Coverage for Remote Diabetic Retinopathy Screening is Declining and Creating Disparities | ASRS 2024

Although diabetic retinopathy is a leading cause of blindness in adults, fewer than half of Americans with diabetes have annual eye exams, Glenn C. Yiu, M.D., Ph.D., director, Tele-Ophthalmology and professor, Department of Ophthalmology at UC Davis Health, said during a presentation at the American Society of Retina Specialists 2024 meeting in Stockholm.

Teleophthalmology can fill in the gaps in screening, but those who would benefit most often have limited insurance coverage for telehealth.

Glenn C. Yiu, M.D., Ph.D.

“Teleophthalmology increased but payments declined, and lower reimbursements disproportionately impacted vulnerable populations, including the elderly, women, Blacks, and lower income patients,” Yiu said.

UC Davis’s teleophthalmology program was launched in 2018 at one institution and was able to increase screening by 15%, Yiu said. Image quality was good, and the center was able to identify not only possible retinopathy, but also glaucoma, macular degeneration and hypertensive retinopathy. Ultimately, he said, the program referred about one-third of those screened for follow-up.

But only half of the screenings were paid for by insurance, with most denials coming from Medicare, he said. Yiu and his colleagues analyzed use of teleophthalmology screenings and payment for patients newly diagnosed with type 2 diabetes. They used the OptumLabs Data Warehouse, which is a databased with about a 14% market share.

They reviewed claims data from January 2011 to December 2020 for three teleophthalmology codes. Researchers then assessed trends in claims paid, factors associated with insurance payments, and time to first eye exam.

What they found was that over that decade, remote screening increased but reimbursements declined. “We noticed that the insurance coverage for teleophthalmology codes have been drifting down over the last decade, starting from 90% in 2011 when the codes were developed to less than 50% by 2020,” Yiu said.

Additionally, the amount paid per claim has been stagnant over the last decade, he said.

Insurance coverage was also lower for those who were older, who were women, who were Black, who had lower income and those with less education. “This is especially true for those Medicare Advantage, which correlates with this drop in insurance claim coverage for teleophthalmology,” he said.

Teleophthalmology, Yiu’s review found, allows for about a month and half earlier screening for those newly diagnosed with diabetes. “We found that about one-third of these were the same day as the diabetes diagnosis, which suggests that the advantage of teleophthalmology screening is when they are in the primary care office,” he said.

Researchers also assessed time to in-person follow up after a diabetic retinopathy screening. Fewer than half saw an ophthalmologist, with non-English speaking patients and those with comorbidities and diabetes complications being the least likely to follow up.

Last year, UC Davis received a $2 million grant for an interdisciplinary program, the Collaborative UC Teleophthalmology Initiative, or CUTI. The project is in partnership with medical centers at UC San Diego, UC San Francisco and UC Los Angeles to expand eye care access for patients with diabetes, especially underserved populations.

As part of this program, Yiu will conduct a four-year study, collecting retinal images in a centralized database for research using artificial intelligence, which may be able to identify eye disease even earlier.