The
Eye
Care
Trend Report
VOLUME II
Eye Care Trend Report | Volume II
1
Table of Contents
Welcome Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . 2
Part I: The Managed Care Perspective . . . . . . . . . . . 4
Part II: The Ophthalmologist Perspective. . . . . . . . . 14
“Educating Patients About the Differences
Between Brand-Name and Generic Ophthalmic
Drugs is One of Several Effective Strategies”. . . .24
Part III: The Optometrist Perspective. . . . . . . . . . . . 26
“Opportunities Expanding for Optometrists” . . . . . 36
“Screening for Glaucoma and Beyond”. . . . . . . . . 37
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Comparisons and Conclusions . . . . . . . . . . . . . . . . 39
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Report Contributors. . . . . . . . . . . . . Inside Back Cover
Sonnenreich P, Zoeller J, eds. The Eye Care Trend Report, Volume II. Irvine, CA, Allergan, Inc. 2016.
Dear Colleague,
On behalf of Allergan and the National Association of Managed Care Physicians (NAMCP), we present
The Eye Care Trend Report, Volume II. This report, second in a series, examines the clinical events and
managed care policies that drive eye care today. This report can be a useful tool not only for broadening your
understanding of current issues affecting eye care, but for benchmarking the performance of your organization.
Here is some background about
The Eye Care Trend Report:
•The information is based on the
responses of 127 optometrists,
65 ophthalmologists, and 83
managed care clinical and
business professionals, who
participated in three separate
surveys
DID YOU KNOW?
Optometrists, ophthalmologists, and managed care
professionals sometimes—but do not always—see eye-to-eye
on the issues. For example, everyone agrees that medication
adherence is essential. However, the paths to that goal are
divergent, with healthcare providers favoring combination
products and cost-conscious managed care formularies
preferring individual generics. Healthcare providers also have
different perspectives on their industry: optometrists want
an expanded role for optometry, while ophthalmologists are
concerned about a potential shortage within their ranks.
•Responses were analyzed by
our Editorial Advisory Panel,
an independent cross-sectional
—The Eye Care Trend Report, Volume II
group of 10 medical directors,
pharmacists, ophthalmologists,
and optometrists. Panel members
also provided commentary on the survey findings and shared their own experiences in the eye care space
•Three articles on related topics provide insights into the current literature
•Where appropriate, survey findings were compared among the three groups of respondents
•The report spotlights potential areas of collaboration between payers and providers, including patient
education, patient adherence, patient outcome, and quality of life issues
At Allergan, we value our customer relationships and appreciate the critical role customers like you play in
providing quality health care for everyone. We hope that the information in this report will help to spark
discussion, improve communication, and create opportunities for payers and eye care specialists to explore new
ways of working together to collectively brighten outcomes for the patients we serve.
Sincerely,
Mark Devlin
Senior Vice President
Managed Markets
Allergan
Eye Care Trend Report | Volume II
W. C. (Bill) Williams III, M.D.
Executive Vice President
National Association of Managed Care Physicians
1
Executive Summary
Topline Findings From the
Managed Care Survey (n=83)
• Among managed care respondents, 15% expect
to pay a great deal of attention to the eye care
category in the future (n=80), up from 13% who
report that they currently pay a great deal of
attention to the category (n=80)
• Eye care is more of a concern for Medicare plans,
say 48% of survey respondents (n=81)
• Eye drops account for 81% of eye care
prescriptions, with intraocular injections at 6%
(n=83). In 5 years, eye drops are expected to
account for 78% and intraocular injections for 9%.
(n=83)
• Most eye care prescriptions, 87%, are covered
under the pharmacy benefit (n=79). The exceptions
are intraocular injections and implants, of which
92% are covered under the medical benefit (n=83)
• Generics account for 75% of all prescriptions,
according to survey respondents (n=83) and 66%
of eye care prescriptions (n=73). Preferred brands
account for 14% of all prescriptions filled and 22%
of eye care prescriptions
• When a generic is added to a therapeutic class,
58% of managed care respondents enforce generic
substitution on the next refill (n=80)
• Clinical efficacy, with a rating average of 4.5 on
a 5-point scale, closely followed by cost, generic
availibility, and safety, with 4.4 each, top the list
of factors considered when evaluating a new drug
within a class from a managed care perspective
(n=83)
• Managed care respondents agree that in glaucoma,
lowering intraocular pressure (IOP) preserves
2
vision,1,2 with a rating of 4.2 on a 5-point scale
(n=82) and that medication is preferable to surgery,
with a rating of 4.1 (n=81). Dry eye is seen as a
disease, with a rating of 3.9 (n=81)
• Utilization management techniques respondents
deem most effective are generic substitution, with
a rating average of 4.4 on a 5-point scale; prior
authorization, 4.2; and quantity limits, 4.1 (n=81)
• Patient outcomes and pharmacy costs top the list
of important factors when developing adherence
programs, with rating averages of 4.4 and 4.3,
respectively, on a 5-point scale (n=82)
• Asked to name challenges or opportunities
ahead, managed care respondents listed: rising
cost of care; aging population/growing patient
population; shortage of ophthalmologists; patient
adherence; replacing injections with topicals or
orals; and coverage under the medical v pharmacy
benefit
Topline Findings From the
Ophthalmologist Survey (n=65)
• Conditions driving the most patient visits to
ophthalmologists are refractive errors, 29%;
cataracts, 24%; dry eye, 22%; and glaucoma, 21%
(n=65)
• The largest proportion of practice revenue for
ophthalmologists is from diagnosis and treatment
of the eye, 43%, followed by surgeries of the eye,
22%, and vision services, 19% (n=65), according to
survey respondents
• Efficacy and adherence are the most important
considerations of survey respondents when
prescribing medications, each with a rating average
of 4.7, using a 5-point scale (n=65)
Eye Care Trend Report | Volume II
• Medicare is the largest payer of ophthalmologists’
services, according to survey respondents,
accounting for an average of 43% of patient visits
(n=65). Another 30% of visits are covered by
commercial health plans, followed by Medicaid,
with 12%
• Commercial health plans are more likely than
Medicare plans to have formulary restrictions
on products used in the treatment of ocular
conditions. A total of 94% agree that commercial
plans have formulary restrictions on all or most
ocular products (n=65) versus 72% saying the same
for Medicare plans (n=65)
• Ophthalmologists strongly agree on the need to
keep an alternative product containing a different
active ingredient on the formulary, with a rating of
4.4 on a 5-point scale (n=65)
• While 42% of survey respondents say they start
treatment with a generic, 36% will start treatment
with a branded product (n=64)
• Ophthalmologists prefer prostaglandin analogues
for treating glaucoma, with 81% in agreement
(n=64)
• According to survey respondents, the factors
that most help patients adhere to their eye drop
regimen are ease of dosing, with a 4.5 rating on a
5-point scale; comfort of dosing, 4.4; and cost of
regimen, 4.3 (n=65)
• More than half of respondents, 52%, agree that
patients dosing eye drops are less adherent on
average than patients dosing oral medications
(n=63)
• All responding ophthalmologists say they monitor
adherence by asking patients (n=63). Sixty percent
check for improved clinical values, such as lower
IOP. One-third check for gaps in refill requests
• Nearly half, 47%, of ophthalmologist survey
respondents believe that there will be a shortage of
ophthalmologists within 10 years (n=64)
• Asked to name challenges facing the
ophthalmology profession, declining
reimbursements topped the list, followed by
government mandates, including ICD-10,
Physician Quality Reporting System (PQRS)
measures, and electronic medical records
Eye Care Trend Report | Volume II
Topline Findings From the Optometrist Survey (n=127)
• Optometrists' practice revenue is derived from
vision services, 45%; optical dispensary, 31%; and
diagnosis and treatment of eye pathologies, 20%
(n=127), according to survey respondents
• On average, 35% of patient visits are covered by
vision care plans, according to survey respondents
(n=127). Commercial plans cover 18% of patient
visits, followed by self-pay, 17%; Medicare, 15%;
and Medicaid, 13%
• For an average of 10% of patient visits,
optometrists will refer patients to an
ophthalmologist or other specialist (n=126)
• Optometrists favor use of drug combination
products to simplify dosing regimens, with a rating
of 4.4 on a 5-point scale (n=127)
• Most optometrists, 46%, start treatment with a
generic or low-cost therapeutic alternative (n=127)
• “Efficacy and safety of therapy” tops the list of
factors influencing optometrists’ prescribing
decisions, with a rating average of 3.8 on a 4-point
scale (n=127). Next is patient adherence, with 3.5,
followed by patient cost of therapy with 3.3
• A total of 74% of optometrists prescribe
prostaglandin analogues as first-line therapy (n=124)
• “Ease of dosing” is the most important factor in
influencing how well patients adhere to eye drop
regimens, with a rating average of 4.3 on a 5-point
scale, followed by “cost of regimen,” with 4.2
(n=127)
• Nearly all optometrists (97%) monitor adherence
by asking patients, followed by checking for
improved clinical values, 55%, and checking for
gaps in refills, 35% (n=127)
• Optometrists expect to become the “primary care
physicians” for eye care within the next 10 years,
according to 77% of optometrists surveyed (n=127)
• Asked to name challenges and opportunities ahead,
optometrists identified the following: decreasing
reimbursements; managed care policies in general;
online eye exams and online sales of glasses; aging
of the population; government regulations; vision
care v medical practice; expanding scope of practice;
high deductibles; oversupply of optometrists; and
the future of private practice
3
PART I
The Managed Care Perspective
The eye care category is managed
using the tools of managed
care but with some flexibility,
according to survey responses and
experts interviewed. Management
of eye drop therapies tends to
be slightly less restrictive than
therapies delivered orally, in
part because of the sensitivity
and difficulty of delivering
medications to the eye. This,
combined with the relatively low
cost of most eye drops, means
that tight management of the
category has not been a high
priority to date.
Four managed care experts
were interviewed to interpret
the survey findings:
Currently, the category is
split between intraocular
injections, managed under the
medical benefit mainly by prior
authorization, and eye drops,
managed under the pharmacy
benefit with an emphasis on
use of generics. Greater use of
more costly intraocular injections
could result in more scrutiny
of the category and how such
medications are covered in the
future. These are among the
findings of Part I: The Managed
Care Perspective of The Eye Care
Trend Report, Volume II. A total of
83 managed care executives were
surveyed on these and other eye
care issues.
•Andy Szczotka, PharmD, Vice
President, Clinical Services,
Emdeon, Twinsburg, OH
4
•Ross M. Miller, MD, MPH, a
medical advisor for the California
Department of Health Care
Services and past senior medical
director, Cigna
•Fredrick A. May, MD, Solutions
for Managed Care, Indianapolis,
IN
•Dale A. Bultemeier, RPh,
Assistant Vice President, Ancillary
Services, Physicians Health Plan
of Northern Indiana, Indianapolis
Only 13% of managed care
survey respondents report that
they currently pay a great deal of
attention to the eye care category
(n=80) (Figure 1).
“Eye care medications are not
expensive—generics make up a
large percentage of the market—
and therefore are not a big concern
for managed care,”observes
Ross M. Miller, MD, MPH, a
medical advisor for the California
Department of Health Care
Services.“ The category is not on the
radar with the exception of products
that are injected into the eye that
are getting peoples’ attention.”
“The eye care category is not a
budget-buster, with eye drops
costing $100 or less a month.
Instead, our attention is focused
on managing specialty drugs
costing thousands of dollars a
month,” says Dale A. Bultemeier,
RPh, of Physicians Health Plan of
Northern Indiana.
Figure 1
How much attention does your
organization pay to the eye
care category?
n=80
52.5%
12.5%
35%
A great deal of attention
Neutral
Less attention
Eye Care Trend Report | Volume II
Figure 3
Figure 4
What proportion of eye care
prescriptions are for:
What do you project the
proportions will be 5 years
from now?
Figure 2
Do you anticipate paying more
attention to the eye care
category in the future?
n=83
n=80
n=83
13%
15%
77.5%
7.5%
A great deal of attention
81%
6%
Oral medications
Neutral
Eye drops
Less attention
Intraocular injections
Concern regarding the costs
associated with specialty drugs is
well-founded. The drug trend for
commercial plans was 13.1%
overall in 2014, composed of just
6.4% for traditional drugs but
30.9% for specialty drugs,
according to The Express Scripts
2014 Drug Trend Report Commercial.3
“Attention to the eye care
category will increase with
development of more
high-cost medications.”
