How eye care gets ahead in rural communities

Susan Quinn, OD, examines a pediatric patient on the Vision to Learn van. Image credit: Vision to Learn

In a small southeastern county in Ohio, a public school teacher discovered a significant improvement in academic performance from one of her students over the course of the school year. When the teacher commented on the student’s improved reading comprehension and newfound enjoyment of reading, the student said, “Well, I can read now. I’ve got my glasses.”

This is a common outcome of students who benefit from a collaborative effort made by Vision to Learn, Foundation for Appalachian Ohio, the Ohio Optometric Association, and the Ohio Optometric Foundation’s In-School Eye Exam (iSee) program to bring free vision services to pediatric patients in need in southeastern Ohio. These services are provided as a mobile vision clinic, with vans visiting schools in over a dozen different counties to conduct eye examinations, fit patients with frames, and order glasses to be delivered to students by a licensed optician.

Erica Shelton, MD, MPH, MHS, helps fit glasses at Nelsonville-York Elementary. Image credit: Vision to Learn

School nurses have reported that while being prescribed glasses can be an alienating experience for students, they often hold their heads high and find pride in their new frames when their classmates are prescribed at the same time, according to Thomas G. Quinn, OD, MS, FAAO, who was one of the first to work on the van in southeastern Ohio with his wife, Susan Quinn, OD. “In this program, we’re seeing a bunch of kids all once, and they’re all getting glasses at the same time,” Thomas Quinn said. “It’s kind of like there’s this peer group that supports each other and it’s a cool thing. Kids are doing much better at wearing the glasses that are prescribed, instead of feeling like, ‘Oh, I’m different. I’m not going to wear them because people make fun of me at school.’”

Drs Quinn, who co-owned a practice together in Athens, Ohio, before selling it and retiring in 2019, said that working on the van has shed even more light on the significant lack of access to care that southeastern Ohio’s residents experience. This lack of access to care is much like that in other largely rural regions of the US, where finding both the modes of transportation and time to travel long distances for appointments are major barriers to care. Susan Quinn said the mobile vision clinic eliminates at least some of those barriers by bringing the services to patients. “We practiced here for 38 years, so I felt like I understood the level of need in this area, but I was working in a practice for patients who somehow could get to me,” she said. “By being out in the hills and hollers in public schools, we’re intercepting kids [who], for a variety of reasons, would never be able to get to me. We see that kind of long-standing deprivation or the needs that one way or another, we could not have bridged that gap of work for this program.”

“We thought we were pretty accessible being where we are in Athens, Ohio, but there’s a whole community of people that couldn’t get to us,” Thomas Quinn said. “It’s just such a game changer.”

Where the need lies

The need to meet patients where they are is evident in the volume of eye examinations completed each school year by the mobile vision clinic. In the 2022-2023 school year, the clinic completed over 5200 eye examinations and sent out over 4200 pairs of glasses to patients. The program’s first full year, starting in 2021, provided 3100 eye examinations.¹ Susan Quinn said between 80% and 85% of students seen on their van are prescribed glasses, which are delivered within 2 weeks of the examination and can be replaced for free if the pair breaks or is lost within the first year.

Licensed Dispensing Optician Heather Taggart with a group of students who she helped fit with glasses. Image credit: Vision to Learn

Susan Quinn said a patient population that particularly struggles to receive adequate care is those who have binocular vision complications, citing a deficiency in providers with specialty practices. These patients who need referrals to specialists, along with patients who may require an eye drop for a comprehensive eye examination, can be tricky to treat given the need for follow-up visits and additional parental consent, respectively.

Rural care and access

Many different factors, including health care coverage and economic status, contribute to rural patients’ lack of access to eye care. With rural residents experiencing a poverty rate of 15.4%, compared with the US nationwide average of 12.8%,² these economic challenges have been shown to exacerbate lack of insurance coverage and low health literacy.³ According to The Commonwealth Fund, more than one-third of rural Americans reported having skipped needed health care because of costs, with nearly a quarter reporting either serious trouble paying medical bills or the inability to pay altogether.⁴ In a study assessing rural and urban eye care insurance coverage in Arkansas, 45% of rural residents reported having insurance coverage for eye care services, compared with 55% of urban residents. Rural residents were also less likely (45%) to have a dilated eye exam than urban residents (49%).⁵

