Cost Utility of DR Telemedicine

Diabetic retinopathy is the leading cause of blindness among working age adults. Can telemedicine diabetic retinopathy screening (TMDRS) in the primary care clinic cost-effectively prevent vision impairment from diabetic retinopathy? We were asked to review the available technologies and report on the cost utility and return on investment (ROI) of such systems. Certainly TMDRS is a cost-effective solution where access to eye care services is limited, but can telemedicine technologies and screening strategies provide cost utility and ROI for primary care settings over all?

The annual cost associated with blindness from diabetes in the US is estimated at $5 billion, and yet it is mostly preventable through yearly examination of the retinas coupled with appropriate treatment of high-risk patients. However, half the patients most at risk fail to have their annual exams, where the retinal evaluation is performed as a live exam by referral to an eye care specialist.

Telemedicine has now made the annual exam accessible, affordable and simple to perform right in the primary care clinic. But what about cost and benefits (cost utility)? Cost utility can be considered from   three perspectives: 1) The patient’s perspective - the COST of the service to the patient (including transportation and lost time from work) versus the PERCEIVED BENEFIT AND SATISFACTION with the screening; 2) The healthcare organization’s and/or payer’s perspective - the COST of providing the service in RETURN FOR valuable quality measures and savings from averted costs for treating complications; 3) Society’s perspective- the COST of providing the service in RETURN FOR the cost of vision impairment ( lost productivity, increased social services, and disability benefits).  

Cost-utility is related to, but different from, return on investment (ROI), which affects organizations and individuals who directly pay for the service as well as telemedicine providers who gain revenue from the service. The ROI calculation is essentially the business case for providing the service, i.e., the added revenue or cost savings from deferred complications and unnecessary services, less the expense of providing the service.

ROI for TMDRS has been difficult to justify except in vertically integrated health care systems (ie, systems that bear the cost of blindness and vision impairment, such as government health services or large health maintenance organizations).  Adequate reimbursement and incentives to produce a positive ROI have been elusive for primary care clinics with regard to providing TMDRS; however, many payers are changing policies to provide sustainable support for these programs in the near future. Even with the low or sometimes negative ROI for non-vertically integrated systems, an increasing number of clinics have adopted TMDRS because of the proven clinical merit of the service for identifying patients with sight-threatening disease and the clinic’s own mission to serve their patients’ needs.

Telemedicine-based DR screening has grown steadily world-wide during the past decade and has become well established in several large organizations. While clinicians continue to struggle with reimbursement from payers for the service, the clinical and societal benefits are well documented. Patients are generally satisfied with the service, but often do not understand the benefits or rationale for the service. It is crucial to incorporate effective patient communication in order to realize the full benefits of telemedicine for effective triage of sight-threatening conditions and for better systemic control of chronic disease. Local primary care providers involved in shared-care arrangements with remote eye care providers (“telementoring”) can effectively increase compliance with treatments and lower the long-term costs of DR screening.

Technology for increasing the efficiency and effectiveness of TMDRS is evolving rapidly. Lower-cost imaging devices, electrodiagnostic devices, optical coherence tomography, integrated information systems, and automated algorithms for detection of retinal lesions are being used to expand access to TMDRS and to improve the precision of identifying who needs retinal screening and who needs referral for secondary and tertiary ophthalmic care. New telemedicine programs are in development for detection of macular degeneration, glaucoma, and other sight-threatening conditions. These new programs will be important in order to sustain the service in the future.

Eye care telemedicine is here to stay. The question is not whether it will be sustainable in the future, but what other eye care services will be added to the networks that are forming now.

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