In January 2002, United States (US) eye doctors celebrated what was perceived as a huge victory: Medicare’s first-time coverage of a screening benefit for an ocular disease, glaucoma. The benefit covers an annual dilated eye examination with an intraocular pressure measurement and direct ophthalmoscopy or slit-lamp biomicroscopic examination for individuals at high risk of glaucoma. Initially, high-risk individuals were defined as all African Americans aged 50 or older and individuals of any age or race/ethnicity with diabetes or a family history of glaucoma. In 2006, the benefit was expanded to cover Hispanics aged 65 and older. These groups were selected because primary open-angle glaucoma (POAG) is 4-5 times more common in African Americans than in whites, African Americans are far more likely to be blinded by glaucoma, and the prevalence of POAG in older Hispanic populations can be as high as in African Americans.

Glaucoma is a silent disease that can be detected only by trained professionals. Screening for the disease remains controversial. The US Preventive Services Task Force ruled that evidence was “insufficient” to recommend for or against glaucoma screening at the population level ; however, it recommended “population-based trials” of visual and quality-of-life outcomes of screening, particularly in high-risk populations, which are targeted by the Medicare benefit. Proponents of a screening benefit emphasize the importance of identifying glaucoma before irreversible damage occurs. The rate of undiagnosed glaucoma is over 90% in some countries and up to 75% in Latinos in the US. In high-risk populations, screening is particularly important to detect glaucoma at an earlier stage, when blindness is more likely to be prevented. A growing body of evidence suggests that contrast-sensitivity degradation and visual field (VF) loss irrespective of visual acuity impairment can have profound effects on quality of life, activities of daily living, and risk of falls and fractures, all of which can result in greater disability, morbidity, and mortality. Screening for glaucoma might appear more beneficial and cost-effective if studies assessed a wider range of outcomes that occur in association with contrast sensitivity and VF loss prior to visual acuity impairment or blindness, including morbidity and mortality from systemic medical diseases related to decreased physical activity.

We analyzed publicly available Medicare Part B National Summary Data to determine the impact the screening benefit has had on identifying persons with glaucoma and discovered that the benefit essentially has been unused. Between 2002 and 2010 the benefit was billed roughly 10 000 times, averaging 1100 times annually. To put this in perspective, we estimate that at least 250 000 African Americans and 140 000 Hispanics aged 65 and older in the US have undiagnosed glaucoma and are eligible for the screening benefit. Not only is the benefit underutilized, but its use has declined over time: 2943 claims were billed in the first year, and the number dropped from 1205 in 2006 to 405 in 2010. The screening benefit appears to have been a failure.

Why has the glaucoma screening benefit, which pays doctors to examine high-risk subjects, failed to be used in any meaningful way while other covered screening tests, such as mammography and colonoscopy, are commonly performed in the Medicare population? Three key factors likely contribute. First, patients must present to an eye doctor to be screened. If a patient already has had a billed eye examination in the past 11 months, Medicare will not cover the benefit. In essence, the benefit is targeted at bringing previously unexamined individuals into the eye-care system. Second, the system provides a disincentive for eye doctors to bill under the screening code. The average reimbursement for screening was $46 in 2010, making reimbursement less than the amount doctors would receive for a routine eye examination (approximately $75). Thus if a doctor believes additional testing is warranted at the time of examination, the doctor would be unlikely to use the glaucoma screening code and might instead bill an examination using the glaucoma suspect diagnosis code. Finally, unlike some other screening benefits, which do not require a co-payment or other direct cost to the beneficiary, Medicare requires beneficiaries to pay 20% of the screening visit cost after the standard $162 annual deductible has been met. Individuals with limited financial resources who have not met the annual deductible may not be able to pay these costs, making it a less attainable benefit for the needier segments of the population.

An effective alternative to the current glaucoma screening benefit in the Medicare population needs to be identified. Although glaucoma is the second-leading cause of blindness and a major cause of morbidity among the elderly, other eye diseases also are more common with increasing age and should not be overlooked. Those entering Medicare are at substantial risk of having at least 1 treatable eye condition. This population has a relatively high rate of visual impairment from uncorrected refractive error and cataract, and glaucoma and most retinal diseases require periodic examination in order to detect and treat them before irreversible vision loss occurs. Medicare currently does not cover routine eye care unless an individual meets the criteria for the glaucoma screening benefit or has diabetes. However, Medicare does cover the medical and surgical treatment costs for ocular conditions that have been diagnosed and the treatment costs of blind individuals.

A broader screening approach that will bring more of our population’s older individuals into eye care and keep them there may be cost-effective. One option is to include a covered referral to an eye doctor for a complete eye examination by an eye doctor following the “Welcome to Medicare” initial preventive physical examination and to provide coverage for regular follow-up eye examinations. This approach likely would lead to earlier detection of visual impairment and the underlying cause(s) before irreversible vision loss or blindness occurs, and hence may reduce total Medicare costs. A recent analysis showed that a dilated eye examination at the start of Medicare coverage is highly cost-effective. However, more research is necessary to determine the most cost-effective approach to identifying, monitoring, and treating ocular conditions in the older segments of our population. In addition, a better approach is needed for providing necessary eye-health screening opportunities to individuals aged 50-65 years in high-risk, underserved populations, such as African Americans, Hispanics, and diabetics.