– Fredrick May, MD
Payers and physicians anticipate
that eventual United States (U.S.)
Food and Drug Administration
(FDA) approval of biosimilars will
provide cost-effective options
for specialty drugs, according to
Eye Care Trend Report | Volume II
findings of a study led by Joshua
Cohen, PhD, of Tufts Center for the
Study of Drug Development.4
Most managed care respondents
(78%) are neutral on whether they
will pay more attention to the eye
care category in the future, with
15% expecting to pay a great deal
of attention (n=80) (Figure 2).
“Attention to the eye care category
will increase with the development
of more high-cost medications,”
says Fredrick A. May, MD, of
Solutions for Managed Care.
“Eye care will get more attention
with significant treatment
developments, significant cost
issues, and/or new quality
measurements,” says Andy
Szczotka of Emdeon.
Eye care is more of a concern
for Medicare plans, say 48%
of survey respondents (n=81)
14%
77.5%
8.5%
Oral medications
Eye drops
Intraocular injections
(chart not shown). “With an
older population, there is more
concern for cost and appropriate
utilization. Injections such as those
for macular degeneration are
subject to more review,” says Mr.
Bultemeier.
Medication
Dosage Forms
Eye drops account for 81% of eye
care prescriptions, with intraocular
injections at 6% (n=83) (Figure 3).
In 5 years, eye drops are expected
to account for 78% and intraocular
injections for 9% (n=83) (Figure
4).“The percentage of eye drop
prescriptions is expected to remain
high,” says Dr. Miller.
“Percentage use of intraocular
injections is, on average,
lower among commercial plan
members—the average age of our
5
commercial plan members is 35
years—and higher among older
Medicare plan members,” says
Mr. Bultemeier. “The projected
increase in intraocular injections
from 6% to 9% in 5 years is being
driven by the baby boomers and
aging of the population.”
Coverage of
Eye Care Treatments
Most eye care prescriptions,
87%, are covered under the
pharmacy benefit (n=79) (Figure
5). The exceptions are intraocular
injections and implants, of which
92% are covered under the
medical benefit (n=83) (chart not
shown).
According to the Magellan Rx
Management Medical Pharmacy
Trend Report™, for all medications
covered under the medical benefit
in 2014, the average coinsurance
percentage was 18% and the
average co-pay amount was $51.5
Figure 5
What proportion of eye care
prescriptions are covered under:
Eye care remains a small part
of the pharmacy budget for the
Medicare population, accounting
for 7% in 2014 and is expected
to increase to 8% in 2016 (n=44)
(Figure 6).
For the younger commercial plan
population, eye care accounted for
just 5% of the pharmacy budget in
2014, and is expected to increase
to 6% in 2016 (n=44) (chart not
shown). “Eye care costs are higher
for the Medicare population with
more cases of glaucoma and
macular degeneration,” says Mr.
Bultemeier.
Generics v
Brand-Name”
Generics account for 75% of all
prescriptions in 2014, according to
survey respondents (n=83) (chart
not shown) but just 66% of eye
care prescriptions (n=73) (Figure
7). Preferred brands account for
14% of all prescriptions filled but
22% of eye care prescriptions.
“There seems to be more brands
prescribed for eye drops than
is typical for tablets,” notes Mr.
Bultemeier. “There may be an
issue with prescribers not being
as comfortable with generic eye
drops,” says Dr. Miller. According
to the FDA, a generic drug is
identical—or bioequivalent—to
a brand-name drug in dosage
form, safety, strength, route
of administration, quality,
performance characteristics, and
intended use. (The FDA was not
included in this research.)6
Generics are expected to maintain
their slow but steady climb,
projected to account for 70% of eye
care prescriptions by 2016 (n=79).
(Figure 8). “Most plans are 80% to
85% generics,” says Mr. Bultemeier.
“Generic utilization is increasing
because of some brands losing
patent protection but also because
of plan design changes,” says Dr.
Miller.
According to managed care
respondents, on average, 83% of
members have their prescription
switched to a generic within 1 year
after a generic becomes available
for all therapeutic categories
(n=83) (chart not shown).
For eye care, the average is 81%
(n=82) (chart not shown).“The
n=79
Figure 6
For your Medicare population, what percentage of the
organization’s pharmacy budget is spent on eye care?
13%
The medical benefit
The pharmacy benefit
6
8%
Response Percent
87%
n=44
10%
6%
4%
6%
7%
8%
2%
0%
2013
2014
Anticipated 2016
Eye Care Trend Report | Volume II
switch rate is high once a generic
equivalent becomes available,” says
Dr. Miller.
Managed care survey respondents
agree that generic substitution
benefits patients, with a rating
average of 4.3 on a 5-point
scale, and that generics are
fully equivalent to brand-name
medications, with a rating average
of 4.2 (n=82) (Figure 9).
formulary, with a rating of 3.5.
They are nearly split (44% disagree
v 38% agree) on the statement
that non-active ingredients in
eye drops make no difference in
effectiveness and tolerability, with
a rating average of 3.0 (n=82).
Respondents are nearly split (38%
disagree v 32% agree) on the
statement that prescribers know
best when to choose a brandname v a generic, with a rating
average of 2.9 (n=82).
Respondents agree on keeping
a branded product containing a
different active ingredient on the
“Most formularies provide
Figure 7
Response Percent
60%
n=73
66%
50%
40%
30%
20%
22%
10%
9%
2%
Non-preferred
brand
Specialty
pharmacy
0%
Generic
Preferred brand
Figure 8
Approximately what proportion of your organization’s
eye care prescriptions were for generics?
n=79
80%
Response Percent
70%
60%
50%
62%
66%
70%
40%
30%
20%
10%
0%
Generics in 2013
Eye Care Trend Report | Volume II
Generics in 2014
When a generic is added to a class,
58% of managed care respondents
enforce generic substitution on
the next refill (n=80) (chart not
shown). “That would be our stance
as well,” says Mr. Bultemeier. “The
patient may elect to continue on
the brand but pay a higher co-pay,”
says Dr. Miller.
Combination
Products
Please note the approximate percentage of total
prescriptions filled for eye care in 2014:
70%
several therapeutic choices
within medication classes while
encouraging use of generics,”
says Mr. Szczotka.“The goal of
managed care is to provide highquality care at an affordable price.”
Projected generics
in 2016
Only 26% of managed care
respondents frequently or very
frequently include a combination
product on formulary when
two single generic products are
available (n=80) (Figure 10). One
survey respondent commented
that it depends on the product’s
cost and dosing regimen.
“It depends on cost,” says Mr.
Bultemeier.“If the two generics
cost less than the combination
product, we would probably leave
it off the formulary.”
“If the combination product is
cost-neutral, it will improve the
chances of being added to the
formulary to improve compliance,”
says Mr. Szczotka.
“With two generics, the co-pay is
doubled, which can approach the
cost of the branded product,” says
Dr. May. “Plans are more likely to
cover combination eye drops than
pills because eye drops are harder
to administer,” he adds.
The branded combination product
would be considered a non7
Figure 9
What is your perception of generics and brands?
n=82
Generic substitution
is beneficial to patients
4.3
Generics are fully equivalent to the
brand-name medications in all classes
where generics are available
4.2
Eye drops that combine 2 compounds
commonly prescribed together simplify
dosing and help assure that patients are
compliant with necessary therapies
3.8
Preservative-free formulations of eye
drops are preferable to ones
containing preservatives
3.5
In classes where there is a generic
available, it is preferable to keep a branded
product with a different active ingredient
on formulary for those who are not
responsive or can’t tolerate the generic
3.5
The non-active ingredients in eye drops
make no difference in the effectiveness
and tolerability of the product
3.0
Prescribers know when it is in the best
interest of patients to prescribe
brand-name drugs, and when
it is best to prescribe generics
2.9
1
Strongly
disagree
2
3
4
Neutral
5
Strongly
agree
Rating Average
Percentages were converted to ratings using a 5-point scale.
According to the FDA, a generic drug is identical—or bioequivalent—to a
brand-name drug in dosage form, safety, strength, route of administration,
quality, performance characteristics,and intended use.
(The FDA was not included in this research.)6
8
Eye Care Trend Report | Volume II
Figure 10
How frequently will your organization include a combination
ocular product on formulary when there are 2 single generic
products available?
n=80
Very frequently
Survey respondents agree that in
glaucoma patients, lowering IOP
preserves vision,1,2 with a rating
of 4.2 on a 5-point scale (n=82)
(Figure 13), and that medication
is preferable to surgery. Dry eye is
seen as a chronic disease, with a
rating of 3.9.
6%
Frequently
20%
50% of the time
20%
Infrequently
30%
Rarely
13%
Not applicable
11%
0%
10%
20%
30%
40%
Response Percent
preferred brand at the highest
co-pay tier, say 74%; 22% would
make it a preferred brand (n=77)
(chart not shown).
Formulary Factors
Clinical efficacy, with a rating
average of 4.5 on a 5-point scale,
closely followed by cost, generic
availability, and safety, with
4.4 each, top the list of factors
considered when evaluating a
new drug within a class (n=83)
(Figure 11).“I was glad to see
clinical efficacy beat out cost,”
says Mr. Bultemeier.“Typically,
top criteria include safety, efficacy,
and comparative clinical data to
current standards of care,” says Mr.
Szczotka.
Factors most likely to trigger a
category review are: FDA approval
of new therapy, selected by 79%,
and generics entering the category,
65% (n=80) (Figure 12).“There
are two types of class reviews:
clinical and financial,” says Dr.
Eye Care Trend Report | Volume II
Glaucoma, Dry Eye,
Microinvasive
Glaucoma Surgery
(MIGS)
Miller.“A new product coming out
may trigger one or both types of
review.”
Studies of comparisons of brands
by approved indication are seen
as most valuable, with a rating
average of 2.8 on a 3-point
scale (n=81) (chart not shown).
“Everybody likes to see head-tohead studies, both brand v brand
and brand v generic,” says Dr.
Miller.
“Without comparative studies,
health plans need to do more
interpretation of the available
clinical data and draw their own
conclusions,” notes Mr. Szczotka.
“Comparative effectiveness studies
will become more important once
biosimilars enter the market,” adds
Dr. May.
“We would like to see new
drugs compared to the current
treatment standard, not just
to placebo,” says Dr. May. “In
addition, inclusion of more real
world data, if available, would be
helpful,” says Dr. Miller.
Survey respondents were generally
unaware of MIGS options for
treating glaucoma, with a rating of
2.6 on a 5-point scale, and neutral
on whether MIGS will result in
lower pharmacy costs in treating
glaucoma, with a 3.0 rating, and
on whether MIGS appears to be a
promising treatment for glaucoma,
with a 3.1 rating.
“There is room for education
on dry eye disease.”
– Dale Bultemeier, RPh
“Nearly everyone agrees that
lower IOP preserves vision and
that medications are preferable
to surgery,” notes Dr. Miller.
“Payers need to be educated about
microinvasive glaucoma surgery.”
“Stages of dry eye disease are not
considered in formularies,” says Dr.
May.“There is room for education
on dry eye disease,” says Mr.
Bultemeier. Dr. Miller agrees. Only
6% of survey respondents say
they are very aware of the stages
of progression of dry eye disease
and treatment options; 60% are
somewhat aware (n=79) (chart not
shown).
9
Utilization management
techniques that respondents
deem most effective are generic
substitution, with a rating average
of 4.4 on a 5-point scale; prior
authorization, 4.2; and quantity
limits, 4.1 (n=81) (Figure 14).
“High use of generic eye drops
helps keep costs down on the
pharmacy side,” says Dr. Miller,
“with prior authorization used
to manage injectables under the
medical benefit.”
Figure 11
How do you rate the following factors when evaluating
a new drug within a class?
n=83
4.5
Clinical efficacy
Cost
4.4
Generic available
4.4
Safety
4.4
Pharmacy cost
4.2
Tolerability/adverse events
4.2
Adherence
Patient outcomes and pharmacy
costs top the list of important
factors when developing
adherence programs, with
rating averages of 4.4 and 4.3,
respectively, on a 5-point scale
(n=82) (Figure 15).
