The Economic Burden of Vision Loss
and Eye Disorders
among the U.S. population younger than 40
John Wittenborn
Wittenborn-John@norc.org
JohnSWittenborn@gmail.com
Presenter Disclosures
• 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
2
Overview
• review previous estimates
• ARVO guidelines
• prevalence
• medical costs
• other direct costs
• indirect costs
• total costs
• sensitivity analysis
• comparing costs to older adults
3
Previous estimates – landmark studies
• 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
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.
4
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
health
utility,
$10.50
medical
costs,
disorders,
$16.20
medical
costs, low
vision, $5.12
informal
care, $0.36
lost
productivity,
$8
other direct
costs,
$11.20
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
Previous estimates - limitations
• 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
6
ARVO guidelines
• Association for Research in Vision and Ophthalmology
released consensus guidelines (Frick et al 2010)
• Defined analysis perspectives and cost categories
Cost Category
Perspective
Government
Healthcare
System/ Insurance
Patient
Payer
Comprehensive
Societal
Direct Costs
Medical costs
Other health costs
Aids/adaptations
Indirect Costs
Productivity loss
Caregivers
Deadweight loss
Loss of well-being
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.
7
Prevalence – low vision, 2005-2008 NHANES
• 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
Mild Impairment
Age Group
Age 0–17 b
Age 18–39
Total < 40
Moderate Impairment
Blind
Total Vision Loss
Prevalence Population Prevalence Population Prevalence Population Prevalence Population
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)
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)
1.12%
1,853
0.12%
204
0.06%
98
1.30%
2,155
(1,116–2,376)
(0.01% - 0.23%)
(22–386)
(0.01% - 0.20%)
(6–336)
(0.69% - 1.87%)
(1,144–3,098)
Population in
thousands
(0.67%
- 1.43%)
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
8
Prevalence – diagnosed disorders, 2003-2008 MEPS
• 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
Ages 0–17
Ages 18–39
Total < 40
Prevalence,% Population Prevalence% Population Prevalence% Population
Disorders of the globe
0.67
499
0.45
417
0.57
916
Injury and burns
0.38
280
0.56
511
0.49
791
Disorders of conjunctiva
1.76
1,302
0.54
493
1.42
1,795
Other eye disorders
0.51
377
0.46
422
0.48
799
Strabismus, binocular eye movements
0.24
175
0.03a
27
0.21
202
Visual disturbances
0.26
196
0.17
160
0.22
356
Blindness and low vision
0.09
69
0.12
107
0.11
176
Condition
Disorders of lacrimal system
0.18
136
0.13
120
0.16
256
Cataract
0.01a
11
0.05
48
0.05
59
Retinal detachment, defect, disorders
Disorders of the eyelids
Glaucoma
Optic nerve and visual pathways
Total
0.04
0.16
0.04a
0.02a
4.13
31
121
28
14
3,063
0.05
0.19
0.11
0.03a
2.62
48
174
97
24
2,405
0.05
0.18
0.09
0.02a
3.22
79
295
125
38
5,887
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.
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
Population in thousands,
9
a Not distinguishable from zero
Medical costs, 2003-2008 MEPS
• 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
Trogdon JG, Finkelstein EA, Hoerger TJ. Use of econometric models to estimate expenditure
shares. Health Serv Res Jan 29 2008.
10
Medical and other health costs, 2003-2008 MEPS
• 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
11
Medical costs by diagnosis, 2008 MarketScan data
• 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
12
Low vision aids, devices and guide dogs
• 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
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.
13
Caregivers
• 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
• 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
14
Special education
• 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
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
15
School and Pre-school Vision Screening
• 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
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.
16
Federal assistance programs
• 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
17
Transfers, tax losses and deadweight loss
• 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
p
• 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
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.
q
18
Productivity losses
• 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
19
Loss of well-being
• 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
20
Results – total costs, $millions
Age Group
Perspective
a
Ages 0–17
Gov.
Insurance
Transfer payments not
included in costs
Ages 18–39
Patient
All
Gov.
Insurance
Patient
Total < 40
All
All
Direct Costs
Diagnosed disorders
Medical vision aids
Undiagnosed vision
Low vision aids/devices
Education
School screening
Assistance programs
Total Direct Costs
633
252
13
—
615
95
26
1,634
1,274
312
18
—
—
—
—
1,604
720
909
14
402
—
—
—
2,045
2,623
1,512
44
402
615
95
26
5,315
693
120
135
—
—
—
17
966
2,566
756
205
—
—
—
—
3,528
1,112
2,491
115
623
—
—
—
4,340
4,674
3,406
437
623
—
—
17
9,157
7,297
4,918
481
1,025
615
95
42
14,472
—
—
8
—
3
12
—
—
—
—
—
—
—
602
—
—
—
602
—
602
—
—
3
605
—
—
484
5
184
674
—
—
—
—
—
—
12,213
—
—
—
—
12,213
12,213
—
—
—
184
12,398
12,213
602
—
—
188
13,003
1,646
1,604
2,646
5,920 1,639
3,528
16,554
21,555
27,475
Indirect Costs
Productivity loss
Caregivers
Entitlement programs a
Tax deduction a
Transfer deadweight loss
Total Indirect Costs
Total Costs
Results – proportion of insurance costs by diagnosed
condition, 2008 MarketScan commercial claims database
Conditiona
Disorders of the globe
Ages 0–17
Ages 18–39
Total < 40
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
Disorders of optic nerve and visual
pathways
Total
1%
3%
2%
1%
2%
1%
100%
100%
100%
A Excludes
disorders of refraction and accommodation as few of these costs are
filed to private insurance
22
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
Quality of Life Measure
Ages 0–17
Ages 18–39
Total < 40
QALY losses
Visual impairment
Blindness
Total QALYs lost
79,799
110,534
190,333
1,663
23,177
24,840
81,462
133,711
215,173
$4,073
$6,686
$10,759
Monetary value of quality of life losses
$50,000 per QALYa
A Monetary
costs are in millions.
