Age-Related Macular Degeneration Treatments: Determining Appropriate Use - Episode 5
Peter L. Salgo, MD: If we’re going to screen everybody, how do we do it? What type of test do you want to do? How do you go about it? Who can do it?
Jared Nielsen, MD: Well, the optometrist is—at least, in my state of Iowa—a great resource and a partner to help in this. Most people in the community will have an optometrist, and they will offer a dilated eye exam and be able to screen for this condition. An ophthalmologist could certainly do this as well or even a retina specialist in certain circumstances.
Peter L. Salgo, MD: The last time I saw an optometrist, and this is a good thing, it took half an hour. It was extraordinarily thorough.
Jared Nielsen, MD: That’s correct. I think that primary eye care providers often have a lot of time to spend with people and speak with them. But the important things that need to be done in a screening visit are a dilated eye exam and then—what I find to be the most helpful tool—an OCT, or optical coherence tomography.
Peter L. Salgo, MD: What’s that in English?
Jared Nielsen, MD: It’s a laser that scans the back of the eye and allows us to look at the anatomic layers of the retina to discern if there are any abnormalities, areas of degeneration, or exudation that would warrant treatment.
Peter L. Salgo, MD: Is that a screening test after you pick something up on the general exam?
Jared Nielsen, MD: Well, we’ll look in and we’ll see that they have macular degeneration. This is the next step to determine the severity of the disease and whether or not there’s any exudative activity.
Peter L. Salgo, MD: So, the screening, then, is that you look dilated at the back of your eye. If there’s some suspicion, the next thing you do is get this laser test. What after that? Is there another test or are you done?
Charles Wykoff, MD, PhD: It’s important to remember that, in the eye care arena, there are actually many different specialists. Even when the patient gets treated by Jared or myself, they actually continue to need their primary eye care professional. They need their optometrist or general ophthalmologist. We, as retina specialists, focus on treating the macular degeneration, but we don’t typically give glasses, give prescriptions, or do the other things that primary care is involved with.
Peter L. Salgo, MD: Right, but we’re still talking MD here. If we can rely on, as much as we can, optometrists or primary care to make the diagnosis, somebody is then going to get referred, which is where we’re going to go with this. “This is AMD. This is out of my area of comfort.” Certainly an optometrist isn’t going to treat it.
Charles Wykoff, MD, PhD: Correct.
Peter L. Salgo, MD: How quickly do get they referred, in your experience, from an exam to your desk?
Charles Wykoff, MD, PhD: In our area, we educate all of our referring doctors that we want to see these people within a day or 2, certainly within a week. These are the kinds of people where you want to get on the phone and ask, “Look, can you get them in tomorrow?”
Peter L. Salgo, MD: Is that happening?
Charles Wykoff, MD, PhD: Yes, absolutely. We make room for these people on our schedule. We always joke that retina specialists, at least around Houston, are the only doctors that will see patients the next day.
Jared Nielsen, MD: Or on Friday.
Charles Wykoff, MD, PhD: Or Saturday morning, absolutely, because these are important things. You’re talking about vision. If you lose vision, it’s much harder to regain it than it is to prevent the loss in the first place.
Peter L. Salgo, MD: And there was that shocking statement about losing vision within a day or 2. You can go from vision to no vision. So, from Friday morning to Saturday, that’s an important 24 hours.
Jared Nielsen, MD: It can be for patients. Many patients will be okay for a week, but you’ll have some that could suffer massive bleeding and have a disastrous result.
Peter L. Salgo, MD: Now, that being said, somebody has got to pay for all this screening. I know I paid out-of-pocket for my optometrist, but are you guys covering screening for AMD?
Peter Dehnel, MD: I was just going to ask if you gentlemen are experiencing any barriers with payment for the services that you’ve providing. Are there certain CPT codes or diagnostic codes you’re using that will guarantee coverage versus somebody having to send it to a review process?
Jared Nielsen, MD: As retina specialists, we’re not involved in a lot of screening. But my organization is a large eye care practice, and we have a lot of optometrists and general eye care providers who do those screening tests. One challenge we run into is when somebody has had these tests initially and then we go into the treatment phase. Sometimes, there is a cap on the limit of these important diagnostic tests that we use to manage patients, and Charlie already alluded to the number of visits sometimes being limited. So, when we look at a patient who’s going to end up needing treatment for wet AMD, they’re going to be in 13 times at least, and that’s if they don’t have any complications or other sorts of trouble during the visits. One challenge is just making sure that there are enough visits and that there’s no cap on the testing to prevent us from being able to do what we need to do.
Peter L. Salgo, MD: So, if we can use money to direct healthcare policy and to drive patients one way or another, and if we then agree—it’s a compound question—that AMD is a big problem, we would like people to be screened. Do you guys have financial incentives in place to get people screened for AMD? Or is it not on your radar?
Gary L. Johnson, MD, MS, MBA: First of all, we don’t have programs to encourage or find people and we don’t seek them out. We leave that to the primary care doctor and the primary optometry services.
Peter L. Salgo, MD: And the second part was then, “Why not?” effectively.
Gary L. Johnson, MD, MS, MBA: I think the reason is, again, priorities. And I totally agree that our vision, for most of us, is probably the top priority in our medical care. But patients with this condition are not something that I think most managed care plans actively seek out.
Charles Wykoff, MD, PhD: From a cost perspective, I have 2 interesting sides to that. The earlier you diagnose one’s disease, the less frequently they need treatment. So, it’s actually cheaper if you get these patients early. We also know that it’s cheaper because they have less other problems. The worse people see, the more their other healthcare costs. So, if we screen better, we can also be cheaper.
Jared Nielsen, MD: The other big thing, too, is that the economic burden of someone who’s visually impaired is staggering. If we can find somebody early and keep them productive, keep them working in the job that they want to continue to work in, that has a huge societal benefit.
Gary L. Johnson, MD, MS, MBA: And I think that’s the reason we don’t put barriers in front of screening. We don’t actively seek out screening, but on the other hand, we certainly don’t…
Charles Wykoff, MD, PhD: So, maybe incentives, not just no barriers.
Peter L. Salgo, MD: Is it fair to ask you guys to step in, be proactive, and not just say, “We’re not going to provide barriers to getting this done,” but also “We’re going to encourage you to do it, we want you to screen, and we’re going to pay for it”?
Peter Dehnel, MD: This sounds like a quality plan of some sort that we would implement for wet AMD or other retinal conditions. We pay claims, and it’s usually somebody else’s money that’s coming in to pay for those claims. In terms of going forward, we can talk about what’s happened in the past, but we can’t impact that at all. But going forward, what are some reasonable recommendations? And what would be some quality plans? What is the value of screening once somebody is diagnosed? What is a reasonable quality plan to say that, at the end of 1 or 2 years, they’re likely to have better vision? I’d be very open to that for further conversation.
Peter L. Salgo, MD: Let me just say, before we move on, that I did hear something that I know you believe and I know is true, which is that we pay claims—but you do more than that. With the financial incentives that you can invoke, you can do more to influence healthcare than just pay claims.
Peter Dehnel, MD: And I think, in the emersion reality, that more and more quality payments are part of our experience. So, if we then decide that this is a priority item and—similar to what Gary is saying, where does this fall on our radar screen?—if it is raised to a higher level, then we can have more of a conversation.