United States Genwal Accounting Office Report to Congressional Requesters ’ Febmmy 1990 MEDICARE Withdrawing Eyeglass Coverage Recommended Following Cataract Surgery GAO/HRlMO-31 United States GAO General Accounting Office Washington, D.C. 20648 Human Resources Division B-237435 February 8,199O The Honorable Fortney H. (Pete) Stark Chairman, Subcommittee on Health Committee on Ways and Means House of Representatives The Honorable Willis D. Gradison, Jr. Ranking Minority Member Subcommittee on Health Committee on Ways and Means House of Representatives In your February 9,1988, letter, you asked us to examine a number of issues relating to Medicare reimbursement for cataract surgery. On April 10, 1989, we presented the results of our review in testimony before the Subcommittee. In addition to the issues discussed in our testi- mony, we also followed up on an earlier GAOrecommendation to the Administrator of the Health Care Financing Administration (HCFA)that has not been implemented. This recommendation dealt with Medicare’s policy of paying for conventional eyeglasses for a beneficiary who has undergone cataract surgery and has had his or her natural lens replaced by an implanted prosthetic intraocular lens (IOL). In brief, there is a disparity between the Medicare policy on coverage of conventional eyeglasses for beneficiaries who have undergone cataract surgery and those who have not.] Virtually all people 65 years of age and older need eyeglasses for near vision (to help with reading and other close-up tasks), distance vision, or both. But since its inception, Medicare law has generally prohibited paying for conventional eye- glasses. HCFA,however, makes an exception for beneficiaries who have undergone cataract surgery. In such instances, HCFAconsiders eyeglasses to be a prosthetic (artificial) device-and therefore eligible for cover- age-even though the function of these glasses is the same as for benefi- ciaries who have not had cataract surgery. Eliminating this HCFA-created exception to Medicare law would result in an estimated saving of over $98 million annually. In a March 1984 report,’ we recommended that HCFAchange its policy of paying for conventional eyeglasses following cataract surgery. The ‘The policy also includes contxt lenses for near or far vision. ‘Medicare Reimbursement for Ckxwentional Eyeglasses (GAO/HRD 8444, Mar. 7,1984). Page 1 GAO/HlW-90.31 Medicare Eyeglass Coverage E-237435 Department of Health and Human Services (HHS) Inspector General made the same recommendation in 1988. HCFA has considered the recom- mendation, but has not acted on it. As recently as June 1989, HCFA stated that it would continue to review the issue, but had no immediate plans for a regulatory change. In order to eliminate the inequity to benefi- ciaries that currently exists and to provide a uniform Medicare policy, HCFA should issue a regulation specifically excluding Medicare coverage of conventional eyeglasses and contact lenses for cataract surgery patients who have IOL implants. The Medicare program, authorized by title XVIII of the Social Security Background Act in July 1966, helps pay medical costs for about 28 million people 65 years of age and older and for about 3 million disabled people. Over- all responsibility for administering Medicare lies with HHS. HCFA, as part of HHS, develops policies and is responsible for ensuring compliance with Medicare legislation and regulations. One of the most frequently performed major surgical procedures paid for by the Medicare program is cataract surgery. Medicare paid for 1 million cataract surgery procedures in 1987, at a cost in excess of $2 billion. In cataract surgery, the clouded natural lens of the eye is removed. To regain vision, the extracted lens is replaced with some type of prosthetic lens. For cataract patients, physicians may use one or a combination of three types of prosthetic devices: cataract eyeglasses, cataract contact lenses, or surgically implanted 10~s. The use of 10~sis now the preferred method because they offer many advantages over cataract eyeglasses and con- tact lenses. In 1987, IOLS were used in about 98 percent of cataract sur- gery procedures reimbursed by Medicare. However, IOL and cataract contact lenses cannot adjust for both near and distance vision. Typi- cally, IOLSor contact lenses are focused for either distance, middle, or near vision; conventional eyeglasses are prescribed to improve the focusing ability of the eye. For example, if 10~s are focused for distance vision, conventional eyeglasses are prescribed for near vision. The inability of an IOL to adjust focus is also characteristic of the aged natural lens. Nearly everyone over the age of 65 has a problem in focus- ing for near vision, Beginning at about the age of 40, the lenses of the eyes begin to lose their natural capability for close-up focusing. This functional loss continues until a person reaches the age of 45 to 50, mak- ing reading difficult without corrective reading glasses. page2 GAO/HBD9031MedicareEyeglassCoverage E-237435 According to medical texts and ophthalmologists that we consulted, con- ventional eyeglasses serve the same purpose-to correct the focusing ability of the eyes-for both Medicare beneficiaries who have had cat- aract surgery