Capitol building in Washington DC

Roxann Mayros headshotBy Roxann Mayros, President & CEO, VisionServe Alliance

Did you know that vision rehabilitation therapists are the only medical/rehabilitative professionals NOT reimbursed by Medicare or insurance companies (third-party payers)?  Here is why this is important.  Think about the person who has a stroke.  They lose their ability to use their right arm to brush their teeth. An occupational therapist is paid by Medicare or insurance to provide needed therapies.  That stroke also caused the person to lose the ability to speak clearly.  Medicare or an insurance company pays for speech therapy.  That stroke also caused a severe balance issue.  You guessed it, Medicare or insurance pays for a physical therapist.  BUT, if that same stroke victim, also loses some or all of their eyesight, no insurance company or Medicare will pay for important therapies provided by a specialized and nationally certified vision rehabilitation therapist, low vision therapist, or orientation and mobility specialist.

There are many reasons for this disparity and no easy solutions.  Due to my long-time tenure in the blindness and low vision field, being involved in and leading previous attempts to seek third-party payment, and my quickly approaching retirement, I have been asked to document why vision rehabilitation professionals are not currently reimbursed by Medicare or medical insurance.

Background

From 1990 through 2012, nonprofit organizations providing vision rehabilitation therapies and services to people with vision loss underwrote the expensive cost of, and spent untold hours leading, a national effort to secure third-party reimbursement for vision rehabilitation therapists to teach independent living skills, low vision therapists to teach the use of remaining vision as aided by magnification devices and techniques, and orientation and mobility specialists who teach safe movement and travel skills using a white cane or guide dog.

Why did it take so long?  Because it literally took an Act of Congress!    Medicare law must be amended by Congress to add a new category of services for which Medicare will provide reimbursement, i.e., establish coverage.  Congress must authorize the Secretary of Health and Human Services to establish rules, assign codes, and provide reimbursement.  Once these rules and codes are established and Medicare begins to reimburse for vision rehabilitation therapies, then other third-party payers (medical insurance companies) will begin to reimburse.  Congress doesn’t normally do this out of the goodness of their hearts, but only after intense and protracted advocacy from their constituents.

This decades-long and very expensive process produced four separate bills (none were ever brought to the floor for vote) and the only study at the time about the rate and cost of vision loss (The Lewin Report).  Our biggest champions were Congressman Michael Capuano of Massachusetts (his mother had lost her vision due to macular degeneration and was not referred for vision rehabilitation therapies by her medical doctor) and Senator John E. Sununu of New Hampshire.

Congressman Michael Capuano of Massachusetts
Congressman Michael Capuano of Massachusetts
Senator John E. Sununu of New Hampshire
Senator John E. Sununu of New Hampshire

Senator Sununu was most especially important because his vote was needed to pass legislation that created Part D (prescription drug coverage) under the Medicare Modernization Act of 2003. When asked by President George W. Bush to enter his deciding vote in favor of establishing prescription drug coverage, Senator Sununu boldly asked the President to support Medicare reimbursement for vision rehabilitation professionals.  Negotiations resulted in a Congressional order to the Centers for Medicare and Medicaid Services (CMS) to create and oversee a Five-Year Demonstration Project in the states of North Carolina, Kansas, New Hampshire, and Washington; and in the five boroughs of New York City and specific zip codes in the city of Atlanta.

US Department of Health & Human Services building
Washington, UNITED STATES: The US Department of Health and Human Services building is shown in Washington, DC, 21 July 2007. The department, which began operations in 1980, has more than 67,000 employees. SAUL LOEB/AFP/Getty Images

It was in 2005, as the new Executive Director of VisionServe Alliance (a consortium of nonprofits providing vision rehabilitation services) that I was assigned the task of working with CMS to implement and oversee the “Demonstration Project.”  CMS had experience in developing demonstration projects for established and traditional medical providers (Diabetic Educators, for example), but they were inexperienced in establishing a demonstration project for non-medical providers like vision rehabilitation therapists who earn their Master’s degrees through University Departments of Education and not Departments of Allied Health as physical or speech therapists do, and are traditionally employed by nonprofit agencies, the Veterans Administration, or State Agencies for the Blind.

The Demonstration Project was not successful for several reasons, including 1) how CMS designed the project – patients were required to live in the same New York borough or Atlanta zip code as the doctor’s office; 2) CMS assumed that vision rehabilitation professionals worked in physicians’ offices (which they didn’t); 3) that referrals for services came solely from physicians; and 4) by placing demonstration sites in low population or rural states like New Hampshire. The Project was also negatively impacted by the lack of standardized reporting, outcome measurements, and physician referrals within the field of vision rehabilitation.  These issues resulted in only one participant in each Demonstration State – nonprofit agencies already performing vision rehabilitation therapies.  Neither Optometrists nor Ophthalmologists participated because they did not (and would not) employ vision rehabilitation professionals. The lack of participation resulted in very low patient numbers, thereby not creating enough data to determine if the Demonstration Project proved the need for this professional category (vision rehabilitation) to be reimbursed by Medicare.

Those of us who had our “boots on the ground” advocating for reimbursement and the nonprofit agencies who participated in the Demonstration Project learned many lessons that should impact future endeavors seeking third-party reimbursements.  Watch for our next installment of Lessons Learned from the Vision Rehabilitation Demonstration Project 2006-2011.