Integrating models of diabetic eye care

Excerpted from page 32 of the November/December 2020 edition of AOA Focus.

Fear is the best motivator, right?

For years, “blindness” ranked chief among Americans’ greatest health fears, even above loss of memory or a limb. Yet, when it comes to diabetic eye disease, fear seems to have its limits. Although an annual, dilated eye examination can reduce the risk of blindness from diabetes, nearly two-thirds of people with diabetes over 40 fail to follow their eye exam schedule.

So how can optometry get more patients with diabetes into an exam chair more routinely? That’s the $500 million/year question—the cost of diabetes-related blindness in the U.S., the Centers for Disease Control and Prevention (CDC) reports—that could be answered by creative, integrated care delivery models finding success in states hardest hit by the disease.

Old problem, new twist

Today, over 34 million Americans have diabetes with as many as 21% of those adults unaware of their condition. An additional 88 million U.S. adults are at such severe risk of developing the disease that they’re considered prediabetic. Although new diabetes cases are significantly down among adults over the past decade, little solace can be found when considering that not only are new cases among those 20 and younger up significantly, but also there’s ample room for improvement in preventing diabetes complications, notes the CDC’s 2020 National Diabetes Statistic Report.

But true to 2020, there’s yet another shoe to drop when it comes to diabetes. Emergence of SARS-CoV-2, the virus causing COVID-19, has created a “pandemic on top of a pandemic” with diabetic populations among the greatest risk. In fact, the CDC estimates people with underlying health conditions are six times more likely to face hospitalization and 12 times more likely to die from COVID-19.

Michael Duenas, O.D., AOA chief public health officer and optometric representative to the Diabetes Advocacy Alliance (DAA), notes that among people with diabetes infected by COVID-19, it is possible that higher body-mass index and A1c levels are linked to worse outcomes, while disruptions caused by the pandemic—e.g., change in care, diet, physical routines—may also exacerbate health disparities. Still more evidence points to another ominous development.

“New research suggests that COVID-19 and diabetes may be a two-way street,” Dr. Duenas says. “Not only do people with diabetes and COVID-19 suffer disproportionately higher rates of severe outcomes, but it also is possible that COVID-19 is triggering new cases of type 1 and type 2 diabetes or a new type of diabetes altogether. Among people with existing diabetes, it may be triggering severe metabolic complications, such as diabetic ketoacidosis.”

Post-COVID-19, sudden onset diabetes is still a working theory, yet it’s not without precedent. Researchers documented a similar occurrence associated with the severe acute respiratory syndrome (SARS) scare of the 2000s—a genetically related coronavirus to SARS-CoV-2—where the virus damages cells that control blood sugar. The association has prompted creation of a global database to explore the chicken-or-egg situation, and forthcoming evidence could shape the way health care identifies and manages diabetes.

In the meantime, the DAA is working to find out more and translate that into actionable information for health care providers. Dr. Duenas, who chairs the DAA’s COVID-19 and Diabetes Workgroup, says optometry should pay close attention to how this evidence develops, considering doctors of optometry may be among the first providers to detect diabetic changes in an otherwise asymptomatic or recovered COVID-19 patient.

“Hyperglycemia and insulin resistance promote glycosylation end products and pro-inflammatory cytokines resulting in oxidative stress along with increased adhesion molecules that mediate tissue inflammation. This may help explain a higher propensity of infection and worse outcomes.

“There is, therefore, a very urgent need to characterize such COVID-19-related diabetes to inform the clinical management of people affected and explore potentially novel mechanisms of disease, particularly in communities disproportionally affected with poor outcomes in COVID-19 infections—those of Black ethnicity and those with increased body weight or [body-mass index],” Dr. Duenas notes.

Once again, optometry stands to make a difference. Optometry is not only well-positioned to provide this level of primary eye health care—practicing in more than 10,176 communities nationwide, per the AOA Health Policy Institute—but also able to detect the earliest diabetic changes via a dilated, comprehensive eye exam and perhaps in the ocular signs of an inflammatory cascade. In fact, 20% of people first learn they’re diabetic through the results of an eye exam.

