In the world of managed care and increasingly knowledgeable patients, optometrists frequently encounter conversations about cost, value and benefits of our recommendations. Most of the time, value is something we find easy to convey because the patient has a clear need, and the solution available is either something they ask for or something we can offer to them. When they have common vision concerns, it is not unusual for a patient to want contacts or multiple pairs of glasses to meet their needs. Because many of our common solutions are mainstream options, most optometrists easily find ways to convey the value, clearly discuss the costs and help patients understand the benefits. It is much more challenging to convey the value and benefit of a solution to a current problem with a focus on future benefits, as is the case with myopia management.

With specialized care such as myopia management, there are significant challenges to consider. Optometrists must develop a plan with patients and parents to ensure everyone is on the same page throughout the process, from acquiring the proper tools, training staff, marketing and implementation. It is essential to provide clarity of treatment necessity and protocol, as well as expectations both for the patient outcomes and the costs. Often, the cost discussion becomes the barrier that either slows an optometrist’s momentum with specialized care or prevent them from taking the leap in the first place.

We will dive into some of those obstacles that are commonly encountered and how we have dealt with them to ensure our patients receive excellent care in the world of myopia management. Consider some of the commonly asked questions, and our perspective on how to convey the importance of the investment in myopia management, for both the patient and the practitioner.

Is myopia management covered by insurance?

DA: In some cases, vision benefits may cover portions of the treatment options, like contact lenses or glasses that control the growth of the eye. However, vision benefits typically do not cover the services involved to monitor and follow young myopes along their journey. In many cases, only part of the treatment is covered, and the remaining amount is an out-of-pocket cost to the parent. Additionally, most medical plans will not cover myopia management services or materials, including atropine eye drops. 

Optometrists must have not only clear fee structures and communication on what is included for the fees; they and their staff must also be able to explain the differences between covered services and those intended for myopia management. Convey the importance of follow-up appointments along with the value of slowing the growth of the eye. This can be daunting, but I have always started these discussions long before a child needs one of the myopia management methods. I start this discussion with pregnant moms—long before the child has their first exam—and with the parents at the child’s first visit.

TS: We are still in a space where the vision insurance plans do not cover myopia management because it is outside of routine/standard eye care, although arguably it is now “standard of care.” Unfortunately, medical insurances do not cover myopia because it is not considered a medical condition, even though it is an epidemic that leads to ocular disease later in life that we are trying to prevent. Some vision insurance plans are starting to offer coverage with materials benefits for spectacle lens and contact lens options but still not for the service fees. Low-dose atropine is not covered by medical insurance drug plans because it is still an off-label non-FDA-approved treatment. However, families can use FSA/HSA for any of these products or services, which is helpful.

Dr. Anderson with his first MiSight patient. Even in pandemic times, the importance of myopia management was conveyed. It is great to see patients back years later and to see how little their refractive errors have progressed. Click image to enlarge.

How long will children need this treatment?

DA: This can be a challenging one to address because most treatments that continue to hit our offices do not have clear and conclusive answers to this question. I typically leave it open-ended and provide expectations that the child will continue to need treatment if their eyes are at risk for continued growth. I make sure they understand that the method of treatment may change over time. Having open and consistent conversations about the treatment course helps determine if alternative or more aggressive treatments are needed. This does alter the cost at times, but transparency and consistency allow us to change course and stay on track. Ultimately, the more we discuss the potential treatment course can help me project how long a child will need those treatments and how well they are working.

TS: I usually present that, ideally, a child would be on some form of myopia management all throughout their growing years, because if the body is growing, the eyes are growing. However, the first option a family starts with does not have to be their choice forever; we can adjust as the child matures. Previously, I would almost always start the youngest kids on low-dose atropine, but now we have spectacle lenses that work very well in the beginning as well. Then, as they get a little older, we can move into contact lenses if they would like to. For younger children, this could mean myopia management for 10+ years, but this can always be adjusted as we watch the individual data and re-assess the treatment plan as needed.

