Trends in Medicare Service Volume for Cataract Surgery and the Impact of the Medicare Physician Fee Schedule

Immediate Sequential Bilateral Cataract Surgery: Opinions among Refractive Surgeons in the United States and a Comparative Analysis with European Consultants

Purpose

To analyze the perspectives of practicing refractive surgeons regarding the implementation of Immediate Sequential Bilateral Cataract Surgery (ISBCS) in the United States (US) and to compare their perspectives with those of European colleagues. Setting. Online refractive surgery forum.

Design

A survey-based questionnaire.

Methods

An electronic survey was emailed to all surgeon members of the Refractive Surgery Alliance (RSA) in the US. Participants were prompted to score their impressions regarding various aspects regarding ISBCS. Responses were compared to published reports conducted among European surgeons.

Results

The electronic link to the survey was emailed to US-based surgeon members of the RSA, where 107 participated (44.6%). Twenty-seven (25.2%) reported that they currently perform ISBCS. Twenty-three (22.5%) of the respondents indicated they felt ISCBCS should be offered as a standard of care for routine cataract surgery. For surgeons that do not perform ISBCS, the most important factors were related to medicolegal issues and decreased reimbursement, whereas evidence of effectiveness and complications related to ISBCS were less important. Compared to practitioners abroad, 67.2% of European ophthalmic surgeons, compared to 25.2% of US surgeons, perform ISBCS (p < 0.0001).

Conclusions

While US refractive surgeons often perform bilateral corneal procedures, many significant barriers exist to the widespread adoption of ISBCS. Concerns reported by US surgeons mirror those reported by surgeons in Europe. The majority of the US refractive surgeons in this survey indicate that ISBCS should not be the standard of care in routine cases, with the prevailing reason being concerns about decreased physician reimbursement and potential medicolegal issues, not safety.

United States Medicare Reimbursement Trends for Glaucoma Procedures: 2000 to 2020

PURPOSE

To investigate United States medicare reimbursement trends for common glaucoma procedures from 2000 to 2020.

MATERIALS AND METHODS

Current Procedural Terminology codes for Glaucoma procedures in the United States Centers for Medicare and Medicaid Services database were used to conduct this economic analysis. Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for the selected procedures and compensation trends were investigated after adjusting for inflation in 2020 US dollars from the unadjusted data between 2000 to 2020.

RESULTS

The average adjusted reimbursement for the analyzed procedures decreased by 20.5% (95% confidence interval [CI], -15.4% to -25.6%) over the twenty-year period. On average, there was a 1.03% decrease in reimbursement rates per year (95% confidence interval [CI], -0.74% to -1.33%) with an adjusted Compound Annual Growth Rate of -1.35% (95% confidence interval [CI], -1.07% to -1.64%). The results show an overall declining rate in reimbursement for the glaucoma procedures analyzed in this study.

CONCLUSIONS

United States medicare reimbursement for glaucoma procedures in the United States showed a significant decline between 2000 to 2020. These findings may be relevant to understanding changing practice patterns for glaucoma care.

THE ASSOCIATION BETWEEN COMPLEX CATARACT SURGERY AND SOCIAL DETERMINANTS OF HEALTH IN FLORIDA

PURPOSE

To analyze differences between rates of complex and routine cataract surgery based on demographics and social determinants of health (SDOH) at the community level.

METHODS

Data from adults ages 18 to 84 relevant to cataract surgery billing codes were extracted from the 2017 Florida Ambulatory Surgery dataset from the Agency for Healthcare Research and Quality merged with SDOH measures from the American Community Survey. A multivariable logistic regression model was used to determine associations between complex cataract surgery and SDOH according to patient ZIP code. Outcomes were reported as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

A total of 171,754 and 11,340 patients received routine and complex cataract surgeries, respectively; females received the majority of routine surgeries (58.87%); most common age group (79.11%) was from 65 to 84 years. Male (odds ratio [OR] 2.034; p < 0.0001) and black patients (OR 1.998; p < 0.0001) more likely received complex surgery. Compared to Medicare patients, patients insured with Medicaid (OR 2.058; p < 0.0001), private insurance (OR 1.057; p = 0.0182), or self-pay (OR 1.570; p < 0.0001) were more likely to receive a complex surgery. ZIP codes with higher adult poverty (OR 2.614; p < 0.001) were more likely complex surgery patients, whereas those with higher rates of high school attendance (OR 0.487; p = 0.0193) and home occupancy (OR 0.704; p = 0.0047) were less likely to be complex.

