Optometry, FQHCs positioned to address underserved communities’ eye care
Significant barriers exist for Americans seeking eye health and vision care at community health centers with less than 3% of patients receiving such services in 2019, prompting the AOA’s call for greater access among underserved populations.
In a webinar hosted by the Association of Clinicians for the Underserved (ACU), AOA Trustee Lori L. Grover, O.D., Ph.D., presented the findings of a joint AOA-ACU white paper, titled, Integrating Eye Health and Vision Care for Underserved Populations into Primary Care Settings, that detailed the lack of and challenges to accessing vision care services among underserved populations—and how federally qualified health centers (FQHCs) can address these shortfalls by integrating doctors of optometry into their comprehensive care models. Such service expansions come with fiscal and logistical challenges for FQHCs, yet advocates argue the benefits far outweigh the challenges in providing primary eye care services that are not only noticeably absent but also medically necessary for these at-risk populations.
“Prevention, like everything else in health care, is absolutely key and that starts upstream with primary care,” Dr. Grover noted on the Dec. 1 webinar with FQHC administrators and care teams. “If we can get more access to quality primary eye care up front, we could reduce the negative impacts of vision loss.”
Medical eye care necessary at FQHCs, CHCs
Currently, chronic vision impairment or blindness affects some six million Americans while another 48 million live with refractive errors, amounting to an economic toll of nearly $145 billion. But as the U.S. population ages and demographics shift, vision impairments are expected to double by 2050 while costs quintuple to $717 billion unless existing infrastructure and resources are expanded to address vision health, the white paper notes.
These figures become ever more poignant when considering one of the most common challenges for the Health Resources and Services Administration’s (HRSA’s) Health Center Program—namely, the systemic burden of diabetes. Nearly 1 in 7 patients treated at FQHCs have diabetes with 1 in 3 of those patients exhibiting uncontrolled diabetes. Unfortunately, these populations face significant health-related disparities that impact patients’ access to and uptake of health care, such as patients of Hispanic or African descent being twice as likely as Caucasians to go blind from diabetic retinopathy or glaucoma, Dr. Grover notes.
“Gratefully, FQHCs are uniquely positioned to help improve access to eye health and vision care because of their reach in underserved communities and their emphasis on providing integrated, whole-person care to underserved populations,” Dr. Grover says.
Citing the National Academies of Science, Engineering and Medicine (NASEM) 2017 report on eye health and vision care, Dr. Grover emphasized that FQHCs are often the only source of eye care available to these populations and other low-income individuals even though FQHCs are not fully equipped to provide comprehensive eye care. For instance, in 2019, HRSA reported only 444 full-time equivalent doctors of optometry and ophthalmologists across nearly 1,400 health centers with some 13,000 service delivery sites. Such is the case, less than 3% of health center patients received vision care services, representing 0.89% of all clinic visits that year.
Consequently, adding or expanding health centers’ eye and vision care services bolsters patients’ access and follows through on the NASEM report’s conclusion that “promoting optimal conditions (i.e., access to eye examination) for vision and health, can positively influence many social ills, including poverty.”
To counter anticipated financial challenges, the white paper suggests health centers first consider referral relationships to supplement the available eye care for patients or contracting with a local eye care provider to work on-site, part-time, while also increasing patient education about the importance of eye health as it relates to their disease and emphasizing bidirectional referrals, so eye care providers are notified when high-risk patients require comprehensive eye exams.
“Strategically, the need for access to and availability of eye care offered by health centers should be a programmatic priority, just as you would ensure primary health care is available for diabetes and other systemic issues, this really is a parallel to primary health care,” Dr. Grover says. “Eye care is health care, and that’s important to remember when you’re working toward prevention and primary care.”
Brandon Thornock, chief operations officer for the Shasta Community Health Center, spoke to FQHC administrators’ and representatives’ concerns regarding the cost to expand services that are not typically reimbursed by Medicare and modestly reimbursed by Medicaid. In discussing several successful partnerships with local eye care providers and grant or voucher opportunities to help uninsured patients, Thornock noted that the at-risk health concerns of many in the community health centers’ population often mean routine eye care services turn medical.
“If you’re an administrator at a community health center, don’t let this prohibit you from expanding,” Thornock said. “More often than not, routine eye exams become medical in nature because there are so many underlying medical conditions that are contributing to fluctuations in our patients’ vision. The visit that may have been scheduled as a routine eye exam very often comes back medical.”
AOA’s advocacy for FQHCs, CHCs
On-site, primary eye care services have grown at FQHCs in recent years with double-digit gains in doctors of optometry; however, that growth hasn’t been spread equitably nationwide. In fact, the AOA Health Policy Institute (HPI) found a 53% increase in optometry full-time equivalents between 2014 and 2016 with utilization of eye care services also increasing, yet most of those increases came in only three states—California, New York and Massachusetts.
At the time of the AOA HPI report’s publication, FQHCs in 21 states still employed less than one optometry full-time equivalent. In 2019, HRSA reported optometry provided 985,812 clinic visits or about a 22% increase in clinic visits since the AOA HPI report’s timeframe.
To enlist more doctors of optometry at FQHCs, the AOA repeatedly backs legislation that restores the eligibility of optometry students in the National Health Service Corps scholarship and loan repayment program. That program relieves student debt for service at health centers and has been a point of AOA advocacy for years.
It is said that a message must be repeated multiple times before it sinks in with an audience. During a satellite media tour, AOA President Ronald L. Benner, O.D., used that strategy to extol the essentialness of annual back-to-school eye examinations and link them to student performance in the classroom.
Change in standard of care is not yet warranted, say doctors of optometry who wrote editorial for study. Additional research is needed.