Fighting glaucoma can sometimes feel like Groundhog Day. I estimate that nearly a third of my follow-up visits with patients being treated with topical medications end with some version of the same conversation: “Okay, let’s get back on those eye drops, see me again in a few weeks, and make sure those pressures come back under control.” It is repetitive. After many years of treating glaucoma, I don’t think this problem is ever going to disappear.
Glaucoma suffers from a problem of immediacy. Patients generally come to the doctor to have something fixed. They do not come expecting to hear that they may be taking their excellent vision for granted and that preserving it may require them to do something every day for the next 15 or 20 years. In that sense, glaucoma violates the basic concept of medical care as many patients experience it. Successful glaucoma treatment frequently does not make patients see better or feel better. Often, success simply means that nothing bad happens. Our field has responded to this problem in increasingly clever ways, including laser therapy, sustained drug delivery, and procedural interventions that reduce our dependence on daily patient behavior. We are fighting a very good fight.
Ironically, however, I have begun to wonder whether the problem of immediacy is limited to our patients. Perhaps our payers suffer from it as well. Increasingly, I find myself drafting letters to insurance companies, presenting arguments to Medicare contractors over proposed LCDs, and fighting to ensure that patients can access remarkable new procedures and technologies. Just this year, I have seen insurers impose unreasonable step edits, propose endothelial cell requirements for which I struggle to see a clinical justification, and otherwise insert payment policy into decisions that should primarily be made by physicians and patients. What makes this particularly frustrating is that many glaucoma interventions are relatively inexpensive compared with the disability we are trying to prevent.
There is an important difference, of course. For patients, reluctance to act early is human nature. For payers, this reluctance arises from the architecture of American health care. The expense of prevention appears immediately on somebody’s balance sheet, while the economic benefits of preserved vision ultimately accrue elsewhere: fewer falls and fractures, continued independence, less caregiver burden, less home health and nursing care, and perhaps years of continued productivity. Savings from the catastrophe that never happened may appear years later in somebody else’s budget—or never appear on a balance sheet at all.
This creates a peculiar paradox for glaucoma. Once vision is lost, we must spend considerable resources dealing with the consequences of disability. Before it is lost, however, every expenditure intended to preserve it seems to require a demonstration of value. Perhaps that is why those of us who care for patients with glaucoma need to participate in the reimbursement conversation as vigorously as we participate in the scientific one. In this issue of Glaucoma Physician, we discuss not only some of the remarkable technologies changing glaucoma care but also the coding, coverage, and payment architecture that determines whether our patients can actually receive them. I encourage you to read about both—and, more importantly, to become involved in advocating for access to the treatments that can preserve vision before our patients discover how valuable that vision was. GP
