C. Stephen Foster MD
Increasingly restrictive “gate keeping” policies of health maintenance organizations, insurance companies, and other medical insurance plans have created increasing pressure on ophthalmologists to be parsimonious in their use of medical services in both the diagnostic and therapeutic care of patients with a variety of medical disorders, including those with uveitis. These pressures are particularly prominent in the physician’s care of patients with chronic disorders, and ophthalmologists caring for patients with uveitis are increasingly experiencing this restrictive pressure. We wondered what the cost of diagnostic and therapeutic care of a patient with uveitis might be, given what we, as a uveitis referral center, see as appropriate yet fiscally prudent care. The cost of care obviously varies greatly, depending on the underlying cause and on the severity of the patient’s uveitis and associated complications. As a first step in estimating the total annual direct cost in the care of patients with uveitis we restricted our analysis to patients with HLA-B27 associated uveitis. We also restricted our analysis to the direct medical cost of caring for such patients, recognizing that direct non-medical costs, indirect morbidity costs, and other intangible economic loss costs, disability payments, absences from work, etc. are real but difficult to measure costs of the total cost of the patient’s illness. Direct medical costs are transactions and expenditures for medical products and services, including diagnostic studies, physician fees, hospitalization costs, surgical costs, rehabilitation and subsequent long-term care costs.
A cohort of 105 patients with HLA-B27 associated uveitis were studied in 2002. The diagnosis in each instance was established on our Service, and a minimum follow-up of two years existed for each patient. The medical records were reviewed for the diagnostic studies and costs of each performed, the physician and hospital fees associated with visits and/or surgery, in the cost of medical therapy. The average direct annual cost per patient per year was calculated. A stepladder approach to therapy was employed in an effort to eliminate recurrences of uveitis. The first step on the stepladder was the use of steroids, through any route required to achieve the goal of quieting the uveitis. Oral non-steroidal anti-inflammatory agents were added, if recurrence typically continued despite the use of steroids. Immunosuppressive chemotherapy was employed if patients continued to have recurrence of inflammation despite the use oral non-steroidals. Ten patients eventually required the use long-term oral immunosuppressive agents, and 30 patients were on chronic oral non-steroidal anti-inflammatory drugs. The average annual cost of care of the patients with HLA-B27 associated uveitis was $4,108.60 (range $433 to $9,683.18). These results reflect an average cost of caring for a cohort of patients with recurrent HLA-B27 associated uveitis of varying severity. The results may serve as an indicator, to health maintenance organizations and other pooled-risk insurers, of the cost of prudent care of patients with this form of uveitis. We would emphasize that we were very cautious and parsimonious in our use of laboratory tests and frequency of return visits, striving for the greatest degree of economy, while at the same time striving for the best possible outcomes (for outcomes analysis studies performed on these and other patients with uveitis, please refer to the Bibliography section of this Web Site). Clearly, patients with recurrent or chronic uveitis require significant expenditure of the health care dollar. It is, however, money well spent, since the preservation of sight from modern care of such patients profoundly reduces the prevalence of blindness secondary to uveitis, and hence reduces the economic burden on our society in total.