Is payment needed all up front?

DA: This question is common, and I have always wanted to do what I can to minimize barriers to the care these children need. We do not charge for a full lifetime of treatment, as mentioned above, the treatment and number of visits are likely to change over time. We do, however, charge a global fee for most of our treatments, as this ensures the patient will follow-up for their care, and helps the parent understand the cost of treatment for the year.

TS: Typically, we use the global fee in the first year, which is likely to have the most follow-ups, where the family will pay up front for the year. After that, they pay per visit, which is usually two visits per year—their comprehensive exam and a six-month follow-up. For materials, low-dose atropine and soft-contact lenses have more pay-as-you-go options, while spectacle lenses and orthokeratology (ortho-K) require full payment from the start.

Dr. Sprague measuring axial length. When assessing risk, we look at multiple data points, one of them being axial length. We typically measure this twice a year on our myopia management patients. Click image to enlarge.

What happens if more office visits are needed outside what was discussed?

DA: In eye care, it can be really confusing for patients to understand what is covered and what isn’t. Often, there is dual coverage, with patients have both vision benefits and healthcare benefits. This is both a blessing and curse, as it adds to patient confusion. Fortunately, it also allows doctors the ability to choose what insurance coverage is used for circumstances that arise. 

The key is related to the reason the patient is in your chair. A young myope’s comprehensive exam may usually be billed to a vision plan if their chief complaint is vision-related. If myopia management treatments are begun at that time, the global fee will be charged. 

Some common visual complaints that may occur after treatment has begun include near blur with atropine drops or distance blur with change in refractive error. These both fall under the global fees and would not require additional charges. If the complaint is something related to an obvious health issue, such as redness while wearing contact lenses, this is likely to be sent to medical insurance. The overarching theme is to give an overview of the covered issues up front so there are no surprises along the way.

While I do not spend a lot of time discussing these issues, I tell the patients that most things that happen during treatment will fall under the global fee. However, in cases where it falls outside this, we do our best to submit for payment to any willing payor on the patient’s behalf.

TS: Usually if I explain the reason for the additional visit, families are on board. This is something we are working on together as a team, and when parents know that we both have the best interest of their child as top priority, I do not usually run into difficulty with getting them to come back for another visit.

What other costs are involved?

DA: Although I cannot predict all outside costs that may be involved for patients, I clearly lay out what is covered (and not covered) under the global fee—both services and products. I set the expectation that, depending on the option chosen, there may be additional costs involved. I openly share each treatment option, including my recommendation and the potential costs associated with each.

I have always enjoyed the benefits of ortho-K, as this tends to have amongst the lowest cost when looked at for the entirety of use. This is because an ortho-K lens can often be used for more than one year, and in most cases, glasses are not needed. This can make it similar to or even lower in cost than to soft contact lens options.

That said, regardless of choice, each patient may have different needs that would change the additional costs. Specifically, if they choose soft lenses, they will also need a pair of glasses, an expense that may continue annually as a child grows and finds that their frames no longer fit. If the atropine option is chosen, they will not only need glasses each year but will be responsible for the cost of the drops, which are not covered by insurance. Either way, there are always ongoing costs to any choice. I communicate with families that this cost is far outweighed by the benefit of slowing the eye growth and point to long-term effects if myopia management is not considered, including quality-of-life considerations and risk of future ocular disease, in addition to costs. Glasses will become more expensive, requiring thinner and lighter lens options as the child becomes more myopic over time.

TS: Ortho-K usually has the highest up-front cost, but families save by not needing to purchase glasses. With soft lenses, patients will need a pair of glasses as well, so that method likely ends up being the most expensive. The specialized spectacle lenses and atropine prices are comparable, with atropine users needing to purchase regular glasses, too.

This graph illustrates that the earlier the age of onset of myopia, the more nearsighted the child is likely to become. It is more important to stress myopia management in these younger patients, and imperative to bring it up earlier, at their first visit with you, rather than later. Click image to enlarge.