Still, it wasn’t that long ago that optometry was relegated to a traditional, triage role of detecting and identifying vascular changes. Now, doctors of optometry are engrained in the diabetic care and management team, serving as primary eye care providers and diabetes educators, or even moving closer toward point-of-care testing for better detection and diabetic management. If diabetes itself wasn’t serious enough, emergence of COVID-19-related complications should embolden optometry to get even more involved in diabetic eye care.

“What this tells me is that we’re really at a transition point as a profession, and how we pivot to delivering care is going to be extremely critical to meeting the public need going forward,” Dr. Duenas says.

Fortuitously, many states are already positioned to meet that need.

Diabetes and value-based care

In Pennsylvania, optometry witnessed progressive increases in the state’s rate of adults diagnosed with diabetes—from 7.7% in 2006 to 9.6% in 2016—and decided it was time to take matters into its own hands. The Pennsylvania Diabetic Eye Health Alliance (PDEHA) was the solution, essentially a panel of doctors who agreed to provide dilated eye examinations to patients with diabetes as well as provide correct reporting to both primary care providers (PCPs) and medical insurance plans, says Steven Eiss, O.D., a Pennsylvania Optometric Association past president and AOA’s Third Party Center chair.

But it wasn’t enough just to enlist this group of dedicated primary eye care providers. There needed to be a tangible action that would be the difference—and that’s where payers came into play.

Health insurers have a vested, financial interest in keeping their beneficiaries healthy. The cost of treating diabetes in the U.S. is already some $327 billion with 1 in every 4 health care dollars spent on treating diabetes and its complications, notes the American Diabetes Association. What’s more, patients with diabetes are generally older and sicker than the population without diabetes. A 2018 study in Diabetes Care found that when comparing health care expenditures between those with diabetes vs. those without, people with diabetes have expenditures 2.3 times higher than would be expected of a person without diabetes ($16,752 vs. $7,151). The same study concluded that “a large portion of medical costs associated with diabetes costs is for comorbidities.”

Keeping these comorbidities at bay keeps the relative price of care down, while early identification of prediabetes could trigger lifestyle modifications that keep a patient from progressing altogether. Optometry’s willingness to see more patients with diabetes, as evidenced through the PDEHA, plus the clinical value of dilated eye exams, made for a commonsense alignment with health plans. Yet, that wasn’t the only carrot for payers.

Enter quality performance metrics, such as the Healthcare Effectiveness Data and Information Set (HEDIS) and the Centers for Medicare & Medicaid Services’ Star Ratings. These standardized quality measures essentially score how well health plans perform in providing service and care to members. Employers and consumers turn to such quality metrics when evaluating their options, and plans pay close attention to how they rank. In fact, 90% of U.S. health plans rely on HEDIS to evaluate their performance, notes the National Committee for Quality Assurance.

For the PDEHA, these incentives led to an alliance with Geisinger Health Plan in 2015, and it’s been a success ever since. In 2019 alone, the PDEHA delivered over 2,800 dilated exams of the 3,100 requested for a success rate of 90%. That’s compared with success rates of mobile clinics or retinal imaging in the sub-30% range, Dr. Eiss says.

“The plans we work with have been very motivated to utilize this to help close their care gap in dilated eye exams,” Dr. Eiss says. “There is a significant financial benefit for even a relatively small increase in HEDIS and Star scores. More importantly, early detection and intervention will help improve patients’ outcomes and overall health. In theory, this should decrease the patient’s cost of care in the long term, which would also save health care money.”

The AOA utilized Pennsylvania’s model to roll out a national version of the diabetic eye health alliance, administered on a state-by-state basis and customizable to the local needs or opportunities available, Dr. Eiss notes.

“The beauty of this program is that once a state sets it up and enrolls doctors in the alliance, you can utilize it in whatever opportunity presents itself,” Dr. Eiss says. “We hope that as we have more data from numerous insurance plans, there will be more demand from other plans nationwide to do the same. States that have begun the process of implementing the alliance will be better prepared for these opportunities.”

Adapting models for success

North Carolina is one state that saw an opportunity in the diabetic eye health alliance model and adapted it to its own needs. Instead of allying directly with plans, North Carolina’s model of diabetic referrals takes a different but no less successful tilt that goes straight to the source of referrals—patients’ primary care providers.

