The cost-effectiveness of Welcome to Medicare visual acuity screening and a possible alternative welcome to medicare eye evaluation among persons without diagnosed diabetes mellitus

Abstract

Objective: To estimate the cost-effectiveness of visual acuity screening performed in primary care settings and of dilated eye evaluations performed by an eye care professional among new Medicare enrollees with no diagnosed eye disorders. Medicare currently reimburses visual acuity screening for new enrollees during their initial preventive primary care health check, but dilated eye evaluations may be a more cost-effective policy.

Design: Monte Carlo cost-effectiveness simulation model with a total of 50 000 simulated patients with demographic characteristics matched to persons 65 years of age in the US population.

Results: Compared with no screening policy, dilated eye evaluations increased quality-adjusted life-years(QALYs) by 0.008 (95% credible interval [CrI], 0.005-0.011) and increased costs by $94 (95% CrI, −$35 to$222). A visual acuity screening increased QALYs in less than 95% of the simulations (0.001 [95% CrI, −0.002 to 0.004) and increased total costs by $32 (95% CrI, −$97 to $159) per person. The incremental cost-effectiveness ratio of a visual acuity screening and an eye examination compared with no screening were $29 000 and$12 000 per QALY gained, respectively. At a willingness-to-pay value of $15 000 or more per QALY gained, a dilated eye evaluation was the policy option most likely to be cost-effective.

Conclusions: The currently recommended visual acuity screening showed limited efficacy and cost-effectiveness compared with no screening. In contrast, anew policy of reimbursement for Welcome to Medicare dilated eye evaluations was highly cost-effective.

Figure 1

Simulation design. Individuals diagnosed with eye disorders or diabetes mellitus prior to age 65 years are excluded from the analysis because current recommendations direct their use of eye care.

Figure 2

Probability that each screening option is the most cost-effective at each willingness-to-pay value by payer (indicated by shape) and scenario (indicated by color). MCR acuity indicates visual acuity screening in primary care at age 65 years from a Medicare perspective; MCR exam, dilated eye examination by an eye care professional at age 65 years from a Medicare perspective; MCR none, no intervention from a Medicare perspective; Patient acuity, visual acuity screening in primary care at age 65 years from a patient perspective; Patient exam, dilated eye examination by an eye care professional at age 65 years from a patient perspective; Patient none, no intervention from a patient perspective; Societal acuity, visual acuity screening in primary care at age 65 years from a societal perspective; Societal exam, dilated eye examination by an eye care professional at age 65 years from a societal perspective; Societal none, no intervention from a societal perspective.