4.1
Assuring best practices
Duplication of existing
treatment option
4.0
3.9
Compliance and persistency
3.8
Ease of dosing regimen
3.7
Minimizing drug interaction
1
2
3
Not
important
4
Neutral
5
Very
important
Rating Average
Percentages were converted to ratings using a 5-point scale.
Figure 12
What factors cause your organization to initiate a category review?
(multiple responses) n=80
FDA approval of new therapy
79%
Generics entering category
65%
58%
Required annual review
Rise in cost of
medications within category
56%
Change in current labeling
51%
34%
Contract renewal
0%
10%
20%
30%
40%
50%
Response Percent
10
60%
70%
80%
“For patients taking an expensive
hepatitis C medication, we call
members every month to remind
them to take the medication,”
says Mr. Bultemeier.“The highercost eye drops might warrant an
adherence program.”
Once-daily dosing is very effective
for improving adherence, agree
70% (n=82) (chart not shown).“I
agree,” says Mr. Bultemeier.
In Dr. May’s opinion: “Dosing eye
drops twice a day is more difficult
than taking pills. Combination
eye drops are more likely to be
on formulary than other types of
therapies.”
Most plans, 53%, do not send
adherence/compliance data to
prescribers (n=80) (chart not
shown).“We generally don’t do
this unless there is a specific issue
or request,” says Mr. Bultemeier.
Respondents are split on
whether to provide additional
Eye Care Trend Report | Volume II
Figure 13
Please state how strongly you agree or disagree with the following statements:
n=82
For the majority of glaucoma patients,
lower IOP preserves field of vision
4.2
For glaucoma patients, medications are preferable
to surgery if appropriate IOP is maintained
and patient tolerates treatment
4.1
3.9
Dry eye is a chronic, progressive disease
MIGS appears to be a promising treatment
for glaucoma
3.1
MIGS is highly likely to lower pharmacy
costs for glaucoma patients
3.0
I am aware of the new MIGS
options for treating glaucoma
2.6
1
Strongly
Disagree
2
3
Neutral
4
5
Strongly
Agree
Rating Average
Percentages were converted to ratings using a 5-point scale.
reimbursement to improve
adherence, with 49% saying no,
34% saying yes, and 19% saying
we already do so (n=80) (chart not
shown).“Pay for performance is
the wave of the future,” says Mr.
Bultemeier.“Payers would need to
be convinced that doing so would
reduce costs,” says Dr. May.
Medication Costs
Prescribers infrequently or rarely
know the cost of their patients’
medications, say 72% of managed
care respondents (n=82) (Figure
16).“I agree,” says Mr. Bultemeier.
“Typically they have no clue,” says
Dr. May.
Eye Care Trend Report | Volume II
Nearly half of respondents, 46%,
are unsure whether there will be
a shortage of ophthalmologists
within 10 years (n=81) (Figure
17). Two respondents note that
demand for services will continue
to expand. Others suggest medical
specialists in general will face
shortages. Dr. May notes that
optometrists have expanded their
roles.
Mr. Szczotka sees optometrists
becoming more involved in
screenings for conditions such as
glaucoma.
Asked to name challenges or
opportunities ahead, survey
respondents made 140 comments,
citing: rising cost of care (20);
aging population/growing patient
population (12); shortage of
ophthalmologists (4); patient
adherence (4); replacing injections
with topicals or orals (3); and
medical v pharmacy benefit (3).
Notes one respondent: “There
is a divide between medical and
pharmacy management. I think
there will be more combining
of medical and pharmacy
management in the future.”
“Will there be sufficient numbers
of specialists to meet the eye care
needs of the baby boomers?”
11
wonders Mr. Bultemeier.
“There will be opportunities for
optometrists to expand their
knowledge and skills into new
areas. Some will want to take
classes and develop new skills
while others would rather just stick
with doing eye exams.”
Figure 14
Which utilization management techniques do you find
most effective for eye care products?
n=82
Generic
substitution
4.4
Prior
authorization
4.2
“The challenge for health care is to
demonstrate value for the dollars
being spent, with greater emphasis
on improving quality outcomes
using quality measures,” says Mr.
Szczotka.
4.1
Quantity limits
Step therapy
3.9
Dosage limits
3.9
Selected brandname exclusions
3.7
Dose optimization
3.7
Therapeutic
interchange
“Health plans are looking to
biosimilars as the next big thing
on the horizon. With a price
differential of 20% or more, I
think they will shake things up,”
concludes Dr. May.
3.6
Medication
therapy
management
3.5
Prescribing
restricted
to specialist
3.4
Over-the-counter
coverage
3.2
Restricted
pharmacy network
3.0
1
Least
effective
2
3
Neutral
4
5
Most
effective
Rating Average
Percentages were converted to ratings using a 5-point scale.
12
Eye Care Trend Report | Volume II
Figure 15
Please rate the importance of the following factors
when developing adherence programs:
n=81
4.4
Outcomes
4.3
Pharmacy costs
Potential insurer
cost savings
4.2
Risk of adverse events
4.2
Potential patient
cost savings
4.1
Ease of implementation
4.1
Administrative costs
4.0
Hospitalizations
4.0
Lifetime cost of care
4.0
Patient participation
3.9
Patient quality of life
3.9
Patient education
3.9
1
Not
important
2
3
Figure 17
4
Neutral
5
Very
important
In your opinion, will there
begin to be a shortage of
ophthalmologists within the
next 10 years?
n=81
Rating Average
Percentages were converted to ratings using a 5-point scale.
46%
Figure 16
In your opinion, how frequently do providers know the
dollar amount that members pay for their medications?
25%
n=82
29%
Very frequently 0%
7%
Frequently
17%
50% of the time
Unsure
35%
Infrequently
37%
Rarely
Yes
4%
Not applicable
0%
10%
20%
30%
40%
No
Response Percent
Eye Care Trend Report | Volume II
13
PART II
The Ophthalmologist Perspective
Demand for eye care is expected
to grow with the aging of
the population and with the
introduction of promising
new therapies. Meanwhile,
ophthalmologists are being
challenged by declining
reimbursement rates, government
mandates, formulary restrictions,
and, longer-term, a shortage of
clinicians. They favor therapies
and delivery systems that simplify
dosing, enhance tolerability,
improve adherence, and improve
the quality of care. They also look
to new technology to improve
procedures.
These are among the findings
of Part II: The Ophthalmologist
Perspective of The Eye Care Trend
Report, Volume II. A total of 65
ophthalmologists were surveyed
on these and other issues affecting
the delivery of eye care.
Three ophthalmologists shared
their interpretation of the
survey findings:
• Nathan M. Radcliffe, MD,
glaucoma specialist and cataract
surgeon, New York University
Langone Ophthalmology
Associates, New York Eye
Surgery Center
14
Figure 18
What percentage of your patient visits is
related to the following conditions?
n=65
29%
Refractive errors
24%
Cataracts
Keratoconjunctivitis
sicca (dry eye)
22%
21%
Glaucoma
19%
Blepharitis (lid margin disease)
17%
Age-related macular degeneration
15%
Fitting of glasses/contact lenses
Diabetic retinopathy/
macular edema
13%
10%
Optical dispensary
7%
Allergic conjunctivitis
Accidents/trauma
4%
Bacterial conjunctivitis
4%
Cosmetic/aesthetic treatments
and surgeries
3%
0%
10%
20%
30%
Response Percent
Eye Care Trend Report | Volume II
• Anurag Shrivastava, MD,
glaucoma specialist and Director
of Residency Education,
Montefiore, Bronx, NY,
Associate Professor, Department
of Ophthalmology and Visual
Sciences, Albert Einstein College
of Medicine
Figure 19
Approximately what percentage of your
practice revenue is derived from:
n=65
Diagnosis and treatment of pathologies
of the eye, not including surgeries
43%
Surgery for
pathologies of the eye
22%
Vision services/routine
eye exams
19%
• Thomas K. Mundorf, MD,
glaucoma specialist, Mundorf
Eye Center, Charlotte, NC
8%
Optical dispensary
LASIK/refractive surgeries
& procedures
4%
Cosmetic/aesthetic treatments
and surgeries
3%
2%
Other
0%
10%
20%
30%
40%
50%
Response Percent
Figure 20
How important is each of the following to you
when prescribing medications?
n=65
Efficacy
4.7
Adherence
4.7
Safety
4.6
Tolerability/adverse events
4.6
Assuring best practices
4.4
Ease of dosing
4.4
Minimizing drug interactions
4.4
Assuring minimum
effective dose
4.2
Cost of each treatment
4.2
The largest proportion of revenue
for ophthalmology practices is
from diagnosis and treatment
of eye disease, 43%, followed
by surgeries of the eye, 22%,
and vision services, 19% (n=65)
(Figure 19), according to survey
respondents.
4.1
Annual cost of treatment
1
Not
important
2
3
4
Neutral
Rating Average
Percentages were converted to ratings using a 5-point scale.
Eye Care Trend Report | Volume II
Conditions driving the most
patient visits to ophthalmologists
are refractive errors, 29%; cataracts,
24%; dry eye, 22%; and glaucoma,
21% (n=65) (Figure 18).“There
is likely overlap of comorbidities
in this data, such as patients with
both glaucoma and cataracts,”
says Anurag Shrivastava, MD.
“Figure 18 provides a good
summary of conditions treated by
ophthalmologists,” says Nathan
Radcliffe, MD.“Most of these
conditions are chronic,” notes
Thomas K. Mundorf, MD,“and
make up the majority of reasons
for visits.”
5
Very
important
“With government and
commercial insurance
reimbursements declining,
growth in cosmetic procedures
and other services paid for by
patients is likely as physicians
seek alternative revenue sources,”
suggests Dr. Mundorf.
Efficacy and adherence are the
most important considerations
15
of survey respondents when
prescribing medications, each with
a rating average of 4.7, using a
5-point scale (n=65) (Figure 20).
Cost of each treatment and annual
cost of treatment are seen as only
slightly less important, with ratings
of 4.2 and 4.1, respectively.
“Adherence is highly correlated
with cost to patients. For my
patient population, when the cost
goes up even a little bit, adherence
can plummet,” says Dr. Shrivastava,
“and we as clinicians need to be
very cognizant of that.”
Responding ophthalmologists
identify the factors far and away
most important to payers as
annual cost of treatment and
cost per treatment, with a rating
average of 4.8, each using a 5-point
scale (n=65) (chart not shown).
“Doctors recognize that those
creating formularies are concerned
about treatment costs,” says Dr.
Radcliffe.“Ophthalmologists
surveyed don’t think health plans
are factoring in ease of dosing (2.4)
and adherence (2.6) when creating
formularies. Even efficacy received
a low rating (2.8).”
Health Plans
Nearly all responding
ophthalmology practices, 97%,
accept commercial health plans
and Medicare plans while 47%
also accept vision plans (n=65)
(chart not shown).
Medicare is the largest payer
of ophthalmologists’ services,
according to survey respondents,
accounting for an average of 43%
of patient visits (n=65) (Figure
21). Another 30% of visits are
covered by commercial health
plans, followed by Medicaid, with
12%.
16
Figure 21
Approximately what percentage of your patient visits is
reimbursed by each of these payers?
n=65
Medicare
43%
Commercial health plans
30%
12%
Medicaid
Vision/routine eye care plans
6%
Self-pay (cash)
6%
Veterans Affairs
2%
0%
10%
20%
30%
40%
50%
Response Percent
Figure 22
Do commercial health insurers have formulary restrictions
on products used to treat ocular conditions?
n=65
All commercial insurers
have formulary restrictions
for ocular products
31%
The majority of commercial
insurers have formulary
restrictions for ocular products
63%
Few commercial insurers
have formulary restrictions
for ocular products
5%
No commercial insurers
have formulary restrictions 0%
for ocular products
2%
Not applicable
0%
10%
20%
30%
40%
50%
60%
70%
Response Percent
Eye Care Trend Report | Volume II
Formulary restrictions are
common with commercial health
plans, and are more likely than
Medicare plans to have formulary
restrictions on products used in the
treatment of ocular conditions. A
total of 94% agree that commercial
plans have formulary restrictions
on all or most ocular products
(n=65) (Figure 22) versus 72%
saying the same for Medicare
plans (n=65) (chart not shown).
For both types of plans, formulary
restrictions apply most often to
glaucoma treatments, with a rating
of 3.0 on a 4-point scale (n=65)
(commercial, chart not shown;
Medicare, Figure 23).