When the North Carolina Academy of Family Physicians reached out about a strategic partnership to close Comprehensive Diabetes Care-Eye (CDC-E) care gaps within the state, the North Carolina Optometric Society (NCOS) saw an invaluable partnership that led to the creation of the state’s diabetic eye care collaborative (DECC). Once again, the model is a win-win for both family physicians and optometry.

Essentially, the DECC works like this: Family physicians refer patients with diabetes to participating optometry practices, then doctors of optometry provide a dilated eye exam and furnish CDC-E documentation to the referring family physician or endocrinologist. The records-sharing satisfies quality standards for family physicians while also mutually supporting each member of the diabetic care team and ensuring patients never fall through the cracks.

Best of all, it’s a relatively hands-off process. Participating doctors of optometry add their practice to the statewide DECC database, and when a family physician needs a referral, they can query the database to identify a trusted eye care provider. As opposed to Pennsylvania’s alliance that involves insurers directly and offers the promise of better HEDIS or Star scores, Jamie Casper, O.D., an NCOS past president, says there’s no gold star or carrot per se for participating in the DECC. Instead, the collaborative is an effective utilization of optometry’s accessibility and recognition of the level of care that optometry is willing to provide. To some extent, it’s also a practice builder.

“The DECC was set up to give family physicians access to doctors of optometry who participate in the medical model,” Dr. Casper says. “It’s very basic in its creation and implementation; it doesn’t really do more than what many doctors are already doing. But it does give family physicians who don’t know who or where to send their patient an ability to establish relationships with doctors who will help them find their patient care.”

In other words, a low-maintenance yet high-reward kind of program. The dilated, comprehensive eye exam is a required element of evidence-based diabetes care, and not without good reason, as the ocular findings have direct bearing in the management of that patient. That’s where this seamless transition between providers adds to the practice of value-based medicine, Dr. Casper says.

“Ultimately, you want to prevent serious progression of the disease, and optometry is absolutely a part of that by providing physicians with additional information that they may not have,” Dr. Casper says.

In West Virginia, North Carolina’s model was adopted in large part from its reported successes. However, the stakes were somewhat higher—nearly 15% of West Virginia’s adult population is diabetic with an additional 11% prediabetic. This represents the highest diabetic rate in the nation.

Laura Suppa, O.D., West Virginia Association of Optometric Physicians (WVAOP) board member and legislative chair, says the association knew there was an opportunity to partner with PCPs and endocrinologists, considering the sheer accessibility of doctors of optometry statewide. In fact, doctors of optometry provide primary eye care services in 51 out of the state’s 55 counties. Similar to North Carolina’s model, the WVAOP established a database of participating doctors of optometry that was accessible to the state’s academy of family physicians and other medical associations, and following a diabetic eye exam, doctors would furnish the AOA’s Diabetic Report (or similar 1-page document) to the patient’s PCP or endocrinologist. But things got interesting when an outside management services organization inquired about adopting the program in a clinically integrated eye care network.

“This service has taken our already established DECC guidelines and used their resources to begin approaching larger entities to include our West Virginia optometric physicians as providers in alternative payment models, as well as other value-based care and contracting opportunities,” Dr. Suppa says.

The WVAOP still continues the DECC program to hold doctors to a higher standard of care, Dr. Suppa notes, but this clinically integrated eye care network now operates separate from the association.

Additionally, the DECC model caught the attention of the insurer Highmark, which has since approached the WVAOP about an opportunity to participate in its Diabetic Retinal Eye Exam Incentive Opportunity.

Dr. Suppa explains that Highmark’s new program contacts individual doctors with a list of diabetic Medicare Advantage members for which they are listed as the provider in the past three years, and doctors contact those patients about scheduling an exam and providing a report to patient’s PCPs.

In turn, Highmark issues an incentive payment of $20/exam to the practice based on claims received through the end of 2020.

“We are excited that our DECC program has afforded such opportunities to our participating WVAOP members,” Dr. Suppa says. “Providing care for patients with diabetes is an everyday job for our West Virginia optometric physicians, and we are proud to provide such a high level of care for those in need.”

That goes equally for doctors of optometry nationwide, looking for creative ways to deliver the quality care that patients need every day.

Access the AOA’s Evidence-based Clinical Practice Guideline: Eye Care of the Patient with Diabetes Mellitus, Second Edition and listen to a podcast.

Interested in the DECC model?

Reach out to the AOA’s Third Party Center about adapting the model in your state.