Same-day exams during wet AMD anti-VEGF therapy could save up to $7 billion
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The Modifier-25 same-day exams during anti-VEGF therapy for neovascular age-related macular degeneration reduced treatment and travel costs at the patient and population levels, according to an expert at the virtual American Society of Retina Specialists meeting.
“Modifier-25 allows for the billing of an exam and an injection in the same day in some circumstances, but it is currently under scrutiny by payers,” H. Alexander Leder, MD, fellow of the American Academy of Ophthalmology, said during his presentation. “The purpose of this study was to evaluate the cost-benefit of office examinations in wet AMD therapy, compare the different costs of treatment paradigms and anticipate the clinical and financial implications of changes in reimbursement.”
In this study, the researchers estimated the cost vs. benefit of same-day office visits during intravitreal injections for wet AMD.
Using U.S. population statistics, clinical literature and CMS provider use data, Leder and colleagues assessed treatment parameters for injections, office exams and OCT testing payments. They created a spreadsheet to model different anti-VEGF treatment scenarios for wet AMD, then compared costs and benefits for three established scenarios:
- continuous therapy (10.1 injections, 1.9 office examinations per year);
- office-based treat and extend therapy (5.8 injections, 5.8 same-day office visits per year); and
- therapy in an injection clinic (8.6 injections, 4.7 same-day office visits per year).
Leder and colleagues found that all three exam-directed treatment paradigms resulted in cost-savings per patient and for the U.S. population compared with automatic treatment.
The results showed that office exams and OCT costs were higher for treat-and-extend therapy and therapy in an injection clinic compared with continuous treatment ($858 and $497 vs. $280); however, the model predicted lower yearly treatment costs for treat and extend therapy and therapy in an injection clinic than continuous treatment ($6,858 and $10,131 vs. $11,860). Further, travel costs were lower for treat and extend therapy and therapy in an injection clinic compared with continuous treatment ($536 and $672 vs. $942).
Compared with continuous therapy, the researchers calculated a cost savings of $7.2 billion (treat-and-extend therapy protocol) and $2.7 billion (injection clinic) annually for the U.S. population. Leder and colleagues also reported that early detection of wet AMD in the fellow eye during same-day office examinations resulted in a 2.1 and 1.8 benefit in quality-adjusted life years (QALY) for each patient in the treat and extend and injection clinic cohorts compared with continuous treatment, with an advantage of $5,402 and $2,891 per QALY.
“Our model found that complete exams of both eyes with OCT testing can reduce travel costs, treatment costs and improve screening of the fellow eye, resulting in robust cost savings and improvements in quality-adjusted life years for improvement of vision in the fellow eye,” Leder said. “We conclude that it is important to advocate for our patients and retain the option to customize treatment to the different needs of each patient with exams and OCTs.”
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Leder HA, et al. Modifier-25 examinations reduce travel burden, decrease treatment cost, and improve QALY for exudative age-related macular degeneration patients. Presented at: American Society of Retina Specialists annual meeting; July 24-26, 2020 (virtual meeting).
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