Trends in Medicare Charges, Reimbursements, and Utilization for Ophthalmic Versus Non-Ophthalmic Procedures

Objective

To investigate trends in Medicare charges, reimbursements, and utilization for ophthalmic and non-ophthalmic procedures.

Methods

We examined all ophthalmic, non-ophthalmic, and the 15 most performed ophthalmic medical/surgical procedures in Medicare Provider Utilization and Payment Data from 2013 to 2019. Monetary values were adjusted for inflation based on the 2019 United States (US) dollar using the Bureau of Labor Statistics Consumer Price Index. We calculated annual procedural utilization by adjusting service counts per million Medicare beneficiaries and examined trends for ophthalmic and non-ophthalmic procedures from 2013-2019 using descriptive statistics.

Results

From 2013-2019, Medicare inflation-adjusted charges and reimbursements changed by -14% and -23%, respectively, for ophthalmic procedures compared to +14% and +5%, for non-ophthalmic procedures, and -24% and -31% for the 15 most common ophthalmic procedures. Utilization of ophthalmic, non-ophthalmic, and common ophthalmic procedures changed by +2%, -15%, and +17%, respectively.

Conclusions

Lower reimbursements likely compensate for higher utilization in ophthalmology, especially since the magnitude of change in charges and reimbursements was larger for the 15 most performed ophthalmic procedures. In future reimbursement deliberations, policymakers should consider the declining reimbursements for procedures in ophthalmology relative to other medical specialties.

Public Interest Summary

Medicare reimbursement rates for common ophthalmic procedures decreased by 31% from 2011-2020. These reductions may lead to lower hospital revenue and, subsequently, higher prices. This shifts the financial burden onto uninsured and underinsured patients and is a potential barrier to care. Additionally, as there are not enough ophthalmologists in the US to adequately meet demand, further reimbursement reductions may influence student interest and contribute to earlier retirements in the existing ophthalmic workforce. This study identifies a decline in charges and reimbursements as utilization concurrently increased for ophthalmic procedures. In contrast, there has been an increase in charges and reimbursements with a decrease in utilization for non-ophthalmic procedures. Policymakers should take these findings into consideration in future decisions on reimbursement changes for ophthalmology.