Medicare Payments for Retinal Procedures are Down | AAO 2023

John T. Thompson, M.D.

There has been a downward trend in Medicare reimbursement for retinal surgeries from 2011 to 2020 that has not kept up with inflation, John T. Thompson, M.D., an ophthalmologist with Retina Specialists of Maryland, said during a presentation today at the American Academy of Ophthalmology 2023 annual meeting.

At the same time, Medicare reimbursement for primary care has increased. In 2021, Medicare changed physician reimbursement levels for outpatient and office-based evaluation and management (E/M) services, with payments for surgical procedures decreasing. For common retinal procedures, reimbursement decreased about 6.9% overall, according to a study released in January 2023.

Yesterday CMS released its 2024 fee schedule, which will cut payments to physicians by 1.25% compared with 2023, even though the medical inflation index increased by 4.6%. It is expected that payments for visits for many services, such as primary care and longitudinal care, will increase, as will payments for hospitals and ambulatory surgical center services.

Thompson said a decrease in Medicare reimbursement usually results in lower payments from private insurers as well. “The net effect has been to reward primary care more than surgery,” he said.

Reimbursement for retinal procedures has gone down partly because the time it takes a retinal specialist to complete a procedure has decreased. For example, innovations such a small gauge vitrectomy — a minimally invasive surgery to treat retinal detachments, macular holes and vitreous hemorrhages — can be completed more rapidly with better patient outcomes. Thompson argued, however, that reimbursement should also consider the complexity of the procedure and not just the time it to takes to complete.

During his presentation, Thompson highlighted several studies that looked at the impact of Medicare reimbursement on practices that conduct vitrectomy surgeries. These studies suggest there is an opportunity cost to physicians who do retinal surgeries. One study showed that ophthalmologists would make a small profit at the current reimbursement levels, but Thompson said it would not be possible to continue to maintain a practice at those levels.

Thompson said during his presentation that is critical for organizations that provide retinal procedures to also be busy with providing other kinds of retina care for patients with macular degeneration and diabetic retinopathy and those taking medications such as hydroxychloroquine who need retina checkups because the medication can damage the retina.

Separately, a poster at the meeting assessed the challenges that women in ophthalmology face. The researchers, led by Ron A. Adelman, M.D., at the Yale School of Medicine, found that the Medicare income to female ophthalmologists was half as much as the payment to male colleagues. The researchers found that the number of patients seen is the reason for the difference. The gap was smaller for those with five to 10 years of experience, and Adelman and his colleagues researchers theorized the gap increases after a physician has her first child.