Diabetic retinopathy (DR) is the most common microvascular complication of diabetes, affecting more than two in five Americans with diabetes.
Diabetic retinopathy (DR) is the most common microvascular complication of diabetes,1 affecting more than two in five Americans with diabetes.2 The National Eye Institute expects the number of Americans with DR to reach more than 10 million by 2030 and 14.6 million by 2050.3 In the United States, DR causes approximately 80% of instances of legal blindness in people aged 20 to 74.4
Patients typically experience DR as a slow, pain-free decrease in vision, with symptoms that can fluctuate and may include blurred, double or distorted vision; floaters; or refractive error changes.4 The spectrum of visual problems associated with DR — from minor vision problems to legal blindness — can substantially affect patients’ quality of life (QOL).
In addition to reduced QOL, DR is associated with high costs. In 2013, medical costs for retinal disorders in the United States were $8.7 billion, with nearly half — $4.1 billion — of these costs attributed to diabetes-related retinal disorders.5 Per-person-per-year medical costs for those with diabetic retinopathy are an estimated $3,640.5 Other nonmedical support resources — such as nursing home care, government purchase programs and guide dogs — and loss in productivity also can be costly. Results from a retrospective analysis on patients aged 40 or older with visual impairment showed that in 2004, all-cause visual impairment was associated with $10.96 billion in nursing home care costs and $13.7 billion in state and federal government spending.6
Importance of diabetic retinopathy screening
Because DR typically shows no symptoms in beginning — and potentially through advanced — stages of disease, screenings are a critical tool for early detection and should be conducted annually for people with diabetes.7,8 With early detection and treatment, 95% of vision loss associated with DR can be prevented.7,9 In addition, adherence to guideline recommendations for DR screening and treatment may save the U.S. health system $600 million annually.10
Despite the importance of annual screenings for DR, patient adherence is low. Approximately 50% of Americans with diabetes receive annual eye exams with dilation,11 and this rate is even lower in underserved and minority populations — an average of 10% to 12%.12 Patients who miss an annual eye exam report various contributing barriers, including transportation issues, illness, physical disability, too many other health care appointments, costs associated with the screening and not making the appointment with their eye care provider a priority.10
To address these barriers to adherence, primary care providers (PCPs) and endocrinologists are beginning to incorporate telehealth-based DR screenings at point of care in their clinics. Traditionally, eye care practitioners have been the primary providers of DR screenings.8 However, at least 90% of patients with diabetes are treated by a PCP, which often puts PCPs in the position of initial point of contact with the patient.11 PCPs can leverage their access to patients with diabetes to help increase the rates of early DR detection and treatment by referring patients to eye care practitioners when needed.
Value of telehealth-based screenings and barriers to implementation
Telehealth-based DR screenings offered by PCPs and endocrinologists at point of care can increase patient access to screening, thereby helping to improve clinical outcomes.13 Providers can also benefit from offering annual DR screening at the point of care, as reimbursement rates are increasingly tied to meeting quality measures such as DR screening. For example, the Centers for Medicare & Medicaid Services (CMS) has a Merit-based Incentive Payment System (MIPS) that includes a measure for DR screening; the final provider performance scores given by MIPS influence reimbursement.14,15 Likewise, the Healthcare Effectiveness Data and Information Set (HEDIS) serves as a performance improvement tool, with scoring based on 90 performance measures, one of which includes DR screening on patients 18 to 75 years old with diabetes.16,17 HEDIS scores serve as highly credible indications of quality care. More than 90% of health plans use HEDIS to measure quality performance,18 and more than 190 million patients are enrolled in these plans.16
Topcon Screen Program
The Topcon Screen program, a telehealth platform that uses robotic instruments and an interconnected reading network of board-certified clinicians for DR screening, is an example of a telehealth-based tool that has helped increase rates of DR screening among patients with diabetes when coupled with additional initiatives.19 It has helped providers meet HEDIS requirements for DR screening.13,17
