This article first appeared in the St. Louis Beacon, Dec. 22, 2008 - Since early in the decade, the Missouri Optometric Association has pushed hard for legislation that requires comprehensive eye examinations for children. A bill mandating such exams for students in kindergarten or first grade finally became law in the summer of 2007 and went into effect this fall.
It hasn’t received the same kind of support from ophthalmologists. Dr. Oscar A. Cruz, director of Saint Louis University’s department of ophthalmology, lobbied against the bill multiple times. Nonetheless, he is the sole pediatric eye doctor on the children’s vision commission established to carry out the law. Soon, he’ll also be the chairman.
Cruz doesn’t take issue with an argument made by the law’s supporters that exams can catch more problems than school screenings. Nor does he downplay the benefits of doctor visits to some students. But he said requiring everyone to be examined isn’t the best use of eye doctors’ time and parents’ money.
“I worry that it’s not an effective use of resources,” he said. “In my experience, most children who come in for exams either don’t have eye problems or have already had them identified. Probably 90 percent are completely normal, and it bothers me to do normal exam after normal exam.”
The debate over resources and cost effectiveness is a piece of a larger discussion about the law’s merits and implementation. Questions have already arisen about decisions not to penalize students who don’t get examined, and to begin enforcing the law without having a complete data reporting system.
Cruz said that with only 10 pediatric ophthalmologists in Missouri, there’s hardly enough capacity to handle a burgeoning case load. Optometrists are likely to handle most student exams.
Cruz is a proponent of revamping screenings to catch more eye problems, and offering them for children before they start school for the first time. Those results should then determine who needs a full examination, he said. While no screening mechanism is 100 percent effective, Cruz said focusing efforts on devising better and earlier screening for younger children will do more to ensure they receive proper care before it is too late and in the most cost effective manner.
While an eye exam might cost $75, schools can screen a student for a few dollars, he said. Parents are already struggling with medical bills and shouldn’t be required to bear unnecessary costs, he added.
Effect of the Opt-out Provision
Parents or legal guardians have until Jan. 1 to submit to schools evidence of the vision exam. But they can submit a written request to opt out of the requirement without penalty – a provision that remains controversial.
“The purpose isn’t to penalize the child,” said LeeAnn Barrett, executive director of the Missouri Optometric Association. “We want to educate parents that having an eye exam before their child starts school is the right thing to do.” Linda Neumann, president-elect of the Missouri Association of School Nurses, and a school nurse in the Webster Groves School District, said without penalties for noncompliance the law lacks teeth. “That deadline in January doesn’t mean a whole lot right now,” she said.
And the opt-out provision threatens to distort and diminish the usefulness of student vision data. Michael Frier, chair of the children’s vision commission, said that if a large number of students don’t get examined, statistics about undocumented eye problems in Missouri won’t be as valid.
“We’re already finding a lot more kids at risk than we would have without the law,” said Frier. “This would be more substantial if we required students to have that exam and not have such an easy ability to opt out. A lot of time parents don’t want to mess with [an exam] even though they have insurance. It’s hard to legislate parental follow through.”
At a recent health conference, Neumann took an unofficial poll of state nurses and found that at least 10 percent of students have turned in an opt-out letter and roughly half haven’t given any notice to schools of their intentions.
Tom Cullinane, a Creve Coeur optometrist and a Missouri Optometric Association trustee, said he’s spoken to colleagues who have seen more elementary school-age patients this fall and others who have been surprised at the lack of visits given the new law. Cullinane said he falls into the latter group.
Both Cullinane and Neumann said they suspect the commission’s late start in getting the word out to school districts will result in lower exam completion rates than hoped. Marjorie Cole, school health services program manager for the Missouri Department of Health and Senior Services, which oversees the vision commission, said parents have been confused about who can administer the exam. Pediatricians cannot, for instance. Neumann said she is still fielding compliance questions from nurses and parents.
“This is a difficult law to implement,” Neumann said. “Nurses support it, but things still need to be ironed out. The first year isn’t going to be perfect.”
A System Not Ready for Action?
Concerns about the law’s effectiveness aren’t limited to its approach. They extend to whether it will produce the information it is designed to generate. At the center of the discussion is an online reporting system that the health department is waiting for funding to complete. Without the electronic reporting tool, some doctors are holding onto exam forms and others have sent them to schools or directly to the department itself.
“I still have concerns about the lack of a mechanism to collect and analyze the data,” Cruz said. “The legislature passed a law requiring exams but established no way to collect and analyze data to measure whether it is worthwhile and effective. No one has any idea about how many children are being tested.”
Cruz said that while he is frustrated with the lack of an organized data collection system, it’s not the fault of the health department. He said the legislature has “tied everyone’s hands” about what can be done before the January deadline.
The cost of care -– and barriers to access
Approximately 70 percent of children are insured for comprehensive eye exams through private insurance, Medicaid, State Children's Health Insurance Programs or federal programs, according to the American Optometric Association. Barrett said the same is roughly true in Missouri.
But this means about 30 percent of children lack insurance for comprehensive eye exams. There are physicians who don’t take Medicaid. Support from charitable organizations is not always available.
More informationThe law creates a small fund that helps cover costs for students who aren’t Medicaid eligible or who lack health insurance with a vision benefit. State money will pay for a total of 1,868 exams statewide for students whose problems were identified during screenings. Schools receive the vouchers based on a formula and nurses decide which students best qualify. Both Cruz and Neumann said the pool of money set aside from the law is insufficient to cover the needs of children.
Groups like the Lion’s Club and the Salvation Army help low-income children pay for vision care. The commission is also compiling a list of free or reduced-cost exams or treatment available from private and public sources. The idea is to have the information available to school administrators and nurses. Barrett said she also has a list of eye doctors who have agreed to see patients at a reduced cost or for free.