The American Academy of Ophthalmology (AAO) represents more than 18,000 ophthalmologists in the United States providing eye care to individuals of all ages. The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) represents more than 1,200 ophthalmologists in the United States with a practice focus on eye care for infants, children, and teenagers. The American Academy of Pediatrics (AAP) represents more than 60,000 pediatricians and pediatric specialists in the United States. Our organizations share a concern that children in all health care settings have access to high quality and necessary screening, vision, medical, and surgical eye care. We further recognize that the country is faced with rapidly escalating health care costs, so that cost-effective strategies for providing necessary eye and vision care to our nation’s children are a priority. The Patient Protection and Affordable Care Act of 2010 (ACA) has created an important opportunity to improve access to all aspects of eye care for all children irrespective of the setting and nature of their access to care.
AAO, AAPOS, and AAP commend Congress and Administration for specifically including children’s eye and vision care in the Patient Protection and Affordable Care (ACA). Three components of eye care need to be considered. Screening services for children consistent with Preventative Services Task Force (USPSTF) and Health Resources and Services Administration (HRSA) guidelines were included in health care coverage provided under the ACA. These include ocular risk assessment and red reflex testing from birth to 3 years of age, followed by vision screening for all children starting at age 3 years and continuing at specified intervals until 21 years. For children or adolescents who fail a screening or risk assessment, those who report a visual problem, and those who cannot complete a screening (e.g., developmental delay), a comprehensive eye examination (including refraction) should be a covered service. Medical and surgical eye care covered as part of typical private health insurance would continue to be covered.
ACA mandated the establishment of “qualified health plans.” Such plans must meet the standard of providing an essential health benefits package. In section 1302, these benefits include “Pediatric services, including oral and vision care.” A description of these basic benefits is to be formulated by the Secretary of HHS. The law further demands that this benefit be equal in scope to those benefits provided under a typical employer plan as determined by the Secretary of Labor. A report was furnished on April 15, 2011 to Secretary Sebelius. The Institute of Medicine has been charged with developing recommendations to define and update these benefits. That report is due later in 2011. The unstated but necessary characteristic of these benefit packages will be to balance affordability with generosity.
Regulations need to consider all aspects of eye and vision care that have been mandated. These include screenings, vision care and medical/surgical eye care. Each plays an important part in ensuring the ocular and visual health of our nation’s children.
The ACA includes a provision that requires public and private health insurance plans that are written after September 23, 2010 to cover, without cost sharing, all evidence-based preventive care and screening for children recommended in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) or recommended by the United States Preventive Services Task Force (USPSTF). For vision services, there are two pertinent recommendations: Bright Futures from HRSA and Vision Screening from USPSTF. Bright Futures was created by HRSA’s Maternal and Child Health Bureau in 1990.1 Bright Futures is a national health promotion and disease prevention initiative that provides health supervision guidelines for all aspects of recommended well-child visits from birth through adolescence, including physical, developmental, mental health and vision screenings. Today the program is run jointly by HRSA and the American Academy of Pediatrics (AAP).
In 2011 USPSTF granted a B-level recommendation to vision screening in preschool children 3 to 5 years of age.2,3. A B-level recommendation is defined as “the USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” USPSTF suggested that a variety of screening techniques for the primary care office including visual acuity testing, stereoacuity, cover-uncover test, Hirschberg light reflex test, autorefraction, and photoscreening may be utilized.
Both Bright Futures and the USPSTF support a routine program of vision screening for the detection of eye disease and refractive disorders. Visual acuity screening was also shown to be an effective means of detecting refractive errors in young children.4 Automated refraction is effective in preschool children as well as in older children 5. A single screening or single comprehensive examination at school entry is insufficient and is not recommended by the guidelines or other research.6
Pediatric medical and preventative care is provided by pediatricians and other health care providers in an office-based setting. It is in that setting that children receive the recommended preventative health care interventions. The comprehensive Bright Futures program recommends 31 specific assessments and/or evaluations from birth to 21 years for each child. There are two specific preventative-care activities regarding vision and ocular health. The time line for completion of these activities begins at birth and extends to age 21 years. (See Appendix 1)
The first activity is a series of ocular and vision risk assessments from birth to 3 years of age. The second activity is periodic vision screening beginning at age 3 years. AAO and AAPOS have a policy statement that is in general agreement with the Bright Futures philosophy calling particular attention to the provision of an ocular risk assessment and measurement of visual acuity in the preschool age range and beyond.7 Such redundancy helps to assure that problems do not escape detection for a long time or that a child who misses a screening has many other opportunities for detection. This strategy of vision screening with redundancy is effective at detecting children with eye problems and is more fiscally responsible than mandating a comprehensive eye exam for all children.
