprinted in Low Vision Rehabilitation: Service Delivery, Policy, and Funding, Massof RW, Lidoff L (eds.), AFB Press, New York, NY, 2001;267-306]
  3. Stelmack J. Emergence of a rehabilitation medicine model for low vision service delivery, policy, and funding. Optometry. 2005 Jun;76(6):399-404.
  4. Gerritsen B. Use it or lose it: The Medicare Low Vision Demonstration Project. J Vis Impair Blind 2007;101:197-202.
  5. Stelmack JA, Tang XC, Reda DJ, Rinne S, Mancil RM, Massof RW, et al. Outcomes of the Veterans Affairs Low Vision Intervention Trial (LOVIT). Arch Ophthalmol 2008;126:608-617.
  6. Low Vision Rehabilitation Demonstration, CMS Manual System, DHHS, CMS, Pub 100-19, CR3816, 2006.
  7. Medicare Program; Competitive Acquisition for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Other Issues. Center for Medicare and Medicaid Services, DHHS, RIN 0938-AN14, 2006.
  8. Watson GR, De L'Aune W, Stelmack J, Maino J, Long S. National survey of the impact of low vision device use among veterans. Opt Vis Sci, 1997;74:249-259.

 

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Apr 7 2010
bryangerritsen's picture

Article on Medicare by Dr. Massoff


Thank you for your insightful article on Medicare, with several critical topics and points you made.  It is unfortunate that so few have taken advantage of the Medicare Low Vision Demonstration Project, and so few claims have been filed by providers in the 6 regions.  I concur that sadly, CMS/Medicare is likely to come to the conclusions that you listed.  I was also intrigued by your listing of abandonment rates of various devices by VA patients, and the comments about seeming efficacy in a low vision clinic vs. in daily routines in a patient's home.  Research is called for in following abandonment rates of various devices among non-VA patients. 

 

One comment you made near the end of the article states that "We do not know which devices are optimal for which patients."  While this is largely true, Robert Christiansen, MD and I have made several studies regarding patients' contrast sensitivity function (CSF) scores, and their preferences for magnifiers and other devices for reading.  Generally, patients with poor CSF scores need devices with the brightest illumination.  An article I wrote in this month's JVIB takes this one step further, and rates various illuminated stand magnifiers from the brightest to the least bright.  Interestingly, one of the least expensive brands of illuminated stand magnifiers is almost consistently the brightest, across the range of strengths.  Patients with very poor CSF often self-select the brightest illuminated magnifiers or devices for reading.  Therefore, it becomes helpful to know which devices are indeed the brightest. 

 

I am so grateful for all the work you and others at Johns Hopkins have done regarding low vision rehabilitation and workinig with Medicare to help make it more available for patients with a vision loss.  We appreciate your great efforts.  We also appreciate your cooperative effort with the LOVIT study team to help document that low vision rehabilitation is indeed efficacious for patients. 

 

Finally, we also appreciate the pending study by Duane Geruschat on O&M for low vision persons, and look forward to that moving forward.  Thank you for this excellent website. 

Bryan Gerritsen, CLVT

Bryan Gerritsen, CLVT


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