Diabetic Macular Edema: Addressing Barriers to Screening

Kenneth J. Snow, MD, MBA: In trying to get folks screened, the first challenge is to make sure that they’re seeing a physician. There’s been a number of initiatives—some by payers, some by societies—trying to encourage folks to go in for their annual checkup, see the physician, and make sure they get screened to see if they have diabetes. Of course, if they get identified at that point or if they already know they have diabetes, those are the folks who need to be referred to an ophthalmologist or a trained diet professional to make sure that they get appropriate screening.

Even when that occurs, there’s a lot of reasons why people don’t go. First of all, it’s a pain in the neck—people are busy. They have other things in their lives. This is screening, so by definition, they’re not having any problems. Their eyes feel fine, their vision’s good, and there’s no problem. In today’s busy world, people have a lot of other things keeping them busy, let alone a problem that they can’t even detect.

But that’s exactly the reason why they need to be screened. We know that diabetic eye disease is without any symptoms until fairly late. If we wait until you notice something, you’ve really missed an opportunity. So, physicians are encouraging their patients to get in. Payers are encouraging their members to get in. Hopefully, patients are getting in to be screened.

Even beyond just that inertia of patients being busy, there’s also the issue of having to see an ophthalmologist. It’s [in] a different office—a different place that they need to get to. In some parts of the country, that can be a distance that they need to travel. And then, there’s also been the issue of cost. Even for folks with insurance, there’s often a share of the cost that they’re responsible for.

Fortunately, many payers, certainly Aetna included, have been very active in creating new products for patients so that the cost that they (patients) have to pay out-of-pocket is either minimized, or actually goes to zero. They’re not responsible for any payment to go and be appropriately screened. We recognize the importance of this. Even a small amount of money, for some people, can be a significant barrier. We want to make sure that barrier isn’t there.

In terms of making sure that people get the care that they need and that they are getting the screening that they need, there are a number of different systems in play. Unfortunately, there’s not one overall process that guarantees this, as much as we would like to see that. For some primary care physicians, they’re responsible for doing this and they’re looking out for their patients. But, they don’t necessarily know if their patient has been screened. They know if they’ve sent the patient [for screening], but they don’t necessarily know if it’s occurred.

In a big medical group practice, where the ophthalmologist is part of their system, then they may be able to identify it. But in many parts of the country, that’s not the case. [Instead], the patients will be going to a physician who is outside the primary care physician and they won’t know [if the patient has gone for screening]. As we move to more programs, such as accountable care organizations and patient homes, that improves. But that’s not the only place where we know whether somebody’s seeing their ophthalmologist.

Now, that’s a role where the payer comes in. We know if somebody has seen an ophthalmologist because we pay the ophthalmologist. We got a bill for it. We can check our records to see. “Has there been a bill?” We’re happy to pay that bill because we want that patient to be seen. If we see that the patient has not been to an ophthalmologist or that there’s been no bill submitted, we can get in touch with that patient or their physician and just say, “It appears that they haven’t had their screening and we encourage it to occur.” So, payers are taking a much more active role in trying to provide that information to the primary care physician and a reminder to the patient.

At Aetna, we have a very active case management program. Specifically, one of our programs is for disease management in diabetes. We have nurses who reach out to our members to make sure that these types of screenings are occurring, and that they [patients] are seeing any specialists that would be appropriate so that [screening] occurs in as timely a fashion as possible. Also, it allows our case managers to discuss with a patient what barriers may exist for them and see how we can help them (patients) overcome them (barriers).