among the U.S. population younger than 40

John WittenbornWittenborn-John@norc.orgJohnSWittenborn@gmail.com

The Economic Burden of Vision Loss and Eye Disorders

2

• John Wittenborn • The following personal financial relationships with

commercial interests relevant to this presentation existed during the past 12 months:

– No relationships to disclose

Footer Information Here

Presenter Disclosures

Overview

• review previous estimates• ARVO guidelines• prevalence • medical costs• other direct costs• indirect costs• total costs• sensitivity analysis• comparing costs to older adults

3

4

• Landmark studies by Frick (2007) and Rein (2006) reported costs for the population aged 40 and older in 2004

• Rein et al• Calculated direct medical costs from Medicare and Marketscan

claims for 4 diseases– macular degeneration, cataracts, glaucoma, and diabetic retinopathy

• Estimated other direct and indirect costs– Government programs, long-term care placement, productivity losses

• Frick et al• Econometric analysis of MEPS data

– Medical costs of low vision– Loss of well-being

Previous estimates – landmark studies

Frick K, Gower EW, et al. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol 2007;125:544-550.Rein DB, Zhang P, et al. The economic burden of major adult visual disorders in the United States. Arch Ophthalmol 2006;124(12):1754-1760.

medi-cal

costs, disor-ders;

$16.20

other direct costs; $11.20

lost pro-

ductiv-ity, $8

infor-mal

care, $0.36

medi-cal

costs, low vi-

sion; $5.12

health utility; $10.50

Previous estimates – PBA report

• Rein and Frick papers were combined by Prevent Blindness America (PBA) to form an overall estimate of the economic burden of vision loss and eye disorders in the US

• $51.4bn in 2004• $35.4bn from Rein et al• $16bn from Frick et al

Prevent Blindness America. The economic impact of vision problems: The toll of major eye disorders, visual impairment, and blindness on the US economy. Chicago: Prevent Blindness America; 2007. 5

6

• Did not include the population younger than age 40• Direct medical costs limited to private medical insurance and

Medicare claims for 4 major age-related eye diseases• Rein et al costs have not yet been updated

Previous estimates - limitations

7

ARVO guidelines

Cost Category PerspectiveGovernment Healthcare

System/ InsurancePatient Payer Comprehensive

SocietalDirect Costs

Medical costs

Other health costs

Aids/adaptations

Indirect Costs

Productivity loss

Caregivers

Deadweight loss

Loss of well-being

• Association for Research in Vision and Ophthalmology released consensus guidelines (Frick et al 2010)

• Defined analysis perspectives and cost categories

Frick K, Kymes SM, Lee P, et al. The cost of visual impairment: purposes, perspectives and guidance. Invest Ophthalmol Vis Sci 2010;51(4):1801-1805.

8

• Auto-refractor corrected visual acuity in the better-seeing eye• Analysis excludes uncorrected refractive error

• Thresholds are >20/40, >20/80, and >20/200 for mild, moderate impairment and blindness, respectively

• Self-reported blind persons included in blindness• NHANES does not measure contrast sensitivity or visual field before age 40• NHANES does not measure acuity among children <12

• Instead, prevalence imputed based on UK blindness registry incidence rates

Population in thousands

Prevalence – low vision, 2005-2008 NHANES

Age GroupMild Impairment Moderate Impairment Blind Total Vision Loss

Prevalence Population Prevalence Population Prevalence Population Prevalence Population

Age 0–17 b 1.07% 775 0.10% 76 0.01% 6 1.16% 857

(0.58%–1.22%) (434–903) (0.01%–0.20%) (6–145) (0.00%–0.03%) (0–20) (0.59% - 1.44%) (440–1,068)

Age 18–39 1.17% 1,078 0.14% 128 0.10% 92 1.41% 1,298

(0.74%–1.60%) (682–1,473) (0.02%–0.26%) (16–241) (0.01%–0.34%) (6–316) (0.77% - 2.21%) (704–2,030)

Total < 40 1.12% 1,853 0.12% 204 0.06% 98 1.30% 2,155 

(0.67% - 1.43%) (1,116–2,376) (0.01% - 0.23%) (22–386) (0.01% - 0.20%) (6–336) (0.69% - 1.87%) (1,144–3,098)

National Center for Health Statistics. National Health and Nutrition Examination Survey Data. Hyattsville, MD: US Department of Health and Human Services; September 1, 2011. 2005–2008.

