A recent study published in Translational Vision Science & Technology assessed the relationship between health insurance status and the economic burden of diabetic retinopathy (DR) in an underserved patient population.
Give me some background on DR.
DR is a microvascular complication of diabetes mellitus (DM) that affects nearly ⅓ of individuals with diabetes; it’s also the leading cause of preventable blindness in adults aged 20-74 in the United States and worldwide.
Earlier screening and preventative care have been found to be critical for detecting and managing DR before the onset of irreversible visual damage.
Bring in the economic burden of DR.
Several previous studies have outlined the cost-effectiveness of earlier screening, management of risk factors, and early treatment of DR.
However, there has been less research on the economic and treatment burden for underserved patients with DR—which are necessary to understand to improve and implement preventative care strategies for vulnerable patient populations.
Now talk about the study.
In this retrospective cohort study, investigators analyzed the electronic health record (EHR) data of DR patients from January 2014 to December 2020 at Denver Health Medical Center—a safety-net institution.
Note: While exact definitions vary, generally safety-net institutions have a mandate to serve low-income populations regardless of their insurance coverage, ability to pay, or immigration status.
How did they categorize patients?
Patients were classified by disease severity and organized into five groups based on insurance status:
- Medicare
- Medicaid
- Private insurance
- Uninsured
- Two discount insurance plans specific to low-income patients in Colorado
- Colorado Indigent Care Program (CICP)
- Denver Financial Assistance Program (DFAP)
DR-specific costs were measured using Current Procedural Terminology (CPT) codes over a 24-month follow-up period.
Findings?
Of the total 313 patients, a higher proportion of non-English speaking patients (63.9%) were uninsured.
Additionally, rates of proliferative DR (PDR) at presentation varied between insurance groups (P = 0.016):
- Uninsured: 62%
- Discount plan: 42%
- Medicare/Medicaid: 33%
Tell me more.
There was a significant difference in the total median cost between the discount plan patients and both Medicare and Medicaid patients:
- Discount plan: $1,258 (interquartile range [IQR] $0 to $5,901)
- Medicare: $751 (IQR $0 to $7,148, P = 0.037)
- Medicaid: $593 (IQR $0 to $6,299, P = 0.025)
Expert opinion?
Per the study authors: “Financial concerns, lack of insurance, decreased access to care, and language and communication difficulties are established barriers to receiving eye examinations and likely contributed to decreased utilization of eyecare in [the] uninsured group.”
Limitations?
Of note, these findings might not be generalizable to patient populations with higher socioeconomic status and different ethnic diversity.
Also, a 24-month follow-up period may not be sufficient to fully understand the differences in costs and outcomes with DR as it is a slowly progressing disease.
Tie it all together.
Disparities in DR care can stem from a variety of economic and societal factors that disproportionately impact minority and underserved populations, leading to increased disease severity at presentation, such as:
- Inadequate health insurance
- Lack of coverage for preventative screening and early treatment
- Communication and language barriers
Advanced diabetic disease and increased downstream healthcare utilization and cost vary across insurance types—indicating that improved access to preventative care is needed in these specific at-risk populations.
Next steps?
Further research with a larger cohort over a longer period of time is warranted to evaluate the long-term economic burden of DR at the population level.