• Medicare Reimbursement to Ophthalmologists

    Written By: Lynda Seminara
    Selected By: Richard K. Parrish II, MD

    Journal Highlights

    American Journal of Ophthalmology, November 2017

    Download PDF

    In a recent public report on Medicare Part B spending for 2012 and 2013, ophthalmologists (who account for 2% of the physician workforce) were iden­tified as having a disproportionate share of disbursements (7.7% in 2013). Han et al. reviewed data for the same period and determined that, unlike trends noted in other specialties, a substantial number of ophthalmology reimburse­ments were related to medication use, primarily injections of anti–vascular endothelial growth factor (VEGF) drugs.

    For this retrospective cross-sectional study, the authors reviewed Medicare Physician and Other Supplier data (both aggregate and private use) to determine ophthalmic beneficiary demographics, Medicare Part B payments, and medical services provided. Codes were used to categorize each service as a procedure, drug, or office visit. The data set was limited to ophthalmologists in office or ambulatory surgical settings; optome­trists were excluded.

    Ophthalmology patients represented 3.7% and 3.6% of Medicare benefi­ciaries in 2012 and 2013, respectively. The mean age was 75 years; 61% were female. Aggregate ophthalmology payments totaled $5.6 billion in 2012 and $5.8 billion in 2013, for an increase of 3.6%. Although the quantity of reimbursed ophthalmic services rose 2% from 2012 to 2013, the mean dollar amount per service decreased by 5.4%.

    According to gross reimbursements, 5 services accounted for 85% of pay­ments to ophthalmologists in 2013, an increase of 11% from 2012. Cataract surgery topped the list, followed closely by injection of anti-VEGF drugs.

    Drug-related reimbursement accounted for 32.8% of Medicare payments ($1.9 billion) to ophthal­mologists in 2013; ranibizumab and aflibercept represented 95% of these payments. The only specialty that re­ceived higher reimbursement for drugs was hematology-oncology. Overall, the mean reimbursement per ophthalmol­ogist was higher for procedures than for drugs or office visits.

    The authors concluded that, although Medicare disbursements for drugs are high for ophthalmology as a specialty, this is not surprising given the growing demand for anti-VEGF agents as the population ages. In addition, they said, findings should be interpreted with caution because data sources did not include either Medicare members with private insurance or patients on Medicaid.

    The original article can be found here.