Figure 23
How frequently do Medicare health insurers have formulary
restrictions for pharmaceutical products used to treat the
following ocular conditions?
n=65
3.0
Glaucoma
Pre-operative/postsurgical care
2.9
Keratoconjunctivitis
sicca (dry eye)
2.8
Allergic conjunctivitis
2.8
Bacterial conjunctivitis
2.8
Blepharitis
(lid margin disease)
2.7
Wet macular
degeneration
2.7
Diabetic retinopathy/
macular edema
2.6
Age-related
macular degeneration
2.6
1
Never
2
3
Rarely
Usually
4
Always
Rating Average
Percentages were converted to ratings using a 4-point scale.
Figure 24
In your opinion, is it appropriate that payers use formularies
and utilization management methods?
n=65
Very appropriate
3%
14%
Appropriate
28%
Neutral
29%
Inappropriate
25%
Very inappropriate
I don't prescribe medications
subject to formulary restrictions
2%
0%
10%
20%
Response Percent
Eye Care Trend Report | Volume II
30%
“Our prescription drug choices
are influenced by formularies,”
acknowledge all three editorial
panelists.“It is significant that 94%
of responding ophthalmologists
acknowledge that health plans
have a bearing on what they
prescribe,” says Dr. Shrivastava.
“For glaucoma, many different
treatment options are available
in each therapeutic class, and
formularies may practically limit
the options available to a patient.
In contrast, there may be fewer
marketed treatment options for
other conditions, and branded
medications may therefore be
more likely to be accessible to
patients,” he explains.
“Earlier today I requested a
medicine that works better than its
competitors to lower intraocular
pressure after trying each of
them for a second time,” says Dr.
Mundorf.“The insurance company
still turned down my request. This
patient may need to have surgery
that will cost a lot more but the
drug benefit side doesn’t seem to
care about incurring additional
medical costs.”
17
Figure 25
How helpful are health plan formulary and utilization management
in aiding you to provide quality health care to your patients?
n=65
Very helpful
3%
Helpful
3%
Neutral
25%
Unhelpful
31%
Very unhelpful
39%
0%
10%
20%
30%
40%
Response Percent
More than half of survey
respondents, 54%, consider it
inappropriate or very inappropriate
for payers to use formularies and
other utilization management
tools (n=65) (Figure 24). “A better
reimbursement system could have
insurance companies paying the
same amount regardless of therapy
choice, doing away with rebates
and costs associated with prior
authorization, and resulting in a
more transparent system,” suggests
Dr. Mundorf.
Most survey respondents, 70%,
find formularies and utilization
management tools unhelpful or
very unhelpful in providing quality
care to patients (n=65) (Figure
25).“I am in the very unhelpful
camp. As a physician, ideally my
decisions are based on what I
think is best for patients and not
what their plan wants to pay for,”
says Dr. Radcliffe.“Formularies are
unhelpful because they limit my
choices based on what the health
plans are paying, not what patients
are paying,” says Dr. Mundorf.
18
“Patients often choose cost over
efficacy, and the ophthalmologist
then may have to alter the
treatment plan.”
Drug Formulations
Ophthalmologists agree most
strongly on the need to keep an
alternative product containing a
different active ingredient on the
formulary, with a rating of 4.4 on a
5-point scale (n=65) (Figure 26).
“This is for two reasons,” says Dr.
Radcliffe: “in case of lack of efficacy
or lack of tolerability.”
Survey respondents also favor
combination eye drops to improve
adherence, with a rating of 4.3.
The statement that generics are
fully equivalent received a low
average rating of 2.3.“A majority
of respondents disagree,” notes
Dr. Shrivastava,“yet we are often
put in a position where we write
for generics that may not be
equivalent” (see sidebar,“Educating
Patients About the Differences
Between Brand-Name and
Generic Ophthalmic Drugs is One
of Several Effective Strategies,”
page 24.)7 According to the FDA,
a generic drug is identical—or
bioequivalent—to a brand-name
drug in dosage form, safety,
strength, route of administration,
quality, performance characteristics,
and intended use. (The FDA was
not included in this research.)6
Responding ophthalmologists
disagree that non-active eye drop
ingredients make no difference in
effectiveness and tolerability, with
a rating of just 2.0.“Non-active
ingredients do make a difference
in both effectiveness and
tolerability,” agree Drs. Shrivastava
and Radcliffe.“Generic eye drops
are not tested for tolerability,” adds
Dr. Mundorf.
While 42% of survey respondents
say they start treatment with a
generic, 36% will start treatment
with a branded product (n=64)
(Figure 27).“I like to start with a
sample to see if the medication
works in a specific patient before
the patient buys it,” says Dr.
Mundorf.
A patient’s health plan formulary
has a great (34%) or moderate
(42%) influence on the prescribing
decision, say 76% of survey
respondents (n=64) (Figure 28).
“That explains why in Figure
27 many physicians will initiate
therapy with a generic; it is how
formularies are pushing them,”
says Dr. Radcliffe.
“In my practice, I don’t switch
therapy that’s working unless
I am pushed to do so, which
generally happens when patients
no longer have affordable access
to their medications,” explains
Dr. Shrivastava.“Glaucoma, for
example, is a tough disease to
Eye Care Trend Report | Volume II
Figure 26
What is your perception of generics and brands in the ocular treatment categories?
Please state how strongly you agree or disagree with the following statements:
n=65
In classes where there is a generic
available, it is preferable to keep a
branded product with a different active
ingredient on formulary for those
who are not responsive or
can’t tolerate the generic
4.4
Eye drops that combine 2 compounds
commonly prescribed together simplify
dosing and help assure that patients are
compliant with necessary therapies
4.3
Prescribers know when it is in the
best interest of patients to prescribe
brand-name drugs, and when it is
best to prescribe generics
4.1
Preservative-free formulations of
eye drops are preferable to
ones containing preservatives
3.9
Generic substitution is
beneficial to patients
2.9
Generics are fully equivalent to the
brand-name medications in all classes
where generics are available
2.3
The non-active ingredients in eye drops
make no difference in the effectiveness
and tolerability of the product
2.0
1
Strongly
disagree
2
3
Neutral
4
5
Strongly
agree
Rating Average
Percentages were converted to ratings using a 5-point scale.
According to the FDA, a generic drug is identical—or bioequivalent—to a brand-name
drug in dosage form, safety, strength, route of administration, quality, performance
characteristics, and intended use. (The FDA was not included in this research.)6
Eye Care Trend Report | Volume II
19
treat. Even small changes in
Second-line therapy for glaucoma
therapy can set patients off course,” is largely split among beta-blockers,
adds Dr. Radcliffe.
32%; combination eye drops, 27%;
and alpha-adrenergic agonists, 21%
Ophthalmologists will frequently,
(n=63) (chart not shown).
very frequently, or always
prescribe a combination ocular
product rather than two single
generic products, say 83% of
survey respondents (n=65)
(chart not shown). Drs. Radcliffe
and Shrivastava agree that a
combination product is preferred
for ease of dosing and improved
adherence.
Glaucoma Treatment
Ophthalmologists prefer
prostaglandin analogues for
treating glaucoma, with 81%
in agreement (n=64) (chart
not shown). A total of 29% of
glaucoma patients on average
require second-line therapy (n=64)
(chart not shown).
Figure 27
Given treatment alternatives,
where are you most likely to
begin patient treatment for an
ocular condition?
n=64
“I frequently use a fixed
combination eye drop as
second-line therapy for patients
demonstrating functional and
structural deterioration,” says Dr.
Shrivastava. Use of combination
eye drops has increased, says Dr.
Radcliffe.
Use of eye drop regimens to
reduce IOP is needed after
glaucoma surgery often, usually
or always, say 74% of survey
respondents (n=64) (chart not
shown).“Many patients need to
continue eye drops even after
surgery,” notes Dr. Shrivastava.
generally preferred over surgery,
with a 4.4 rating.
“Physicians have certainly heard
about MIGS procedures, but there
is some skepticism when they are
marketed as a replacement for more
traditional invasive procedures”
says Dr. Shrivastava. “MIGS
procedures are sometimes viewed
as reducing the eye drop burden in
select patients, but not necessarily
eliminating it in the long term.
Patients with advanced progressive
disease continue to very often
require more invasive procedures.”
Dry Eye
Awareness of MIGS is high, with a
4.4 rating on a 5-point scale (n=64)
(Figure 29). However, fewer
survey respondents agree that
MIGS are a promising treatment,
garnering a rating of 3.9, or that it
is highly likely to lower pharmacy
costs for glaucoma patients, with
a 3.6 rating. Medications are
Dry eye is a disease, agree 98%
of responding ophthalmologists
(chart not shown).“Incidence
and awareness of dry eye has
exploded,” says Dr. Mundorf. “We
are looking for it more.”
Artificial tears are the first-line
treatment for dry eye, agree 89% of
survey respondents (n=65) (chart
not shown). “Artificial tears are
safe, effective, over-the-counter,
relatively inexpensive, and widely
available so, of course we try them
Figure 28
42%
To what degree does the patient’s formulary influence
the prescribing decision?
n=64
Great influence
36%
22%
Generic or low-cost
therapeutic equivalent
Branded product
Over-the-counter products
34%
Moderate influence
42%
Mild influence
17%
No influence
6%
0%
10%
20%
30%
40%
50%
Response Percent
20
Eye Care Trend Report | Volume II
Figure 29
Please state how strongly you agree or disagree with the following statements:
n=64
I am aware of MIGS for treating glaucoma
4.4
For glaucoma patients, medications are
preferable to surgery if appropriate IOP is
maintained and patient tolerates treatment
4.4
For the majority of glaucoma patients,
lower IOP preserves field of vision
4.4
4.1
Dry eye is a chronic, progressive disease
MIGS appears to be a promising
treatment for glaucoma
3.9
MIGS is highly likely to lower pharmacy
costs for glaucoma patients
3.6
1
2
Strongly
disagree
3
Neutral
4
5
Strongly
agree
Rating Average
Percentages were converted to ratings using a 5-point scale.
first,” says Dr. Shrivastava. “Many
plans require that patients try
more conservative therapy before
authorizing branded therapeutic
agents,” he adds.
According to survey respondents,
the factors that help patients
adhere to their eye drop regimen
are ease of dosing, with a 4.5
rating on a 5-point scale; comfort
of dosing, 4.4; and cost of regimen,
4.3 (n=65) (Figure 30).“When
doctors prescribe eye drops, it is
important that they have patients
demonstrate that they are familiar
Eye Care Trend Report | Volume II
with proper dosing technique,”
says Dr. Mundorf.
“Incidence and awareness
of dry eye has exploded.”
–- Thomas Mundorf, MD
The patient is most responsible
for adherence to the treatment
regimen, agree 60% of survey
respondents (n=63) (chart
not shown). Prescribers are
second, with 30%. Health plans
received 2% of responses.
Comments by survey respondents
included: “patients need to
take responsibility for their
own health”; “prescribers have
to explain and follow-up to
make sure patients are taking
medication”; and “all of the above”
are responsible for adherence.
“Patients may be most responsible
but we have to help patients be
adherent and compliant,” says Dr.
Mundorf.
Knowing whether patients are
adhering to prescribed therapy is
seen as very important or important
21
Figure 30
Figure 31
How do you rate the following factors when
evaluating a new drug within a class?
In your opinion, how does
patient compliance for eye
drops differ from compliance
for oral medications?
n=65
n=63
4.5
Ease of dosing
52%
4.4
Comfort of dosing
10%
4.3
Cost of regimen
Complexity
of regimen
38%
4.1
Understanding of
disease and disease
progression
Patients dosing eye drops are
less compliant than patients
taking oral medications
3.9
1
2
3
Not
important
4
Neutral
5
Most
important
Rating Average
There is no difference in
compliance between patients
dosing eye drops and patients
taking orals
Patients dosing eye drops are
more compliant than patients
taking oral medications
Percentages were converted to ratings using a 5-point scale.
by 100% of survey respondents
(n=64) (chart not shown).
Figure 32
How often are you aware of the total cost of the medications
your practice prescribes for a specific patient?
More than half of respondents,
52%, agree that patients dosing
eye drops are less adherent on
average than patients dosing oral
medications (n=63) (Figure 31).