Is myopia management worth it? Which families can't afford it?

DA: This is always a tough one, and I wish it were a covered insurance benefit for all kids, regardless of their circumstances. Myopia management is one area in eye care that could be improved upon in managed care.

Families’ personal finances may change over time, or they may have a greater appreciation of the value over time. We cannot prejudge our patients or families; we always have to assume they want the best for themselves and their kids. Sharing the benefits and values of myopia management—as well as the risks posed by abstaining from treatment—is our duty. The families always have the choice, but if we approach each family with empathy and provide them the facts, this allows them to understand their decision, even if it is truly unaffordable to them. Finally, I do continue to discuss it every year with those that would benefit, regardless of their past decision.

TS: It is important to consider myopia management on a very individualized basis. While I would love for every child to have my ideal treatment plan, I am realistic and present risks appropriately. It’s important to emphasize myopia management the most in patients with highly nearsighted parents, and the younger the patient is with the higher myopia, the greater risk they have of developing high myopia and later ocular disease.

Right now, as discussed above, many myopia management interventions involve out-of-pocket costs. If enrolling their child would cause a significant financial burden to the family, then it is likely not the right choice at the time. I always present all options and let them make the decision if the value is worth it, but push harder in higher-risk cases. There are always alternatives as well, such as monthly replacement contact lenses rather than daily disposables, which is less expensive for some families.

Parent education is key. We provide verbal explanations in the exam room but also send home physical information for further review and schedule a myopia management follow-up with baseline axial length scan after their comprehensive exam. Click image to enlarge.

Making a Difference

During patient care, we have encountered numerous opportunities to make a difference in the lives of our patients—whether it is helping them learn and read through vision therapy, fitting an irregular cornea with a scleral contact lens or treating their infections or other acute eye issues. However, this all pales in comparison to the ability to change the course of a child’s life with myopia management. We are opening opportunities to these children that they may not otherwise have access to, and at the same time, reducing their risk for permanent injury by slowing their eye growth. By choosing myopia control treatment, these children can wake up and see their world more clearly for the rest of their lives.

While being a myope still means the birds in the backyard are blurry, they will not need to hold their phone or shampoo bottle two inches from their face to see it. As an adult, they may become a part-time glasses wearer, being able to read or spend time at the computer without glasses. They can enjoy uncorrected vision more safely and comfortably, and this is something often overlooked by both patients and practitioners. Beyond this, they will always have a greater quality of life with their corrective needs. Their glasses are less heavy and expensive; they can get their exact contact lens power vs. an approximation in the higher powers; and they now have the option of refractive surgery if they so choose.

We truly believe in myopia management, so when talking to families, it is our duty to present our expertise on what is best for their child. The value is not just in the moment for these children, but for their entire lifetime. We work hard to convey this message, which results in a better quality of life and a better future for our patients. We are not just correcting their vision at that visit; we are changing the course of these children’s lives.

Additionally, we are connecting their families to us and our practice for their long-term care needs. Not only do these families recommend our practice to others, but we also often get referrals from other doctors in the community, making myopia management a great practice-builder. Being equipped with specialized treatment options such as myopia management can offer your patients and community an immediate and lasting impact while also strengthening your practice

Dr. Anderson treats glaucoma and other eye diseases, with a focus on dry eye disease and myopia management, at Miamisburg Vision Care in Miamisburg, OH. He is a graduate of The Ohio State University College of Optometry. He is a past president of the Ohio Optometric Association and continues to serve on many committees at the state and national level. He is a former instructor in the Ocular Disease Clinic at The Ohio State University College of Optometry.

Dr. Sprague is passionate about children’s vision care and her clinical interests include strabismus, amblyopia and myopia management while treating patients at Miamisburg Vision Care in Miamisburg, OH. She graduated from The Ohio State University College of Optometry and completed her residency in binocular vision and pediatrics at Indiana University School of Optometry. Dr. Sprague is a fellow of the American Academy of Optometry. They have no financial disclosures.