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ment, income levels in the aged population are relatively low, and as has been indicated, this age group is the one requiring vision services most. Developing sound, effective means for providing optometric care to our aging citizens is one of the most important and urgent matters of unfinished business before our nation. More attention to the problem is urgently needed due to the critical shortage of optometric manpower and the lack of philanthropic funds which limit our optometric societies' capacity to provide all the vision care needed to protect the independence and dignity of our elderly people.
Our Association is delighted that Congress has given the Public Health Service Surgeon General the funds needed to provide grants for developing and researching new systems of health services, and renovating old systems. It is our hope that full advantage will be taken of the opportunity to assist in providing more and higher quality vision care for our senior citizens.
Optometry is primarily concerned with adding “life to years.” We look forward to learing that the result of these hearings by your Committee may assist us to fulfill this mission.
Your kind attention to this statement is greatly appreciated. I respectfully request that it be entered into the transcript of your hearings together with the two attachments I have discussed.
If you have any questions, I will be happy to attempt answers to them.
Denver, Colo., October 28, 1957.
Denver, Colo. DEAR MR. JUSTUB : Your request for data and suggestions on the inclusion of vision care in the projected health care program for Colorado old age pension recipients has been carefully considered by the Board of Directors of Colorado Vision Services, Inc., and its parent organization, The Colorado Optometric Association, Inc.
For your consideration we are submitting a study completed by our Group Health Consultant, Donald A. Seastone, Professor of Economics, University of Denver. His observations, suggestions, and series of recommendations give full consideration to the best experience available in the field of prepaid vision care.
You will note that no single, definite proposal is recommended in this study. This is in line, I believe, with discussions among you and members of your staff and representatives of Colorado Vision Services and the Colorado Optometric Association, including Dr. H. J. Kendrick, Association president, William B. O'Rourke, field representative for Colorado Vision Services and myself.
In addition, the possible alternatives outlined should make it possible for you to develop a vision care program for inclusion in your overall program for oldage pension recipients which can be expanded as your health program fund builds. Representatives of our profession are ready to discuss the specific details of this program whenever you are ready. In addition, if there are any phases of the study which are not clear to members of your staff or need additional explanation, we will be pleased to furnish whatever additional information you need.
In the case of each suggested program outlined in the attached study, yon will note that a provision is made for the cost of developing a small reserve and for the payment of administrative expense. This figure is based on a 7 percent surcharge of the dollar volume of each of the suggested programs.
This amount is intended to cover the program's proportionate share of office overhead, the processing of claims and services, the enforcement of professional standards and the handling of grievances, the preparation of reports which your Department may require and the conduct of an education program for the profession and the beneficiaries, in addition to the above-mentioned reserve or contingency.
Colorado Vision Services, Inc., the non-profit corporation which would execute any contract with the State Department of Public Welfare in the field which this study encompasses, is most anxious to work directly with you and your state board on any-program which is developed to provide vision care. We believe C.V.S. is the most logical vehicle available for the execution of such a program since it is operated by members of the profession and can provide an effective means of insuring high standards of care for the recipients of any program that is adopted. In addition, by working through Colorado Vision Services, Inc. it should be possible for the State Department of Public Welfare to simplify the problems involved in operating such a program and to hold administrative costs to a minimum. Please do not hesitate to call on us for any help we may be able to provide. Sincerely yours,
RICHARD L. HANEY, 0.D.,
President, Colorado Vision Services Inc. UNIVERSITY OF DENVER (COLORADO SEMINARY) DENVER 10, COLORADO, ESTIMATES
OF COST OF VISION CARE FOR AGED PENSIONERS UNDER VARIOUS AssuMPTIONS
There are some 54,000 pensioners in Colorado who might be entitled to vision care under a master contract. Depending on the type of contract and its utilization experience, the cost of vision care protection will vary significantly.