Population in thousands

9

• Identified ICD-9 diagnosis codes related to eyes• Eye diseases and disorders, visual function disorders, conjunctivitis, eye injuries and burns,

disorders of ocular adnexa• Estimated prevalence of any of these ICD-9s as a primary diagnosis in MEPS

conditions file

Prevalence – diagnosed disorders, 2003-2008 MEPS

Population in thousands, a Not distinguishable from zero

Condition Ages 0–17 Ages 18–39 Total < 40Prevalence,% Population Prevalence% Population Prevalence% Population

Disorders of the globe 0.67 499 0.45 417 0.57 916Injury and burns 0.38 280 0.56 511 0.49 791Disorders of conjunctiva 1.76 1,302 0.54 493 1.42 1,795Other eye disorders 0.51 377 0.46 422 0.48 799Strabismus, binocular eye movements 0.24 175 0.03a 27 0.21 202

Visual disturbances 0.26 196 0.17 160 0.22 356Blindness and low vision 0.09 69 0.12 107 0.11 176Disorders of lacrimal system 0.18 136 0.13 120 0.16 256Cataract 0.01a 11 0.05 48 0.05 59Retinal detachment, defect, disorders 0.04 31 0.05 48 0.05 79Disorders of the eyelids 0.16 121 0.19 174 0.18 295Glaucoma 0.04a 28 0.11 97 0.09 125Optic nerve and visual pathways 0.02a 14 0.03a 24 0.02a 38Total 4.13 3,063 2.62 2,405 3.22 5,887National Center for Health Statistics. National Health and Nutrition Examination Survey Data. Hyattsville, MD:

US Department of Health and Human Services; September 1, 2011. 2005–2008.ICD-9-CM: International classification of diseases. ICD-9-CM Index Addenda. In: National Center for Health Statistics, ed. Hyattsville, MD: National Center for Health Statistics; 2011

10

• Estimated medical costs attributable to diagnosed disorders and undiagnosed vision loss

• 2-part GLM model, gamma distribution with log link• Primary dependent variable is total medical expenditures

excluding “optometry” costs• Independent variables

– comprehensive diagnosed eye disorder variable (diagnosed disorder)

– self-reported low vision without any eye diagnosis (undiagnosed low vision)

– socio-demographics, hypertension and diabetes

Medical costs, 2003-2008 MEPS

Trogdon JG, Finkelstein EA, Hoerger TJ. Use of econometric models to estimate expenditure shares. Health Serv Res Jan 29 2008.

11

• Optometry visits and medical vision aids (glasses, contacts) are not included in the MEPS medical provider component

• Diagnosed disorders and low vision predict only a small fraction of these costs

• Costs are self-reported and not verified by MEPS• We calculated total patient-reported optometry visit and

medical vision aid costs in MEPS• Accounting approach• Costs are calculated based on weighted average per person

costs

Medical and other health costs, 2003-2008 MEPS

12

• MarketScan commercial claims database can show the breakdown of costs by individual diagnosis

• MarketScan only includes private health insurance claims, it does not capture:

• Government payers (Medicaid, CHIP etc.)• Vision insurance plans• Most out of pocket costs• Other costs attributable to conditions (i.e., depression, injuries)

• Costs can be considered a subset of the total costs from MEPS

• Due to this, we do not report any $ values from MarketScan• MarketScan is used to show the relative insurance costs of individual

diagnoses

Medical costs by diagnosis, 2008 MarketScan data

13

• Low vision aids are non medical personal, home, and workplace devices for low vision

