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COVER STORY
Cost-effective
Glaucoma Care
Seeking the best outcome for each patient at the lowest cost
to that person and, one hopes, society.
BY JEFFREY D. HENDERER, MD, AND GEORGE L. SPAETH, MD
M
edical care in the United States requires a
great deal of money. “Total Medicare costs
… will grow from approximately 3.5 percent
of Gross Domestic Product (GDP) in 2013 to
5.3 percent of GDP by 2035,”1 more than the projected
federal deficit for 2014 of 2.9% of the GDP.2 Medicare
Part A, which funds hospital payments, is projected to be
depleted by 2030.1
In this context, delivering cost-effective care is a high
priority, but what exactly is cost-effective care? At the
levels of the US population and the patient, it means
delivering the best health outcome for the lowest cost.
In the field of glaucoma, it means providing exactly the
right amount of care, not more or less.
We try to keep societal costs in mind as we treat individual patients, but as physicians, we believe we have a
responsibility to seek the best outcome for each patient
at the lowest cost to that patient. We hope that translates into societal benefits of both improved health and
lower cost.
BIOLOGIC RISK FACTORS
Physicians intervene by modifying risk. Identifying
risk factors associated with future disease is critical to
determining who needs treatment. For example, a host
of risk factors can be modified in a cost-effective way to
prevent diabetic complications.3 In glaucoma, there are
fewer biologic risk factors to identify and only one to
treat. Evidence shows that, for one form of the disease—
normal-tension glaucoma—treating all patients is costeffective.4 Treating all patients with ocular hypertension,
however, is not. Rather, therapy for those with select
risk factors (advanced age, high IOP, thin corneas, and
enlarged cup-to-disc ratios) is considered cost-effective.5
Screening for glaucoma might be most cost-effective
using optic nerve photography and screening-mode
Figure. The glaucoma graph. Reprinted with permission
from Spaeth GL, Paulus A. The colored glaucoma graph and
its use in caring for patients with glaucoma: a new system
of management presented in three parts. Journal of Current
Glaucoma Practice. May-August 2010;4(2):83-90.
perimetry with or without tonometry in populations at
high risk.6-9
OTHER RISK FACTORS
The studies we have cited are very helpful for identifying biologic risk factors that can be applied to a patient,
but it is also necessary to take into consideration other
risk factors when determining an individual’s overall
risk of disease progression. Only then can we decide
the appropriate treatment goal to minimize this risk,
thereafter further refining our thinking by selecting the
lowest-cost strategy to achieve that goal. To the biologic
JANUARY/FEBRUARY 2015 GLAUCOMA TODAY 29
COVER STORY
TABLE 1. SUGGESTED TARGET PERCENTAGE
IOP REDUCTION
Risk of
Progression
Amount of Disease
Minimal
Mild
Moderate
Severe
High
30
40
50
60
Medium
20
30
40
50
Low
0
20
30
40
Minimal
0
0
20
30
risk factors we add life expectancy, the estimated rate of
disease progression, the ability (and even interest) of the
patient to care for him- or herself, and the likelihood a
treatment will be successful.
We estimate disease progression by plotting disease
versus time for each patient in what we call “the glaucoma graph” (Figure). It highlights where we expect
the patient’s disease to head. On the vertical axis is the
amount of glaucomatous damage, and on the horizontal axis is how long the patient is expected to live. Life
expectancy need not be terribly precise, but it does merit
consideration. Online calculators ranging from simple10
to complex11 are available; a customer can obtain an estimate with a quick call to his or her life insurance agent. It
can be helpful to remember that, in general, the longer a
person has lived, the longer he or she will live. A 65-yearold will, on average, live to be 85 (20 years), an 80-yearold will live to age 89 (9 years), and a 90-year-old to age
94.5 (4.5 years).12 Our intent with the glaucoma graph
is to identify patients at high risk of experiencing visual
disability in their lifetime. One more element, however, is
needed: patients’ ability to care for themselves.
Some patients are able to afford medicine, and some
are not. Some patients can use their medications appropriately, and some cannot. Others—despite resources
and ability—fail to comply. Certain individuals, despite
warnings about disease progression, do not want treatment. This powerful element of risk must be considered
when formulating the treatment plan.
CUSTOMIZATION
Ideally, treatment should be customized to a
patient’s risk. Minimal risk requires minimal treatment.