as well as for beneficiaries who have not. In 1984, HHS’S National Center for Health Statistics reported that 91 percent of people 65 years of age and older wore conventional eyeglasses. Medicare law (42 USC. 1395y(aX7)) specifically excluded coverage of Medicare Law Excludes Eyeglass ‘a, eyeglassesor eye examinations for the purpose of prescribing, fitting, or chang- ing eyeglasses,procedures performed (during the course of any eye examination) to Coverage to Correct determine the refractive state of the eyes. .” Vision Problems Consequently, Medicare regulations do not allow payment for routine eye care or conventional eyeglasses for near or distance vision since both are considered “refractive corrections,” which improve the focus- ing ability of the eye. Although conventional eyeglasses provide essentially the same benefits HCFA Covers for all older people, HCFApayment practices differ. HCFAdoes not allow Eyeglasses as a payments for conventional eyeglasses to beneficiaries who have not had Prosthetic Device cataract surgery. It considers conventional eyeglasses for those benefi- ciaries who have had cataract surgery, however, to be a prosthetic device and therefore eligible for coverage. HCFA’Spolicy is based on the premise that conventional eyeglasses, used with IOLSor cataract contact lenses, are needed to restore the ability of fully functioning natural lenses to focus for near and distance vision. Therefore, HCFAconsiders the combination of IOLS(or cataract contact lenses) and conventional eyeglasses to be prosthetic devices. As such, this combination and related fitting fees are eligible for Medicare payment. Subsequent con- ventional eyeglasses or contact lenses are also eligible for Medicare pay- ment since Medicare coverage of prosthetic devices includes their replacement when medically necessary. We believe HCFA’Spolicy of paying for conventional eyeglasses in such cases is questionable. Although 10~sor cataract contact lenses typically restore distance vision, HCFA’Spolicy is based on the underlying premise that correction of both near and distance vision is needed to restore vision of fully functioning natural lenses. As such, the policy does not consider that for those over the age of 65, a fully functioning natural Page 3 GAO/HRINO-31 Medicare Eyeglass Coverage - B.237436 lens does not include the capability for near-vision focusing had a cat- aract not existed. Further inconsistencies are apparent in HCFA’Spayment policy for ser- vices needed to prescribe conventional eyeglasses for patients with IOLS or cataract contact lenses. Although HCFAconsiders the conventional eyeglasses themselves as prosthetic devices and therefore pays for them and related fitting fees, HCFAdoes not pay for the services needed to prescribe the glasses because it considers them routine and not allowed by Medicare. Medicare payments for conventional eyeglasses for beneficiaries under- going cataract surgery have increased significantly, from about $60 million in 1985 to about $98 million in 1987. In March 1984, we recommended that the HCFAAdministrator discon- Previous Reports Have tmue payments to cataract patients for conventional eyeglasses worn Recommended over IOU or over cataract contact lenses. In an April 11, 1984, letter, the Discontinuing HCFAAdministrator agreed that our recommendation had merit and stated that HCFAwas considering a change to its policy. According to a Payments July 1985 internal agency document, HCFAofficials concluded that there was no basis for the coverage of corrective eyeglasses. The document states that “Medical information we have reviewed supports the GAO contention that eye- glassesare not an integral part of the prosthetic lens provided to aphakic patients: although eyeglassesfor those patients do serve a refractive need in that they cor- rect near vision, they do essentially no more for the aphakic patient than reading glassesdo for nonaphakic patients who require near vision correction.“” In August 1986, the FCCFA Administrator again informed us that HCFAwas still considering the change. In July 1988, the HHSInspector General also recommended that HCFA develop regulations to specifically preclude Medicare from paying for conventional eyeglasses for beneficiaries with 10~s. Because some patients cannot have their vision fully restored after cataract surgery without wearing conventional eyeglasses, HCFAstated in response, it had ‘Aphakiarefersto the absena> of the naturallensof theeye. Page4 GAO/HRD9@31 MedicareEyeglassCoverage B-237435 reservations about withdrawing this coverage. In June 1989, HCFA offi- cials informed us that their position, as reflected in comments to the HHS Inspector General report, had not changed. Medicare’s policy of paying for conventional eyeglasses only for benefi- Conclusion ciaries who have cataract surgery, but not for other beneficiaries, is unjustified because conventional eyeglasses and contact lenses serve essentially the same function for both groups-the improved ability to focus for near or distance vision. Medicare law generally prohibits pay- ments for this purpose. Thus, payments for eyeglasses after cataract surgery create an inequity that we continue to believe should be elimi- nated,? and they increase program costs