May 2, 2022
By Melanie Frogozo, OD, FAAO
Vision plans are structured to drive patients to the optical — not to engage in long-term, complex medical management of ocular conditions.
Globally, the rate at which children are developing myopia is accelerating. This myopia epidemic raises the incidence of high myopia and its sight-threatening consequences. Treatments limiting myopia progression are available, including an FDA-approved contact lens option. These medical devices limit the elongation in axial length and subsequent myopic refractive error. Early intervention is critical and is associated with more significant reductions in myopic progression.
The FDA-approved contact lens option is a dual-focus soft hydrophilic daily disposable contact lens. It operates on the optical principle of creating peripheral retinal defocus, a stimulus that retards myopic progression. Other contact lenses of similar design can also elicit the myopia control effect and are viable options for off-label usage. As of this writing, no medical insurance or managed vision plan covers the process of myopia management. One vision plan explicitly makes OrthoK, or myopia control, a private matter between the patient and provider. Confusingly, patients may elect to use their contact lens benefit (typically a set dollar amount) to help defray the cost of the materials. The question is: Should managed vision care plans cover myopia management?
The Answer Isn’t Simple
The answer to the above question is, frustratingly, “It depends.” Various stakeholders may have disparate views on the subject. Parents of emerging myopes, for example, may wish to have these treatments covered with minimal out-of-pocket costs. Vision plans, however, see myopia management as something beyond the scope of their mission. They undoubtedly observe the commonality of myopia and calculate that covering myopia management would not be profitable under their current business model. Public health officials may wish for greater access to myopia care. In contrast, providers are stuck between wanting the best outcomes for their patients and the economic realities of running their practices.
The current standard of care in myopia management includes services, special testing, medical decision-making, and office procedures beyond standardized comprehensive eye exams. For example, measuring axial length requires an optical biometer, training, documentation, and interpretation that is not accounted for in routine vision plan coverage. The myopia management process is analogous to treating ocular conditions requiring medically necessary/specialty contact lenses. Certainly, vision plans provide coverage for services and devices to treat conditions that meet defined criteria of medical necessity, such as keratoconus. Coverage for these conditions is aimed primarily and simply at enabling sight and is, therefore, aligned with the mission of the vision plan. In myopic children, without a complicating layer of rare disease, spectacles and/or contact lenses explicitly used for refractive purposes meet the plan’s end goal.
Day-to-day cases of myopia control may involve only modest levels of medical decision-making and relatively uncomplicated, commonly available contact lens designs to achieve the treatment goal of slowing myopia progression. However, the variables can quickly compound such that some cases may be intractable to all but the most highly trained and experienced providers using complex, bespoke devices to restrain the development of high myopia. Regardless of complexity, treatments are of long duration involving regular follow-up visits, potential parameter changes, and an overall time horizon measured in years. Ongoing, complex management of a common condition where the primary endpoint is the lack of something happening is beyond vision plans’ current reimbursement schema. To complicate matters, there is a lack of public and professional awareness and/or concern for the myopia epidemic and its consequences that might otherwise force a change in how vision plans conduct business.
Improving Optometric Education
The public is accustomed to simple solutions for nearsightedness. Vision plans are structured to drive patients to the optical — not to engage in long-term, complex medical management of ocular conditions. Optometric education is focused on competencies for routine eye exams and the management of ocular diseases such as glaucoma. Despite the long-term availability of OrthoK, its use specifically for myopia management is a relatively recent development. The acquisition of expertise in myopia management has traditionally been a post-graduate pursuit. This is due to the complexities involved in a rapidly evolving, newly recognized field of research and practice.
As safe and effective myopia management treatments become mainstream and more treatments receive FDA approval, optometric education will change to meet current realities. It remains to be seen if vision plans and/or traditional medical insurance will alter their business models to offer equitable coverage for myopia management. Perhaps an outcomes-based reimbursement structure will reward providers for preventing their patients from developing high myopia in the future.
Melanie Frogozo, OD, FAAO, is the owner of Alamo Eye Care in San Antonio, Texas, where she directs the Contact Lens Institute.