Journal Of Visual Impairment & Blindness Research Articles

Use it or Lose it: The Medicare Low Vision Demonstration Project

The Low Vision Demonstration Project is now one year old. This project constitutes a unique and pivotal opportunity for vision rehabilitation professionals. If it succeeds, it will open up significant opportunities for funding and provision of services. But, if it fails, it could represent another nail in the coffin of specialized services. The question now is whether professionals in the field of visual impairment and blindness will step up to the plate to ensure that this project is successful. The achievements of the project have been encouraging so far, but there are a number of significant weaknesses, and there is still much to do. This column offers a progress report on the project and examines its serious implications. Although some reports have appeared in previous issues of the Journal of Visual Impairment & Blindness (JVIB) (see, for example, the Comment entitled Medicare Coverage for Orientation and Mobility Services, by Lorraine Lidoff, which appeared in October 2005; and the special report that appeared in the From the Field department of the August 2006 issue), let me first provide an overview of the project for anyone who is not familiar with it. SCOPE OF THE PROJECT Begun on April 1, 2006, the Low Vision Demonstration Project is a five-year project established to help deliver services in a new manner and evaluate the utilization of funding for vision rehabilitation services by a new set of providers who had not previously been covered by Medicare: certified low vision therapists, orientation and mobility (OM however, the demonstration project also covers vision rehabilitation training that may be provided in the eye care specialist's office or at a qualified agency. Because the project is funded by Medicare, service providers are obliged to follow its requirements, which may differ from customary procedures in vision rehabilitation. Specifically, all services must be preceded by a written plan of care, with specific goals and a statement of the location at which the services are to be provided, which must be approved by the supervisory physician and reviewed every 30 days. The service provider must detail the training provided and the progress made by the patient. Training is limited to nine hours total, to be provided within 90 consecutive days, and cannot be extended. Vision rehabilitation services are billed in 15-minute increments. For this demonstration project, six different sites in four states and two cities throughout the United States have been selected: Atlanta, Georgia; Kansas; New Hampshire; the five boroughs of New York, New York; North Carolina; and Washington State. The patient must reside in one of these six areas, and the supervising eye care specialist must have his or her practice in one of the six sites. The patient must have a corrected visual acuity in his or her best eye of 20/70 or worse, or have a documented central scotoma, a general constriction of the visual fields, or bilateral hemianopia. Qualifying patients must show a medical necessity for the services rendered, be capable of progress, and be able to derive a benefit. …

A Look Back

Those of us who entered the field of visual impairment and blindness in the 1970s experienced the vision movement--that is, the shift in philosophical focus from saving to sight enhancement. During the first half of the 20th century, children with low vision were encouraged to not use their vision, but to save it. This philosophy was so pervasive that some schools for the blind still have photographic evidence of children with low vision reading braille with cloth over their hands so they could not use their vision to read the dots. In the second half of the century, in contrast, sight enhancement was encouraged, and specific curricula were developed to teach children with low vision how to use their remaining vision. This fundamental change created a host of developments, including the subsequent emphasis on the development of visual skills in children with low vision, introduction of university courses on the topic of low vision, development of an interest group on low vision within our professional organization, growth of entire conferences dedicated to low vision, inclusion of the category of vision therapist for certification, and the increased appearance of manuscripts in the Journal of Visual Impairment & Blindness (JVIB) on the topic of low vision. In this centennial essay, we offer details of the volume of manuscripts published in the 100-year history of JVIB and its predecessors on this single topic, thus illustrating the journal's dedication to the topic of low vision. According to research presented in 2005 by Goodrich and Arditi, in the years 1999 to 2003, JVIB featured more manuscripts on low vision (18%) than any other journal in the field of visual impairment and blindness. (In second place was the American Journal of Ophthalmology, which published 6%.) After poring over 100 years of material for this overview of the literature on low vision, we decided to organize this essay according to the model of the public health continuum of care, which has three phases: prevention, treatment, and rehabilitation and education. We believe this model will not only allow us to capture the broad themes of the literature on low vision, but also reflects our strong philosophical belief that the best low vision service is interdisciplinary. PREVENTION goal of public health practitioners is to prevent disease. Looking through the journal, we found that the information published in the early 1900s provided a fascinating glimpse into the state of health care, specifically eye care, during that time period. For example, two of the leading causes of blindness and visual impairment in the United States in the early 1900s were ophthalmia neonatorum and trachoma. Ophthalmia neonatorum--a form of conjunctivitis caused by untreated venereal disease that is contracted by the unborn infant as he or she traverses the birth canal--was first mentioned in Outlook for the Blind in 1908. second cause, trachoma, was also a type of conjunctivitis. We were somewhat stunned to learn that trachoma was once endemic in North America and Europe. Although trachoma remains the leading cause of blindness in the world today, it is extremely rare in developed countries. However, in 1910 a physician reported on incidences of trachoma in western Pennsylvania to draw attention to its practically ignored ravages among certain classes (Harris, 1910). Dr. Harris wrote: Much has been accomplished by skilled medical and surgical measures, in addition to certain hygienic directions, but we are very far from the desired goal, inasmuch as we have yet failed to discover the exciting cause of the disease or find a remedy that is in a strict sense curative (p. 113). Perhaps in an attempt to raise awareness, the opening of the Autumn 1915 editorial, entitled The Trachoma Problem, was: Why have you given so much space to Trachoma in this issue of the Outlook for the Blind? …