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Eye Care for the Elderly: Looking Better! Seeing Better!
Eye Care for the Elderly: Looking Better! Seeing Better! Introduction ALFRED SOMMER, MD This is the second in a series of multidisciplinary symposia designed by the Academy's Public Health Committee to address broad issues of policy and management affecting our profession and the public's welfare. That it addresses the opportunities, challenges and problems associated with delivering eye care to the older segment of society is most appropriate. The elderly represent our single most important constituency. They are the largest recipients of major ophthalmic care and to a great degree represent the health impact we make on society. They certainly have the highest rate of blindness (Fig 1)1; the highest rate of serious ocular disorders (age-related cataract, age-related macular degeneration, etc.); and their health care costs are paid straight from federal coffers, providing government a direct and immediate interest in the way monies are spent. We find ourselves in a unique paradox: unprecedented technologic developments, especially in cataract surgery and lens implantation, have contributed to a revolution in visual expectations and lifestyles of the elderly. Quite appropriately, they take a dim view of dim vision. The logical consequence has been a rise in the number of procedures performed and an increase in physician reimbursement. In 1983, Medicare-approved charges for physician services (Table 1) were highest for ophthalmologists; and the two most common in-patient surgical procedures (Table 2) were cataract extraction and lens insertion. Even in an era of cost-containment and budget cutting, it would be difficult for Congress to reward improved public health with penal regulations were it not for the flagrant profiteering and commercialization practiced by a small minority of our profession. A full-page advertisement (Fig 2) using blatant scare tactics illustrates
From the Dana Center for Preventive Ophthalmology, Wilmer Institute, Johns Hopkins Hospital, Baltimore. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, November 1986. Reprint requests to Alfred Sommer, MD, Wilmer 120, Johns Hopkins Hospital, Baltimore, MD 21205.
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where current trends can lead and confirms Margo's assessment2: "It is difficult to reconcile an alternative purpose of advertising-to convince people to want something they do not necessarily need-with the goals of medicine." Our scientific revolution may well have had an unintended and particularly egregious side effect. By attracting more practitioners to dazzlingly sophisticated technology, we are increasingly viewed as technicians, with a concomitant loss of interest and competence in the humanistic art of medicine. Our main claim to being physicians is treatment ofthe patient, not just his eyes. Ifwe fail to remember that, so will others. New technology must be more than dazzling or even beneficial. The push for cost-containment requires it be cost-effective and have a material impact on the public's health. Photocoagulation clearly reduces, or at least retards, loss of vision in selected patients with macular degeneration. Increasingly, we will need to demonstrate that this improvement is meaningful and relevant to a substantial proportion of all patients with the disease, and that we have not lost sight of the needs of the rest, who still constitute the vast majority of affected individuals. The bottom line is whether scientific advances, government policies, and the organization of eye care services will continue to improve the level of eye health among the elderly. Recent studies now in progress in Baltimore indicate that 13% of the black population Table 1. Medicare Approved Charges per PhYSiCian, 1983* Physician Services
Costs
Ophthalmology Radiology Urology Cardiology Gastroenterology Internist
$120,724.00 $116,679.00 $77,964.00 $76,458.00 $54,382.00 $39,154.00
* Modified from Burney I, Schieber G. Medicare physicians' services: The Composition of spending and aSSignment rates. Hlth Care Fin Rev 1985; 7:81-96.
SOMMER
z o
3000
~
::::>
Fig 1. Age specific rate of persons on blindness registers (MRA states). (Adapted from Kahn HA, Moorhead HB. 1)
a.. o a.. o o
o
•
•
INTRODUCTION
White Non- white
2000
q 1000
o o
0::: W
a.. O~--~---L--~L---~--~--~L---~--~
<5
10
20
Todav. thousands 01 people will choose not to read this ad. Nextv.ear many 01 them won't be able to. Fig 2. Introductory paragraph to full-page advertisement appearing in the Baltimore Sun, 1986.
over age 40 have significant, unmet ocular needs; and one third of a free-living, largely white group of senior citizens had pathology requiring further investigation or intervention, including 5% with dense, blinding cataract.
