Study Reveals Eye Care Disparities for Native American Patients

OAKLAND, CA – MARCH 26: (L-r) Outreach worker Elijah Chhum walks by the tent where people are receiving the Johnson & Johnson COVID-19 vaccine at the Center for Empowering Refugees in collaboration with Native American Health on Friday, March 26, 2021 in Oakland, California. The state of California lowered the age of eligibility for the coronavirus vaccine on March 25 and community health clinic leaders and state health officials worry that will cause even more people without access to the Internet or with transportation or language barriers to be left behind in acquiring their vaccinations. (Gabrielle Lurie/The San Francisco Chronicle via Getty Images)
These patients have higher condition claim rates, yet lower service claim rates.

Medicare data reveals substantial disparities in claims rates for diagnosed ophthalmic conditions and services for Native American Medicare fee-for-service (MFFS) beneficiaries vs non-Hispanic White MFFS beneficiaries, according to a report published in JAMA Ophthalmology.

Previous research has shown that Native Americans experience higher rates of diabetes, cirrhosis, hypertension, and cardiovascular disease than non-Hispanic Whites. In addition, regional studies have found that Native Americans have a higher prevalence of visual impairments and treatable eye diseases than other groups of Americans. However, this research has been focused on individual tribes, not the population as a whole.

Investigators involved with the current study sought to uncover whether disparities in ophthalmic conditions and services exist between Native American and non-Hispanic White patients living in the United States. They analyzed MFFS enrollment data from the Vision and Eye Health Surveillance System (VEHSS), including 177,100 claims from Native Americans and 24,438,000 claims from non-Hispanic White patients.

Their analysis revealed that Native American patients had “significantly different” claim rates in 16 of 17 ophthalmic condition categories and 6 of 9 service categories compared with non-Hispanic White patients. More specifically, there were higher ophthalmic condition claim rates but lower service claim rates for Native American patients for:

  • Refractive errors (ophthalmic condition, 17.2 vs 11.1; service, 48.3 vs 49.6, respectively; P <.001)
  • Blindness and low vision (ophthalmic condition, 1.48 vs 0.75; service, 19.2 vs 20.1, respectively; P <.001)
  • Injury, burns, and surgical complications (ophthalmic condition, 1.8 vs 1.7; service, 19.2 vs 20.1, respectively; P <.001)
  • Orbital and external disease (ophthalmic condition, 15.7 vs 13.3; service, 48.3 vs 49.6, respectively; P < .001)

In addition, Native American patients had higher ophthalmic condition claim rates for diabetic eye diseases compared with non-Hispanic White individuals (5.22 vs 2.20), but no difference in service claim rates (14.4 vs 14.8; P =.26), according to researchers.

In contrast, there were lower ophthalmic condition and service claim rates for Native American patients for corneal disorders, optic nerve disorders, neoplasms of the eye, infectious or inflammatory disease, strabismus and amblyopia, age-related macular degeneration, retinal disorders, other visual disturbances, and all other eye disorders. Additionally, there were lower condition rates for retinal detachments/defects and glaucoma for Native American patients, but no differences in the service rates. Only for cataracts was the ophthalmic condition claim rate lower for native American patients, but the service claim rate was higher.

“To our knowledge, there are no known genetic bases to account for differences in rates of eye disease between North American Native individuals and non-Hispanic White individuals,” according to study authors. “Thus, differences approximated through MFFS ophthalmic condition and service claim rates for North American Native individuals vs non-Hispanic White individuals likely highlight disparities in health care access. Disparities may exist in part because North American Native populations are more likely to live in rural areas farther away from medical specialists, including ophthalmologists, among other contributing social factors.”

This study had several limitations, including that the VEHSS MFFS database only contains information for MFSS beneficiaries aged 65 years and older and/or disabled. Secondly, routine annual eye exams are not an MFFS benefit unless the beneficiary has specific risk factors for eye disease. In addition, the MFFS portion of the VEHSS contains only claims submitted when Medicare is the primary insurer; claims with Medicare as a secondary insurer are excluded from the database, producing a claims undercount. Also, the MFFS database cannot capture data on non-claimants, inhibiting the ability to report true eye disease prevalence rates. Further, claims databases exclude people whose eye conditions have not been formally diagnosed. In addition, by using the VEHSS version of the MFFS claims database rather than raw data, researchers needed to adjust analytic methods to the available information. Lastly, since this study only included Native American patients with MFFS insurance, it is not generalizable to the entire population.


Woodward MA, Hughes K, Ballouz D, et al. Assessing eye health and eye care needs among north american native individuals. JAMA Ophthalmol. Published online December 23, 2021. doi:10.1001/jamaophthalmol.2021.5507