There is no difference, say 38%.
n=64
3%
Always
Very frequently
22%
Frequently
50% of the time
13%
22%
Infrequently
Rarely
14%
Never
3%
0%
10%
20%
Response Percent
22
“Adherence is very important and
eye drops are harder to take than
pills,” says Dr. Radcliffe.“The most
important factor is ease of dosing,
which speaks to the value of fixed
combinations and prostaglandin
analogues,” he says.
23%
30%
All responding ophthalmologists
say they monitor adherence by
asking patients (n=63) (chart not
shown). Sixty percent check for
improved clinical values, such as
Eye Care Trend Report | Volume II
Figure 33
Figure 34
In your opinion, will there
begin to be a shortage of
ophthalmologists within the
next 10 years?
How has the electronic medical record (EMR) impacted
patient care in the following areas?
n=59
Minimizing
drug interactions
4.2
Assuring prescriptions
are filled correctly
n=64
3.9
Patient outcomes
3.8
Compliance
with therapy
3.8
47%
26.5%
26.5%
3.5
Patient satisfaction
Understanding
of patient
3.3
Time spent on
direct patient care
Yes
No
3.2
1
Greatly
decresed
2
3
No change
4
Unsure
5
Greatly
increased
Rating Average
Percentages were converted to ratings using a 5-point scale.
lower IOP. One-third check for
gaps in refills.
While most survey respondents
(63%) do not receive patient
adherence data from health plans,
31% receive data from a few health
plans (n=64) (chart not shown).
Treatment Costs
Survey respondents frequently
are aware of the total cost of
medications prescribed, say 48%
(n=64) (Figure 32). They are less
likely to know patients’ out-ofpocket amount, with 40% saying
they frequently know the amount
(n=65).
“We don’t always know the cost
of therapy or what patients pay
Eye Care Trend Report | Volume II
out of pocket,” acknowledges Dr.
Radcliffe.
“Adherence is very
important and eye
drops are harder to
take than pills.”
–- Nathan Radcliffe, MD
Two types of patient support
programs offered by manufacturers
are seen as providing high value to
patients: financial assistance, with
a rating of 4.5 on a 5-point scale,
and co-pay assistance, 4.4 (n=64)
(chart not shown).
EMR
A total of 76% of respondents use
an EMR system (n=62) (chart not
shown).
EMRs have helped practices in
some areas, notably in minimizing
drug interactions, with a rating
average of 4.2 on a 5-point scale;
assuring prescriptions are filled
correctly, 3.9; patient outcomes, 3.8;
and compliance with therapy, 3.8
(n=59) (Figure 33). Time spent on
patient care merited only 3.2. One
survey respondent notes: “EMR
takes a lot longer than paper so we
have less time to educate patients.”
Nearly half, 47%, of survey
respondents believe that there will
be a shortage of ophthalmologists
within 10 years (n=64) (Figure
34).“There is already a shortage,”
writes one survey respondent.
23
“Many are retiring early,” writes
another.“Less pay equals fewer
doctors,” pens a third. A fourth
cites an aging population as
contributing to a shortage.
Will optometrists become the
“primary care physicians” for eye
care? Ophthalmologists are split;
41% say no, 31% say yes, and
28% are unsure (n=64) (chart
not shown). One respondent
suggests that optometrists
could fill networks with lower
reimbursement tiers.
Asked to name challenges
facing the profession, declining
reimbursements topped the list,
with 18 responses, according to
survey respondents. Also high
on the list with 17 responses:
government mandates, including
ICD-10, PQRS measures, and
EMRs. ICD-10 is described as a
“huge hassle.” Other concerns:
cost of therapies (9), rising
patient co-pays (7), optometrists
exceeding their authority and
skill level (6), and supply of
ophthalmologists not keeping up
with growing demand because of
an aging population (4).
“There is some controversy in
ophthalmology as to whether
optometry will or should take on a
bigger role,” says Dr. Radcliffe.
“There are opportunities for
ophthalmologists and optometrists
to work together to see more
patients both professionally and in
actual practice,” says Dr. Mundorf.
“However, most ophthalmologists
don’t want to be limited to surgery
alone; they want to take care of
patients as they always have.”
“The comments by the survey
respondents reflect accurate
observations,” says Dr. Shrivastava.
“There is already a functional
shortage of ophthalmologists
as more of our rapidly aging
population continues to need
medical and surgical care.
Reimbursements are declining,
and we are close to reaching a
tipping point as cost of health care
keeps rising. We are getting more
regulations on coding, quality
measures, and EMRs, thereby
taking time away from patient care
and affecting productivity.”
“Doctors are tired of being made
out to be the bad guy driving
up costs even while actual
reimbursements to doctors are
declining,” says Dr. Mundorf.
“When I started the practice in
1986, Medicare paid $2000 for
cataract surgery. Now they pay
$600 for better results. Doctors
are frustrated with the restrictions
placed on them. The challenge
is how can we best take care of
patients? Insurance companies
and doctors need to have a dialog
on how to accomplish that.”
“Drug delivery systems can
improve patient adherence,” says
Dr. Shrivastava. “Technology can
improve patient outcomes, reduce
complications, and improve quality
of life. Surgeries are becoming
more efficient, and providing
improved outcomes according to a
variety of metrics.”
Educating Patients About the Differences Between
Brand-Name and Generic Ophthalmic Drugs is One
of Several Effective Strategies
By Virginia Pickles, Contributing Editor,
Ophthalmology Management
When a provider writes — or clicks — “no
substitution” or “dispense as written” on a
prescription form, there’s no guarantee the
preferred drug will be dispensed. Depending on
circumstances — if a brand-name drug is not on
a third-party payer’s formulary or if the co-pay
is high — a patient may request a less costly
generic alternative. What’s more, pharmacists
24
proactively alert patients to the availability of
generic equivalents, and some health plans and
pharmacy benefit managers offer incentives to
providers when they successfully make a switch
from brand to generic.8
Another tactic to increase generic drug utilization
was explored at the University of Pennsylvania
School of Medicine. Researchers there changed
the default setting on electronic health records in
the general internal and family medicine clinics to
initially display only generic equivalents of betaEye Care Trend Report | Volume II
blockers, statins and proton-pump inhibitors,
with the ability to opt out.9 They concluded
that making generic drugs the default choice
for prescribers may help reduce unnecessary
spending and improve healthcare value.
With such concerted efforts to increase utilization
of generic drugs, physicians who want a patient
to use a specific brand-name drug must be both
vigilant and persistent. Educating patients so
they can be their own advocates is important.
Explain the Differences
Many patients are accustomed to using generic
systemic drugs, such as antihypertensives and
statins, without problems, says Keith A. Walter,
MD, professor of ophthalmology at Wake Forest
University School of Medicine in Winston-Salem,
NC. That is why they need to be educated about
the differences that exist with branded and
generic ophthalmic drugs.
“You have to talk to your patients,” Dr. Walter
says.“It doesn’t take more than 30 seconds of
chair time.”
Dr. Walter believes this type of patient education
is most effective coming from the doctor, but
it’s essential that staff members also support his
philosophy.
Present the Evidence to Insurers
Even when patients understand and advocate
for a brand-name drug at the pharmacy, they
may encounter a barrier with their insurance
carriers. Dr. Walter has prepared a form letter
for these situations and includes supporting
documentation from the literature. In the case of
a drug he’s prescribing post-corneal transplant,
he also emphasizes the economic consequences.
“Once I explain the consequences, they usually
approve the drug,” he says.
School of Medicine and in private practice at
Ophthalmology Associates in St. Louis, used to
educate patients one-on-one. Today, patients
view a 30-minute video about their upcoming
surgery in which he describes risks and
complications along with the reasons why he is
prescribing specific drugs for them.“I explain why
I think it’s important for them to use the branded
drugs I prescribe,” he says.“I also tell them if they
can’t afford a drug, they should let us know, so
we can do something about it.”
The videos, along with handouts about specific
procedures, ensure that all pre-op patients
receive the same information and that it is
disseminated efficiently.
Have Patients Bring in Their Bottles
Generic substitution can occur unexpectedly, says
Robert D. Fechtner, MD, professor and director
of the glaucoma division of UMDNJ-New Jersey
Medical School in Newark.“I never know when
I write a prescription if it’s on formulary,” he
says.“And every January, there’s a chance that
patients whose IOPs were successfully controlled
on a particular medication will need to change
because their insurance carrier has a new
formulary. It’s really confusing for patients. That’s
why I think it’s more important than ever that
patients bring their eye drop bottles with them
to their appointments, so I can see what they’re
getting.”
Inform Patients About
Assistance Programs
Deliver a Consistent
Message Efficiently
Patients who are unable to afford their
prescription medications may be able to take
advantage of assistance programs offered by
several nonprofit organizations and some
pharmaceutical companies. In fact, according
to Dr. Walter, through these programs, some
branded drugs become more affordable than their
generic counterparts.
Gregg J. Berdy, MD, an assistant professor of
clinical ophthalmology at Washington University
Reprinted with permission from Ophthalmology
Management. 2015;19(November): 20-22.7
Eye Care Trend Report | Volume II
25
PART III
The Optometrist Perspective
Optometrists are expanding into
medical services, treating more
eye disease, and seeking coverage
of these services by health plans
while continuing to provide
traditional vision care. They are
also being challenged by managed
care formulary restrictions,
declining vision care plan
reimbursements, new technology,
and growing Internet competition.
At the same time, opportunities
are expanding for optometrists
because of an emerging shortage
of ophthalmologists. These are
among the findings of Part III:
The Optometrist Perspective of The
Eye Care Trend Report, Volume II.
A total of 127 optometrists were
surveyed on these and other eye
care issues.
Three optometrists were
interviewed to interpret the
survey findings:
• Jill C. Autry, OD, RPh, owner/
partner, Eye Center of Texas,
Houston, with six locations
• Scot Morris, OD, Morris
Consulting Associates, Chief
Optometric Editor, Optometric
Management, and Clinical
Director, Eye Consultants of
Colorado, Conifer
26
Figure 35
Approximately what percentage of your
practice revenue is derived from:
n=127
Vision services/
routine eye exams
45%
31%
Optical dispensary
Diagnosis and treatment of
pathologies of the eye
20%
1%
Vision therapy
3%
Other
0%
10%
• Ian Benjamin Gaddie, OD,
owner and Director, Gaddie Eye
Centers, Louisville, KY, with four
locations
Optometrist practice revenue
is derived from vision services,
45%; optical dispensary, 31%; and
diagnosis and treatment of eye
20%
30%
Response Percent
40%
50%
pathologies, 20% (n=127) (Figure
35), according to optometrists
responding to the survey.
Revenue from diagnosis and
treatment of eye pathologies has
grown the most over the past
year, according to 55% of survey
respondents (n=127) (Figure 36).
Eye Care Trend Report | Volume II
Figure 36
How has practice revenue changed from last year for each of these categories?
n=127
Diagnosis and treatment
of pathologies of the eye
55%
39%
6%
Vision services/
routine eye exams
46%
35%
19%
31%
Optical dispensary
53%
13%
9%
Other revenue sources
47%
3%
Vision therapy
4%
74%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Response Percent
Increased
“That so many optometrists see
an increase in treating diseases of
the eye is encouraging,” says Scot
Morris, OD, of Eye Consultants of
Colorado.
“Optometry practices
are branching out into
different types of services
and becoming more
medically oriented.”
-– Jill Autry, OD, RPh
“Optometry practices are
branching out into different types
of services and becoming more
medically oriented,” notes Jill
Autry, OD, RPh, Eye Center of
Texas.“Optometrists are treating
more pathologies themselves
Eye Care Trend Report | Volume II
Unchanged
Decreased
rather than referring out.” (see
sidebar,“Screening for Glaucoma
and Beyond,” page 37).
“In recent years, we have focused
on specialty contact lenses,
vitamins, and sunglasses,” says
Dr. Morris,“all of which are up
significantly. We’ve treated a high
percentage of patients with eye
disease for many years.”
Health Plans
v Vision Plans
On average, 35% of patient visits
are covered by vision care plans,
according to survey respondents
(n=127) (Figure 37). Commercial
plans cover 18% of patient
visits, followed by self-pay, 17%;
Medicare, 15%; and Medicaid,
13%.“As optometrists treat more
pathologies, they are asking
patients about their medical
coverage,” says Dr. Autry.“It is a
paradigm shift. Diseases of the
eye are not covered by vision care
plans and patients may not be
aware of the differences.”
