Disparities in Receipt of Eye Exams Among Medicare Part B Fee-for-service Beneficiaries With Diabetes — United States, 2017

Elizabeth A. Lundeen, PhD; John Wittenborn; Stephen R. Benoit, MD; Jinan Saaddine, MD

Disclosures

Morbidity and Mortality Weekly Report. 2019;68(45):1020-1023. 

In This Article

Discussion

This report of recent state-level prevalence of receiving an eye exam among Medicare Part B fee-for-service beneficiaries with diabetes found that, although Medicare covers annual eye exams for beneficiaries with diabetes, only 54.1% of these beneficiaries received an eye exam in 2017. Among Hispanic and black beneficiaries and those in seven states, <50% of beneficiaries received an eye exam.

These findings are consistent with those from other studies. An analysis of the 2005–2008 National Health and Nutrition Examination Survey data found that 51.2% of adults aged ≥40 years with diabetes had an eye exam in the past year.[5] A study of claims for U.S. patients aged 10–64 years with commercial or employer-sponsored health insurance found that among persons with diabetes and no diabetic retinopathy, 48.1% had not received an eye exam during the 5-year study period and 15.3% had an annual or biennial exam.[6]

Dilated eye exams are an important preventive care practice for early detection of diabetic retinopathy. Seventy-three percent of persons with diabetic retinopathy are unaware of their disease.[7] Early detection and timely treatment can prevent irreversible vision loss. The efficacy and cost-effectiveness of diabetic retinopathy screening among persons with diabetes is well established,[4] and professional organizations recommend annual screening. The American Diabetes Association recommends that persons with diabetes have annual eye exams, with consideration of biennial exams if there is no evidence of retinopathy on at least one annual eye exam and blood glucose is controlled.[3]

Studies have documented enablers and barriers to obtaining regular eye exams. A study using a small sample of Medicare beneficiaries aged ≥65 years found that 37% had an eye exam at least once every 15 months during a 5-year period.[8] Factors associated with more frequent eye exams included older age, being married, higher educational attainment, and a higher score on the Charleson Comorbidity Index (which predicts mortality for a patient with a range of comorbid conditions).[8] Factors associated with lower frequency of eye exams included being male, living ≥20 miles from an ophthalmologist, low cognitive function, and limitations in instrumental activities of daily living (skills and abilities needed to perform certain day-to-day tasks associated with living independently). A study of adults with diabetes in 22 states found that the factors most commonly cited for not seeking annual eye care were not perceiving a need for care and cost or lack of insurance; other factors included a lack of transportation, distance to an eye doctor, and not having or knowing of an eye doctor.[9] These findings highlight a lack of perception of the need for eye care and geographic and transportation barriers. Telemedicine might be a promising health care innovation to address geographic barriers in accessing eye care professionals for diabetic retinopathy screenings.[10] Through following evidence-based recommendations and providing patient education, health care providers can play an important role in improving the rate of receipt of annual eye exams among persons with diabetes. In addition, optimizing systems for eye care referrals and reminders (e.g., clinical decision support tools in electronic health records) and improving care coordination between clinicians managing diabetes and those providing eye care might address barriers attributable to low patient awareness.

The findings in this report are subject to at least four limitations. First, some beneficiaries who had eye exams might be nonadherent with recommendations; claims provide insufficient detail to identify dilated eye exams. Second, patients might have multiple insurers, and services reimbursed by a supplemental plan would not be recorded in Medicare claims, thereby underestimating eye exam prevalence. Third, Medicare data do not include care provided by the Indian Health Service; therefore, the data presented are likely not representative of the American Indian/Alaska Native population. Finally, this analysis excluded the 33.9% of Medicare beneficiaries enrolled in Medicare managed care plans.***

Although annual eye exams are covered for all Medicare Part B fee-for-service beneficiaries with diabetes, only approximately half of these beneficiaries received an eye exam in 2017. Geographic and racial/ethnic disparities in adherence to this preventive care practice were identified. This low prevalence of receipt of annual eye exams could have significant implications for vision loss from diabetes-related eye diseases. CDC's Vision and Eye Health Surveillance System, which provides data on U.S. vision and eye health conditions and use of eye care, is an important tool to identify trends and assess eye health disparities among persons with diabetes.††† These data can be used to inform strategies and interventions to prevent vision loss among Medicare beneficiaries with diabetes.

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