OBJECTIVES: Amblyopia is the most common cause of vision loss in young people. It has an estimated prevalence of 5.6% in schoolchildren and 3.29% in the adult population. We developed a budget impact model (BIM) tool from a US insurers perspective to investigate impacts of reimbursing a novel digital therapeutic. This could be tailored according to specific insurers’ populations.

METHODS: The BIM was constructed using an agent-based time-series simulation model of 50,000 amblyopic patients, weighted by prevalence in each age group and their proportions in the general population. Digital treatment was only made available where glasses had previously failed, which was assumed to be standard of care. The total cost to both patients and the insurer per annum was calculated (assuming Medicare Part D standard benefit limits in the base case), as was the increased number of family plans required to be sold to offset this extra cost. Total societal productivity gains for the working age population was also estimated.

RESULTS: For a plan with 100,000 members, 3,647 were estimated to have amblyopia. The estimated cost to the insurer of reimbursement ranged from ~$30,000 in year 1 to ~$125,000 in year 5 (Total ~390k).The out-of-pocket cost to a new patient was $611. Assuming a 2.1% profit margin and a family plan cost of $22,221, the insurer would need to sell further ~750 family plans over the five years to break even. About 700 patients would be cured of amblyopia over this time, and reimbursement would lead to total productivity gains of ~$5,400,000.

CONCLUSIONS: Amblyopia is a common form of visual impairment in the United States, however the potential budget impact to an insurer is expected to be predictable and manageable. Covering a novel digital therapeutic may also expand an insurers premium base and offset additional expenditure.