Any estimate made in advance of an actual experiment with some form of contract will be subject to wide margins of error. No adequate statistical series offering a sound basis for prediction appears to be available. For the purposes of this memorandum, certain assumptions are used as the basis for calculating costs. Almost every person over 60 uses glasses whether part time or full time. Moreover, in later years, vision is subject to more deterioration than in middle years. Ostensibly, therefore, every person over 60 ought to have a vision examination at least once a year, and some will be tempted to seek service more often.
Let us assume, first, that a screening examination, and referral if needed, will cost $5.00; that a refraction and related service will cost $15.00, instead of the $5.00 charge for the screening examination alone; that lenses for single vision will average $5.50 per pair; that lenses for bi-focals will average $12.00 per pair; and that frames will be provided up to $5.00, but at an average cost of $4.00. which will buy a good pair-choices of frames costing more would not be charged against the program. Finally, it is assumed that the program could be administered with a *7 per cent surcharge.
The highest cost estimate would arise from the premise that no charge would be made to the pensioner, except for frames costing more than $5.00, for the portion above $5.00. It can be assumed that if there were no limit upon the program, every pensioner would use the service every year, resulting in 100% utilization.
Of the 54,000 pensioners, it can be further assumed that not more than twothirds would require refractions and new lenses annually, and that not more than one-third would require new frames in any given year. The following costs would result: 18,000 screening only, at $5.00.
$90,000 36,000 refractions and service, at $15.00.
510, 000 13,000 single lenses, at $5.50
71, 500 33,000 bifocals, at $12.00
276, 000 18.000 frames, at $4.00
72, 000 C'nder these assumptions, the high cost of this program, if utilization lived up to these estimates, would come to $1,049,500 for service and materials, plus $73.500 surcharge, or $1,123,000 in all. If by any chance, utilization showed any tendency to go above this cost and this seemed to be the upper limit to be supported, the program could place a limit covering one full service a year per client.
Assuming that the program would be initiated under a provision that the client would pay the first $5 of the cost of service, this would provide both a co-insurance feature, and place some inhibition upon utilization. The effect might well be to restrict the utilization significantly below the levels set forth under the estimate above, so that only 50% of the aged had refractions, lenses, and fittings, and only 25% had new frames each year. Then there would be no charge to the fund for those taking the screening examination. The $5.00 charged for the visit
•See explanatory note in letter of transmittal.
would reduce the charge against the fund for refractions and service to $10.00. The cost estimates that would result are: 27,000 refractions and service, at $10.00---
$270, 000 9,500 single lenses, at $5.50
52, 250 17,500 bifocals, at $12.00
210,000 13,500 frames, at $4.00
586, 250 Given these assumptions, the service cost would total $586,250 plus 7% sur charge of $41,000 to make the total cost $627,250. The cost through insurance funds could be reduced further by raising the co-insurance cost to the pensioner so that he pays the first $10.00 per year for service rendered. It may be expected that this charge to the pensioner would further reduce the demand for service so that costs might be as follows: 23,000 refractions and service, at $5.00 (Net charge to the fund $15 less $10).
$115, 000 8,000 single lenses, at $5.50_.
44, 000 15,000 bifocals, at $12.00.
180,000 11,500 frames, at $4.00
46, 000 Given these assumptions, the service cost would total $385,000, which together with $27,000 surcharge would total $412,000.
Another way of limiting cost would be to have the client pay one half of the first $30.00 of the cost, with the fund to pay all of the balance of the service needed. Assuming that this would restrict demand for service to a figure somewhat below that shown for the first estimate, utilization might result in these costs : 15,000 screening only, at $2.50..
$37, 500 30,000 refractions and service, at $7.50
225, 000 10,500 single lenses, at $2.75
29, 000 19,500 bifocals, at $6.00--
118, 000 10,000 frames, at $2.00
20,000 The apparent cost of service under these assumptions would total $429,500 but there would be several thousand cases among this group which would have a combination of costs that would total more than $30.00, and the cost based upon this assumed utilization might be nearer $140,000, plus $31,000 surcharge, making a total of $471,000. This approach is more costly than that arising out of charging the client the first $10.00 as shown above, because it involves having the fund pay a portion of every service rendered.
