Cost-Effectiveness of a ‘Welcome to Medicare' Style Expanded Visual Screening Exam

Beginning in 2005, Medicare instituted reimbursement for preventive physical examinations, including visual acuity screening, of all newly enrolled patients within their first year of enrollment. Policy makers have also considered the possibility of a companion ‘Welcome to Medicare' comprehensive eye exam to identify progressive asymptomatic visual disorders before they result in vision loss. Given current resource constraints, the future of these screening programs is unknown and their value sometimes questioned. In this paper we used a simulation model of five major eye disorders, age-related macular degeneration, diabetic retinopathy, glaucoma, and nuclear cataracts to test the incremental cost-effectiveness of existing Welcome to Medicare visual acuity screening compared to the rates of screening expected without the program, and of comprehensive eye examinations compared to simple acuity screening. We measured cost-effectiveness in terms of the incremental net benefit of screening evaluated at a range of willingness to pay values per day of impaired functionality averted. We used probabilistic sensitivity analysis and bootstrapping with replacement to estimate Bayesian credible intervals for each of our key model outputs. Because current utilization of the ‘Welcome to Medicare' screening is so low (3.2% in 2007), we performed threshold analyses of recruitment costs to determine how spending additional resources to raise utilization would impact cost-effectiveness. The results of these analyses can be used by policy makers to help prioritize visual health screening efforts with other Medicare policies.