Unlike most commercial health
plans under which provider
reimbursement rates can vary,
Medicare and Medicaid pay
optometrists the same rate for
services as ophthalmologists, adds
Dr. Autry.
“While many patients have
coverage under vision care and
medical plans, most revenue
for optometry practices is from
patients,”says Ian Benjamin Gaddie,
OD, of Gaddie Eye Centers.
27
Formulary Restrictions
Figure 37
What percentage of patient visits is
reimbursed by each of these payers?
n=127
Vision/routine
eye care plans
35%
Commercial health plans
18%
Self-pay (cash)
17%
Medicare
15%
Medicaid
13%
Veterans Affairs
1%
Other
1%
0%
10%
20%
30%
Response Percent
40%
“We frequently have formulary
issues on nearly every one of
those products, especially for preoperative/post-surgical care and
dry eye,” says Dr. Morris.“Often
substitution can occur at the
pharmacy without the prescriber
even being aware of it.”
Figure 38
How frequently do Medicare health insurers have formulary
restrictions for pharmaceutical products used to treat the
following ocular conditions?
n=125
2.8
Glaucoma
“My responses are ‘very frequently’
for each category,” says Dr. Gaddie.
“I will prescribe a medication to
treat glaucoma and then receive a
fax that the drug is not covered and
I must use a generic. Then I have to
make sure the generic is working.
If not, I have to go through
step therapy and obtain prior
authorization to use a branded
product. I am unsuccessful 30%
of the time and may then have to
add a second medication to get the
desired therapeutic effect.”
2.8
Allergic conjunctivitis
Keratoconjunctivitis
sicca (dry eye)
2.7
Bacterial conjunctivitis
2.6
Blepharitis
(lid margin disease)
2.6
Pre-operative/
post-surgical care
2.4
Age-related
macular degeneration
2.4
Wet macular
degeneration
2.3
Diabetic retinopathy/
macular edema
2.3
1
Never
2
3
Occasionally
Frequently
4
Very
frequently
Rating Average
Percentages were converted to ratings using a 4-point scale.
28
Health plans frequently have
formulary restrictions on products
used to treat common eye
conditions, although Medicare
plans are slightly less likely than
commercial plans to have such
restrictions. For Medicare plans,
frequency rating of formulary
restrictions is highest for glaucoma
treatments at 2.8 on a 4-point
scale (n=125) (Figure 38). For
commercial plans, frequency rating
of formulary restrictions is highest
for allergic conjunctivitis at 3.0 on
a 4-point scale (n=125) (chart not
shown).
Almost half (47%) of respondents
say they find it inappropriate or
very inappropriate for payers to
use formularies and utilization
management; 35% were neutral
(n=127) (chart not shown). Our
advisory panelists disagree.“It is
appropriate,” agree Drs. Autry,
Morris, and Gaddie.“In my
experience as a pharmacist serving
Eye Care Trend Report | Volume II
Figure 39
What is your perception of the use of generic drugs and product formulations in eye care?
n=126
Prescribers know when it is in the best interest
of patients to prescribe brand-name drugs,
and when it is best to prescribe generics
4.5
Eye drops that combine 2 compounds
commonly prescribed together simplify dosing
and help assure that patients are compliant
with necessary therapies
4.4
In classes where there is a generic available,
it is preferable to keep a branded product
with a different active ingredient on formulary
for those who are not responsive or
can’t tolerate the generic
4.3
Preservative-free formulations of eye drops are
preferable to ones containing preservatives
4.1
3.6
Generic substitution is beneficial to patients
Generics are fully equivalent to the
brand-name medications in all classes
where generics are available
2.6
The non-active ingredients in eye drops
make no difference in the effectiveness
and tolerability of the product
1.9
1
Strongly
disagree
2
3
4
Neutral
5
Strongly
agree
Rating Average
Percentages were converted to ratings using a 5-point scale.
According to the FDA, a generic drug is identical—or bioequivalent—
to a brand-name drug in dosage form, safety, strength, route of
administration, quality, performance characteristics, and
intended use. (The FDA was not included in this research.)6
Eye Care Trend Report | Volume II
29
on a Pharmacy and Therapeutics
committee at a hospital, it is a
balance between containing costs
and meeting the needs of patients
and prescribers,” says Dr. Autry.
“However, there needs to be a way
to change a medication that may
not be working for a particular
patient.”
“Health plans are running a
business,” adds Dr. Morris. Notes
Dr. Gaddie: “There needs to be
some controls, although I don’t
always agree with some of the
methods used.”
More than half, 59%, find health
plan formularies unhelpful or very
unhelpful in providing quality care
(n=127) (chart not shown).“It is
not helpful at all,” says Dr. Morris.
“It is unhelpful,” agrees Dr. Gaddie.
“I am just trying to do what is best
for my patients.”
According to responding
optometrists, cost is far and away
the factor most important to
payers in developing formularies
and utilization management
protocols, receiving the highest
rating average of 4.4 on a 5-point
scale (n=127) (chart not shown).
Next is safety, with 3.4.“In a
perfect world, the leading factor
would be assuring best practices,
followed by efficacy and then cost,”
says Dr. Morris.
strength, route of administration,
quality, performance
characteristics, and intended use.
(The FDA was not included in this
research.)6
drug combination products to
simplify dosing regimens, with a
rating of 4.6 on a 5-point scale.
“Combination products are
beneficial in improving adherence,”
says Dr. Gaddie.
“While use of generics can
be beneficial for patients, I
disagree that generics are always
fully equivalent to branded
medications,” says Dr. Gaddie.
Optometrists generally favor use
of preservative-free eye drops with
a rating of 4.1.
Optometrists disagree that nonactive ingredients in eye drops
Optometrists favor use of
Figure 40
Given treatment alternatives, where are you most likely to
begin patient treatment for an ocular condition?
n=127
Generic or low-cost
therapeutic equivalent
46%
Over-the-counter products
29%
Branded product
I don't prescribe medications
25%
0%
0%
10%
20%
30%
40%
50%
Response Percent
Figure 41
To what degree does the patient’s formulary
influence this prescription decision?
n=127
Use of Generics
While optometrists regard generic
substitution as generally beneficial
to patients (3.6 on a 5-point
scale), they also feel strongly that
prescribers know best when to
choose brand-name v generic
drugs, with a rating of 4.5 (n=126)
(Figure 39). According to the FDA,
a generic drug is identical—or
bioequivalent—to a brand-name
drug in dosage form, safety,
30
31%
Great influence
Moderate influence
43%
Mild influence
18%
No influence
8%
0%
10%
20%
30%
40%
50%
Response Percent
Eye Care Trend Report | Volume II
Figure 42
Please note the extent that the following factors influence your prescribing decisions:
n=127
3.8
Efficacy and safety of therapy
Ability of the patient to
adhere to therapy
3.5
3.3
Cost of therapy to the patient
2.9
Peer-reviewed journal articles
Pharmaceutical manufacturer
patient support
2.1
2.0
FDA-approved package insert
Pharmaceutical manufacturer
promotional material
1.9
Practice reimbursement
for therapy
1.9
Continuing education sponsored
by medical specialist organization
1.8
Continuing education sponsored
by pharmaceutical manufacturer
1.7
1
2
No
influence
3
Mild
influence
Moderate
influence
4
Strong
influence
Rating Average
Percentages were converted to ratings using a 4-point scale.
make no difference in effectiveness
and tolerability, with a 1.9 rating on
a 5-point scale.“Inactive ingredients
play a role in how eye drops
perform. Any formulation changes
that affect pH, viscosity, or cause
burning can alter an eye drop’s
effectiveness,”explains Dr. Autry.
“While the active ingredients
remain the same, inactive
ingredients can vary from brand
to generic and generic to generic,”
Eye Care Trend Report | Volume II
says Dr. Gaddie.“I find differences
in efficacy as well, which is of
greater concern than tolerability.”
Referrals
For an average of 10% of patient
visits, patients are referred
to ophthalmologists or other
specialists (n=126) (chart not
shown).“We can take care of
most issues except for cataract
and retina surgery and only refer
5% of patients,” says Dr. Gaddie.
He notes that optometrists
in Kentucky, Oklahoma, and
Louisiana can perform eyelid and
laser surgery.
Most optometrists, 46%, start
treatment with a generic or
low-cost therapeutic alternative
(n=127) (Figure 40). Dr. Gaddie
starts with generic antibiotics and
steroids but prefers to start with
a branded product for chronic
conditions, such as glaucoma.
31
The patient’s plan formulary exerts
a great or moderate influence on
therapy choice, say 74% of survey
respondents (n=127) (Figure 41).
Dr. Gaddie agrees, adding,“ I wish
plans were more forthcoming with
their formularies.”
“Efficacy and safety of therapy”
tops the list of factors influencing
optometrists’ prescribing decisions,
with a rating average of 3.8 on a
4-point scale (n=127) (Figure 42).
Next is patient adherence, with 3.5,
followed by patient cost of therapy
with 3.3.“All three have an impact,”
says Dr. Gaddie.
Figure 43
What is your preferred course of treatment for these glaucoma
patients who have progressed to a second line of therapy?
n=119
45%
Beta blockers
23%
Refer to ophthalmologist
Alpha-adrenergic agonists
16%
14%
Combination eye drops
6%
Carbonic anhydrase inhibitors
3%
Prostaglandin analogues
2%
Selective laser trabeculoplasty
Treating Glaucoma
Prostaglandin analogues are
preferred first-line therapy for
open-angle glaucoma, according
to 74% (n=124) (chart not shown).
Drs. Autry, Morris, and Gaddie
favor prostaglandin analogues as
first-line treatment.
An average of 17% of glaucoma
requires second-line therapy
(n=117) (chart not shown), most
often beta blockers (45%) (n=119)
(Figure 43).
“I usually use an alpha-adrenergic
agonist or combination product,”
says Dr. Autry. Dr. Morris agrees.
“After that, I would probably refer
the patient to an ophthalmologist
for surgical intervention.
Dry Eye
Optometrists overwhelmingly
(94%) regard dry eye as a disease
(n=127) (chart not shown).
Preferred first-line therapy is
artificial tears, agree 86% (n=126)
(chart not shown). Drs. Gaddie
and Morris favor use of nutritional
supplements in addition to
artificial tears for dry eye.
32
All other
1%
0%
10%
20%
30%
40%
50%
Response Percent
Figure 44
In your opinion, which factors most aid patients to
adhere to eye drop regimens?
n=127
4.3
Ease of dosing
4.2
Cost of regimen
Understanding of
disease and
disease progression
4.1
Comfort of dosing
4.1
Complexity
of regimen
3.9
1
Not
important
2
3
Neutral
4
5
Most
important
Rating Average
Percentages were converted to ratings using a 5-point scale.
Eye Care Trend Report | Volume II
Figure 45
How do you monitor compliance?
n=127
97%
Ask patient
Check for improved clinical
values (e.g., lower IOP)
55%
“I will ask patients how often
they are taking their drops and if
they’ve had any problems,” says
Dr. Autry.“We ask the patient but
will also check gaps in refills and
visits,” adds Dr. Gaddie.
35%
Check for gaps in refill requests
We do not monitor compliance
5%
Receive reports from insurers
4%
I do not contract
with health plans
“I receive adherence
data from a few
commercial plans and find it
helpful.”
2%
0%
20%
40%
60%
80%
100%
Response Percent
Figure 46
Do you currently receive
adherence/compliance data
from any of the health plans
with which you contract?
n=126
12%
3%
1%
84%
I receive data from all the
health plans with which I contract
I receive data from the majority of
health plans with which I contract
I receive data from a few
health plans with which I contract
I do not receive any
compliance data
Eye Care Trend Report | Volume II
Nearly all optometrists surveyed
(97%) monitor adherence by
asking patients, followed by
checking for improved clinical
values, 55%, and checking for gaps
in refills, 35% (n=127) (Figure 45).
Adherence
“Ease of dosing” is the most
important factor in influencing
how well patients adhere to eye
drop regimens, with a rating
average of 4.3 on a 5-point scale,
followed by “cost of regimen,” with
4.2 (n=127) (Figure 44).“Once a
day products certainly help with
ease of dosing,” says Dr. Autry.