Maximal risk merits maximal treatment—sometimes
immediately. Assuming a patient wants to be treated,
as a general guide, we can combine these elements of
30 GLAUCOMA TODAY JANUARY/FEBRUARY 2015
TABLE 2. THERAPEUTIC OPTIONS
Possible Options for a Given Goal Percentage
IOP Reduction
20%
25%
Selective
b-blockers
Nonselective
b-blockers
30%
40%+
Multiple medical therapy
Topical
a-agonist
Topical
prostaglandins
Topical
carbonic
anhydrase
inhibitor
Dualcombination
medical
therapy
Laser trabeculoplasty
Microinvasive glaucoma
surgery
Filtering or shunt surgery
“Ideally, treatment should be
customized to a patient’s risk.
Minimal risk requires minimal
treatment. Maximal risk merits
maximal treatment—sometimes
immediately.”
risk to determine a final risk value, which we then crossreference with the current disease state to figure out a
target IOP reduction (Table 1). Within each target goal,
we then consider the actual therapeutic options as well
as the pros, cons, and costs of each (Table 2).
If you went fishing and the fish were on the bottom of
the lake, you generally would not choose a surface lure
first. If the fish were on the surface, you would not fish
for them on the bottom of the lake. If a patient needed a
60% IOP reduction, would you choose monotherapy with
a prostaglandin analogue? Would you perform selective
laser trabeculoplasty? Would you try a series of monotherapy one-eyed trials followed by various options combining
medications spaced over 1-month intervals? Of course
not. It would waste time and needlessly repeat costly visits.
Instead, you would have the patient start using multiple
medications simultaneously and then probably head to
surgery. Likewise, if the patient needed a 20% reduction
in pressure, would you choose $5 timolol or microinvasive glaucoma surgery? Yes, if the patient could not use
the medication, surgery would be the better choice, as it
would more likely prevent visual disability. If timolol were
COVER STORY
TABLE 3. PRICING FOR PROSTAGLANDIN ANALOGUES AT THE AUTHORS’ LOCAL PHARMACY AND
TEMPLE UNIVERSITY HOSPITAL
Drug
Retail cash price Wholesale cost
commercial
commercial
pharmacya
pharmacy
Retail cash price
Temple University
340B
Wholesale cost
Temple University
340B
Retail cost
Medicaid
Latanoprost 2.5 mL
(brand/generic)
$150.99/$68.59
$10.61 (generic)
$12.86 (generic)
$2.86 (generic)
$1.00
Travoprost Z 2.5 mL
$148.99
$110.83
$18.00
$3.01
$1.00
Bimatoprost 2.5 mL
$150.99
$110.48
$28.00
$21.01
$1.00
Tafluprost
30 dropperettes
$132.99
$99.34
$79.00
$60.87
$1.00
Unoprostone 2.5 mL
$162.99
$122.70
$132.70
$122.70
$1.00
aCVS,
King of Prussia, Pennsylvania; accessed November 19, 2014. Data for other columns from the Temple Outpatient Pharmacy;
accessed on November 20, 2014.
an equivalent choice, however, it would take many, many
years of follow-up before microinvasive glaucoma surgery
became the lower-cost option.
The situation is not always so clear. If a patient needed
a 30% reduction in IOP, for example, would you choose
generic latanoprost, or would you select Travatan Z (travoprost ophthalmic solution 0.004%; Alcon) or Lumigan
(bimatoprost ophthalmic solution 0.01% or 0.03%;
Allergan)? That depends. Some patients’ insurance coverage makes one of the brand-name drugs the cheapest
option. Others have access to pharmacies that can offer
cheaper cash prices than they would pay using their insurance. The Temple University Hospital outpatient pharmacy is one of these 340B pharmacies,13 and Temple has
partnered with local commercial pharmacies to bring this
discounted pricing to more patients. (Table 3 provides an
example of the pricing.) Because pricing changes at least
yearly, we have given up on trying to remember which
medication is cheapest on which plan. We now choose
a generic drug when possible and ask the patient at least
annually how much his or her medication costs. If price
becomes an issue, we work to find a lower-cost option.
If the target IOP reduction is achieved, we have to be
sure that it is sufficient. Monitoring is done by talking
with patients and examining them for signs of glaucomatous progression (narrowing of the disc rim or
definite worsening of the visual field, as determined by
valid, relevant imaging and testing). The frequency of
such monitoring again depends on the individual’s risk
of worsening disease. The exact parameters to follow
are still being established. If the patient has minimal
disease, has achieved a 25% reduction in IOP, has experienced no change in visual complaints, and has stable
visual fields and nerve imaging, then perhaps he or she
can be observed with annual examinations and testing. Glaucoma suspects at low risk of developing the
disease might be seen every 1 to 2 years. Those at high
risk might be seen quarterly or even monthly. Some
patients can be monitored remotely by telemedicine.
