Reimbursement Model Must Change: Glaucoma Patients Need More Than Eye Drops

More than 76 million people worldwide are living with a disease that, if left untreated, will eventually rob them of their eyesight.[i]

That’s because glaucoma, a chronic eye condition affecting one’s sight, progresses slowly. And many people, once diagnosed, don’t get the care that will help prevent them from losing vision. That is why glaucoma is still the second leading cause of blindness worldwide.

There is no cure for glaucoma, but a patient can prevent blindness by using daily eye drop medications. Despite the drops’ success in halting disease progression,[ii] at least half of glaucoma patients do not take their medications as prescribed.[iii]

As a glaucoma specialist at the University of Michigan Kellogg Eye Center, I hear many patient stories as I talk with them in my clinic.

One older gentleman with glaucoma visited my clinic as his vision was worsening. His wife, who put his eye drops in for him, had recently passed away. Now, he had no help. I asked him to demonstrate how he put in his drops. After struggling to open the bottle, his multiple attempts dribbled down his cheeks. The medications keeping his vision from further deteriorating never made it into his eyes.

Research has proven that counseling and education, particularly from health coaches, improves outcomes for people with diabetes.[iv] Including glaucoma counselors in a team-based model of care with ophthalmologists could give people with glaucoma the support they need to control their disease. Our lab has shown that our 6-month personalized glaucoma coaching programme improved adherence to glaucoma medications from 60-81% among 39 people with poor adherence[v] and we are currently enrolling participants to test this programme in a larger randomized controlled clinical trial.[vi] However, insurers would need to reimburse for counseling and team-based care for glaucoma just as they do for diabetes.

Our current reimbursement model does not incentivize education and counseling as part of eye care. Today, ophthalmologists receive much higher reimbursement rates for making diagnoses and performing surgery than for talking with patients.

Another patient explained how she used her daily glaucoma medication—which can cost upward of $80 per month—every other day to “make it last.” When she started treatment, she received a brand name medication sample. Her doctor refilled the medication, never asking if cost was a concern despite the availability of a cheaper generic equivalent.

Helping people better manage glaucoma so they do not lose their vision and independence as they age is imperative. Some innovative health insurance programmes reimburse team-based care for chronic illnesses like diabetes. Health coaches are reimbursed for providing counseling, and physicians receive a small bonus for managing patients’ issues as they arise between visits. This also would work for glaucoma patients. Aligning reimbursement with improved communication between patients and their health care team is critical to improving glaucoma care.

Patients play a central role in managing their glaucoma. However, health plans and policy makers must improve incentives for team-based care to boost patient adherence to treatment recommendations. Team-based care, where eye doctors work with health coaches to provide counseling and ongoing glaucoma support, needs to be reimbursed in a way that rewards talking to people as much as prescribing a new medication.

[i] Tham YC, Li X, Wong TY, Quigley HA et al. Global Prevalence of Glaucoma and Projections of Glaucoma Burden through 2040 A Systematic Review and Meta-Analysis. Ophthalmology 2014;121:2081-2090.

[ii] Garway-Heath DF, Crabb DP, Bunce C, et al. Latanoprost for open-angle glaucoma (UKGTS): A randomised, multicentre, placebo-controlled trial. Lancet. 2015;385:1295-1304.

[iii] Reardon G, Kotak S, Schwartz GF. Objective assessment of compliance and persistence among patients treated for glaucoma and ocular hypertension: A systematic review. Patient Prefer Adherence. 2011;5:441-463.

[iv] Spencer MS, Kieffer EC, Sinco B, et al. Outcomes at 18 Months From a Community Health Worker and Peer Leader Diabetes Self-Management Program for Latino Adults. Diabetes Care. 2018;41:1414-1422.

[v] Newman Casey PA, Niziol LM, Lee PP, Musch DC, Resnicow K, Heisler M. The Impact of the Support, Educate, Empower (SEE) Personalized Glaucoma Coaching Pilot Study on Glaucoma Medication Adherence. Ophthalmology Glaucoma 2020; 3(4): 228-237.

[vi] https://www.clinicaltrials.gov/ct2/show/NCT04735653?term=Newman-Casey&cond=Glaucoma&cntry=US&draw=2&rank=2