With rural residents in the US more likely to live in underserved communities and be economically disadvantaged, they are also more likely to enroll in Medicaid. The coverage rate increased from 21% to 26% between 2013 and 2015 in response to the Affordable Care Act in expansion states, with 14 million (17%) Medicaid enrollees living in rural areas in 2021. Rural residents over the age of 65 years are also less likely to have private insurance coverage and are more likely to be uninsured than are urban residents.⁶

Additionally, the US sees more geographic health disparities than many other high-income countries, including Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom, according to The Commonwealth Fund’s 2020 International Health Policy Survey. The rate of skipping care because of costs is more than twice that in 6 of those countries, with fewer than 1 in 10 rural residents in the United Kingdom, Norway, and Sweden skipping care due to costs. Additionally, fewer than 1 in 10 rural adults in all 10 countries struggle to pay medical bills.⁴

Barriers and insurance compensation

For rural patients, the issues regarding access to care compound on one another. For instance, Susan Quinn said that Vinton County in Ohio does not have an eye care provider, so those needing eye care services must take time off of work to travel a longer distance to receive care. With fewer practices available to a larger demographic, wait times can exceed months. Additionally, those wait and travel times can be exacerbated by local practices not taking Medicaid. “If you’re willing to wait 2 months for an exam but the doctor doesn’t take Medicaid to start with, then you’re really out of luck,” Susan Quinn said.

Additionally, due to travel and communication barriers for rural residents, making it to these specialists and follow-up appointments can be challenging for caregivers, according to Chris Lopez, OD, of Griebenow Eyecare in Clintonville and New London, Wisconsin. “There is often a higher no-show rate, and this is common knowledge among Medicaid providers and those of us [who] take care of patients on state insurance,” he said. These transportation barriers can also complicate comanagement relationships for patients needing cataract surgery or LASIK, with patients needing to travel for several postoperative appointments, according to Lopez.

While Thomas Quinn said that many practices don’t take Medicaid because they fear their staff being overrun by demand, Lopez said lack of compensation from state insurance is a major factor for practices striking Medicaid. He said due to rural and Medicaid patients often having more comorbidities and requiring more chair time, history-taking, documentation, and special testing services, caring for rural patients often requires intensive care and follow-up, all which takes a deeper level of staff training. “To do all of that for pennies is extraordinarily difficult,” Lopez said.

Additionally, state insurance pay is expected to only decline for physicians. A new 2025 Medicare physician payment schedule has health care providers facing a 2.8% pay cut, which would be the fifth year in a row that funding has been decreased.⁷ “[Reimbursement] should be reasonable, and it should be in line with the value that we are providing, not just for our patients in their societies, but for all of the country and as eye care providers,” Lopez said. “I think we often unfortunately undervalue our services and the value that we provide. We have to acknowledge the fact that without us, a lot of people would be worse off than they are.”

References:

• Getting results in Ohio. Vision to Learn. Accessed August 28, 2024. https://visiontolearn.org/wp-content/uploads/Ohio_RegionalPages_09.pdf

• United States. Rural Health Information Hub. Accessed August 28, 2024. https://www.ruralhealthinfo.org/states/united-states

• Ervin AM, Solomon SD, Shoge RY. Access to eye care in the United States: evidence-informed decision-making is key to improving access for underserved populations. Ophthalmology. 2022;129(10)1079-1080. doi:10.1016/j.ophtha.2022.07.011

• Gunja MZ. Rural Americans struggle with medical bills and health care affordability. To the Point. Commonwealth Fund. July 24, 2023. Accessed August 28, 2024. https://www.commonwealthfund.org/blog/2023/rural-americans-struggle-medical-bills-and-health-care-affordability

• Kilmer G, Bynum L, Balamurugan A. Access to and use of eye care services in rural Arkansas. J Rural Health. 2010;26(1):30-35. doi:10.1111/j.1748-0361.2009.00262.x

• Advising Congress on Medicaid and CHIP policy. Medicaid and CHIP Payment and Access Commission. April 2021. Accessed August 29, 2024. https://www.macpac.gov/wp-content/uploads/2021/04/Medicaid-and-Rural-Health.pdf

• O’Reilly KB. Latest proposed cut—2.8%—shows need for Medicare pay reform. American Medical Association. July 10, 2024. Accessed August 29, 2024. https://www.ama-assn.org/practice-management/medicare-medicaid/latest-proposed-cut-28-shows-need-medicare-pay-reform