Disparities in Medicaid and Medicare Physician Reimbursements for Ophthalmic Procedures

Abstract

Purpose : Medicaid provides health insurance for many of the most medically underserved populations in the U.S. However, Medicaid tends to reimburse physicians at lower rates than Medicare. Lower reimbursement for Medicaid patients could contribute to disparities in eye care access and quality. We performed a retrospective, cross-sectional study to compare Medicaid and Medicare reimbursement for commonly performed ophthalmic procedures and correlate our findings with ophthalmologist’s acceptance of Medicaid patients in their practice.

Methods : Medicaid and Medicare physician reimbursement data for 18 commonly performed ophthalmic procedures (9 outpatient procedures and 9 surgeries) were acquired from 2021. Forty-eight US states and 1 territory were included in the analysis. Paired t-tests were used to compare mean Medicaid and Medicare reimbursement rates. These differences were compared by procedure for each state and between states. The coefficient of variation (CV), a measure of variability, in Medicaid and Medicare reimbursement data was quantified. Our data was also compared to a 2021 AAO practice environment member survey (n=937) assessing ophthalmologist’s acceptance of Medicaid and Medicare patients.

Results : The mean Medicaid reimbursement rate was lower than the mean Medicare reimbursement rate for surgeries (p<0.001) and for outpatient procedures (p<0.001). The average Medicaid reimbursement for surgeries was lower than the average Medicare reimbursements in 42/49 (85.7%) states. For outpatient procedures, the mean Medicaid reimbursement was lower in 36/49 (73.5%) states. We found that the Medicare reimbursement CV was 0.07 for all procedures, but the Medicaid reimbursement CV ranged from 0.36 to 0.62 for outpatient procedures and from 0.29 to 0.58 for surgeries. When comparing our results to the 2021 AAO survey data, we observe that provider respondents who routinely accept all Medicaid patients in their practice ranges from 56% to 66% based on region. This is in contrast to near total acceptance of Medicare patients by provider respondents.

Conclusions : Reimbursement is significantly lower for Medicaid when compared to Medicare, and it varies substantially by state for Medicaid. Given that some of our country’s most vulnerable populations’ health relies on Medicaid, it is important that we further explore how these disparities may affect access to and quality of eye care.

This abstract was presented at the 2023 ARVO Annual Meeting, held in New Orleans, LA, April 23-27, 2023.