Vision Screening Claims for Young Children in the United States

Vision screening plays a pivotal role in the early detection and management of visual impairments among young children, which if undiagnosed can significantly affect their overall development.¹  In this issue of Pediatrics, Oke et al²  describe trends in vision screening among young children with private insurance in the United States between 2010 and 2019 using administrative claims data from the IBM MarketScan Commercial Claims and Encounters Database.

According to the study, the percentage of children with claims for vision screening increased 165%, from 16.7% in 2010 to 44.3% in 2019. The increased use of instrument-based screening for children under the age of 3 was primarily responsible for this change.²  The study also points out a worrying decline in payments over time for instrument-based screening, raising concerns about adoption and use of vision screening technology.

The findings of this study demonstrate that vision screening in the primary care office setting is becoming more frequent, which is reassuring, but is still not being performed universally in early childhood. The prevention of long-term effects that can adversely impair young children’s learning and development depends on the early identification and treatment of visual abnormalities in young children.³  Every child should get a vision test at least once between the ages of 3 and 5, sooner if there are risk factors or concerns, according to the American Academy of Pediatrics.⁴  However, vision screening, including assessment of ocular function, should begin in the newborn nursery and continue throughout infancy.

Prior research has found that receipt of vision screening varies by social factors, including race, ethnicity, and family income.³  For children over 3 years of age, vision screening tests that typically include measures of acuity (eg, Snellen chart, LEA symbols, HOTV chart) can be effective. However, instrument-based screening (eg, photorefraction, autorefraction) can be highly effective for preverbal children or children who are challenging to screen.^4,5 

Although vision screening may be increasing, the overall rate is still low. With claims from only 44.3% of privately insured young children for vision screening in 2019, many are missing out on this essential preventive service. It is concerning to note that a survey revealed only 3% of pediatricians initiate vision screening at the recommended age of 6 months.⁶  Additionally, it is worth noting that the use of chart-based screening methods appears to be lower compared with instrument-based screening. This discrepancy may be attributed to the challenges associated with conducting chart-based screenings in young children who may have difficulty cooperating with the test.

The decrease in payment for instrument-based screening observed in this study is also concerning. Practitioners are less likely to adopt new screening devices if they are not adequately compensated for their use. This trend might reflect how preventive services reimbursement is lower than diagnostic and treatment services, presenting challenges for their implementation.

Several limitations to this study should be considered. The study used administrative claims data, which may not accurately reflect the actual use of vision screening in clinical practice. Claims data may also be subject to coding errors and incomplete documentation, which could affect the accuracy of the results. The study also only included children with commercial insurance, which may not be representative of all young children in the United States. It is unclear how the coronavirus disease 2019 pandemic has affected vision screening and access for children in the United States. However, according to a recent study, school-aged children experienced a 1.4 to 3-fold increase in myopia after the pandemic.⁷  To assess the impact of coronavirus disease 2019 on childhood vision metrics, including vision screening prevalence and unmet vision care, researchers analyzed data from the 2020 National Survey of Children’s Health. The study found a significant decline in vision screening prevalence from 2016 to 2020, with a further decrease after the pandemic onset. Moreover, there was a significant rise in reports about unmet vision care after the pandemic onset.⁸  This trend is alarming because vision screening is essential to prevent negative outcomes in children’s vision.

This study provides excellent insights into the trends in vision screening among young children in the United States between 2010 and 2019. The increase in vision screening observed in this study is encouraging, but there is still room for improvement. Efforts to increase the utilization of vision screening, particularly in young children, should be a priority for health care providers, policymakers, and insurers. To make sure that clinicians are fairly reimbursed for providing preventive services, including vision screening, continued efforts to increase compensation for this screening test may be required. Ultimately, the goal should be to ensure that all young children receive a vision screen as a key component of preventive services needed to support their learning and development.