The point? Follow-up intervals and testing should be
customized, and patients should not be seen automatically every 3 months just because they have glaucoma.
PAYMENT
The way physicians and hospitals are being paid is
changing. No longer is fee for service the only payment
model. Pay for performance is becoming common. The
Centers for Medicare & Medicaid Services already mandates value-based purchasing in which hospitals are paid
a percentage of the allowable fee, and only if they meet
certain quality measures can they collect the remainder.
Gain-sharing contracts and pay-for-performance models
are also already in use. Primary care physicians can be
paid substantial bonuses by insurance plans based on
meeting certain quality metrics (Healthcare Effectiveness
and Data Information Set or HEDIS scores), and even
Medicaid plans are paid by individual states for meeting
quality scores. In addition, hospitals are now paid partly
based on patient-satisfaction scores.
In ophthalmology, everyone is required to report some
quality measures using the Physician Quality Reporting
(Continued on page 33)
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COVER STORY
(Continued from page 31)
System, or he or she faces a reimbursement penalty. It is
probable that the specialty will follow much of the rest
of medicine and move to other performance-based payment systems, including patient-satisfaction scores just
like for hospitals. In such a model, it is to be hoped that
providing the identical outcome for a lower cost will be
rewarded with extra reimbursement.
CONCLUSION
Just as with any other chronic medical condition, in
the subspecialty of glaucoma, physicians strive to prevent the disease or its progression. Given societal financial constraints and probable reimbursement models, we
believe every clinician should be seeking to achieve this
goal at the lowest cost to the patient and, by implication, society. n
Jeffrey D. Henderer, MD, is a professor of
ophthalmology and the Dr. Edward Hagop
Bedrossian chair of ophthalmology at Temple
University School of Medicine in Philadelphia.
He acknowledged no financial interest in the
products or companies mentioned herein. Dr. Henderer
may be reached at (215) 707-2374;
[email protected].
George L. Spaeth, MD, is the Esposito
research professor and the emeritus director
of the William and Anna Goldberg Glaucoma
Service and Research Laboratories at the Wills
Eye Institute in Philadelphia. He receives grant
support from Allergan and Merck and has served as
a consultant to Pfizer. Dr. Spaeth may be reached at
(215) 928-3960; [email protected].
1. Social Security and Medicare Boards of Trustees. A summary of the 2014 annual reports. Official Social Security
website. www.ssa.gov/OACT/TRSUM/index.html. Accessed November 15, 2014.
2. Congressional Budget Office. An update to the budget and economic outlook: 2014 to 2024. www.cbo.gov/
publication/45653. Published August 27, 2014. Accessed November 15, 2014.
3. Li R, Zhang P, Barker LE, et al. Cost-effectiveness of interventions to prevent and control diabetes mellitus: a
systematic review. Diabetes Care. 2010;33(8):1872-1894.
4. Li EY, Tham CC, Chi SC, Lam DS. Cost-effectiveness of treating normal tension glaucoma. Invest Ophthalmol Vis
Sci. 2013;54(5):3394-3399.
5. Stewart WC, Stewart JA, Nasser QJ, Mychaskiw MA. Cost-effectiveness of treating ocular hypertension.
Ophthalmology. 2008;115(1):94-98.
6. Glaucoma screening Platform Study group, Burr JM, Campbell MK, Campbell SE, et al. Developing the clinical
components of a complex intervention for a glaucoma screening trial: a mixed methods study. BMC Med Res
Methodol. 2011;11:54.
7. Tuulonen A. Cost-effectiveness of screening for open angle glaucoma in developed countries. Indian J Ophthalmol. 2011;59 suppl:S24-30.
8. Burr JM, Mowatt G, Hernández R, et al. The clinical effectiveness and cost-effectiveness of screening for open
angle glaucoma: a systematic review and economic evaluation. Health Technol Assess. 2007;11(41):iii-iv, ix-x,
1-190.
9. Vaahtoranta-Lehtonen H, Tuulonen A, Aronen P, et al. Cost effectiveness and cost utility of an organized screening programme for glaucoma. Acta Ophthalmol Scand. 2007;85(5):508-518.
10. Calculators: life expectancy. Official Social Security website. http://ssa.gov/planners/lifeexpectancy.htm.
Accessed November 15, 2014.
11. How long will I live? http://gosset.wharton.upenn.edu/mortality/perl/CalcForm.html. Accessed November
15, 2014.
12. Life expectancy by age. http://life-span.findthebest.com. Accessed November 15, 2014.
13. Health Resources and Services Administration. 340B Drug Pricing Program. US Department of Health and
Human Services website. http://www.hrsa.gov/opa/index.html. Accessed November 15, 2014.
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