Abstract
Purpose :
There are variations in the reimbursements of healthcare services determined by the Centers for Medicare & Medicaid Services (CMS) and third-party payers, leading to financial pressures on clinics and hospitals. We propose a novel reimbursement disparity index (RDI) comparing differences between charges and allowable payments as a proxy for differences between CMS and third-party payers.
Methods :
Using the U.S. Medicare Provider Utilization and Payment Data (Physician and Other Supplier) from the CMS for ophthalmologists in 2017–2020, RDI was calculated (average submitted charge/average standardized payment by Medicare). The Medicare Economic Index (MEI) and Chained Consumer Price Index (cCPI) were used to adjust for inflation. Compound annual growth rates (CAGR) for reimbursement of each of the top 5 most billed surgical, diagnostic, and examination HCPCS/CPT codes were calculated. Pearson correlation coefficients and T-tests assessed significant trends and differences.
Results :
There was an average of 55,629,204 services/year performed by ophthalmologists annually from 2017 to 2020. Annual reimbursement per year was on average $7,235,291,582. The average RDI was 4.82 in the facility setting and 3.18 in the non-facility setting (p<0.001). There was a significant increase in RDI from 2017 to 2020 (p<0.001). Average annual reimbursement decreased for each of the 5 most frequently performed services. 0191T (aqueous drainage device into trabecular meshwork) had the greatest decrease in the facility setting (CAGR, -24.222%) and 92250 (fundus photography) in the non-facility setting (CAGR, -17.273%). The average RDI for female ophthalmologists (3.44) was significantly higher than for males (3.27; p<0.001). South Dakota (1.641), Montana (1.766), and Arizona (1.997) were the states with the lowest median RDIs, while Alaska (4.522), Massachusetts (3.844), and Oregon (3.252) had the highest.
Conclusions :
Our findings suggest that the RDI and thus payment disparities are increasing across the most common ophthalmology codes. Increasing RDIs were primarily driven by a decrease in reimbursement for physician work regardless of setting, thus increasing RDI may threaten the financial sustainability of ophthalmic services in both clinic and hospital-based settings. Increases in reimbursement will ensure the viability of ophthalmic care, especially in many rural areas.
This abstract was presented at the 2024 ARVO Annual Meeting, held in Seattle, WA, May 5-9, 2024.