1. Medical Care Cost of Medicare/Medicaid Beneficiaries with Vision Loss
Alan R. Morse, PhD
Bruce Pyenson, FSA, MAAA

2. Background
Blindness and visual impairment are among the 10 most common causes of disability in the United States and are associated with reduced life expectancy as well as quality of life.
Of the US population over age 40:
an estimated 937,000 Americans, 0.78%, are legally blind 2.4 million Americans (1.98%) had low vision, based on an analysis of 2000 census data by Congdon et al.
By 2020, the prevalence of blindness will increase to 1.6 million (1.1%), while the prevalence of low vision will increase to 3.9 million (2.5%).

3. Estimating differential use of healthcare resources based on diagnosis or functional limitations has great potential for planning of resource need or allocation as well as the economic impact of changes in population morbidity

4. NYS Hospital Utilization by Patients with Visual Impairment
Previously, we reported on the contribution of visual impairment to average length of stay (ALOS) within inpatient facilities. ALOS was an analog for our present focus – healthcare cost.
If we move from days to dollars, and project the excess days, we could estimate the potential for reducing the national healthcare bill. I think it is important to note that these costs are excess which means that by reducing them we are not adversely impacting on necessary care

5. NYS Hospital Utilization by Patients with Visual Impairment

6. Vision Loss Comorbidity
Vision loss contributes significantly to falls, fractures and restrictions in mobility
Among females, bilateral vision loss is associated with an increase in all-cause mortality and reported vision impairment is an independent predictor of increased mortality. Lee et al.
Among females, decreased acuity and/or contrast sensitivity, increases risk for deaths due to trauma approximately three times over those in the group with the best acuity and contrast sensitivity. Pedula et al.

7. The impact of vision loss on healthcare utilization and costs has been understudied and gaps remain in understanding the impact of vision loss impact on healthcare delivery, utilization, and cost.
Later on, Dr. Spencer discuss some of the factors affecting access to services.
I think that the four factors we should be focusing on in looking at the impact of vision on healthcare are
ACCESS
DELIVERY
UTILIZATION
AND COST.

8. The Present Study
Do current reimbursement methodologies used by Medicare properly estimate and reimburse healthcare costs to patients with vision loss?
My focus is on excess cost, and by analogy, utilization.
Our healthcare system is to a great extent driven by Medicaid and Medicare . Since Medicaid differs from state to state, we’ve chosen to focus on Medicare reimbursement

9. Sample (n=3,372)
We used the public use data set available from the National Pace Association
PACE serves individuals who are:
age 55 or older and eligible for Medicaid & Medicare
certified to need nursing home care
are able to live safely in the community at the time of enrollment
In PACE, we’re talking about people who are medically indigent and either old or disabled since to qualify for Medicare you generally need to be over age 65 or have a permanent disability for a period of more than 2 years.

10. Method
Vision loss was defined, by PACE, as cannot see at all or sees some light and shadows but not obstacles in path
HCC risk adjustors were calculated using diagnoses from inpatient admissions
The CMS-HCC risk adjusted model was applied
CMS posts the formula for HCC calculation on its website. If you are going to engage in that sort of analysis, I strongly recommend that you use an actuary or someone similar

11. Results N Relative Risk All Enrollees 3,372 1.0 Vision Impaired 107
1.097
Non-Vision Impaired
3,265
.994
Vision Impaired non-institutionalized 91
1.131
Vision impaired Institutionalized 16
.91
Non-Vision Impaired Institutionalized
463
.892
Non-vision impaired non- institutionalized
2,802
1.004

12. Discussion
Among PACE members residing in institutions, vision loss has little effect on their healthcare cost risk
Among non-institutionalized PACE members, vision loss significantly increases their risk for incurring excess costs – those outside the reimbursement methodology - by about 13%.
Once patients are sufficiently frail and ill, other conditions and disease states take precedence and the impact of vision loss is minimized.
On the other hand, while residing in the community, and growing older and more ill, the impact of vision on their healthcare cost increases – for example, there will be more hospitalizations, with each being adversely impacted by excess LOS days.

13. Conclusion
We suggest, cautiously, that the HCC reimbursement methodology under-reimburses hospital stays for visually impaired patients because it fails to recognize the risk for excess cost, most probably accounted for substantially by increased LOS.

14. Limitations
Only a small percentage of individuals with vision loss meet the restrictive PACE definition. If appropriate data for patients with vision loss were available, our results could differ significantly
Sample size for the visually impaired population was relatively small
ICD-9 codes for vision loss are frequently excluded from the HCFA form 1500

15. Future Directions
We are completing an analysis of the Medicare 5% sample database by risk score band to further explore the impact of vision loss of healthcare costs and reimbursement

16.
2.00 +
Grand Total
Cost PMPM
616
912
1,219
1,518
1,744
1,836
2,413
1,430
Revenue PMPM
281
593
878
1,079
1,282
1,473
2,507
1,178
Claim Costs / Revenue
219%
154%
139%
141%
136%
125%
96%
121%
Average HCC
0.3568
0.7557
1.1129
1.3720
1.6288
1.8686
3.1557
1.4897