unnecessarily. Implementation of our recommendation would save, based on calendar year 1987 pay- ments, over $98 million annually. We recommend that the Secretary of HHS direct the Administrator of Recommendation to HCFA to discontinue Medicare payment for all conventional eyeglasses or the Secretary of HHS contact lenses following cataract surgery when an IOL is implanted and satisfactory results are achieved. -~ The Secretary of HHS provided written comments on a draft of this Agency Comments report. He said he saw some merit in our conclusion and recommenda- tion, and HHS is considering the publication of a Notice of Proposed Rulemaking to withdraw Medicare coverage of conventional eyeglasses. This is essentially the same response made by the HCFA Administrator in commenting on our 1984 report. The American Academy of Ophthalmology (AAO) does not fully support AA0 Comments our recommendation to eliminate Medicare payments for conventional eyeglasses following cataract surgery. In commenting on the draft, AAO pointed out that the surgery itself will cause the patient to need a change of eyeglasses prescription that otherwise might not have been needed. Thus, the AAO believes that Medicare should pay at least for the first pair of new eyeglasses or contact lenses following cataract surgery. ‘Medicare should continue to provide cataract glasses and cataract contact lenses to the small per- centage of people that do not rereiw 101s since these glassesor contacts act as substitutes for IOLs. Page 6 GAO/HRD9031 Medicare Eyeglass Coverage EL237435 Although it is true that the surgery and the power of IOLS cause a pre- scription change, we do not believe that this is justification for Medicare payment. Generally, cataract surgery with an IOL implant greatly improves the patient’s overall vision, and-as we pointed out (p.2)- conventional eyeglasses just provide refractive corrections to improve the focusing ability of the eye. The Medicare law excludes coverage of eyeglasses for refractive correction and provides no specific exception to this prohibition.” Further, since eyeglasses serve the same function for cataract and non-cataract patients, paying for these eyeglasses only after cataract surgery creates an inequity in Medicare benefits. AAOalso presented several technical comments that we have incorpo- rated into the report. In summary, AAO, while not endorsing our recom- mendation, did not present facts that would justify continued Medicare payment for conventional eyeglasses after cataract surgery. In a letter dated February 9, 1988, the Chairman and Ranking Minority Objective, Scope, and Member of the Subcommittee on Health, House Committee on Ways and Methodology Means, requested that GAO study several issues relating to Medicare pay- ments for cataract surgery. On April 10,1989, we testified before the Subcommittee on the results of this review. As part of this request, we also followed up on our 1984 recommenda- tion that HCFA discontinue Medicare payments for conventional eye- glasses for beneficiaries who have undergone cataract surgery. Because HCFA has not acted on this recommendation, we wanted to determine if our 1984 position was still valid. We reviewed medical texts and scientific journals cited by the Public Health Service and the National Academy of Sciences concerning the aging of the human eye; we also interviewed ophthalmologist consul- tants recommended as experts by AAO. From HCFA'S part B Medicare Annual Data System file, we determined the extent of calendar year 1987 Medicare payments for eyeglasses and related fees for benefi- ciaries with 10~s. We discussed this matter with HCFA officials and obtained written com- ments on this report from HHS. We also obtained written comments from AAOto confirm the technical accuracy of the findings developed in the body of this report. %xtion 1395y (a)(7) of tltlr 42 Page 6 GAO/HltB9@31 Medicare Eyeglass Coverage B-237436 We conducted this portion of our review in May and June 1989 in accordance with generally accepted government auditing standards. We are sending copies of this report to the Chairman, Subcommittee on Medicare and Long-Term Care, Senate Finance Committee; the Director of the Office of Management and Budget; the Secretary of HHS; the Administrator of HCFA; and to other interested parties upon request. Please call me at (202) 275-5451 if you or your staff have any questions concerning this report. Other major contributors to this report are listed in appendix I. / Janet L. Shikles Director, Health Financing and Policy Issues Page 7 GAO/HUD-90.31 Medicare Eyeglass Coverage Appendix I Major Contributors to This Report TT r\ Jane L. Ross, Senior Assistant Director, (202) 275-6195 numan nesources Terence J. Davis, Assistant Director Division, Jerry G. Baugher, Assignment Manager Washington, D.C. Frank C. Pasquier, Evaluator-in-Charge Seattle Regional Office Susan K. Hoffman, Evaluator (106366) Page 8 GAO/HRD90.31 Medicare Eyeglass Coverage . 1 Postage & JTISIS~ GAO Permit No. ( , .:, X.‘., .‘, ,,_ .“ I ’ , ..;- : ,*‘<“ “. ..’
Medicare: Withdrawing Eyeglass Coverage Recommended Following Cataract Surgery
Published by the Government Accountability Office on 1990-02-08.
Below is a raw (and likely hideous) rendition of the original report. (PDF)