Topcon Screen was developed to help effectively detect DR at point of care, increase screening rates among patients with diabetes and support practice referrals for all eye care practitioners. The program addresses common barriers to implementation through its straightforward, time-efficient process. A small-footprint robotic camera performs the screening in less than two minutes (automatically capturing both eyes within a single exam) and automatically transfers the images to Topcon’s reading network, where they are graded and signed by board-certified ophthalmologists within 24 hours and then returned with a completed analysis report.20,21 Subsequently, the patient’s chart or electronic medical record can be updated with the results and tagged as having met the HEDIS measure requirement.13 Topcon Screen manages the entire workflow and provides all necessary hardware, software, staff training, installation and reading network. The camera provided by Topcon Screen occupies only 1 foot of space and can be leased month to month, thereby eliminating any upfront cost or capital investment.19,20 Topcon Screen is reimbursed by most insurance companies, and it offers resources for questions or concerns regarding reimbursement.20,22
Topcon Screen Program interventions and results
Positive results from telehealth-based screenings using Topcon cameras were recently experienced by Valley Medical Group (VMG), an ambulatory medical group practice in New Jersey that is part of a larger integrated health system. VMG participated in a 12-month Together 2 Goal Innovator Track Eye Care Cohort initiative to explore ways to standardize and increase DR screenings among the company’s 8,000 patients with diabetes treated across 30 primary care practices, two endocrinology practices and two ophthalmologists, all of whom share the same electronic health record (EHR). The group’s primary measure, which was adapted from a HEDIS measure, was the number of patients with diabetes in the cohort who had been documented for a DR screening. Key objectives included increasingly closing the gap at the point of care for DR screening and documenting referrals to other providers and specialists.19
Before the initiative, many of the group’s practices did not prioritize eye care for patients with diabetes, and staff did not understand the importance of DR screening. Communication gaps existed between primary care, endocrinology and ophthalmology. To address these concerns, the group implemented interventions such as educating staff and launching a DR screening clinic and telehealth-based screenings to give patients different options for eye care. In addition, a report was built using payer claims data that identified gaps regarding DR screenings, and staff streamlined eye care documentation in the EHR to ensure records were current. Patients who had not received a DR screening within the last year were flagged for education and eye examination scheduling. Staff communicated the importance of eye care to these patients using a tool that had been developed within the initiative to educate patients and increase engagement.19
For the telehealth-based screenings, two Topcon TRC-NW400 retinal cameras were placed in the endocrinology practices. Retinal photos were read internally by the two ophthalmologists. Keeping the readings internal helped facilitate communication between the ophthalmologist, endocrinologist and patient and also offered staff the opportunity to hear feedback on how to improve the quality of the images. To minimize costs, the Topcon cameras were leased. Other efforts to reduce costs included using National Eye Institute educational resources, optimizing workflow and linking DR screenings to compensation to incentivize providers to increase screening rates.19
During the four months the Topcon cameras were used, the medical group completed 120 images; 21% of the patients screened (n = 25) had DR and 30.5% of the patients (n = 36) had another eye disease. Identification of the eye disease resulted in “60 eyeballs saved,” according to VMG. As a result of all efforts combined over 12 months, the medical group experienced a 9.2% absolute increase in DR screening rates, from 40.7% to 49.9%. They also ranked in the 90th percentile for HEDIS quality measures for DR screenings and achieved a five-star rating.19
Overcoming barriers to implementation
Although telehealth-based DR screening has become increasingly available, the United States has been slow to adopt the approach in comparison with other countries, such as the United Kingdom and Australia.13 A large barrier to implementation may involve incorporating diabetic retinopathy screening into existing workflow. A busy endocrinology practice, described in a retrospective longitudinal study, found that eye exams increased the time of an average 15- to 20-minute appointment by approximately eight minutes. Investigators compared compliance rates for diabetic retinal screening completed between December 31, 2016, and December 31, 2018, after implementing a point of service teleretinal DR screening program the first week of June 2017. Study results indicated that the time invested in conducting the screening and the follow-up appointment detracted from time for other tasks. Other concerns noted in the study included insurance reimbursement (low reimbursement, insurance nonpayments or lack of insurance) and the cost of purchasing a retinal camera.13,23
