Use It or Lose It: The Medicare Low Vision Demonstration Project
Print edition page number(s) 197-202
The Medicare Low Vision Demonstration Project is now one year old. This project constitutes a unique and pivotal opportunity for vision rehabilitation professionals. If it succeeds, it will open up significant opportunities for funding and provision of services. But, if it fails, it could represent another nail in the coffin of specialized services. The question now is whether professionals in the field of visual impairment and blindness will step up to the plate to ensure that this project is successful.
The achievements of the project have been encouraging so far, but there are a number of significant weaknesses, and there is still much to do. This column offers a progress report on the project and examines its serious implications. Although some reports have appeared in previous issues of the Journal of Visual Impairment & Blindness (JVIB) (see, for example, the Comment entitled "Medicare Coverage for Orientation and Mobility Services," by Lorraine Lidoff, which appeared in October 2005; and the special report that appeared in the From the Field department of the August 2006 issue), let me first provide an overview of the project for anyone who is not familiar with it.
Scope of the project
Begun on April 1, 2006, the Medicare Low Vision Demonstration Project is a five-year project established to help deliver services in a new manner and evaluate the utilization of Medicare funding for vision rehabilitation services by a new set of providers who had not previously been covered by Medicare: certified low vision therapists, orientation and mobility (O&M) specialists, and vision rehabilitation therapists. In order to participate, service providers must be certified by the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP). Under this demonstration project, such professionals may provide training to persons with a documented visual impairment under the "general supervision" of an optometrist or ophthalmologist (in which the supervising physician does not need to be present), rather than "incident to" supervision (in which the supervisor does need to be in the building). The advantage of general supervision is that vision rehabilitation services may be provided in a patient's home or assisted living center, where the supervising physician would not be present. This new model of service delivery is the thrust of the demonstration project; however, the demonstration project also covers vision rehabilitation training that may be provided in the eye care specialist's office or at a qualified agency.
Because the project is funded by Medicare, service providers are obliged to follow its requirements, which may differ from customary procedures in vision rehabilitation. Specifically, all services must be preceded by a written plan of care, with specific goals and a statement of the location at which the services are to be provided, which must be approved by the supervisory physician and reviewed every 30 days. The service provider must detail the training provided and the progress made by the patient. Training is limited to nine hours total, to be provided within 90 consecutive days, and cannot be extended. Vision rehabilitation services are billed in 15-minute increments.
For this demonstration project, six different sites in four states and two cities throughout the United States have been selected: Atlanta, Georgia; Kansas; New Hampshire; the five boroughs of New York, New York; North Carolina; and Washington State. The patient must reside in one of these six areas, and the supervising eye care specialist must have his or her practice in one of the six sites. The patient must have a corrected visual acuity in his or her best eye of 20/70 or worse, or have a documented central scotoma, a general constriction of the visual fields, or bilateral hemianopia. Qualifying patients must show a medical necessity for the services rendered, be capable of progress, and be able to derive a benefit. Training must be provided one-on-one and face-to-face, not in a group setting, and may only be provided by professionals certified by ACVREP.
It is important to understand that the Medicare Low Vision Demonstration Project is not an evaluation of the need, importance, or efficacy of vision rehabilitation services for patients with vision loss. For the purpose of this project, the need for vision rehabilitation and the effectiveness of such services is accepted as well-established. Rather, the focus of this project is on the provision of services by a new group of providers operating under the model of "general supervision" by a physician and billed through the Centers for Medicare and Medicaid Services (CMS). Why is this model a groundbreaking opportunity for the members of our field? Because it has the potential to pave the way for the establishment of third-party payments for services provided by professionals in the field of visual impairment and blindness. The only way to ensure this opportunity is not lost is to expand participation to fullest extent possible in the six demonstration sites and beyond.
Window of opportunity
The Medicare Low Vision Demonstration Project is a unique window of opportunity for vision rehabilitation professionals provided by Congress and CMS to allow vision rehabilitation professionals to demonstrate their ability to utilize this new service delivery and reimbursement model. Assuming that there is active utilization of this opportunity by service providers, Congress may pass legislation to include ACVREP-certified professionals on the list of approved Medicare service providers and would continue to allow for training to be provided in a person's home or assisted living center according to the "general supervision" model. This approval will provide agencies and contractual service providers with a stable funding stream. Although Medicare funding is not a panacea and will not make our practitioners rich, it would offer a significant new source of funding for the services we provide. In addition, the result would be to give vision rehabilitation professionals certified by ACVREP, which embodies the highest standards for certification in visual impairment, recognition as the gold standard for service providers in this area. This recognition would dramatically shift the debate on certification and standards for providers of vision-related services, both within the field of vision rehabilitation and outside it. Moreover, the high standards and qualifications for ACVREP-certified personnel would ensure that the people we serve receive high-quality care.
However, if CMS concludes at the end of the project that there was minimal participation in the Medicare Low Vision Demonstration Project, the implications could similarly be far-reaching; in fact, it could sound the death knell for specialized services and present an opportunity for other organizations to enter into the certification process. Not only might we fail to gain the breakthrough we are seeking, but Congress might question why it should continue to fund university personnel preparation programs in the areas of vision rehabilitation and O&M if we cannot demonstrate adequate interest in or ability to provide such services to the population of visually impaired individuals in the United States according to this delivery model.