Risk factor assessment by the pediatrician or primary health care provider includes queries regarding general health problems, systemic disease, or use of medications for those conditions known to be associated with eye disease and visual abnormalities. It also includes a family history of conditions that cause or are associated with eye or vision problems and signs or symptoms of eye problems by history or observations by family members. These conditions are detailed in Table 2 of the Pediatric Eye Exam Preferred Practice Pattern of the AAO and on page 231 of Bright Futures.7 Periodic visual acuity measurement and ocular structure assessment are recommended at specified intervals to detect decreased vision in one or both eyes that could be due to amblyopia, strabismus, refractive error, and other eye diseases. Screenings should be supplemented by state-mandated vision screening and eye care programs, and by philanthropic vision programs.
Timely treatment of amblyopia and strabismus is associated with a better treatment response and visual outcomes. Timely treatment of strabismus is also associated with better school performance, particularly in pre-school aged children.
ACA included, but did not define pediatric vision care. Traditionally, vision care has been considered that eye care provided specifically for management of blurred vision from refractive error including farsightedness, nearsightedness, and astigmatism. This would be a basic eye examination including refraction. Eye care for other eye diseases has been covered as part of medical eye care. Some disorders of refraction, covered only under vision services, can lead to amblyopia, a form of visual loss. Amblyopia is improper brain development from loss of neural connections due to the refractive conditions mentioned above and other medical causes, and is one of the most common causes of permanent loss of vision in adults. The disorder is preventable with early recognition of risk factors and also treatable in children. The most important aspect of treatment is provision of necessary eye glasses.
The value of vision care to children is evidenced by its inclusion in the Medicaid Early & Periodic Screening & Diagnostic Treatment Benefit (EPSDT) for children. The Medicaid Act states that screening must be provided for vision services which “at a minimum, include diagnosis and treatment for defects in vision, including eyeglasses. Vision services must be provided according to a distinct periodicity schedule developed by the state and at other intervals as medically necessary.”
In addition to the pediatric vision benefit, the ACA requires that the mandated minimum benefit be equal in scope to the typical employer-provided health care plan prior to enactment of the ACA. It is difficult to determine what is currently available among employer-sponsored health insurance (EHI) plans. All cover medical and surgical eye care, but coverage of vision care as defined above is not universally provided. In a 2010 survey by the Kaiser Family Foundation and Health Research & Education Trust, 18% of firms provided a separate vision benefit beyond vision coverage within a medical plan.8 Large firms with 200 or more workers provide this benefit 55% of the time. The Bureau of Labor Statistics reported in a compensation survey in 2008 that, where there was a vision care plan, full coverage of eye exams was provided by 21%, and limited coverage was provided in 78%. Glasses were provided with full coverage by 9%, while limited coverage was provided by 90%. Specific provisions for children were not addressed, but may be slightly less generous than for the primary policy holder.
These data demonstrate that vision care is not provided to the majority of beneficiaries of EHI plans. Since only a minority of current plans covers vision care, additional coverage is needed by most EHI and exchanges to satisfy the ACA requirement to include pediatric vision care. A reasonable approach is to adopt the solution employed by Center for Medicare and Medicaid Services in Medicaid’s EPSDT program in which vision screening is mandated for all beneficiaries along with the provision of comprehensive examinations and glasses when a vision problem is detected or a pertinent complaint is identified. The frequency of vision screening is not typically described by EPSDT, but determined by each state individually. A national standard would seem to be stipulated by the ACA which follows the comprehensive vision screening program described by Bright Futures.