One final approach to cost estimation would combine both an initial charge of $5 to the client, and then require him to pay half of the next $20 of the service cost, bringing his participation to a maximum of $15 for a full service, except as he might wish frames more costly than $5. The exact impact of such a system cannot be judged any more accurately than in the other estimates shown here. The cost might be something like this: Screening service-no charge to the fund 25,000 refractions and service, at $7.50.
$187, 500 9,000 single lenses (the fund paying half of the first $5.00, and all the balance) estimated average $3.25--
29, 250 16,000 bifocals, estimated average cost to the fund : $9.50.
152, 000 12,500 frames, at $4.00---
Given these assumptions, the service cost would total.----- 418, 750 which, together with surcharge of $30,000 would total $438,750.
These differences in utilization are predicated upon the economic concept of price elasticity of demand, even for vision care. Until more experience has been gained, it is difficult to know whether the differences in impact assumed under alternative payment relationships are reasonable. One can only make an educated guess, and make preliminary judgments thereon. Experience will be the definitive test. Even then, unless experiments are run with different types of arrangements, the impact of co-insurance features, or of deterrent first charges, can only be guessed at. These estimates offer some preliminary estimates that may prove help. ful in analyzing alternatives.
Any contract for this age group, involving as it does wide uncertainties with respect to the predictability of utilization, might well contemplate that if cost varies by more than 10% from the estimate used in the contract, at the end of any 3 month period, when computed cumulatively over the life of the contract to date, shall be the occasion for such modification in either premiums or benefits or both, as may be mutually agreed between the parties. Such a renegotiation clause may be needed for a period of time long enough to also establish predictability in cost estimates.
WHITE HOUSE CONFERENCE REPORT ON THE SENIOR CITIZEN AND OPTOMETRY Prepared by The American Optometric Association Committee on Vision Care
of the Aging
Not many years ago, a pair of spectacles was symbolic of old age, and old age was a vague period of life that most individuals sought to escape. In doing so, they often refused to admit their vision was becoming defective, that what they read easily before, now became a blurred challenge, that, where in most cases, they now had more time for leisure activities, they could no longer fully enjoy them. But pride said, "Don't submit to old age .... don't give in to father time : ... don't show everyone you're getting old . ... by wearing glasses."
Today, we realize that reduced visual efficiency is nothing to be ashamed of. It occurs in both old and young alike. In the aging person, it is a natural physiological change that takes place. When properly corrected, vision offers the senior citizen the facilities to indulge in all his regular activities with interest, vigor, and visual efficiency.
A greatly increased life span (from 20 to 30 years of age during the Roman Empire, to 40 years of age by 1850, to 50 years of age at the turn of the century, to almost 70 years of age today, and even more tomorrow) has created many problems for the human being. Much the same, it has created new areas of research for the ophthalmic professions. Increased longevity has changed our pattern of life, and our modern environment makes more and more demands on vision that optometry must cope with and conquer.
From a clinical viewpoint in optometry, à demarkation had to be made to indicate where youth ends and aging begins. Through studies, the age of 40 was found to be the place in life where presbyopia (a clinical classification for "old age" vision deficiencies) begins. The actual age depends on the individual, but by the age of 50 to 55, the process has taken place in nearly all persons, and some type of visual correction is necessary.
Since presbyopia appears around the age of 40 .... (long before most companies even consider retiring their employees. at least 30 years prior to the end of today's life expectancy), it becomes apparent that vision is no longer a problem of the aged, but rather the aging.
Optomery gives special attention to the vision problems of our senior generation. Recognizing the physiological and psychological changes that accompany normal aging, optometry is concerned with visual acuity, refraction, accommodation, and the visual neuromuscular system. Optical aids and clinical techniques used offer every American a more productive, comfortable, self-sufficient life, even in the late years, through good vision care.
Old age can well be the golden years of human life. The optometric profession can help to make it that, by the proper care of the most vital of senses-vision !