There are numerous implications of this project for vision rehabilitation professionals. As many ACVREP-certified vision rehabilitation professionals as possible need to participate in the demonstration project in order to show sufficient utilization of the services covered by it. Some may already be employed by one of the private agencies in the six demonstration sites that are currently participating in the project and billing Medicare for services. But others--who are self-employed, or work for other employers, or are recently retired--need to become involved in this project through employment with a qualified agency or a physician's office. In short, we need all vision rehabilitation professionals, agencies, and eye care specialists to become aware of and participate in the Medicare Low Vision Demonstration Project lest the opportunity be lost.
Furthermore, since vision rehabilitation professionals certified by ACVREP are the only service providers, other than physicians or occupational therapists, recognized by CMS as able to provide services and training to people with visual impairments, it is imperative that as many professionals as possible become certified by ACVREP in order to maximize participation in this project. At the conclusion of the demonstration project, if it is funded permanently on a national basis, there will need to be sufficient numbers of certified vision rehabilitation professionals--O&M specialists, low vision therapists, and vision rehabilitation therapists--to be able to implement the provision of services under this model. Indeed, one of the factors that Medicare may use in evaluating whether this demonstration project is successful and should be funded permanently is growth in the number of vision rehabilitation professionals certified by ACVREP, such that there are sufficient numbers of certified personnel to accommodate the large number of persons requiring vision rehabilitation training. If sufficient numbers of vision rehabilitation professionals are not involved in the project and adequate numbers are not certified and available at the conclusion of the project, a natural consequence might be for Congress or CMS to seek another group of professionals who could provide these services to the burgeoning number of visually impaired older persons in the United States. Now is the time to seize this opportunity before it is too late.
Strengths and weaknesses
To ensure the success of this project, we need to capitalize on its strengths and successes so far, as well as face the weaknesses that need to be overcome. To a large degree, the Medicare Low Vision Demonstration Project is a reality because of the efforts of directors of the six private agencies who serve people who are blind or visually impaired in the six demonstration sites. These directors helped lobby key legislators to get the project approved and funded, and have implemented the project in their respective agencies with patients served in their coverage areas. They have hired or contracted optometrists and ophthalmologists to approve in writing each plan of care and supervise vision rehabilitation training. They are cognizant of the rules and regulations of Medicare, including documentation requirements and billing procedures, as well as other challenges. They are aware of possible pitfalls, such as the 9-hour maximum allotment for training, the challenges of billing Medicare, and the fact that some patients' secondary insurance providers do not currently cover the co-pay for services. They also recognize the advantages of this project and the important services it extends to persons with vision loss. (It should be noted that New Hampshire has elected to participate in a different way, by not directly offering vision rehabilitation training through its private agency, but, instead, partnering with eye care specialists and vision rehabilitation professionals certified by ACVREP in providing services to persons in the rural communities of the state.)
The private agencies in the six demonstration sites have not only been a blessing to all of us who are working to make this demonstration project a success, but have been and can continue to serve as mentors to others who would like to participate. Although New Hampshire has elected to participate in a different way, its model to serve a more widespread service delivery area through key partnerships could be replicated elsewhere. In addition, the National Council for Private Agencies for the Blind and Visually Impaired may serve as a resource in learning how to become involved, how to bill Medicare, keep proper documentation, and learn the value of participation in the project.
ACVREP has been a beacon in its efforts to raise awareness of the demonstration project among members of the field and in encouraging and assisting participants. Despite the financial demands, ACVREP has dedicated personnel and funds to these efforts. It has sponsored a weekly conference call over the past nine months among key leaders of numerous organizations to help increase participation, to overcome obstacles, and to plan the next steps. It has sponsored a page on the web site of Johns Hopkins University Medical Center, <www.lowvisionproject.org>, which includes fact sheets, announcements, agendas, and polls about the project. It has also supplied information on its own web site, <www.acvrep.org>. It offered a presentation at a general session at the July 2006 international conference of the Association for Rehabilitation and Education of the Blind and Visually Impaired (AER) in Snowbird, Utah, and has hosted sessions at several AER chapter conferences regarding the demonstration project. It has included articles in its newsletters and sent hundreds of e-mails to dispense information and answer questions. ACVREP has been one of the most active organizations in the country to help professionals, agencies, and eye care specialists learn about the project and get accurate information, and to encourage participation.
Personnel at Johns Hopkins University Medical Center have also been helpful in this first year of the project. On the web site dedicated to the project, they hosted three webcasts in 2006 to help vision rehabilitation professionals learn more about the project. Two of these featured Jim Coan of CMS detailing key features of the project and answering specific questions by interested parties. The latest broadcast featured Annie Riddering, a low vision therapist, occupational therapist, and O&M specialist, discussing how to write a plan of care. Each of the webcasts is archived on the Johns Hopkins web site, along with key questions and answers related to the project. The dialogue can be continued by the submission of additional questions. These archived webcasts can serve as an excellent resource for learning more about the demonstration project and how to meet its requirements.
