Part 1: See Part 2 in the September issue of Evidence-Based Diabetes Management.
With the population of Americans who have either type 1 diabetes (T1D) or type 2 diabetes (T2D) now having exceeded 29.1 million,1 the need to reach those at risk for complications is great. The American Diabetes Association (ADA) estimated in 2013 that the disease costs the United States $245 billion each year2 in healthcare spending and lost productivity—and that second part occurs when adults below retirement age develop conditions that make it impossible for them to work.
Eye complications are common among those with diabetes,3 yet with proper care, these complications are preventable and, if they occur, more treatable than ever. In recent years, a new class of therapy called VEGF inhibitors, which target the vascular endothelial growth factor, has emerged to treat ocular conditions associated with diabetes, including diabetic macular edema (DME).
The American Journal of Managed Care recently convened an expert panel for a Peer Exchange, “Diabetes-Related Complications: a Focus on Diabetic Macular Edema.” Experts discussed new therapeutic options in DME, the importance of screening persons with diabetes for eye complications, and the factors that payers consider when evaluating the value of new therapy.
Taking part in the discussion were John W. Kitchens, MD, a vitroretinal surgeon at Retina Associates of Kentucky; Rishi P. Singh, MD, staff physician at the Cleveland Clinic and assistant professor of ophthalmology at Case Western Reserve University; and Steven Peskin, MD, MBA, FACP, executive medical director of Population Health for Horizon Healthcare Innovations in New Jersey. Peter Salgo, MD, associate director of Surgical Intensive Care at New York-Presbyterian Hospital moderated the discussion. This is the first of 2 parts on the discussion; the second part will appear in the September issue of Evidence-Based Diabetes Management.
OCULAR CONDITIONS AND THE COST BURDEN
Singh explained that whereas almost everyone can develop cataracts if they live long enough, about 25% of those with diabetes have retinopathy, which can go unnoticed at first. Kitchens explained that although symptoms are mild at first, the condition can get worse over time. “It can progress to proliferative diabetic retinopathy, where abnormal blood vessels grow in the back of the eye, and those blood vessels can bleed and leak,” he said. This, Kitchens explained, is the leading cause of blindness for patients with diabetes. DME specifically occurs when this leakage causes the retina to swell, after which blurring develops in the central field of vision. As diabetes complications go, Salgo asked if this was among the worst. “Yes, I’d say that’s a pretty profound complication,” Peskin said.
Kitchens said the cost burden of eye complications is substantial—$3 billion a year.5 Singh said a recent study found that the average person with diabetes required $9000 in annual healthcare spending, but a person with diabetic retinopathy required $29,000.6
“That comes from a lot of different things,” Singh said. Imaging, surgery, and lost productivity all contribute to the cost burden. Patients who lose vision become more depressed as well, he said. “It’s a downward spiral,” Kitchens said. “If you can’t see, how are you going to dose your insulin? How are you going to know what pills you’re taking? How are you going to make it to your doctors visits? So now, you’re increasing the burden on your family, and those are all the indirect costs that add up.”
GETTING PATIENTS SCREENED FOR EYE COMPLICATIONS
Kitchens said both the American Academy of Ophthalmology and the ADA call for those with T2D to have a baseline eye screening at diagnosis and for those with T1D, within 5 years of diagnosis. (A recent survey found young adults with diabetes are less likely to get screening at recommended intervals.4)
According to Peskin, payers focus on the annual exam. “Within the health plan, the Health Effectiveness Data and Information Set and the annual dilate exam can be done by an optometrist or an ophthalmologist.” When he teaches residents, Peskin said, he emphasizes the need for the annual retinal exam, as well as the monofilament foot test and the microalbumin screening for early signs of kidney damage.
But getting patients with diabetes an annual eye exam is easier said than done, especially if the burden of checking falls on a primary care physician. Singh said that Cleveland Clinic did a study and found that 75% to 80% of endocrinologists always asked about eye-related issues during exams, but only 15% to 20% of internists did, even with patients who have diabetes. “The internists failed to ask, probably because they are so inundated with everything else, that they failed to get to that point,” Singh said. The result, Kitchens said, is that only about 50% of those at risk for eye complications are being screened on schedule.
WHAT KEEPS PATIENTS FROM GETTING EYE EXAMS?
