Practices may want to focus on office-based medical retina treatment
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An intravitreal injection is the most common procedure performed in ophthalmology.
In the U.S., intravitreal injections are in most cases an office-based procedure. As I have stated many times, the office is a critically important source of revenue for the ophthalmologist, and office-based intravitreal injections can be a meaningful source of income for the practice that provides them. The most common indications are wet age-related macular degeneration, diabetic retinopathy, diabetic macular edema and retinal vein occlusion. The accompanying cover story focuses on wet AMD.
According to the National Eye Institute, approximately 200,000 new cases of wet AMD are diagnosed each year in North America, and a total of 3 million individuals currently manifest this disease. Including all indications, approximately 8 million intravitreal injections are performed each year. The cost to Medicare alone is estimated to be $12 billion per year. This makes an intravitreal injection the highest single expense for Medicare. The cost per treatment includes the injected anti-VEGF, which averages close to $1,800 per treatment for an FDA-approved branded pharmaceutical. The associated eye care provider (ECP) office visit charge when an anti-VEGF is injected is about $225. Along with the pharmaceutical company rebate, an intravitreal injection can generate $400+ per treatment for a practice.
From the perspective of patients and society, the benefit provided by anti-VEGF therapy is enormous, and pharmacoeconomic studies support a positive cost-benefit analysis. The average patient being treated receives eight injections per eye per year, and 70% of ECPs who perform intravitreal anti-VEGF therapy utilize a treat-and-extend protocol rather than monthly injections, which was the approach utilized in the clinical trials.
I was surprised to learn that just more than 50% of patients who begin anti-VEGF treatment voluntarily discontinue therapy within 1 year. This confirms that the challenges to patients and their families in accessing care, along with the economic burden and, in some cases, the pain and fear associated with an injection into the eye, remain an issue. Significant investment is being committed by industry to develop innovations that will reduce the frequency of injections required to alleviate this patient burden.
I was also interested in gaining some insight into who is performing these millions of intravitreal injections each year in the U.S. One paper reported that in 2016, of 3,637 ECPs who performed intravitreal injections, 2,591 (71%) were fellowship trained in retina and limited their practice to this specialty alone, with 1,046 (29%) being non-retina-only eye specialists. Many of them were comprehensive ophthalmologists who had a special interest and training in this form of therapy. This is an area of significant controversy, with the American Society of Retina Specialists firm in its recommendation that an intravitreal injection is best performed by a fellowship-trained retina specialist. Today, in a 3-year ophthalmology training program, the most common procedure performed by many ophthalmology residents is an intravitreal injection. Therefore, it is not surprising that many young well-trained ophthalmologists are including intravitreal injections in their practice offering.
The decision as to who provides any ophthalmic procedure is multifactorial and includes the patient’s preference, the ECP’s training and desires, each individual practice’s guidelines and culture, payer policies, medical licensing board regulations and, when performed in an ASC or hospital outpatient department, the facility’s policies.
There is a significant and growing revenue opportunity for the practice that provides intravitreal injections. In our practice, we have added fellowship-trained medical retina specialists to provide this important service. As I look to the future, I expect many of the ophthalmologists being trained today will be comfortable offering intravitreal injections to their patients. The winds of change never stop blowing, and this is a trend that is already in motion and likely to grow.
After 5 decades in ophthalmology, with a special interest in practice economics, I am often asked by colleagues how I would define the ideal practice. While there is no perfect model, I believe that an attractive practice would have four ophthalmologists in a single office. They would all perform cataract and refractive cataract surgery. They would be equal partners. One partner would have fellowship training or a special interest in glaucoma and manage the more difficult patients with this malady. The second partner would have fellowship training or a focus on the cornea and provide advanced medical and surgical cornea care and perform refractive corneal surgery. The third partner would become expert in oculoplastic procedures and perhaps pediatric ophthalmology. The fourth partner would be trained in retina or develop expertise that would allow the practice to offer medical retina including intravitreal injections. My ideal practice would own its own ASC and employ at least four optometrists and at least one physician assistant or nurse practitioner. If I were founding a practice today, that would be my target. This division of subspecialty interest can also be encouraged in an established practice.
Office-based medical retina is expanding rapidly, with intravitreal injections of complement inhibitors to delay the progression of geographic atrophy likely to become FDA approved as early as 2023. In the next decade, the wise comprehensive ophthalmology practice will find a way to incorporate office-based medical retina treatment, including intravitreal injections, into their patient care offering.
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