Studying Quality of Vision Care for Medicare Beneficiaries

    • July 14, 2009

The Problem: Some 13 percent of Americans age 65 and older have vision problems. Older adults with diabetes have especially high rates of eye disease (e.g., 17 percent to 35 percent have diabetic retinopathy). Medicare managed care has the potential to improve access to eye care for older people with diabetes, but more data were needed comparing the quality of eye care in fee-for-service and managed-care Medicare.

Grantee Perspective: Carol M. Mangione, MD, MSPH, an assistant professor in medicine at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA), wanted to gain a better understanding of the content and quality of vision care services for Medicare beneficiaries in fee-for-service and managed-care plans. As a new faculty member at UCLA, Mangione needed protected time to conduct her research and she needed a way to raise her visibility within the medical school. The Robert Wood Johnson Foundation (RWJF) Generalist Physician Faculty Scholars Program provided protected time and the opportunity for Mangione to learn from some of the top generalist faculty in the country. “The program was a terrific source of mentorship and career guidance from leaders in the field,” she said. “It also opened doors to other opportunities at the medical school.” As a scholar from 1996 to 2001, Mangione and her colleagues analyzed vision care services in fee-for-service and managed-care Medicare. They studied 1,259 Medicare beneficiaries in Los Angeles County:

  • 1,024 were covered by managed care, and their data were obtained from the diabetes registry of a large for-profit health plan.
  • 235 were covered by fee-for-service, and their data were obtained from a Health Care Financing Administration database (now called Center for Medicare & Medicaid Services).

Mangione also received funding from the Agency for Healthcare Research and Quality (1996–99, $688,186) and an additional grant from RWJF for this research (Grant ID# 032072, 1997–99, $163,000).

In a key component of the study, Mangione et al. analyzed the quality of vision care for 311 Medicare managed-care beneficiaries with diabetes and 107 fee-for-service beneficiaries with diabetes.

  • Beneficiaries participated in telephone interviews and received standard “masked” eye examinations conducted by ophthalmologists at UCLA (examinations in which the ophthalmologists did not know which type of insurance the patient had). The telephone interviews covered sociodemographic and clinical characteristics, self-reported eye conditions, medical illness, visual functioning and health status.

Results: In an article in Archives of Ophthalmology (May 2005), Mangione, who is now a professor of public health and medicine at UCLA, and her colleagues, reported:

  • Managed-care and fee-for-service beneficiaries with diabetes reported comparable rates of eye care provider visits and preexisting eye diseases.
  • On masked clinical examination, managed-care participants were more likely than fee-for-service participants to have diabetic retinopathy, visually significant cataract, glaucoma or suspected glaucoma (68% vs. 46%).
  • Managed-care participants were significantly more likely than fee-for-service participants to require further treatment during the next six months (42% vs. 24%).

Based on her work, Mangione received a $2.6-million grant from the Centers for Disease Control and Prevention (CDC) as part of Translating Research Into Action for Diabetes (TRIAD), a study of managed care and diabetes quality of care, costs and outcomes (1998–2003). Mangione was one of six TRIAD principal investigators nationwide. Under this grant, she tested findings from Los Angeles County in a national study.

“I don’t think I could have successfully competed for that award if I hadn’t had this experience in the program,” said Mangione. “The generalist award gave me credibility to be competitive. It really advanced my career.” Mangione later continued this work with another $2.6-million grant from the CDC as part of TRIAD II (2004–09).

As co-director of the Robert Wood Johnson Foundation Clinical Scholars program at UCLA, Mangione devotes a great deal of time to mentoring junior faculty. She also mentored two other Generalist Physician Faculty Scholars, Douglas Bell, MD, PhD, at UCLA, and Chien-Wen Tseng, MD, MPH, at the University of Hawaii. See Tseng’s Grantee Profile.

Through her mentoring activities Mangione hopes to increase the number of successful female and minority faculty in medical schools. In 2005, she received the Society of General Internal Medicine’s Mid-Career Research Mentorship Award, which recognizes the mentoring activities of general medicine investigators.

Mangione is director of the Center for Health Improvement for Minority Elders, one of six Resource Centers for Minority Aging Research funded by the National Institute on Aging to decrease health disparities.

She was also the content editor for the Foundation for Informed Medical Decision Making’s patient decision aid, Living with Diabetes: Making Lifestyle Changes to Last a Lifetime, which won the National Mature Media Bronze Award and Merit Award.

RWJF Perspective: The Robert Wood Johnson Foundation established the Generalist Physician Faculty Scholars Program to create a cadre of respected generalist leaders in medical schools who would be in a position to influence curriculum, admissions and scholarship. Junior faculty in family medicine, internal medicine and pediatrics conducted research and built their careers under the guidance of mentors.