When a child has one or more risk factors, or if the child fails the vision screening during the preventative evaluation, the child should be sent for a comprehensive eye exam as part of vision care. This comprehensive eye examination can be done at any age and should not be delayed for a child to grow out of a suspected condition. The necessary components of the exam include inspection of the anterior and posterior segments, dilated ophthalmoscopy, cycloplegic retinoscopy, and child-appropriate measurement of visual acuity.9(Appendix 3, page 12) Covered comprehensive examinations for refractive error (vision) should have frequency limits, ideally once a year as used by the majority of state Medicaid programs. Vision screenings should be continued, even for children who have previously been referred for a comprehensive examination.
Vision care includes correction of refractive error. Eyeglasses for children are prescribed for vision (refractive error) and medical reasons (i.e., amblyopia, strabismus). Most state Medicaid programs provide coverage. Attention to coverage with annual limits for eyeglasses should be included in the benefit package of qualified health plans. In rare instances, it is necessary for children to wear contact lenses to treat medical conditions that would result in permanent loss of vision or even blindness (e.g., surgical aphakia, high astigmatism).
If glasses, contact lenses, or low vision aids are necessary as determined by a licensed ophthalmologist or optometrist, these services should be covered. Appropriate payment and frequency limits should be negotiated with suppliers.
Early detection of treatable eye disease in infancy and childhood can have far-reaching implications for vision, quality of life and, in some cases, for general health. Our organizations share a concern that children in all care settings must have access to high quality and necessary optical, medical, and surgical eye care. We recognize that the country is faced with rapidly escalating health care costs. As such, cost-effective strategies for providing necessary eye and vision care to our nation’s children are a priority.
We agree with the ACA as enacted that qualified health plans provide timely screening for the early detection and treatment of eye and vision problems in America's children. This includes maintaining a schedule of vision screening during childhood and adolescence as consistent with HRSA and USPSTF guidelines. This care is to be supplemented by the pediatric vision benefit included in the ACA consisting of comprehensive eye examinations for those children and adolescents who fail the screening. Glasses, contact lenses, or low vision aids as necessary as determined by a licensed ophthalmologist or optometrist, should be covered.
Current coverage for medical and surgical conditions should be continued without interruption. The addition of vision screening as recommended by the USPTF and Bright Futures, as well as our organizations, will help detect and treat eye disease and refractive errors in children. This will reduce cases of vision loss and blindness due to preventable or treatable disorders in children, and will also help in school performance for those affected children. Adopting these screening and vision care recommendations of the ACA presents the unique opportunity to significantly positively impact the lives of thousands of children in our country.
1. Bright Futures for Infants, Children, and Adolescents. Department of Health and Human Services, 2011. (Accessed April 29, 2011, at http://mchb.hrsa.gov/programs/training/brightfutures.htm.)
2. US Preventative Services Task Force. Vision Screening for Children 1 to 5 year of age: US preventive services task force recommendation statement. Pediatrics 2011;127:340-6.
3. Vision Screening in Children Ages 1 to 5 years: Clinical Summary of U.S. prevetative task force recommendation. 2011. (Accessed May 5, 2011, at http://www.uspreventiveservicestaskforce.org/uspstf/uspsvsch.htm.)
4. Vision in Preschoolers Study Group. Preschool vision screening tests administered by nurse screeners compared with lay screeners in the vision in preschoolers study. Invest Ophthalmol Vis Sci 2005;46:2639-48.
5. Leone JF, Mitchell P, Morgan IG, Kifley A, Rose KA. Use of visual acuity to screen for significant refractive errors in adolescents. Is it reliable? Arch Ophthalmol 2010;128:894-9.
6. Bodack MI, Chung I, Krumholtz I. An analysis of vision screening data from New York City public schools. Optometry 2010;81:476-84.
7. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern Guidelines:Pediatric Eye Evaluations. San Francisco, California: American Academy of Ophthalmology; 2007.
8. The Kaiser Family Foundation, Health Research & Education Trust. Employer Health Benefits: 2010 Annual Salary. 2010.
9. American Academy of Ophthalmology Pediatric Ophthalmology/Strabismus Panel. Preferred Practice Pattern® Guidelines. Pediatric Eye Evaluations. San Francisco, CA: American Academy of Ophthalmology; 2007.
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