30
40
AGE
50
60
70
__~
80
~85
Table 2. Inpatient Surgical Procedures, 1983 Procedure Extraction of lens Insertion of prosthetic lens Prostatectomy Cholecystectomy Pacemaker
Percent of All Procedures 8.1 6.9 4.4
2.5 2.4
* Modified from Burney I, Schieber G. Medicare physicians' services: The composition of spending and assignment rates. Hlth Care Fin Rev 1985; 7:81 - 96.
The symposium includes experts representing providers, regulators, and recipients, all deeply committed to the delivery of quality eye care to the elderly. Undoubtedly, they will raise more questions than they will answer.
REFERENCES 1. Kahn HA, Moorhead HB. Statistics on blindness in the model report· ing area, 1969-1970. DHEW Pub. No. (NIH) 73-427. Washington, DC: GPO, 1973 . . 2. Margo CE oSelling surgery. N Engl J Med 1986; 314:1575-6.
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From the Dana Center for Preventive Ophthalmology, Wilmer Institute, Johns Hopkins Hospital, Baltimore. Presented at the American Academy of Ophthalmology Annual Meeting, New Orleans, November 1986. Reprint requests to Alfred Sommer, MD, Wilmer 120, Johns Hopkins Hospital, Baltimore, MD 21205.
1178
where current trends can lead and confirms Margo's assessment2: "It is difficult to reconcile an alternative purpose of advertising-to convince people to want something they do not necessarily need-with the goals of medicine." Our scientific revolution may well have had an unintended and particularly egregious side effect. By attracting more practitioners to dazzlingly sophisticated technology, we are increasingly viewed as technicians, with a concomitant loss of interest and competence in the humanistic art of medicine. Our main claim to being physicians is treatment ofthe patient, not just his eyes. Ifwe fail to remember that, so will others. New technology must be more than dazzling or even beneficial. The push for cost-containment requires it be cost-effective and have a material impact on the public's health. Photocoagulation clearly reduces, or at least retards, loss of vision in selected patients with macular degeneration. Increasingly, we will need to demonstrate that this improvement is meaningful and relevant to a substantial proportion of all patients with the disease, and that we have not lost sight of the needs of the rest, who still constitute the vast majority of affected individuals. The bottom line is whether scientific advances, government policies, and the organization of eye care services will continue to improve the level of eye health among the elderly. Recent studies now in progress in Baltimore indicate that 13% of the black population Table 1. Medicare Approved Charges per PhYSiCian, 1983* Physician Services
Costs
Ophthalmology Radiology Urology Cardiology Gastroenterology Internist
$120,724.00 $116,679.00 $77,964.00 $76,458.00 $54,382.00 $39,154.00
* Modified from Burney I, Schieber G. Medicare physicians' services: The Composition of spending and aSSignment rates. Hlth Care Fin Rev 1985; 7:81-96.
SOMMER
z o
3000
~
::::>
Fig 1. Age specific rate of persons on blindness registers (MRA states). (Adapted from Kahn HA, Moorhead HB. 1)
a.. o a.. o o
o
•
•
INTRODUCTION
White Non- white
2000
q 1000
o o
0::: W
a.. O~--~---L--~L---~--~--~L---~--~
<5
10
20
Todav. thousands 01 people will choose not to read this ad. Nextv.ear many 01 them won't be able to. Fig 2. Introductory paragraph to full-page advertisement appearing in the Baltimore Sun, 1986.
over age 40 have significant, unmet ocular needs; and one third of a free-living, largely white group of senior citizens had pathology requiring further investigation or intervention, including 5% with dense, blinding cataract.
30
40
AGE
50
60
70
__~
80
~85
Table 2. Inpatient Surgical Procedures, 1983 Procedure Extraction of lens Insertion of prosthetic lens Prostatectomy Cholecystectomy Pacemaker
Percent of All Procedures 8.1 6.9 4.4
2.5 2.4
* Modified from Burney I, Schieber G. Medicare physicians' services: The composition of spending and assignment rates. Hlth Care Fin Rev 1985; 7:81 - 96.
The symposium includes experts representing providers, regulators, and recipients, all deeply committed to the delivery of quality eye care to the elderly. Undoubtedly, they will raise more questions than they will answer.
REFERENCES 1. Kahn HA, Moorhead HB. Statistics on blindness in the model report· ing area, 1969-1970. DHEW Pub. No. (NIH) 73-427. Washington, DC: GPO, 1973 . . 2. Margo CE oSelling surgery. N Engl J Med 1986; 314:1575-6.
1179