Pediatric vision screening worthy of advocacy

Sacramento, CA-Obtaining reimbursement and resources for vision screening seems to be a thankless task with little return. However, there are strategies that can be used to give pediatric vision screening a fair share of the available health-care funds, according to James Bradford Ruben, MD.

The projection for 10 years from now is that the country will be spending $3.6 trillion a year for medical care, which amounts to one-fifth of the economic output of the country. The question Dr. Ruben would like answered is what percentage of that amount will be allocated for pediatric vision screening. Dr. Ruben is a pediatric eye physician and surgeon at The Permanente Medical Group, Sacramento, CA and clinical professor of ophthalmology at UC Davis School of Medicine.

"And we wonder why we have not done a better job," Dr. Ruben said.

Perhaps the biggest obstacle that prevents pediatric vision screening is money.

"Vision screening is not technically insurmountable. It is not socially insurmountable. There just hasn't been adequate application of venture capital to solve the problem," he said. "Vision screening is easier to do than LASIK. We have tried to educate the pediatricians over the years. If anyone says it is not about money, it is always about money."

Failure to mandate screening

"Our inability to screen for amblyopia in the United States is not a failure of science. It is an economic and political failure," Dr. Ruben said.

He discussed the possible reasons for the failure to mandate vision screening by presenting the following questions. "What value does pediatric vision screening have? Do we not screen because screening is not valuable to society and not a productive way to spend money?"

Studies conducted by public health experts use cost-utility analysis to determine the value of vision screening. These studies allow the determination of an economic value for a disease state. The result is often expressed in a unit entitled "the cost per quality-adjusted life year" (cost/QALY), which is a unit representing the cost of purchasing the benefit of 1 year of perfect health for an individual.

"The higher the cost/QALY, the less effective the intervention is in terms of society spending money to perform the intervention. For example, for a liver transplantation for a patient who does not live long after the surgery and has a great deal of pain, the cost/QALY is high. In contrast, amblyopia has a cost/QALY of a mere $2,300, which represents an exceptional bargain. Any procedure or treatment under $50,000 is considered to be a good deal for society," he said.

"In a recent non-peer-reviewed study funded by the Vision Council of America, it is suggested that a strategy of comprehensive eye exams for all children has an acceptable cost/QALY. However, careful analysis of their data suggests that a vision screening program provides even greater value than blanket comprehensive eye examinations. Also, application of our limited health-care resources to serial vision screening of more children would provide greater benefit than the more expensive approach of mandating comprehensive exams. If the money is limited, we ought to spend it on vision screening first," he emphasized.

The money for pediatric eye care is not likely to increase, Dr. Ruben noted. Rather, "we need to be sure that vision screening receives an adequate slice of the available money for health care in general," he said.