23
Sensitivity analysis - univariate
• Univariate sensitivity analysis shows impact on total results
from changing a single cost or parameter value across a
specified range
Prevalence of vision loss (95% CI)
Productivity losses (95% CI)
Cost of diagnosed disorders (95% CI)
Cost of low-vision aids (50%-150%)
Vision loss ages 0-11 ÷ 12-17 (0 - 1)
Cost of medical vision aids (95% CI)
Special education costs (50%-150%)
Cost of undiagnosed vision loss (95% CI)
Informal care requirement (50%-150%)
Deadweight loss (50%-150%)
School screening costs (50%-150%)
$21
$23
$25
$27
$29
$31
$33
$35
$37
$39
24
Sensitivity – probabilistic sensitivity analysis (PSA)
• 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
Proportion of Replications
25%
20%
97.5%,
$37.4bn
Median,
$27.8bn
2.5%,
$21.5bn
15%
10%
5%
0%
$16
$18
$20
$22
$24
$26 $28 $30 $32 $34
Economic Burden, Billions
$36
$38
$40
$42
$44
25
Results – PSA results with 95% credible intervals
Age 0-17
Age 18-39
Total < 40
$2,623
$4,674
$7,297
($2,343 - $2,935)
($4,243 - $5,148)
($6,586 - $8,083)
Direct Costs
Diagnosed Disorders
Medical Vision Aids
Undiagnosed Vision Loss
Aids/Devices
Education
School Screening
Assistance Programs
$1,512
$3,406
$4,918
($1,431 - $1,613)
($3,178 - $3,661)
($4,597 - $5,275)
$44
$437
$481
($37 - $52)
($368 - $522)
($406 - $573)
$402
$623
$1,025
($197 - $644)
($316 - $1,048)
($534 - $1,640)
$615
$0
$615
($485 - $787)
($0 - $0)
($485 - $787)
$95
$0
$95
($47 - $140)
($0 - $0)
($47 - $140)
$26
$19
$44
($25 - $29)
($9 - $24)
($35 - $50)
$0
$12,213
$12,213
($0 - $0)
($6,609 - $21,327)
($6,609 - $21,327)
$602
$0
$602
($219 - $1,310)
($0 - $0)
($219 - $1,310)
$0
$539
$539
($0 - $0)
($266 - $691)
($266 - $691)
Indirect Costs
Productivity Loss
Caregivers
Entitlement Programs*
Tax Deduction*
Transfer Deadweight Loss
Total Costs
$0
$5
$5
($0 - $0)
$4
($0 - $16)
($2 - $10)
$205
($78 - $310)
($2 - $10)
$209
($82 - $312)
$5,920
$21,578
$27,498
($5,275 - $6,799)
($15,646 - $30,930)
($21,496 - $37,366)
How does this compare to the 40+ costs?
• Major methodological differences limits comparability
• This analysis would predict higher costs for the 40+ population,
especially for utility costs
Ages 40 and older
Over 40 costs
2004 costs
2012 $a
Ages 0-39
All ages
2012 costs
2012 estimates
direct medical
$16.2R
$21.0
$12.2
$33.2
other direct
$11.2R
$14.5
$1.8
$16.3
productivity
$8R
$10.4
$12.2
$22.6
subtotal
$35.4R
$45.9
$26.2
$72.1
low vision
$5.12F
$6.6
$0.5
$7.1
informal care
$0.36F
$0.5
$0.6
$1.1
utility
$10.5F
$13.6
$10.8
$24.4
$15.98F
$20.7
$11.8
$32.5
$0.2
$0.2
$38.3
$104.8
subtotal
deadweight loss
total
$51.4
$66.6
a. Updated from 2004 to 2012 US$ using CPI components
R. Value from Rein et al 2006
F. Value from Frick et al 200+
27
Next steps…
• Paper currently under review
• Wittenborn JS, Zhang X, Feagan C, Crouse W, Shrestha S,
Kemper A, Hoerger TJ, Saaddine J, for the Vision Costeffectiveness 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
28
For more information:
John Wittenborn
1-312-519-5718
Wittenborn-John@norc.org
JohnSWittenborn@gmail.com
Thank You!
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