The way providers so poorly manage diabetic retinopathy is a poster child for what's so wrong about our healthcare system.
This potentially blinding eye disease affects up to 45% of the 26 million Americans with diabetes. It is silent and gradually erodes vision in a way patients often don't notice until it's too late. Unless they're regularly screened for the disease.
It's also very expensive. The malady carries a $900,000 lifetime medical and societal cost per patient.
We could and should do better by these patients, but here's how we thwart efficient quality of care and allow the diabetes cost curve to soar:
We rely on referrals. We want primary care doctors to give their diabetic patients a referral to an ophthalmology retina specialist for annual eye screening, necessitating they make an appointment with yet another practitioner, who in remote or low-income areas may be hard to find.
We have long realized that about half of these patients never make it to the test, either because they can't afford it, live too far away, or just don't understand the urgency. In low-income populations only 10% of patients with diabetes are getting screened for eye disease.
We don't stress the gravity—to patients or other practitioners—that this disease leads to blindness. But if caught early, surgery or other treatments can prevent 90% of patients from progressing to serious vision loss.
We don't compensate primary care doctors to screen. We could have primary care doctors use the patient checkup to get retina photographs. Doctors would have to buy $25,000 cameras that are easy to use and don't require eye dilation, (the cost may dramatically drop soon) then use telemedicine to have contracted retina specialists evaluate the images.
But payers won't reimburse doctors what it would cost, even though it would capture more disease, be cheaper than paying an ophthalmologist, and be a better solution than letting disease silently progress, further damaging other vessels like those in the heart.
We allow turf battles between eye specialists and primary care doctors to block solutions in a way that defies common sense.
Tillman Farley, MD, medical director of Salud Family Health Centers, a practice with 5,000 diabetes patients in Ft. Lupton, CO, agrees. "The way we're doing this today is not a good way, and we'll continue to lose a lot more vision if we continue this way."
Diabetic retinopathy "is a perfect disease to screen for because it has a long silent period. And with this disease, it really matters if you catch it."
James M. Gill, MD, president of Family Medicine at Greenhill in Newark, DE, agrees.
"Anytime you have to refer a patient out of your office, the probability they will get the recommended care goes down dramatically," Gill says. "This would significantly increase the chance this will get done."
This is huge, because diabetes is expected to mushroom in the next 30 years from 26 million people today to 125 million.
Some primary care doctors argue that they don't have time in their busy practices, with all the things they have to worry about already. But they should make time, and payers should compensate them for that.
Ticking time bomb in the eye
I said this earlier, but it bears repeating; Catching vessel damage in the eye can signal asymptomatic damage to other important organ systems such as the vessels of the heart.
"The eye is the only place in the body where we can see blood vessels without having to cut into the body first. So many patients don't know they have a ticking time bomb in their eye," says Seema Garg, MD, a retina specialist at the University of North Carolina, Chapel Hill.
The solution is obvious, but requires a major change in the way primary care medicine is practiced. Once a patient is diagnosed with diabetes, doctors should make the exam simple and easy-to-get.
In a Research Letterpublished Monday in the Archives of Internal Medicine, Garg gives evidence that moving diabetic retinopathy screening from the ophthalmologist's office to the primary care practitioner is effective through telemedicine.
In Garg's study of 1,002 patients with diabetes, when screening was done in an outpatient clinic and images were sent to her electronically, rates of screening rose from a historical 32% to 71% after 12 months. She identified 133 patients with disease who probably would not have gotten care otherwise.
"We can't afford not to do this," Garg says.
Charles Cutler, MD, a Norristown, PA internist and member of the American College of Physicians Board of Regents, thinks Garg's proposal is "great" because he knows how hard it is to get some patients to do what the doctor says. "Sometimes I find the prescriptions I've handed them lying in the parking lot outside," he says.
Another part of the problem is "the turf battle with ophthalmologists," he says.
Ophthalmologists balk
I thought ophthalmologists would be delighted. Yes, they might lose revenue from office visits to screen negative patients. But if millions more patients with eye disease were discovered, they'd have more patients to treat. But within this group there is caution and skepticism.
Trexler Topping, MD, a Boston ophthalmologist and chairman of the American Academy of Ophthalmology's Health Policy Committee, sees numerous problems with a system that would rely on primary care physicians to do eye exams in diabetic patients.
"There is a role for screening in telemedicine, and I think that is certainly going to be used in the future, especially in isolated areas and Indian Health Service populations. It's already being widely used in the Veteran's Affairs Health System where there is not sufficient access to care," he says.
But for starters, the quality of the fundus images is so poor, 10% of the pictures must be thrown out. "For a significant percentage, we just don't have the answer after the picture is taken," he says. (Garg contends that fewer than 5% of the pictures are unusable.)
Second, Topping says, people with diabetes also have higher rates of macular degeneration, cataracts, and glaucoma. If primary care providers screen just for retina disease, other eye diseases that an eye specialist would likely have caught may be missed.
But wouldn't that all be offset when so many more patients are referred as having retina disease? I asked. And wouldn't those patients who have retina disease also be the ones more likely to have glaucoma or cataracts?
"There's no question you would capture more disease if you did indeed screen a higher percentage of the population," Topping replies. "But that's not the optimal way to do it." The eye specialist's equipment and training is just better, he says.
"It's not rocket science."
Farley, at Salud Family Health Centers, uses a fundus camera to screen patients and has learned how to read them himself rather than relying on telemedicine for a retina specialist. There's a simple accepted algorithm, he says. "It's not rocket science."
In the process he avoids a screening cost of about $35 per patient.
"We save way more vision and prevent way more blindness in our system than in any system that depends on an ophthalmologist for screening," he says "even with a test that is not quite as good."
And, telling the patient they could go blind really gets their attention, persuading them to get blood sugars under control more effectively than vague warnings about other health consequences far down the road, he says.
Unfortunately, Farley says, "you get into big turf issues if you go to an ophthalmologist and say family doctors can read these films. You'd get some pushback on that."
He was right. Topping heatedly disagrees, saying that proper training requires far more time than three hours.
Clearly, some details will have to be worked out.
Bottom line, says Garg, is that "the dollars and cents are going to bring a lot more attention to this than the social value of preserving vision. The more you let the smoldering fire burn, the more it's going to take. We have a great opportunity for a partnership rather than a food fight."