Weaknesses and concerns
As already noted, the private agencies in the six participating regions have been pivotal in bringing this project to fruition and have been important in initiating participation in the project. They have also helped to troubleshoot this new service delivery and reimbursement model, including developing documentation and obtaining payments from CMS.
Up to now, however, these agencies have generally provided few services to patients in their homes, which, as already noted, is the thrust of the demonstration project's intent. Instead, the training has generally been given on-site, at the agencies' facilities. The fact that the majority of the training has been given on-site may be, in part, because of the logistical challenge of meeting with a physician to obtain his or her approval for a plan of care for services provided to a client in his or her home or assisted living center, as opposed to on-site at an agency. Agencies may also find it a dilemma to use demonstration project funding to provide training to a person who can only receive nine hours of total training, when the individual may need additional hours of service later on. For example, because only nine hours of vision rehabilitation services are allotted under Medicare, an agency might need to strategically choose the most opportune time to provide services, thus delaying rehabilitation until the patient's needs are greater or his or her vision is worse so that he or she may derive the maximum benefit from such training. Such delays would artificially lower the number of individuals receiving the services provided by the project.
Also of concern is that few or perhaps no ophthalmologists have been involved in the project in the six sites to date. To be truly successful, more than one private agency per site needs to become involved in the project in each of the six sites. Medicare wants to see whether eye care specialists will utilize the demonstration project funds and will link up with vision rehabilitation professionals certified by ACVREP to provide training to patients in their homes. If this type of collaboration does not take place, there is little likelihood that this project will be funded permanently or on a national scale. The private agencies are doing an excellent job in the six sites with initial involvement with this project. However, it has been noted that even within a short geographic distance, such as from one side of New York City to another, a visually impaired person is not likely to travel to seek services from the lone private agency providing training under the demonstration project in his or her state. If the need to travel across a major metropolitan area with ample availability of various means of public transportation is a barrier, how likely is it that an individual living in rural North Carolina or Kansas would travel across a large geographic area to receive services from the one private agency in their own or another state that is participating in the project? Therefore, the involvement of ophthalmologists and optometrists in all six sites is key to increasing the availability and, thus, utilization of the project's services.
Another issue is that ACVREP has limited funds and means to help educate and encourage participation in the project. Other organizations such as AER, the American Academy of Ophthalmology, and the American Optometric Association need to step forward and take a more active role in promoting and assisting in participation of the project.
In addition, the financial terms of the project have not been a strong incentive for many to participate. Some vision rehabilitation professionals have lamented that Medicare's reimbursement rates for them are only about half of what is offered for occupational therapists. Some have correctly noted that the reimbursement rates during the project are only about half of what they were in 2002 when Medicare first changed its rules to allow certified low vision therapists and others to provide vision rehabilitation services under the direct supervision of ophthalmologists in their offices. In this project, Medicare is offering less compensation for the same amount of work, and even if the project is deemed successful by CMS, some feel that it will only prove that they can pay less and get away with it. Thus, some believe it may become somewhat of a "lose-lose" situation. Also, some agencies claim that because of travel time and costs it would not be profitable or feasible to send professionals to patients' homes to provide services, especially when such services require hiring or contracting with an optometrist or ophthalmologist specialist to provide general supervision.
Finally, in my opinion, there has been some evidence of concerns about "turf" this first year that may have slowed what could have been accomplished. Each organization and group understandably has its own agenda and political motivation. However, unity and teamwork are needed and political agendas must be minimized to move the project forward much more quickly than in this first year, and to increase the number of participating physicians and agencies.
The future needs of the project
In summary, in order for the field of visual impairment and blindness to take full advantage of this unique, time-sensitive opportunity, ophthalmologists and optometrists in the six sites need to be informed of the value this important service will add to their practice and their patients, and need to be encouraged to participate. Likewise, vision rehabilitation professionals need to realize the importance of this project and link up with ophthalmologists or a qualified agency to participate. Other agencies, in addition to the private agencies in the six sites, need to get involved with the project. These agencies need to pursue the provision of training to persons in their homes or assisted living centers, rather than solely at the agencies' facilities. More vision rehabilitation professionals need to obtain certification through ACVREP, to increase the pool of persons who can provide these services both now and in the future. ACVREP needs to continue its leadership of the Medicare Low Vision Demonstration Project. In addition, AER and other organizations need to become as actively involved as possible to ensure the success of this project by providing assistance with educating and encouraging participation by vision rehabilitation professionals, agencies, optometrists, and ophthalmologists. All of these activities need to proceed quickly and decisively, without concern about turf or personal or organizational agendas.
Make Your Opinions Known
Readers are encouraged to respond to this Speaker's Corner column by visiting the JVIB message board, <www.afb.org/jvib_message_board.asp>, to engage in an online discussion.
Bryan Gerritsen, M.A., CLVT, low vision therapist for 16 physicians' offices in Utah and Idaho, Low Vision Rehabilitation Services, 439 East 3100 North, North Ogden, UT 84414; e-mail: <firstname.lastname@example.org>.
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