Total financial cost to the U.S. Direct medical costs: Direct non-medical costs: Productivity losses: TOTAL: $16.2 billion $11.2 billion $8.

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2 2 Annual Total Burden to the U.S. Economy of AMD, Cataract, Diabetic Retinopathy, Glaucoma, Refractive Errors, Visual Impairment and Blindness Total financial cost to the U.S. For the year 24, the total financial cost to the U.S. of four common eye disorders (AMD, cataract, diabetic retinopathy and glaucoma), refractive error, visual impairment and blindness in U.S. residents aged 4 and older is estimated at $35.4 billion. Direct medical costs: Direct non-medical costs: Productivity losses: TOTAL: $16.2 billion $11.2 billion $8. billion $35.4 billion Graph 2.1 Annual Total Burden to the U.S. Economy of AMD, Cataract, Diabetic Retinopathy, Glaucoma, Refractive Errors, Visual Impairment and Blindness $35.4 billion $4 $35 $3 Costs (in billions) $25 $2 $15 $1 $5 $16.2 billion $11.2 billion $8. billion $ Direct medical costs Direct non-medical costs Productivity losses Total Categories 7

3 Number of patients (aged 4-64; 65+) incurring direct medical costs for AMD, cataract, diabetic retinopathy, glaucoma or refractive error Shown first is the number of patients aged 4 to 64 with AMD, cataract, diabetic retinopathy, glaucoma or refractive error who incurred direct medical costs (outpatient services, inpatient services, medications and vitamins). The estimates are based on data from privately-insured patients, from the MarketScan Commercial Claims and Encounters Research Database. Outpatient and pharmaceutical services comprise the majority of direct medical costs. Graph 2.2 Number of Patients Aged 4 to 64 Using Medical Services, Medications and Vitamins Number of Patients 2,, 18,, 16,, 12,, 1,, 8,, 6,, 4,, 2,, Outpatient services Inpatient services Medications and vitamins AMD Cataract Diabetic retinopathy Glaucoma Refractive error 186,82 1,683, ,61 2,33,82 18,344, ,455 1,482,941 8

4 Next is the number of patients aged 65 and older incurring direct medical costs annually for each of the five vision disorders, based on Medicare claims data and the National Ambulatory Medical Care Survey. The number of people seeking outpatient medical services in this age group has risen in all areas except refractive error, where it has fallen. The use of prescription drugs, vitamins and other medications has risen among people with glaucoma and AMD. Graph 2.3 Number of Patients Aged 65 and Older Using Medical Services, Medications and Vitamins Number of Patients 1,, 9,, 8,, 7,, 6,, 5,, 4,, 3,, 2,, 1,, Outpatient services Inpatient services Medications and vitamins AMD Cataract Diabetic retinopathy Glaucoma Refractive error 1,48,861 8,919,82 42,697 2,986,937 9,214, ,2,234 5,645,921* *The number for glaucoma medications represents the number of prescriptions for glaucoma medications and not the number of patients. 9

5 Direct medical costs by disorder By combining direct medical costs for all patients, regardless of age, we achieve an overview of the source of the $16.2 billion annual burden of these vision disorders to the U.S. economy. Graph 2.4 Direct Annual Medical Costs for Outpatient, Inpatient and Prescription Drug Services Cost (in billions) $7 $6 $5 $4 $3 $2 $1 $ AMD Cataract Diabetic retinopathy Glaucoma Refractive error 4-64 years old 65 and older Combined costs $.8 $2.14 $.3 $1.76 $3.67 $.49 $4.66 $.2 $1.1 $1.84 $.57 $6.8 $.49 $2.86 $5.51 Graph 2.5 Total Direct Medical Costs by Age Group Combined $16.24 billion 1 Cost (in billions) $18 $16 $14 $12 $1 $8 $6 $4 $2 $ $7.94 billion $8.3 billion 4-64 years old 65 and older Combined costs

6 Direct medical cost per patient by disorder Outpatient and prescription costs comprise virtually all the direct medical costs for patients aged 4 to 64. The costs of outpatient service among those who used any services was $35 for AMD, $1,268 for cataract, $629 for diabetic retinopathy, $276 for glaucoma and $2 for refractive error. Prescription costs, for people who used them, averaged $11 per year for AMD (the estimated annual cost of vitamins recommended by AREDS, the Age-Related Eye Disease Study) and $86 for glaucoma. Inpatient costs represent the average cost for patients who received inpatient services. Although these appear high for cataract and glaucoma, only an extremely small proportion of total patients with these vision problems received any inpatient services (see Graphs 2.2 and 2.3). Graph 2.6 Approximate Annual Direct Medical Cost per Patient per Disorder (4 to 64 years old) $6, $5, $4, Cost $3, $2, $1, $ AMD Cataract Diabetic retinopathy Glaucoma Refractive error outpatient services inpatient services medications & vitamins $35 * $11 $1,268 $5,689 $629 * $276 $2,27 $86 $2 * *There were no inpatients in the sample. Medications and vitamins are not generally prescribed for these vision disorders. 11

