Challenges facing vision rehabilitation services

Boston-Vision rehabilitation services in the United States and Canada exist on a background of different medical systems.

In each country, there is a patchwork of vision rehabilitation national services and regional services, and each has individual and common challenges. 

In this issue: 5 pearls for protecting endothelium during cataract surgery

“Canada has a single-payer system and funds each province to provide health care as long as the province does not charge patients for any services provided by health insurance,” explained Mary Lou Jackson, MD, said. “The United States has both significant payment for health care by the national government, and also payment for health-care services by private insurers.

“Sixty percent of services are publically funded by Medicare and the Veterans’ Administration, and most working-age individuals have insurance through an employer,” said Dr. Jackson, director, Visual Rehabilitation, Massachusetts Eye and Ear Institute, Department of Ophthalmology, Harvard Medical School, Boston.

The difference between the two systems is substantial, she said.

“Canada’s system is predicated on universal access for all Canadians, whereas a proportion of the U.S. population does not have health-care insurance,” Dr. Jackson said. “In January 2014, 16% of the U.S. population had no insurance, an issue currently being addressed by changes in the American health-care system.

“However, health-care-related costs including co-payments and insurance premiums, can cause financial hardship for some in the United States,” she added.

NEXT: Vision rehabilitation services

In the United States, the only national, comprehensive vision rehabilitation service that includes full access to devices is the tiered, multidisciplinary service provided to military veterans.  Some refer to these Veteran Affairs services as the Cadillac of vision rehabilitation, according to Dr. Jackson.

In case you missed it: In defense of Sen. Rand Paul

Medicare and most U.S. insurers provide occupational therapy (OT) for beneficiaries with vision loss provided that the individuals have health-care coverage.

“This OT service is an important and growing element of vision rehabilitation for Americans,” Dr. Jackson said. “The American Occupational Therapy Association is showing commitment to increasing the number of occupational therapists with specific vision training, and given that the majority of individuals with vision loss are elderly, the OT is well positioned and well trained to address vision and age-related issues in concert.”

Both countries have national alternate-format audio libraries available for patients with vision loss or print disability.

Each country has agencies, such as the Canadian National Institute for the Blind (CNIB), which is partially government funded and partially funded by charitable sources.

There is a continuum of vision rehabilitation care in both countries, beginning with diagnosis and moving to visual function assessment, assessment for optical devices, and rehabilitation planning, and on to training and services such as orientation and mobility, and finally to numerous support services that make a difference for patients with visual loss.

“The CNIB and the U.S. State societies primarily provide training and services, such as orientation and mobility and perhaps support services, but each of these national services lacks components of comprehensive vision rehabilitation that would support the full continuum of care,” she said.

NEXT: Complementary services

In the United States, ophthalmologists and optometrists provide components of vision rehabilitation in private practices, academic departments, and independent rehabilitation agencies. The situation in Canada is similar, with optometrists and ophthalmologists in private practices and academic departments providing components of vision rehabilitation that complement services offered by the CNIB.

Optometrists and ophthalmologists in both countries tend to provide visual function evaluation, assessment for optical devices, and rehabilitation planning by assessing visual function, doing refractions, assessing for specific devices, and planning rehabilitation. The U.S. State agencies and CNIB in Canada tend to provide training services or client support services.

Barriers to service

Unfortunately, in both countries, not all individuals who require and can benefit from devices have access to them.

“Although some Canadian provinces offer some device coverage, there is no universal access,” Dr. Jackson said. “In the United States, some states provide some devices, but for many patients with vision loss, purchasing devices is another element of health-care-related financial hardship.”

Other barriers to services for this patient population are transportation to services and referrals. Dr. Jackson cited the American Academy of Ophthalmology SmartSight initiative, spearheaded by Lylas Mogk, MD, which was an effort to address these barriers.

“Level 1 of the SmartSight model of incorporating vision rehabilitation into the continuum of ocular care is encouraging every ophthalmologist to advise patients with acuity less than 20/40, scotoma, visual field loss or contrast sensitivity loss, that vision rehabilitation options exist,” Dr. Jackson said.

“The goal,” she said, “is to have evidence-based services that offer accessible vision rehabilitation as part of the continuum of ocular care.

NEXT: Conclusion

“Both Canada and the United States are countries with great resources,” Dr. Jackson said. “There are elements of vision rehabilitation services in each country that are exemplary, such as the national coverage of OT services for patients with vision loss in the United States.

“However, challenges remain to ensuring access to the spectrum of vision rehabilitation services from which individuals with vision loss may benefit,” she added.