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Study: ‘Dropless’ therapy could save billions of dollars for Medicare, Medicaid and patients
Using a one-time injection to replace antibiotic and anti-inflammation eye drop therapy associated with cataract surgery has the potential for saving government payers and patients billions of dollars over time, according to an economic impact study cited by Imprimis Pharmaceuticals in a press release.
The study, promulgated by Cataract Surgeons for Improved Eyecare and funded in part by Imprimis Pharmaceuticals, found that over 10 years, potential cost savings for patients, Medicare and Medicaid was “a most likely savings estimate of $8.7 billion.”
Currently, Centers for Medicare and Medicaid Services (CMS) does not reimburse for “dropless” therapy, priced at $100 per prescription, nor is the patient allowed to choose to pay for it, according to the study. Conversely, Medicare and Medicaid do reimburse for drop therapy associated with cataract surgery at an average of $323 and $337, respectively, with an average of 3.7 million surgeries being done each year in the U.S., according to the study.
Although the finished formulations of Imprimis’ “dropless” therapies are not FDA approved, the FDA has approved the individual agents: triamcinolone acetonide, moxifloxacin hydrochloride and vancomycin hydrochloride, the release said.
Perspective
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The Accountable Care Act has challenged doctors to achieve the “triple aim” of providing good patient outcomes and generating happy patients, all while reducing costs. This goal can only be achieved through innovation, likely disruptive innovation, meaning we will have to change the way we treat patients significantly.
One area ripe for disruptive innovation is the cataract surgeon’s management of infection prophylaxis and postoperative inflammation with topical drops. In regard to the “triple aim,” while drops are relatively effective and safe when patients take them properly, patients who hate them are rarely compliant in their use and the costs are high. In my city according to GoodRx.com the cash price at Walgreens of my preferred all branded drop regimen is $181 for the antibiotic, $204 for the steroid and $280 for the NSAID for a total of $665, more than I am paid as a surgeon. Of course, many patients have insurance and there are generics available as well as discount coupons, but if I have cataract surgery tomorrow with my personal insurance, my co-pay will be $50 per bottle, or $150 for the three drops I prefer, and my insurance will pay the difference.
One disruptive innovation that can provide high-quality care, generate happy patients and reduce costs is to replace some or all of these drops with an injection of antibiotic and steroid into the vitreous by the surgeon at the time of surgery. I have found the Tri-Moxi injection available from Imprimis for $20 to be highly effective and safe. My patients love it and universally select it when given the option vs. drops, so I now simply use it routinely unless there is a contraindication, which is rare. Versus a branded drop alternative this approach saves the patient and/or third party payer about $250 per case. Multiply that times 3,600,000 cataract surgeries a year and one can calculate a savings of $900,000,000 per year. Plus, intraocular antibiotics, as I read the literature, are at least 10 times more effective in preventing endophthalmitis, so as an additional benefit, 7,000 cases of potentially blinding postoperative endophthalmitis would be prevented.
In my experience, inflammation treatment is clinically similar and compliance issues disappear. Unfortunately, CMS has ruled that since the injection is given at the time of surgery, it is part of the facility fee bundle and no additional charge is allowed, even to the patient. While this is logical from one perspective, when the injection is given, it is not logical from another. The purpose of the Tri-Moxi injection is to replace drops, which are a preoperative and postoperative therapy for which there has always been separate reimbursement. In my opinion, third party payers such as CMS should not only look at when a treatment is given, but also at the purpose of the treatment. The purpose of intraoperative antibiotic and anti-inflammatory injections is to replace preoperative and postoperative drops. A switch to this mode of therapy will improve quality of care, generate happy patients and significantly reduce cost, seemingly a win, win, win, win for patients, doctors, payers and society.
Unfortunately, lack of reimbursement, or even for a willing patient to be allowed to personally pay for this option, severely dampens surgeon adoption. Many, if not most facilities and surgeons just cannot afford, in the face of declining reimbursement, to continuously assume more and more of the cost burden. Intraoperative intraocular antibiotic and steroid injections are not and never have been a part of the standard cataract operation. They are a replacement for preoperative and postoperative drops, and should be reimbursed as such. With proper reimbursement, this disruptive innovation will improve patient outcomes, increase patient satisfaction and significantly reduce costs.