• Utilization rates identified by a special French census• French utilization applied to US specific blindness prevalence and

unit costs• The national cost of guide dogs for the blind was updated

and allocated to the <40 population based on the proportion of blindness

Low vision aids, devices and guide dogs

Brézin A, Lafuma A, Fagnani F, Mesbah M, Berdeaux G. Prevalence and burden of self-reported blindness, low vision, and visual impairment in the French community. Arch Ophthalmol 2005;123:1117-1124. Lafuma A, Brézin A, Lopatriello S, et al. Evaluation of non-medical costs associated with visual impairment in four European countries: France, Italy, Germany and the UK. Pharmacoeconomics 2006;24(2):193-205. Wirth KE, Rein DB. The economic costs and benefits of dog guides for the blind. Ophthalmic Epidemiol Mar-Apr 2008;15(2):92-98.

14

• Relative rates of informal care utilization by the blind identified in French census

• French relative rates of informal care for the blind applied to the average levels of informal care for US children by age based on the American Time Use Survey

• Cost of this time calculated based on US average wage

Caregivers

• We assume no long-term care placement due to low vision

• We assume no informal care use by adults

Brézin A, Lafuma A, Fagnani F, Mesbah M, Berdeaux G. Prevalence and burden of self-reported blindness, low vision, and visual impairment in the French community. Arch Ophthalmol 2005;123:1117-1124. U.S. Bureau of Labor Statistics. American Time Use Survey—2010 Results. In: US Department of Labor, ed. Vol USDL-11-0919. Washington, DC: US Department of Labor; 2011

15

• Individuals with Disabilities Education Act and the Act to Promote Education of the Blind

• requires states to provide free intervention and educational programming for children with blindness through age 21

• Number of children receiving special education due to blindness based on the American Printing House for the Blind registry

• Cost of special education for the blind based on updated value cited by the Act

Special education

Apling RN. Individuals with Disabilities Education Act: Full Funding of State Formula. Washington DC: Congressional Research Service, The Library of Congress; December 27 2001. 97-433 EPW. Distribution of eligible students based on the Federal quota census of January 05, 2009. 2010. http://www.aph.org/fedquotpgm/dist10.html. Updated Last Updated Date. Accessed September 15, 2011

16

• School screening is generally based on individual state law and implemented at the school district level

• Screening ages and frequency based on a nationwide survey of school screening

• Costs and penetration rates of school and preschool screening based on our earlier evaluation of 3 PBA sponsored vision screening programs in NC, VA and GA

• We assume screening is acuity chart with stereopsis

School and Pre-school Vision Screening

Naser N, Hartmann EE. Comparison of state guidelines and policies for vision screening and eye exams: Preschool through early childhood. Paper presented at: Association for Research in Vision and Ophthalmology annual meeting., 2008 Rein DB, Wittenborn JS, Zhang X, Song M, Saaddine JB, For the Vision Cost-effectiveness Study Group. The potential cost-effectiveness of amblyopia screening programs. J Pediatr Ophthalmol Strabismus . 2012 49(3):146-55.

17

• Budgetary costs of federal supportive services• National Library Services for the Blind• American Printing House for the Blind• Committee for Purchase from People who are Blind or Severely

Disabled

Federal assistance programs

18

• Transfer payments are not included in costs• Social Security Disability Insurance (SSDI)• Supplemental Security Income (SSI)• Supplemental Nutrition Assistance Program (food stamps)

• Reduced tax revenue is based on the • prevalence of blindness, the • marginal income tax rate for blind persons 18-39 • blindness income tax deduction

• Deadweight loss (cost of economic inefficiency) is estimated at 38% of transfer payments• Costs allocated to the population younger than age 40 based

on the proportion of legally blind adults that are younger than 40

Transfers, tax losses and deadweight loss

Gallaway L, Vedder R. The impact of transfer payments on economic growth: John Stuart Mill versus Ludwig von Mises. The Quarterly Journal of Australian Economics 2002;5(1):57-65.

p

q

19

• Median income level by self-reported vision status for ages 18-39 based on Survey of Income and Program Participation data