“Ease of dosing is a big factor in
adherence. Patients don’t want to
have to put drops in their eyes all
day long,” says Dr. Morris.
More than half of respondents
(56%) agree patients are primarily
responsible for adhering to their
medication regimen, followed by
prescribers, with 38% (n=126)
(chart not shown).“As a profession,
we need to make patients
aware of the disease process. I
explain to patients the long-term
consequences for their vision of not
adhering to therapy,” says Dr. Autry.
-– Ian Benjamin Gaddie, OD
Most respondents, 84%, say they
do not receive any adherence data
from health plans (n=126) (Figure
46).“I receive adherence data from
a few commercial plans and find it
helpful,” says Dr. Morris.
Medication Cost
A total of 45% of optometrists say
they frequently know the total
cost of medications they prescribe
for patients (n=126) (chart not
shown) while only 26% frequently
know their patients’ out-of-pocket
medication costs (n=126) (Figure
47).
“I usually don’t know the total
cost,” says Dr. Autry.“The out-ofpocket cost varies by health plan.”
“We keep track of what patients
pay at the pharmacy. We ask
patients what they pay and also
use an app that surveys local
pharmacies,” says Dr. Morris.“In
Colorado, we are able to dispense
medications from our office and
save patients money.”
33
“We usually ask patients what
the medication costs,” says Dr.
Gaddie.“I do think it can impact
adherence.”
Figure 47
How frequently do you know the out-of-pocket amount that your
patients pay for the medications you prescribe?
n=126
0%
Always
Patient
Education/Support
11%
Very frequently
Optometrists rate patient
education as very important (76%)
or important (23%) (Figure 48).
“Educated patients are more likely
to be adherent,” explains Dr. Autry.
15%
Frequently
25%
50% of the time
36%
Infrequently
9%
Rarely
4%
Never
0%
10%
20%
30%
40%
Response Percent
Figure 48
How important is patient education in
managing ophthalmic conditions?
EMRs
n=126
Very important
A total of 73% of responding
optometrists use an EMR (n=127)
(chart not shown). EMR has
brought about improvements in
minimizing drug interactions and
assuring prescriptions are filled
correctly (rating of 3.7 on a 5-point
scale for both) (n=113) (Figure
49). However, EMR was seen as
having a negative impact on time
spent on patient care, with a rating
of 2.8.
76%
Important
23%
Neutral
1%
Less important
0%
Not important
0%
0%
10%
20%
30%
40%
50%
Response Percent
34
Of patient support programs
offered by manufacturers,
optometrists rate financial
assistance, insurance co-pay
assistance, and patient education
as having the greatest value to
patients with rating averages
of 4.1, 4.1, and 4.0, respectively
(n=127) (chart not shown).“The
co-pay cards are really helpful,”
says Dr. Gaddie.
60%
70%
80%
Some survey respondents criticized
EMRs.“EMR has gotten more time
consuming because of ‘meaningful
use’ requirements,” notes one.
“Too much time spent inputting
data, taking away from time spent
with patients,” writes another.
“EMR has been a time-consuming
nightmare,” says a third.
Eye Care Trend Report | Volume II
Figure 49
Figure 50
How have EMRs impacted patient care in the following areas?
In your opinion, will optometrists
become the primary care
physicians for eye care
within the next 10 years?
n=113
Minimizing drug
interactions
3.7
Assuring prescriptions
are filled correctly
3.7
n=127
77%
3.3
Patient outcomes
16%
7%
3.3
Understanding of patient
Yes
No
3.2
Patient satisfaction
Unsure
3.2
Compliance with therapy
doesn’t have to worry about reading
the script,”says Dr. Autry.
Time spent on
direct patient care
2.8
1
2
Greatly
improved
3
No change
4
5
Greatly
decreased
Rating Average
Percentages were converted to ratings using a 5-point scale.
“EMRs have reduced the time
spent with patients,” agree Drs.
Autry, Morris, and Gaddie.“I am
spending less time with patients
and more time with the computer,”
notes Dr. Morris.
“At this point, EMR has created
more problems than solutions,”
says Dr. Autry.
“EMR is the worst thing to happen
to medicine,” says Dr. Gaddie.“It
compartmentalizes the clinical
Eye Care Trend Report | Volume II
picture. Before I would use an
exam form and see at a glance the
patient’s entire clinical picture.
Now I have to click on different
boxes to find data, such as what
medications have been prescribed
previously. It has decreased
productively by 30%.”
On a positive note, e-prescribing
is a big help in making sure what
drug is prescribed, agree Drs. Morris
and Gaddie.“The pharmacist
EMRs have not helped with patient
outcomes, agree all three advisory
panel optometrists, at least so far.
Could that change in the future?
“We just joined a registry with the
American Optometric Association
where they are going to aggregate
our data to potentially show
improved patient outcomes and
that our services are cost-effective,”
says Dr. Gaddie.
Looking Ahead
More than half of responding
optometrists, 54%, don’t
expect there to be a shortage
of ophthalmologists within the
next 10 years, although 24% are
unsure (n=126) (chart not shown).
However, both Dr. Autry and
Dr. Morris think there will be a
shortage.“More ophthalmologists
35
are retiring than are being
trained,” says Dr. Autry.“This offers
opportunities for optometrists to
expand their scope of practice,” she
says. (see sidebar,“Opportunities
Expanding for Optometrists,” page
36).10 “Areas where optometrists
could expand include treatment
of infections, eyelid surgery, laser
surgery, and nonsurgical treatment
of glaucoma, but additional
training will be needed. Further
expansion of the optometrist’s role
will happen first in settings where
optometrists and ophthalmologists
practice together.”
Optometrists expect to become
the primary care physicians for
eye care within the next 10 years,
according to 77% (n=127) (Figure
50). Two respondents commented:
“They already are!”
“I agree we already are the primary
care physicians for eye care,” says
Dr. Morris.“I think that share will
increase as more ophthalmologists
focus either on surgery or a
subspecialty.”
Asked to name challenges and
opportunities ahead in eye care,
optometrists identified dozens.
Among them: decreasing
reimbursements (20 responses);
managed care policies in general
(20); online eye exams and
online sales of glasses (18);
aging of the population (6);
government regulations (4);
vision care v medical practice
(2); expanding scope of practice
(2); high deductibles (2);
oversupply of optometrists (2);
and future of private practice
(2). One optometrist would
like to see a better relationship
between optometrists and
ophthalmologists.
Challenges cited by Dr. Autry
include: aging of the population;
getting patients to understand that
most optometrists do more than
just prescribe glasses and contact
lenses; and educating patients on
the difference between vision care
plans and medical plans.
One challenge is the shift to
value-based purchasing of health
care with payers wanting to see
outcomes and cost-efficient
providers.“There has to be an
infrastructure to support it,” says
Dr. Gaddie.
“Optometrists must be able to
deliver medical services. One
wonders in the future whether a
vision care-only practice can be
sustainable.” Other challenges
he cites: the burden of federal
regulations, including meaningful
use; PQRS, and Health Insurance
Portability and Accountability Act
(HIPAA); and diagnosis and eye
exams provided over the Internet.
“The current challenge is managed
care, but looking ahead, it is
technology, including online
refractory exams, kiosk-based
exams, and 3-D printing of
frames,” says Dr. Morris.
A practice needs to have an
automated refracting system
to keep up over the next 5 to
10 years. It allows one to see
three times as many patients,
18 minutes v 1 hour. Managed
vision care is dying out,” he says.
“With declining reimbursements,
practitioners can provide care for
not much more than the co-pay
amount. We will see the day,
perhaps 10 years from now, when
primary vision care is not provided
by an optometrist but by remote
diagnostic testing.”
Opportunities Expanding for Optometrists
Ophthalmologists quoted in a January 1, 2015
article in Ophthalmology Management advocate
team-based care involving optometrists as one
strategy to meet challenges posed by a potential
shortage of ophthalmologists.10
“In particular, ophthalmology’s relationship
with optometry must continue to expand,” says
Robert Wiggens, MD, MHA, who practices
in Asheville, NC, and is senior secretary for
ophthalmic practice at the American Academy
of Ophthalmology.“In our practice, we don’t
have enough ophthalmologists to see all of the
36
routine eye care visits so we’ve hired optometrists
to help take that load off ophthalmologists and
let our practice see more patients than we could
otherwise.”
Contributing factors to the emerging
shortage of ophthalmologists include aging
of the population and limits on funding for
ophthalmology residency programs despite
increased demand for services. For example,
7.32 million people in the U.S. are projected to
have open-angle glaucoma by 2050, an increase
of 170% from 2011.11
Eye Care Trend Report | Volume II
Screening for Glaucoma and Beyond
Interview with Jill Autry, OD, RPh, of Eye Center of Texas, a multispecialty
practice with ophthalmologists and optometrists practicing together
Q: How do optometrists screen for glaucoma?
Dr. Autry: Even when a patient sees an optometrist
to be fitted for glasses or contact lenses, he or she
also receives an eye health examination that includes
tonometry or the checking of eye pressure. As part of
the exam, the optometrist will also look inside the eye
to assess the health of the optic nerve. It is the optic
nerve that is damaged with glaucoma. Further testing
may include visual field screening, optical coherence
tomography (OCT), and pachymetry if glaucoma is
suspected either because of eye pressure readings or
optic nerve appearance.
Q: How often should patients be screened
for glaucoma?
Dr. Autry: The American Optometric Association
recommends that adults have their eyes examined
every one to two years, including checking of eye
pressure and assessment of the inside of the eye.12
Testing should be done more often if a person has a
known risk factor or family history of an eye disease.
Unchecked, glaucoma starts to damage the nerve of
the eye.
Q: What does a glaucoma-damaged nerve
look like?
Dr. Autry: The optic nerve head looks similar to the
head of a nail driven into a piece of wood. You can
only see the very tip of the nerve and it's circular just
like a round nail head. Inside that circular area there
is a slight depression. When that depression is larger
or is not circular, it can signal glaucoma. For some
people with nerve damage, pressure can be normal,
often labeled normal pressure glaucoma.
Q: What are common risk factors?
Dr. Autry: African Americans, Latinos, and certain
Asian populations are at higher risk for various types
of glaucoma. Incidence increases with age. Certain
types of medications, such as steroids, can increase
the risk as can trauma to the eye. Family history raises
the risk. Glaucoma can also occur in the absence of
risk factors. In the past week, I diagnosed glaucoma in
a 38-year-old Caucasian man, an 85-year-old AfricanAmerican man, and in a 13-year-old female.
Eye Care Trend Report | Volume II
Q: Is glaucoma under-recognized or
under-diagnosed?
Dr. Autry: Yes to both. The most common reason
glaucoma is not diagnosed earlier is not because eye
care practitioners are not looking for it, but because
people don’t go in for a general eye health exam
unless they think they need glasses or unless they feel
something is wrong with their eyes.
Glaucoma is a silent taker of vision. People don’t
realize they have a problem right away because there
are no symptoms and side vision is affected first.
Central vision is generally affected last and, at that
point, the patient may already be legally blind due
to loss of peripheral vision. I have patients who are
considered legally blind but can still read“20/20”on an
eye chart.
We need to educate the public they should have their
eyes examined every one or two years whether they
wear glasses or not, just like people are encouraged to
have a colonoscopy at a certain age. Then glaucoma
could be caught earlier and treated earlier.
Q: How does an optometrist treat glaucoma?
Dr. Autry: Most optometrists who treat glaucoma
(and ophthalmologists as well) start with drops,
which lower the pressure. Prostaglandin analogues
are generally first choice as therapy. Dosing is once
daily, which helps with compliance.
Q: What difference does it make if it's caught
earlier? What can you do?
Dr. Autry: If pressure is high, lowering it can slow
or halt the disease process. People can go blind from
glaucoma and often this could have been prevented
with earlier and more aggressive treatment.
Q: Is compliance an issue?
Dr. Autry: Because glaucoma is an asymptomatic
disease, adherence is a big issue. In some cases, we
will diagnose the patient, start drops, and schedule
a follow-up and then the patient doesn’t come back
for two years. The patient will say,“I didn’t feel any
different when I used the drops so I just stopped them.”
37
If two types of drops are needed, we favor use of
combination products where available. However,
often the patient’s medical plan won’t cover a
combination product if the individual ingredients,
which would require two-bottle dosing, are available
at a lower cost.
