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Kevin D Frick, Sissi Sun, David Huang; Analysis of the cost savings from applying optical coherence tomography (OCT) to guide treatment for choroidal neovascularization. Invest. Ophthalmol. Vis. Sci. 2016;57(12):5580. doi: https://doi.org/.
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We compare the cost per patient per month (PMPM) of using OCT to guide treatment decisions before administering ranibizumab with the cost of not using OCT and administering ranibizumab every month as recommended by the FDA for the treatment of choroidal neovascularization (CNV). We use a population of 143,000 Medicare patients being treated with ranibizumab for CNV in 2012.
In the Centers for Medicare and Medicaid Services 2012 database, the average amount that is paid to the manufacturer is $391.41 for a 0.1 mg dose of ranibizumab. The actual amount paid to physician is the manufacturer price plus 6%, or $414.89. The most common dosage is 0.5mg, making the average $2,074.45. This service is provided to Medicare patients under Medicare's Part B program for physician services, outpatient allied health services and drugs provided as part of a procedure. Medicare patients have to pay a 20% co-payment for this service. The Medicare payment amount for per OCT scan is $44.56. The billing codes are called “HCPCS codes" within the Medicare system. For OCT, the HCPCS code is “computerized ophthalmic diagnostic imaging, posterior segment; retina", 92134. The percent of doses avoided is from a literature review of PubMed. Using the FDA-recommended 12 injections per year to equal 100%, an average non-injection rate of 44.3% is found with OCT performed. This allows patients to avoid unnecessary injections almost one-half of the time.
The cost of providing the FDA-recommended monthly dose of 0.5mg ranibizumab to 143,000 patients would be $296,646,350/month. The cost of using OCT to guide treatment decisions–assuming monthly OCT scans–would be $6,372,080. When providing the dose of ranibizumab to only 79,651 individuals per month, the cost of the injections is $165,232,017. The total cost when using OCT on all patients and administering only the necessary doses of ranibizumab is $171,604,097. The cost saving for a population of 143,000 patients is $125,042,253, or $874 PMPM.
The use of OCT to guide treatment decisions for patients with CNV saves momey and improves the quality of the patient care experience. This combination suggests supporting reimbursement for this use of the technology and promoting its use by ophthalmologists. If ophthalmologist income is at risk the payment system could be redesigned as pay for performance.
This is an abstract that was submitted for the 2016 ARVO Annual Meeting, held in Seattle, Wash., May 1-5, 2016.
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