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Cost of glaucoma care decreased in constant dollars from 2002 to 2009
Sampling of Medicare billing found that the cost of cataract and retinal care far exceeded the cost of glaucoma care.
Annual glaucoma care costs per person in the United States decreased in constant dollars from 2002 to 2009 — from $242 to $228 — based on data from a 5% random sampling of Medicare billing information.
The assessment also found that for patients with coded open-angle glaucoma (OAG), 49% of all Medicare payments were for office visits, followed by 31% for diagnostic testing, led by visual field tests.
Surgery accounted for 12% of OAG payments, with half for trabeculectomy fees. Prescription drug costs were excluded from the evaluation because of inconsistent coverage by Medicare programs.
Unbalanced compensation
“I would have thought that the amount of money Medicare pays each year for each person with glaucoma would have been much larger — perhaps four or five times more,” principal investigator Harry A. Quigley, MD, a professor of ophthalmology and director of the Glaucoma Center of Excellence at Wilmer Eye Institute, said.
Harry A. Quigley
“We also were startled that the categories of care for cataract and retinal disease were way in excess of the total for each patient’s glaucoma care (67% higher for non-glaucoma eye care),” Quigley said. “Should it cost significantly more to take care of one eye disease than another? I think this deserves investigation. It may well be that there is a legitimate, perfectly reasonable explanation as to why cataract or retinal disease should be recompensed more than glaucoma by Medicare.”
Over the past decade, co-investigators Emily W. Gower, PhD, an epidemiologist at Wake Forest School of Medicine in Winston-Salem, N.C., and David S. Friedman, MD, PhD, who is a member of the Glaucoma Center of Excellence, have been studying, through a grant from the Centers for Disease Control and Prevention, numerous aspects of ophthalmic care via the Medicare database.
“Friedman and I were specifically interested in the level of glaucoma care, how it is changing and the status of surgery,” Quigley told Ocular Surgery News. “We feel this information is extremely relevant, especially in light of the Affordable Care Act and other issues that are impacting ophthalmology.”
Decreasing cost
Quigley said it is important for the ophthalmic community to consider what it is doing, how effective it is and the cost.
“Are we doing something reasonable for that amount of money?” he said. “In constant dollars, glaucoma care is decreasing in cost per patient per year. This could be attributed to efficient behavior by ophthalmologists and/or attributed to the fact that some of the charges under Medicare were already being reduced. In any event, glaucoma does not represent a huge, escalating part of the pie.”
In 2009, total glaucoma payments by Medicare were $37.4 million for the 5% Medicare sampling, for an estimated cost of $748 million for the entire Medicare population. This glaucoma care represents only 0.4% of an estimated $192 billion for all Medicare fee-for-service (FFS) payments.
The investigators were surprised that surgical and laser procedures constituted only about 10% of glaucoma-related costs.
“I expected that these procedures would represent at least one-third of all costs,” Quigley said. “The reality, though, is not that many patients are having these treatments.”
The analysis, which appeared in Ophthalmology, noted that the proportion of OAG codes to angle-closure glaucoma (ACG) codes is far higher than the roughly five OAG patients to one ACG patient suggested by population-based data.
“The coding for Medicare patients is more like 30 OAG patients for every ACG patient,” Quigley said. “Therefore, we surmise that a lot of persons are simply coded as OAG, when in fact they have ACG, or that there are a lot of ACG patients out there who are not being coded or are not being treated under Medicare. I believe it is more likely that doctors simply code the condition as glaucoma, without differentiating, and use mostly the term OAG.”
Quigley predicted that the stabilization of glaucoma rates will continue until the reimbursement system changes.
“If we were to decrease all the overhead that is inherent in FFS medicine, we would save money,” he said.
A follow-up study will evaluate the trends in surgical and laser treatments over time and among different regions of the United States. – by Bob Kronemyer