Salgo asked, “What are the barriers for patients who want to get eye exams but cannot get them?” Kitchens mentioned insurance, cost, and transportation. Singh said it’s more complicated than that—sometimes it’s not clear whether the exam is covered by a patient’s medical benefit or a vision plan. Since the Affordable Care Act took effect, he said, “People are looking at deductibles and not understanding necessarily where this falls in their deductible range. These are all medical examinations covered by insurance.”
< Peskin said payers are trying to make things less complicated. Besides sending reminders to patients who need annual retinal exams, for Medicaid patients, his company is eliminating co-payments to encourage this group to get the screening.
Salgo asked how health plans keep track of who is getting screened and who isn’t. Peskin said Horizon is tracking longitudinal data and making it available to clinical partners, and the results can be “a bit humbling.” Most physicians, he said, think they are keeping glycated hemoglobin (A1C) for the vast majority of their patients at 8% or below, and they find out that’s not the case. “Making that information available, not in a punitive way, but in a collaborative way, is a big part of what we do,” he said.
Singh and Kitchens contrasted the differences between an academic medical center like Cleveland Clinic—where the eye exam and the rest of care might be under one roof—and private practice, where Kitchens says he deals with a variety of hospital systems and tracking patient care is more challenging.
“Ergo, the 50% who aren’t getting followed,” Salgo said.
Kitchens credits insurers, and the rise of quality metrics, with reinforcing the idea among physicians that those with diabetes need eye screening. Peskin agreed that having claims data is a start and that his insurer is making strides with “harmonizing” that information with the electronic health record.
WHAT IS THE LEVEL OF AWARENESS?
Salgo asked if, in the age of the Internet, those with diabetes had greater awareness that vision was at risk. Kitchens said not really. Socioeconomic factors play a bigger role, and so does age, with Medicare patients more likely to follow up on eye exams than young adults.
< Peskin agreed—to a point. While it’s true that people become more engaged in their health as they age and gain education, it’s not perfect. “We know from research that we’ve done that there are people who are Master’s prepared that are also not health-literate or health-numerate,” he said. “So, we’ve got plenty of challenges in front of us to engage those persons.”
He’s less concerned that patients know words like “retinopathy” than getting across the message that annual eye exams are a must. Horizon, Peskin said, is trying to reach out not only to clinical partners to engage them to take annual measures, but also to employers. “Ultimately, they are the ones who are paying the bills, right?”
Singh said the challenge with raising awareness about screening—or anything with diabetes—is that it’s a very timeconsuming disease. He cited a study that found patients made 20 doctors’ visits a year. That amount of time off, he said, would consume all his vacation.
Kitchens said engaging patients is very difficult. “It’s hard to expect patients to understand their retinopathy when sometimes they come in and they don’t even know their A1C. And that’s a scary thing. I’d say probably 25% of our patients don’t know what their A1C is.”
About the Panel
Peter Salgo, MD, is associate director of Surgical Intensive Care, New York-Presbyterian Hospital.
John W. Kitchens, MD, is a vitroretinal surgeon at Retina Associates of Kentucky.
Steven Peskin, MD, MBA, FACP, is executive director of Population Health, Horizon Healthcare Innovations.
Rishi P. Singh, MD, is staff physician, Cleveland Clinic, and assistant professor of ophthalmology, Case Western Reserve University.
1. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Updated April 1, 2016. Accessed April 28, 2016.
2. American Diabetes Association. Economic costs of diabetes in the US in 2012. Diabetes Care. 2013;36(4):1003346. doi:10.2337/dc122625.
3. Eye complications. American Diabetes Association website. http://www.diabetes.org/living-with-diabetes/complications/eye-complications/. Accessed May 4, 2016.
4. Caffrey MK. Survey finds young patients with diabetes getting fewer eye exams than older patients. Am J Manag Care. 2015;21(SP13):SP446.
5. Salm M, Belsky D, Sloan FA. Trends in cost of major eye diseases to Medicare, 1991 to 2000. Am J Ophthalmol. 2006;142(6):976-982.
6. Lee LJ, Yu AP, Cahill KE, et al. Direct and indirect costs among employees with diabetic retinopathy in the United States. Curr Med Res Opin. 2008;24(5):1549-1559. doi: 10.1185/030079908X297303.