Q: What is the difference between
vision plans and medical plans?
Dr. Autry: Vision plans cover glasses and contact
lenses while medical plans cover disease-related
tests and treatments. With the regular eye exam by
an optometrist, the pressure testing is included as
part of the vision benefit. However, once glaucoma
is suspected, other testing is needed, such as visual
field testing, OCT, and pachymetry, with coverage
under the patient’s medical plan. This can be
confusing and frustrating for patients when they
find out that what they thought would be a $10
vision exam is now turning into a $250 medical
exam plus treatment and their plan has a $5000
deductible.
References
1. Heijl A, Leske MC, Bengtsson B.
Reduction of intraocular pressure
and glaucoma progression. Arch
Ophthalmol. 2002;120:1268-1279.
2. The AGIS Investigators. The
Advanced Glaucoma Intervention
Study (AGIS): 7. The relationship
between control of intraocular
pressure and visual field
deterioration. Am J Ophthalmol.
2000;130:429-440.
3. Express Scripts. The Express Scripts
2014 Drug Trend Report Commercial.
2014:11. http://lab.express-scripts.
com/drug-trend.report/
4. Cohen JP, Felix AE, Riggs K, Gupta A.
Barriers to market uptake of
biosimilars in the US. GaBi J.
2014;Aug 29. http://gabi-journal.net/
barriers-to-market-uptake-ofbiosimilars-in-the-us.html
5. Magellan Rx Management. Medical
Pharmacy Trend Report, Fifth Edition.
2014:30. https://www1.magellanrx.
com/media/216383/2014-magellanrx-trend-report.pdf.
38
Q: Some people say there's going to be a shortage
of ophthalmologists. Do you see opportunities for
optometrists?
Dr. Autry: It could mean more opportunities for
optometrists especially for medically oriented
practices such as ours. We have 15 doctors in our
practice: four ophthalmologists and 11 optometrists.
We don’t do any vision care and don’t accept vision
plans. The optometrists treat glaucoma and other
pathologies, such as diabetic retinopathy or corneal
problems, medically. If surgery is indicated, an
ophthalmologist takes over.
Optometrists in general could do a better job of
educating the public as to what they can do and what
they can't. Some of that is because education and
scope of practice have evolved. There is currently a
disconnect within optometry between optometry
medical practices that also provide vision care and
vision-only practices. I think there will be more
medically-oriented optometry practices in the future
and also more opportunities for ophthalmologists and
optometrists to work together.
6. U.S. Food and Drug Administration.
Generic drugs. Questions and
answers. http://www.fda.gov/Drugs/
ResourcesForYou/Consumers/
QuestionsAnswers/ucm100100.htm.
7. Pickles V. How to ensure a drug is
dispensed as written. Ophthalmology
Management. 2015;19(Nov):20-22.
8. Purvis L. AARP Public Policy
Institute. Strategies to increase
generic drug utilization and
associated savings. December 2008.
http://assets.aarp.org/rgcenter/
health/i16_generics.pdf.
9. Patel MS, Day S, Small DS. Using
default options within the electronic
health record to increase the
prescribing of generic-equivalent
medications: a quasi-experimental
study. Ann Intern Med. 2014;161(10
Suppl):S44-S52.
11.Vajaranant TS, Wu S, Torres M, Varma
R. The changing face of primary
open-angle glaucoma in the United
States: demographic and geographic
changes from 2011 to 2050. Am J
Ophthalmol. 2012;154:303-314.e3.
12.American Optometric Association.
Recommended eye examination
frequency for pediatric patients and
adults. http://www.aoa.org/
patients-and-public/caring-for-yourvision/comprehensive-eye-andvision-examination/recommendedexamination-frequency-forpediatric-patients-and-adults?sso=y
13.The Eye Care Trend Report, Volume
II Methodology for Managed Care
(n=83), Ophthalmologist (n=65), and
Optometrist (n=127) Perspectives.
2016.
10.Tertel Z. Analyzing ophthalmology’s
manpower issue. Ophthalmology
Management. 2015;19(Jan):28-30,67.
http://www.ophthalmologymanagement.com/articleviewer.aspx?articleID=112155.
Eye Care Trend Report | Volume II
Comparisons and Conclusions
• Managed care executives name rising cost of care
as the leading challenge faced in eye care, followed
by an aging/growing patient population. Asked to
name top challenges faced, ophthalmologists and
optometrists both cite decreasing reimbursements.
In second place, optometrists name managed care
policies in general, while ophthalmologists cite
government mandates.
• Only 22% of optometrists (n=126) and 25%
of managed care executives (n=81) but 47% of
ophthalmologists (n=64) expect there to be a
shortage of ophthalmologists within 10 years.
• The largest proportion of practice revenue for
ophthalmologists is from diagnosis and treatment
of the eye, 43%, followed by surgeries of the eye,
22%, and vision services, 19% (n=65), according to
survey respondents. Optometrist practice revenue
is derived from vision services, 45%, optical
dispensary, 31%, and diagnosis and treatment of
eye pathologies, 20% (n=127).
• The largest payer for ophthalmology practices is
Medicare, with 43% of patient visits (n=65). For
optometry practices it is vision plans, with 35% of
patient visits (n=127).
• A patient’s health plan formulary has a great or
moderate influence on the prescribing decision,
say 76% of ophthalmologists (n=64) and 74% of
optometrists (n=127).
• Managed care respondents feel the strongest
of the three groups that generic substitution
benefits patients, with a rating average of 4.3 on a
5-point scale. While optometrists regard generic
substitution as generally beneficial to patients (3.6
on a 5-point scale), they also feel strongly that
prescribers know best when to choose brandname versus generic drugs, with a rating of 4.5
(n=127). Managed care respondents disagree that
prescribers know best when to choose a brand v
generic, with a rating average of 2.9.
Eye Care Trend Report | Volume II
• What role do non-active ingredients in eye drops
play? Optometrists disagree they play no role
with a rating of 1.9 on a 5-point rating scale;
ophthalmologists respond similarly with 2.0.
Managed care responses are neutral at 3.0.
• According to the FDA, a generic drug is identical—
or bioequivalent—to a brand-name drug in dosage
form, safety, strength, route of administration,
quality, performance characteristics, and intended
use. (The FDA was not included in this research.)6
• Once-daily dosing can help with adherence, agree
70% of managed care respondents (n=82). However,
only 26% of managed care respondents say their
plans frequently include combination products on
the formulary if individual ingredients are available
generically (n=80). In contrast, ophthalmologists will
frequently prescribe a combination ocular product
rather than two single generic products, say 83% of
survey respondents (n=65).
• Prescribers infrequently or rarely know the cost of
their patients’ medications, say 72% of managed
care respondents (n=82) but eye care specialists
rate themselves higher. Ophthalmologists
frequently are aware of the total cost of medications
prescribed, say 48% (n=64), with 40% saying
they frequently know the patient’s out-of-pocket
amount (n=65). Among optometrists, 45% say they
frequently know the total cost (n=126) and 26%
frequently know patients’ out-of-pocket costs of the
medications they prescribe (n=126).
• Dry eye is a disease, agree 98% of responding
ophthalmologists (n=64), 94% of optometrists
(n=127) and 77% of managed care respondents
(n=81).
• Optometrists expect to become the primary care
physicians for eye care within the next 10 years,
according to 77% of optometrists surveyed (n=127).
Ophthalmologists are split on this issue; 41% say
no, 31% say yes, and 28% are unsure (n=64).
39
Methodology
Findings of The Eye Care Trend Report, Volume II,
sponsored by Allergan, are based on responses to
three separate surveys. Surveys were sent by fax and
e-mail to managed care executives, ophthalmologists,
and optometrists in 2013 and 2014. A total of 127
optometrists, 65 ophthalmologists, and 83 managed
care respondents completed the survey questions.13
Survey responses were analyzed by an independent
Editorial Advisory Panel, whose ten members also
provided commentary.
Most survey responses are presented as percentages
in the text and charts. Other survey findings are
presented and compared using rating scales. Using
a 5-point rating scale, for example, 5 indicates the
highest rating and 1 indicates the lowest. For all
findings,“n” is used to indicate the total number of
respondents who answered each question.
Managed Care Survey
A total of 83 managed care executives responded to
the survey. The largest proportion of managed care
survey respondents are health plans, accounting
for 36%, followed by pharmacy benefit managers
(PBMs), with 28%, and managed care plans, with
27% (n=81). Most respondents are pharmacy
directors, 49%, or clinical pharmacists, 41%;
8% are medical directors (n=78).
40
Organizations are national in scope (42%), singlestate (30%), or regional (21%) (n=83). Commercial
plans account for 48% of members; Medicare plans
account for 19%; Medicaid, 18%; Affordable Care Act
health exchanges, 7%; federal employee plans, 3%;
and other plans, 4% (n=83).
Ophthalmologist Survey
A total of 65 ophthalmologists responded to the
survey. Nearly half, 45%, of ophthalmologist survey
respondents have been in practice for more than
20 years (n=64). More than half, 54%, specialize in
cataract surgery (n= 61).
More than half, 54%, of ophthalmologist survey
respondents are in a single-specialty group practice
(n=65). Another 26% practice in a multi-specialty
group and 23% are in solo practice. About half, 49%,
maintain one practice site while 17% maintain two
sites and 26% maintain three, four, or five sites (n=65).
Optometrist Survey
A total of 127 optometrists responded to the survey.
Half of responding practices are solo practitioners
(n=126). Another 19% are in a single-specialty
practice and 17% are in multispecialty group
practices. Most (65%) operate just one site; 20%
operate two sites, and 15% operate three or more
sites (n=127). Nearly half (48%) of responding
optometrists have been in practice for more than 20
years (n=126).
Eye Care Trend Report | Volume II
Report Contributors
The Eye Care Trend Report,
Volume II
Sponsor:
Allergan, Inc.
P.O. Box 19534
Irvine, CA 92623
Phone: 714-246-4500
Fax: 714-246-4971
Allergan Customer Service:
1-800-433-8871
Project Director
Paul King
Payer Marketing
Eye Care
Allergan, Inc.
Irvine, CA
Publisher
Peter Sonnenreich
President
Kikaku America International
2001 Jefferson Davis Highway,
Suite 1104
Arlington, VA 22202
Phone: 202-246-2525
Email: [email protected]
Editorial Advisory Panel
MANAGED CARE
W.C. (Bill) Williams III, MD
Executive Vice President
National Association of
Managed Care Physicians
Glen Allen, VA Ross M. Miller, MD, MPH
Medical Advisor for the California
Department of Health Care Services
and Past Senior Medical Director, Cigna
Fredrick A. May, MD
Solutions for Managed Care
Indianapolis, IN
Dale A. Bultemeier, RPh
Assistant Vice President, Ancillary
Services, Physicians Health Plan of
Northern Indiana, Indianapolis
Andy Szczotka, PharmD
Vice President, Clinical Services,
Emdeon, Twinsburg, OH
OPHTHALMOLOGY
Editorial, Research
and Design
Janice Zoeller
Editor
Nathan M. Radcliffe, MD
Glaucoma Specialist and Cataract
Surgeon, New York University Langone
Ophthalmology Associates, New York
Eye Surgery Center
Laura Gill
Director of Market Research
Anurag Shrivastava, MD
Glaucoma Specialist and Director of
Residency Education, Montefiore, Bronx,
NY, Associate Professor, Department of
Ophthalmology and Visual Sciences,
Albert Einstein College of Medicine
Jacolyn Connolly
Copy Editor
Thomas K. Mundorf, MD
Glaucoma Specialist
Mundorf Eye Center
Charlotte, NC
OPTOMETRY
Jill C. Autry, OD, RPh
Owner/Partner, Eye Center of Texas,
Houston, with six locations
Scot Morris, OD
Morris Consulting Associates, Chief
Optometric Editor, Optometric
Management, and Clinical Director,
Eye Consultants of Colorado, Conifer
Ian Benjamin Gaddie, OD
Owner and Director, Gaddie Eye
Centers, Louisville, KY, with four
locations
Ryan Harpster
Design and Production
©2016 Allergan, Inc. All rights reserved. ® marks owned by
Allergan, Inc. www.allergan.com.
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Eye Care Trend Report | Volume II