CONCLUSIONS

Selected patient- and community-level factors including being male, Black, Asian, Hispanic, non-Medicare, or within lower education, higher poverty ZIP codes were associated with a higher likelihood of receiving complex cataract surgery.

What Is the Cost of a Posterior Capsule Rupture Complication?

BACKGROUND AND OBJECTIVE

To examine the cost of a posterior capsule rupture (PCR) in patients who underwent planned phacoemulsification.

PATIENTS AND METHODS

Retrospective review of 8,113 cataract surgeries performed between January 2014 and December 2017 at one academic institution. The rate of PCR was 0.55%, and 34 patients with PCR who met inclusion criteria were identified. Investigators evaluated the added operating room time required to manage PCR, subsequent surgeon visits beyond the typical average, referrals to other specialties, further imaging, and additional required surgeries.

RESULTS

Patients with PCR had an additional 2.76 (standard deviation [SD] ± 3.27) postoperative encounters and 3.06 (SD ± 3.78) visits to another subspecialty. Operating room time was found to average 61.43 minutes (range: 21 to 191 minutes) at an additional cost of $455.48 (SD ± $407.37). Additional visits, imaging, and procedures added $655.59 (SD ± $767.21). The total additional average cost was $1,111.07 (SD ± $1,021.20) per PCR.

CONCLUSION

Posterior capsular ruptures impose a substantial cost burden on the health care system. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:444-447.].

Impact of iStent Micro-Bypass Shunt on Medicare Part B Glaucoma Surgical Expenditure

PURPOSE

To examine the impact of the iStent (Glaukos) on the recent glaucoma surgical expenditure for Medicare Part B beneficiaries.

DESIGN

Retrospective, observational, population-based analysis.

PARTICIPANTS

All applicable cases in the Centers for Medicare and Medicaid Services Part B Summary Data Files.

METHODS

The Part B National Summary Data Files from 2007 to 2017 were obtained through the Centers for Medicare and Medicaid Services. Glaucoma surgical procedures, including trabeculectomy, glaucoma drainage implants (GDIs), and select minimally invasive glaucoma surgeries (MIGS) including the iStent, were queried from the database using Current Procedural Terminology (CPT) codes. We used Chow's test to confirm significant changes in expenditure trajectories. We built a mixed-effects regression model to examine the effect of demographic factors on each state's iStent adoption speed.

MAIN OUTCOME MEASURES

Proportion of iStent in total glaucoma surgical spending for individual states for each year.

RESULTS

Total Medicare part B payment for the selected glaucoma procedures increased from $52.0 million in 2007 to $179.9 million in 2017. The percentage for trabeculectomy and GDIs decreased from 92.3% to 21.2%. Conversely, the iStent, approved by the Food and Drug Administration in 2012, increased to represent 57.9% of total payment by 2017. There were significant changes in the slope of glaucoma surgical Medicare payment (P < 0.00001) and iStent payment (P < 0.0001) trajectories in 2012. Mixed-effect regression analysis showed a wide range among the states' rates of increase in iStent proportion between 2012 and 2017 (range, 5.12%-14.54% per year). Higher male proportion in the population was associated with faster increases in iStent proportions (12.4% per 5% increase in male proportion, 95% confidence interval [CI], 4.3-20.5, P = 0.003). Higher median age of the population was associated with slower increases (-3.6% per 1-year increase in median age, 95% CI, -0.4 to -6.8, P = 0.026).

CONCLUSIONS

Increasing payment for the iStent represents the majority of the increase in glaucoma surgical spending in the recent decade. Male gender and age significantly affect the state-wise speed of adoption for the iStent. The impact of the iStent on the comprehensive glaucoma Medicare expenditure in the same time period warrants further study.