David B. Glasser, MD: The Larger Implications of Telehealth in Ophthalmology

David B. Glasser, MD

New research published in JAMA Ophthalmology reported that telehealth use in ophthalmology was modest compared to other specialties during the onset of the COVID-19 pandemic and returned to mostly in-person visits as restrictions lifted, while others still provided remote care.

The study investigators from the University of California, San Francisco indicated physical examinations and difficulty of remote data collection were limiting factors and played a part in these low numbers. However, a hybrid model combining teleophthalmic visits with asynchronous testing was feasible for subspecialty-level evaluation and often led to change in management.

In an accompanying commentary piece, David B. Glasser, MD, Wilmer Eye Institute, Johns Hopkins University School of Medicine, questioned the unique nature of telehealth in ophthalmology and the need to address reimbursement challenges of new technologies in order to access their full potential.

Here, we delve into Glasser's perspective on this topic. This transcript has been edited for clarity.

The study from Mosenia et al highlighted the difficulties in transferring ophthalmic care to a remote setting, but ultimately suggested the hybrid model led to greater efficiencies with same-day in-person testing and virtual visits. In your opinion, how might greater implementation of a hybrid system improve an ophthalmologist/clinician’s day-to-day workload?

One has to keep in mind that this hybrid system was developed in response to the COVID-19 public health emergency (PHE). It’s primary purpose was to reduce person-to-person spread of the disease, not to improve office workflow efficiency. In fact, it’s not clear that having patients come in for in-person testing followed by virtual visits actually improves office workflow. In an already efficient office, the necessary data will be available for the physician to review at the time of seeing the patient during a traditional in-person visit. In an office where workflow is perhaps less efficient, gathering data in person prior to a later virtual visit could reduce physician down time waiting for test results.

There are several potential downsides to the hybrid system. Slit lamp and fundus examinations cannot be replicated during a virtual visit, and for some patients the ability to obtain a nuanced history may be impeded. If the virtual visit is inadequate, an in-person visit may be necessary. There is typically staff time associated with both in-person testing and virtual visits which could increase practice expense. Those aspects were not addressed by Mosenia et al’s study.

In what ways might a hybrid model ultimately benefit subspecialties like retina and glaucoma, which did not have high levels of telemedicine use, and the patients with these conditions?

The key potential advantage of telemedicine is to increase access to care. The hybrid model did that when access was severely threatened by the PHE. However, most ophthalmology visits went back to in-person once protocols to reduce disease transmission were in place, despite the fact that the shelter-in-place order for non-essential activities was still in force. Clinicians and patients voted with their feet: traditional in-person care was preferable to the hybrid model. As Mosenia et al noted, and I agree, this was likely because current imaging technology of the eye, whether performed in person or remotely, is not a substitute for established slit lamp and fundus examination techniques.

Before we discuss your commentary, could you additionally share some thoughts on the greater promise of telehealth in ophthalmology and its relationship to social determinants of health?

As I mentioned earlier, telehealth’s greatest promise is in extending care to disadvantaged and underserved populations. We often assume these are people living in remote areas, but there are urban populations which are unable to access traditional health care. Telehealth can make medical care available to those who lack transportation or the resources needed to get to an in-person appointment, whether that’s money or time or an available relative or friend to take them. Recently visually impaired patients may not be able to drive themselves to an appointment even if they have a car.

As an example, there are now several artificial intelligence-enabled imaging devices capable of detecting clinically significant diabetic retinopathy in a point-of-care setting. These can be placed in primary care offices, pharmacies, or any number of places that people normally visit anyway, and can detect disease and direct those at risk to see an ophthalmologist before there is any irreversible loss of vision. The potential to expand screening to populations that would never otherwise see an eye doctor holds tremendous promise for improved public health, particularly for disadvantaged populations.

You make the point that CMS and Congress have the authority to reduce coverage/reimbursement hurdles for Medicare patients by increasing funding and reducing barriers to delivery of these telemedicine services. What are the steps required to advocate for the larger benefit of new telehealth technologies for these patients and recognize the important of reimbursement for these services?

Organized medicine has been telling CMS and Congress this for years. We’ve made some progress – for example Medicare payment for remote screening for retinopathy – but it’s not enough. We need more individual physicians to write or call their representatives in Congress. Right now, ophthalmologists can use the American Academy of Ophthalmology’s advocacy tool to write their member of Congress in support of HR 8800, the Supporting Medicare Providers Act of 2022, which would stop part of the nearly 8.5% Medicare payment cut scheduled to take effect January 1.

We also need the general public to speak up. It’s a difficult task because people have so many issues that concern them. But health care is top of mind for most seniors. And Congress listens when their constituents speak up about concerns with access to care.

You mention it in your piece, but how does inflation affect a physician’s ability to do their job properly? Can you share for ophthalmology specifically?

The cost of running a medical practice, measured by the Medicare Economic Index (MEI) has run 22% ahead of Medicare physician reimbursement since 2001, even worse if you compare to the consumer price index. Doctors aren’t starving, but it becomes harder to maintain staff and benefits like health insurance, keep expensive equipment up-to-date, and comply with increasing documentation and reporting burdens imposed by CMS and commercial carriers when their costs are increasing and reimbursements remain flat.

The classic example in ophthalmology is the cost of complying with prior authorization and step therapy requirements. In 2019, CMS gave Medicare Advantage plans authority to implement step therapy: require the patient to fail on a drug chosen by the insurance company for its lower cost before allowing coverage for the drug the physician determines is best for the patient. For a retina specialist giving anywhere from 6 to 20 intravitreal injections annually to each of hundreds of patients with wet macular degeneration, the administrative burden is enormous. I know practices that have had to hire 2-3 staff to deal with pre-authorizations and step therapy paperwork alone.

There are two bills in Congress at the moment addressing these problems. HR 3173/S 3018, the Improving Seniors’ Timely Access to Care Act, has passed the House and is now in the Senate. It would streamline and standardize prior authorization (PA), minimize PA for routinely approved services, and require qualified personnel to make PA determinations. HR 2163/S 464, the Safe Step Act, would require group health plans to provide exceptions to step therapy when medically appropriate.

Do you have any final thoughts about the topic at hand?

Medicare spending increases for physician services are currently capped at $20 million annually. Once that target is exceeded, a process known as budget neutrality kicks in, reducing payments across the board. Twenty million dollars is a ludicrously low cap in a budget that exceeds $90 billion, especially considering that the Medicare population is growing and an increasing percentage of seniors are needing care for diabetes and other chronic diseases. This is not the time to be reducing funding for physician services. Unless additional money is put into the system, access to medically necessary care will suffer. The physician population is aging and more physicians are cutting back hours or retiring. It’s not quick or easy to create new physicians. If we wait until an access to care problem is apparent before moving to fix this, we will be stuck with that access problem for a long time.