7 For patients 65 and older, outpatient costs account for the majority of direct medical costs. Again, inpatient costs represent the average for patients who received these services and very few out of the total number of patients received any inpatient care. Graph 2.7 Approximate Annual Direct Medical Cost per Patient per Disorder (65 and older) $5, $4, Cost $3, $2, $1, $ AMD Cataract Diabetic retinopathy Glaucoma Refractive error outpatient services inpatient services medications & vitamins $272 * $11 $1,196 $4,472 $463 * $254 $4,929 $6* $2 *There were no inpatients in the sample. Medications and vitamins are not generally prescribed for these vision disorders. *This figure represents the cost per prescription and not the cost per patient. Note: "Direct medical costs" broken out per disorder do not include costs related to ongoing consequences or symptoms of these conditions. Further, it remains unclear what effect recent treatment advances (such as those for AMD) or policy changes (such as prescription drug coverage) may have on these figures. 12

8 Direct nonmedical costs Direct nonmedical costs refer to costs attributed to nursing home care, guide dogs and government programs for people who are visually impaired or blind. The government programs are the Department of Education's Independent Living Services for Older Individuals Who are Blind; the American Printing House for the Blind; and the Library of Congress' National Library Service for the Blind and Physically Handicapped. Nearly $11 billion of the total $11.2 billion in direct nonmedical costs goes to nursing home care. Nearly $11 billion of the total $11.2 billion in direct nonmedical costs goes to nursing home care. While only 4.3 percent of the general population aged 65 and older live in nursing homes, for people who are visually impaired or blind the proportion is 16 percent and 4 percent, respectively. Graph 2.8 Estimated Direct Nonmedical Costs for People Who Are Visually Impaired or Blind $11.2 billion Estimated Cost (in billions) $12 $1 $8 $6 $4 $2 $ Nursing home care $1.96 billion Guide dogs $.6 billion $.3 billion $.5 billion $.2 billion Independent Living Services for Older, Blind American Printing House for the Blind National Library Service for the Blind Total Direct Nonmedical Costs 13

9 Lost productivity Lost productivity refers to the cost to the U.S. of lower labor force participation and lower wages for people who are visually impaired or blind compared to people in the same age group with normal vision. According to estimates based on data from the 1997 Survey of Income and Program Participation, approximately 15,583 visually impaired and 74,133 blind people would have worked if they were fully sighted. Assuming the same average annual wage for people with normal vision ($33,195) it is estimated that the reduced labor force participation of these individuals accounts for $6.3 billion in lost productivity annually. Assuming, also, lower earnings by an estimated 125,882 visually impaired and 4,671 blind people who do work, there is an added productivity loss of $1.7 billion, for a total of $8. billion in lost productivity. Graph 2.9 Estimated Cost of Reduced Labor Force Participation by People Who Are Visually Impaired or Blind Estimated Cost (in billions) $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Decreased labor force participation $6.3 billion Decreased wages $1.73 billion Cost Category $8.3 billion Total Productivity Losses 14

10 Acknowledgements Sponsors Funding for The Economic Impact of Vision Problems was provided through the generous grant support of: "The Economic Burden of Major Adult Visual Disorders in the United States," Archives of Ophthalmology, December 26 Principal Investigator David B. Rein, PhD RTI International Co-investigators Ping Zhang, PhD Division of Diabetes Translation National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Advising Organizations Throughout the development of this report numerous organizations provided insight and guidance, including: American Academy of Ophthalmology, American Academy of Optometry, American Optometric Association, American Society of Ophthalmic Registered Nurses, Association for Research in Vision and Ophthalmology, Centers for Disease Control and Prevention, Lighthouse International, National Alliance for Eye and Vision Research, National Association of Chronic Disease Directors and National Eye Health Education Program. Investigators Research described in this report was conducted by two teams of investigators. Their original work was published in two separate journal articles. We gratefully acknowledge the invaluable contribution of data from their work. "Economic Impact of Visual Impairment and Blindness in the United States," Archives of Ophthalmology, April 27 Principal Investigator Kevin D. Frick, PhD Bloomberg School of Public Health Johns Hopkins University Co-investigators Emily W. Gower, PhD Department of Ophthalmology Dana Center for Preventive Ophthalmology Johns Hopkins University John H. Kempen, MD, PhD Center for Preventive Ophthalmology and Biostatistics Department of Ophthalmology University of Pennsylvania Jennifer L. Wolff, PhD Bloomberg School of Public Health Johns Hopkins University Kathleen E. Wirth, BA RTI International Paul P. Lee, MD, JD Center for Health Policy Law and Management Duke University Thomas J. Hoerger, PhD RTI International Nancy McCall, ScD RTI International Ronald Klein, MD, MPH Department of Ophthalmology and Visual Sciences University of Wisconsin Madison James M. Tielsch, PhD School of Hygiene and Public Health Johns Hopkins University Sandeep Vijan, MD, MS Development Center for Practice Management and Outcomes Research Veterans Affairs Health Services Research University of Michigan Jinan Saaddine, MD, MPH Division of Diabetes Translation National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention Text written by Elaine A. Richman, PhD Richman Associates, LLC Report design Soumya Netrabile Cover design Kristin Sekulich

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