• assumes self-reported difficulty seeing = moderate impairment

• assumes self-reported inability to see printed words = blindness

• Productivity losses equal to the reduction in income associated with vision loss, multiplied by the prevalence of moderate impairment and blindness from NHANES

• Restricted to ages 18-39

Productivity losses

20

• Loss of well-being from low vision and blindness based on weighted average reduction in utility reported in 12 published articles

• Utilities converted to quality adjusted life years (QALYs) lost by multiplying utility losses by:

• age-specific background utility rates • the prevalence of mild and moderate impairment and blindness

• Limitation:• All included studies were predominately older adults• We excluded the only child-based study identified

– Very small sample and reported far larger utility impacts than the adult studies

• We do not consider increased mortality from low vision

Loss of well-being

Age Group Ages 0–17 Ages 18–39 Total < 40

Perspective Gov. Insurance Patient All Gov. Insurance Patient All AllDirect Costs

Diagnosed disorders 633 1,274 720 2,623 693 2,566 1,112 4,674 7,297Medical vision aids 252 312 909 1,512 120 756 2,491 3,406 4,918Undiagnosed vision 13 18 14 44 135 205 115 437 481Low vision aids/devices — — 402 402 — — 623 623 1,025Education 615 — — 615 — — — — 615School screening 95 — — 95 — — — — 95Assistance programs 26 — — 26 17 — — 17 42

Total Direct Costs 1,634 1,604 2,045 5,315 966 3,528 4,340 9,157 14,472

Indirect CostsProductivity loss — — — — — — 12,213 12,213 12,213Caregivers — — 602 602 — — — — 602Entitlement programs a 8 — — — 484 — — — —Tax deduction a — — — — 5 — — — —Transfer deadweight loss 3 — — 3 184 — — 184 188

Total Indirect Costs 12 — 602 605 674 — 12,213 12,398 13,003

Total Costs 1,646 1,604 2,646 5,920 1,639 3,528 16,554 21,555 27,475

Results – total costs, $millionsa Transfer payments not included in costs

22A Excludes disorders of refraction and accommodation as few of these costs are filed to private insurance

Results – proportion of insurance costs by diagnosed condition, 2008 MarketScan commercial claims database

Conditiona Ages 0–17 Ages 18–39 Total < 40Disorders of the globe 22% 17% 19%

Injury and burns 11% 20% 16%

Disorders of conjunctiva 17% 8% 12%

Other eye disorders 13% 12% 12%

Strabismus, binocular eye movements 13% 2% 7%

Visual disturbances 5% 9% 7%

Blindness and low vision 3% 9% 6%Disorders of lacrimal system 8% 2% 5%Cataract 2% 6% 4%Retinal detachment, defects and disorders 2% 6% 4%Disorders of the eyelids 3% 4% 4%

Glaucoma 1% 3% 2%Disorders of optic nerve and visual pathways 1% 2% 1%

Total 100% 100% 100%

23

Quality of Life Measure Ages 0–17 Ages 18–39 Total < 40

QALY losses

Visual impairment 79,799 110,534 190,333

Blindness 1,663 23,177 24,840

Total QALYs lost 81,462 133,711 215,173

Monetary value of quality of life losses      

$50,000 per QALYa $4,073 $6,686 $10,759

A Monetary costs are in millions.

Loss of well-being, QALYS lost and cost in $millions

• We do not include monetized loss of well-being in the baseline results

• Including these would increase by $10.8bn to total $38.3bn• Assuming the same $50,000 willingness to pay per QALY gained

value used by Frick et al 2006

24

Sensitivity analysis - univariate

• Univariate sensitivity analysis shows impact on total results from changing a single cost or parameter value across a specified range

School screening costs (50%-150%)Deadweight loss (50%-150%)

Informal care requirement (50%-150%)Cost of undiagnosed vision loss (95% CI)

Special education costs (50%-150%)Cost of medical vision aids (95% CI)Vision loss ages 0-11 ÷ 12-17 (0 - 1)Cost of low-vision aids (50%-150%)

Cost of diagnosed disorders (95% CI)Productivity losses (95% CI)