To address workflow challenges associated with the entire initiative to increase DR screening, the VMG described above coordinated communication among billers, practice managers, office staff and ophthalmology to develop the optimal approach. The group prioritized ongoing communication and revisions that could improve workflow.19 In addition to developing a telehealth-based DR screening program, an onsite screening clinic was established for patients to attend in person if they preferred.19 For the telehealth program, the Topcon cameras were leased rather than purchased, and reimbursement for retinal photos ranged between $16 and $190.19 Most plans provide some type of reimbursement because they have incentives tied to quality ratings.14-17,a,b PCPs can bill the global CPT codes 92250 or 92227; the International Classification of Diseases, Tenth Revision (ICD-10) supports diabetes to establish medical necessity.22
The rate of DR across the United States is high and continues to grow, negatively affecting patient vision and quality of life and resulting in substantial costs to the health care system.2,3 DR screenings have served as an essential tool to help identify DR in its early stages, reduce rates of blindness and decrease costs.7,9,24 To tighten the care journey between primary care and eye care and enhance patient experience, telehealth-based screening options, such as Topcon Screen, have been increasingly offered at point of care.11,13 Continued efforts should be made to more widely implement DR screening options across the health care spectrum, helping to increase adherence rates and improve outcomes for patients.
a Medicare reimbursements may vary depending on region. Various federal and state incentives, quality assurance programs, and legislation may affect the coverage and reimbursement rates of both private insurance and Medicare and Medicaid plans. Topcon recommends that providers check with their patient’s insurance provider to verify reimbursement eligibility prior to screening.21
b CMS issued a National Coverage Determination (NCD 80.6) authorizing Medicare coverage for fundus photography when used for the diagnosis of DR. In recent years, however, Medicare Administrative Contractors (MACs) in several jurisdictions have issued Local Coverage Determinations stating that those jurisdictions will not cover fundus photography for the diagnosis of diabetic retinopathy when performed by non–eye-care specialists. Thus, CMS coverage of fundus photography may vary by state and/or region and coverage should be verified with the relevant MAC.22
c For asynchronous services such as Topcon Screen, there is no application of telehealth codes. The collection of data and the analyzing of those data take place at different times. For synchronous, real-time, bidirectional services between patient and provider, telehealth codes would apply. PCPs can bill the global CPT codes 92250 or 92227, including an International Classification of Diseases, Tenth Revision that supports diabetes, therefore establishing medical necessity.22
1. Murchison AP, Hark L, Pizzi LT, et al. Non-adherence to eye care in people with diabetes. BMJ Open Diabetes Res Care. 2017;5(1):e000333. doi:10.1136/ bmjdrc-2016-000333
2. Diabetic retinopathy. National Eye Institute. Updated August 3, 2019. Accessed December 12, 2019. https://www.nei.nih.gov/learn-about-eye-health/ eye-conditions-and-diseases/diabetic-retinopathy
3. Diabetic retinopathy data and statistics. National Eye Institute. Updated July 17, 2019. Accessed June 11, 2020. https://www.nei.nih.gov/learn-about-eye-health/resources-for-health-educators/eye-health-data-and-statistics/ diabetic-retinopathy-data-and-statistics
4. Coyne KS, Margolis MK, Kennedy-Martin T, et al. The impact of diabetic retinopathy: perspectives from patient focus groups. Fam Pract. 2004;21(4):447-453. doi:10.1093/fampra/cmh417
5. Wittenborn J, Rein D. Cost of vision problems: the economic burden of vision loss and eye disorders in the United States. Prevent Blindness. June 11, 2013. Accessed June 9, 2020. http://preventblindness.org/wp-content/ uploads/2020/04/Economic-Burden-of-Vision-Final-Report_130611_0.pdf
6. Rein DB, Zhang P, Wirth KE, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol. 2006;124(12):1754- 1760. doi:10.1001/archopht.124.12.1754. Published correction appears in Arch Ophthalmol. 2007;125(9):1304.