CHANGES ASSOCIATED WITH AGING
Aging, in its broadest sense, is a biological phenomenon that occurs in every living organism. Although it is difficult to narrow down to an exact definition, it might be best described as “the period when growth or proliferation has ended but the powers of regeneration still remain (Mazow, 1958)". It does not occur in all human beings at the same age, because it is controlled by such factors as heredity and environment, both variables.
When "senescene" or aging takes place, changes in tissue occur to cause visual as well as other disorders. Not all tissues and organs are effected at the same time, because not all of them reach their optimum performance at the same time.
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In addition, general systemic changes occur universally in almost everyone over the age of 40, taking into consideration the considerable variations and differences of physiological and chronological ages in individuals. Few people, if any, reach old age without some complications caused by disease, particularly of a degenerative nature. The most common are heart and vessel trouble, cancer, arthritis, rheumatism, and nervous disorders.
To offer maximum benefit to the aging person, the optometrist must take these systemic disorders into consideration, and coordinate his efforts with those of the other practitioners in the health field.
Like the other organs, the eye participates in the aging changes which take place in the human body. It is subject directly to all the degenerative conditions that prevail, and likewise is often affected by disorders occurring in other organs.
From a psychological aspect, optometrists are deeply concerned with understanding the older years, for they are not only involved in correcting certain anomalies and complaints, but also in the practice of training people in the development of certain practical visual skills.
Many studies show some loss of visual acuity (the ability to see clearly) with age. There are many other questions that can be asked when considering the physiological and pathological changes of age on vision. To corect these, accurate measurement is of extreme importance. This has been the basis for the development of numerous physical and statistical methods for accurately measuring acuity, visual capacity and perception.
Although there are definite refractive changes that come with age, a complete understanding is made difficult by the lack of accurate measurability of some of the structures of the eye. The greatest obstacle is the crystalline lens, which unlike most other body structures continues to grow in size throughout life.
Stenstrom, in 1948, established that the refractive state among young adults is more closely correlated with axial length than any other variable or combination of variables. Studies also show that refractive changes are more marked during major growth spurts. Most experts agree that changes in refraction are rare between the ages of 25 and 40. The concern felt by a patient over forty relative to his “failing eyes” might well be the result of his having gone through 20 years or more of vision in which his refractive state has changed very little. A regular periodic examination is still necessary at any age to properly assess individual refractive changes.
The most dramatic change which occurs in aging is in "accommodation", the ability to change focus from far to near and back. The rate of decrease in ability is fairly gradual and remarkably uniform. There have been, however, some variations leading to proposals that the rate of decrease be used as an aid in predicting the life span of any given individual (Bernstein & Bernstein, 1945).
However, this as yet, has not been proven by longitudinal studies. As the inability to “accommodate" progresses, it eventually becomes necessary to sup plement natural accommodation with a convex lens known as an “add". When this occurs, the condition is termed, "presbyopia" or "old age sight". When most people become aware of their loss of focusing ability for near work, their reaction is that they feel their "arms are too short" for ordinary reading. The supplementary lenses prescribed for older persons to do near work depend on the amount of accommodation still available, plus the distance of the usual work from the eyes and the size of detail involved.
In addition to the inability to change focus, among aging individuals there is often a change toward lack of binocular control of the eyes. Normal binocular vision requires the intraocular and extraocular neuromuscular mechanisms to operate in a coordinated manner, so that a sharp image can be maintained on both foveas at the same time, without undue effort. As one grows older, the possibility of a pathological involvement of the neuromuscular system greatly increases. Examination of the neuromuscular mechanism involves the investigation of fixation (ability to move an eye in order to place and maintain the image upon the fovea), the versions (ability to move the eyes in the same direction), and vergences (ability to move the eyes in opposite directions).
Some of the changes occurring in the ability to control the eyes that accompany aging are generally agreed to be the result of lack of proper care during the formative years. It is in the area of the visual neuromuscular system more than any other that the value of periodic vision examinations is evident. Many of the physical changes affecting the visual neuromuscular system are indications of serious general pathological problems. It is here that the optometrist as a member of the health team often has an opportunity to aid and correct an aging