Medicare physician reimbursement data could be confusing to the public

The Centers for Medicare & Medicaid Services today released to the public data relating to 2013 Medicare payments made to physicians and other providers. In response, the American Academy of Ophthalmology is providing necessary context for the reimbursement data, which in its raw form are often complex and difficult to understand. The Academy, which represents the majority of eye physicians and surgeons within the United States, is offering information about significant factors regarding how ophthalmologists are reimbursed for services in an effort to render the data more meaningful for public use.

The Academy is reminding the public that among medical specialties, ophthalmology has one of the highest percentages of Medicare patients. Common in this patient group are the incidence of eye diseases – including cataract, diabetic retinopathy, glaucoma and age-related macular degeneration (AMD) – that are expensive to treat and could otherwise result in blindness.

The data include Medicare Part B drug payments, which are a significant factor as to why ophthalmology is so prominent in the CMS database. These data reflect only gross payments and do not discern between physician drug compensation and the cost paid by the physicians for the Part B drugs.

"While ophthalmology supports CMS' efforts to promote transparency and accountability, the data still lacks important context," said David W. Parke II, M.D., CEO of the American Academy of Ophthalmology. "The payment release can be extremely confusing for the public to interpret the information, which includes payment for Part B drugs alongside physician payments. Medicare data are incredibly complex, and analyzing this information without proper detail and context can lead to erroneous conclusions."

For example, some of the costliest medications used by ophthalmologists are Food and Drug Administration-approved anti-VEGF drugs for treatment of the more severe "wet" form of AMD, which is the leading cause of blindness among older Americans. Before the advent of anti-VEGF drugs, about two-thirds of wet AMD patients could expect to be legally blind within two years of developing the disease. Anti-VEGF drugs are also used to treat one of the most common causes of severe vision loss in Americans – diabetic retinopathy. They have been found to be particularly effective in the treatment of diabetic macular edema.

Today, there are three highly effective anti-VEGF options: two FDA-approved drugs (Lucentis® and Eylea®) and one off-label use drug, Avastin® (a cancer medication). More than half of ophthalmologists choose the less-expensive Avastin, which costs approximately $50 per dose, while the other two cost between $1,900 and $2,000 per treatment. Ophthalmologists must purchase these anti-VEGF drugs in advance from the manufacturers. Medicare subsequently reimburses the physicians for these costs. The Medicare payments for these medications essentially pass through back to the pharmaceutical companies.

Having multiple treatment options for diseases such as wet AMD and diabetic retinopathy is crucial to providing the best care possible, as individual patients respond differently to different drugs. Ophthalmologists support the availability of each of these medications as they collectively provide a highly effective arsenal against these diseases. Ultimately, which drug is used is dependent upon a variety of factors, including patient choice in partnership with the physician, patient response to each medication (which varies from person to person) and availability. Some states have restrictions around the availability of compounded medications, including Avastin – which must be repackaged into doses specific for the eye – making it difficult to obtain and in some instances, prohibited by law.