7. Sixty percent of Americans with diabetes skip annual sight-saving exams. American Academy of Ophthalmology. October 20, 2016. Accessed December 12, 2019. https://www.aao.org/newsroom/news-releases/detail/ sixty-percent-americans-with-diabetes-skip-exams
8. DeBuc DC. The role of retinal imaging and portable screening devices in tele-ophthalmology applications for diabetic retinopathy management. Curr Diab Rep. 2016;16(12):132. doi:10.1007/s11892-016-0827-2
9. National Eye Institute; National Eye Health Education Program. The importance of treatment with good glucose control cannot be underestimated. Accessed June 11, 2020. https://www.nei.nih.gov/sites/default/ files/2019-06/diabetes-prevent-vision-loss.pdf
10. Kovarik JJ, Eller AW, Willard LA, Ding J, Johnston JM, Waxman EL. Prevalence of undiagnosed diabetic retinopathy among inpatients with diabetes: the diabetic retinopathy inpatient study (DRIPS). BMJ Open Diabetes Res Care. 2016;4(1):e000164. doi:10.1136/bmjdrc-2015-000164
11. Liu Y, Swearingen R. Diabetic eye screening: knowledge and perspectives from providers and patients. Curr Diab Rep. 2017;17(10):94. doi:10.1007/ s11892-017-0911-2
12. Li Z, Wu C, Olayiwola JN, Hilaire DS, Huang JJ. Telemedicine-based digital retinal imaging vs standard ophthalmologic evaluation for the assessment of diabetic retinopathy. Conn Med. 2012;76(2):85-90.
13. Mamillapalli CK, Prentice JR, Garg AK, Hampsey SL, Bhandari R. Implementation and challenges unique to teleretinal diabetic retinal screening (TDRS) in a private practice setting in the United States. J Clin Transl Endocrinol. 2019;19:100214. doi:10.1016/j.jcte.2019.100214
14. MIPS overview. Centers for Medicare & Medicaid Services. Accessed June 10, 2020. https://qpp.cms.gov/mips/overview
15. American Medical Association. Quality ID #117 (NQF 0055): diabetes: eye exam. Version 4.0. Quality Payment Program. November 2019. Accessed June 10, 2020. https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2020_Measure_117_MIPSCQM.pdf
16. HEDIS and performance measurement. National Committee for Quality Insurance. Accessed June 10, 2020. https://www.ncqa.org/hedis
17. Comprehensive diabetes care (CDC). National Committee for Quality Insurance. Accessed June 10, 2020. https://www.ncqa.org/hedis/measures/ comprehensive-diabetes-care/
18. HEDIS publications: overview. National Committee for Quality Insurance. Accessed June 10, 2020. http://store.ncqa.org/index.php/performance-measurement/hedis-publications-outline.html
19. Valley Medical Group. Together 2 Goal Innovator Track Eye Care Cohort case study. AMGA Foundation. Accessed September 1, 2020. http://www.together2goal.org/assets/PDF/CS/Cohort_Valley_Med.pdf
20. Topcon screen: diabetes eye exams at point of care. Topcon Healthcare. Accessed June 12, 2020. https://topconscreen.com
21. Topcon screen: diabetic retinopathy screenings at point of care. Topcon Healthcare. Accessed July 14, 2020. https://topconscreen.com/wp-content/ uploads/Topcon-Screen-Brochure-Final-MCA495930686.pdf
22. How it works. Topcon Healthcare Solutions. Accessed September 30, 2020. https://topconscreen.com/how-it-works/
23. Shen BY, Mukai S. A portable, inexpensive, nonmydriatic fundus camera based on the Raspberry Pi computer. J Ophthalmol. 2017;2017:e4526243. doi:10.1155/2017/4526243
24. Zhang X, Low S, Kumari N, et al. Direct medical cost associated with diabetic retinopathy severity in type 2 diabetes in Singapore. PLoS One. 2017;12(7):e0180949. doi:10.1371/journal.pone.018094