Prevalence of vision loss (95% CI)

$21 $23 $25 $27 $29 $31 $33 $35 $37 $39

• PSA varies all major parameters in the analysis• All parameters are simultaneously sampled from their respective prior

distributions• Sampling is repeated for 10,000 replications• 95% credible intervals are derived as the 2.5 and 97.5 percentile cost

values from the results of the 10,000 replications

25

Sensitivity – probabilistic sensitivity analysis (PSA)

$16 $18 $20 $22 $24 $26 $28 $30 $32 $34 $36 $38 $40 $42 $440%

5%

10%

15%

20%

25%

Economic Burden, Billions

Prop

ortio

n of

Rep

licati

ons

2.5%, $21.5bn

Median,$27.8bn

97.5%, $37.4bn

Results – PSA results with 95% credible intervalsAge 0-17 Age 18-39 Total < 40

Direct Costs      Diagnosed Disorders $2,623 $4,674 $7,297

($2,343 - $2,935) ($4,243 - $5,148) ($6,586 - $8,083)Medical Vision Aids $1,512 $3,406 $4,918

($1,431 - $1,613) ($3,178 - $3,661) ($4,597 - $5,275)Undiagnosed Vision Loss $44 $437 $481

($37 - $52) ($368 - $522) ($406 - $573)Aids/Devices $402 $623 $1,025

($197 - $644) ($316 - $1,048) ($534 - $1,640)Education $615 $0 $615

($485 - $787) ($0 - $0) ($485 - $787)School Screening $95 $0 $95

($47 - $140) ($0 - $0) ($47 - $140)Assistance Programs $26 $19 $44

($25 - $29) ($9 - $24) ($35 - $50)Indirect Costs      Productivity Loss $0 $12,213 $12,213

($0 - $0) ($6,609 - $21,327) ($6,609 - $21,327)Caregivers $602 $0 $602

($219 - $1,310) ($0 - $0) ($219 - $1,310)Entitlement Programs* $0 $539 $539

($0 - $0) ($266 - $691) ($266 - $691)Tax Deduction* $0 $5 $5

($0 - $0) ($2 - $10) ($2 - $10)Transfer Deadweight Loss $4 $205 $209

($0 - $16) ($78 - $310) ($82 - $312)       Total Costs $5,920 $21,578 $27,498  ($5,275 - $6,799) ($15,646 - $30,930) ($21,496 - $37,366)

27a. Updated from 2004 to 2012 US$ using CPI componentsR. Value from Rein et al 2006F. Value from Frick et al 200+

How does this compare to the 40+ costs?

Ages 40 and older Ages 0-39 All agesOver 40 costs 2004 costs 2012 $a 2012 costs 2012 estimates

direct medical $16.2R $21.0 $12.2 $33.2other direct $11.2R $14.5 $1.8 $16.3productivity $8R $10.4 $12.2 $22.6subtotal $35.4R $45.9 $26.2 $72.1

low vision $5.12F $6.6 $0.5 $7.1informal care $0.36F $0.5 $0.6 $1.1utility $10.5F $13.6 $10.8 $24.4subtotal $15.98F $20.7 $11.8 $32.5

deadweight loss $0.2 $0.2

total $51.4 $66.6 $38.3 $104.8

• Major methodological differences limits comparability• This analysis would predict higher costs for the 40+ population,

especially for utility costs

28

• Paper currently under review• Wittenborn JS, Zhang X, Feagan C, Crouse W, Shrestha S,

Kemper A, Hoerger TJ, Saaddine J, for the Vision Cost-effectiveness Study Group. The Economic Burden of Vision Loss and Eye Disorders Among the U.S. Population Younger than Age 40. in process.

• Most of the way towards estimating total US population costs

Next steps…

Thank You!

For more information:John Wittenborn1-312-519-5718Wittenborn-John@norc.orgJohnSWittenborn@gmail.com

Funding provided by the US Centers for Disease Control and Prevention

The findings and conclusions in this paper are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention or NORC at the University of Chicago