Ophthalmologists say their benefits are lower than the data suggests

Although consumers and health experts will ponder the newly released Medicare data for months or even years to come, startling information has already emerged demonstrating some of the complexity inherent in the long-contested information on 880,000 health care providers. Across the country.

More than any other specialist, ophthalmologists — not cardiologists, oncologists, or orthopedic surgeons — were the biggest recipients of Medicare money in 2012. The 17,000 providers, most of whom are concentrated in Florida, Texas , in California and New York, accounted for 7 percent. — $5.6 billion — reimbursements to physicians and other providers. This amount includes $929 million for cataract surgery, about $1 billion for expensive eye medication and $707 million for eye exams.

In other words: of the 100 doctors who receive the largest payments from Medicare, almost half are eye specialists.

The reasons speak volumes for an aging population and a specialty that performs many procedures, some involving very expensive drug, all of which are well reimbursed by Medicare. They also talk about the difficulty of interpreting the data and what the numbers do and do not reveal.

Credit…Michael Nagle for The New York Times

In ophthalmology, for example, a small number of doctors are able to perform a large number of high-paying cataract operations or administer many injections to patients with a serious eye disease known as macular degeneration, a condition that can, if left untreated, lead to blindness. They are also likely to treat a large portion of Medicare patients in their practices.

“There are only those pockets of profitability in the system,” said Dr. Lisa Bielamowicz, executive director and chief medical officer for research at the Advisory Board Company.

Ophthalmologists say their strong representation among the list of major recipients is misleading. Much of what Medicare pays them, they say, goes to the cost of the drugs they administer to patients in their offices and most of that money ultimately goes to drug companies.

The most expensive drug, Lucentis, which is used for macular degeneration, as well as other retinal diseases, accounted for about $1 billion in Medicare spending in 2012, according to figures released Wednesday by the Centers for Medicare and Medicaid. Services.

Lucentis, made by Genentech, costs nearly $2,000 to inject into the eye, as often as once a month. A cancer drug from Genentech, Avastin, can also be used off-label to treat eye disease, at a cost of around $50 per injection, although this choice is not without its problems.

Dr. John C. Welch, a Nebraska eye doctor who received $9.5 million in Medicare payments in 2012, said the high reimbursement was a result of treating large numbers of patients and the cost of injections. . He says he does not benefit significantly from any of the drugs he uses, earning less than 3% on Lucentis. (Whether he benefits from it is hotly debated in the medical world. Some experts say doctors shouldn’t profit at all from the drugs they use.) He said he preferred the drug because his patients could go longer between treatments. He also said patients were more comfortable with a Food and Drug Administration-approved drug — like Lucentis — and didn’t need to be prepared at a special pharmacy, like Avastin does. He said he was now using a newer drug, Eylea from Regeneron, because it seemed patients could be treated less frequently.

The prices of these drugs and the difference in approval are not the doctors’ fault, he said. “It’s basically a problem created for us by the medicare system,” he said.

Many cancer specialists who are also heavily reimbursed also buy chemotherapy drugs, the cost of which is also included in what Medicare pays them. Experts say the payments also don’t reflect the cost of expensive equipment a doctor may use to treat patients.

“If an internist admits someone to the hospital with pneumonia and they go to intensive care and have a $300,000 bill that’s not labeled to the doctor,” said Dr. John Thompson, president from the American Society of Retina Specialists. “But when we treat someone for macular degeneration, it’s attributed to the doctor.”

Ophthalmologists also say that, compared to many other specialties, they primarily treat older people. “One would expect ophthalmology to be strongly represented in a payment system for those 65 and older,” said Dr. Michael X. Repka, medical director of government affairs at the American Academy of Ophthalmology.

Still, there are financial incentives that may push doctors to use the more expensive Lucentis rather than Avastin.

Doctors make a margin when they buy a drug and then use it. Medicare is supposed to pay 6% more than the average drug price. This percentage represents a greater number of dollars for an expensive drug than for an inexpensive drug.

Retina specialists tell of co-workers earning huge amounts of frequent flyer miles by buying Lucentis with a credit card.

Genentech encourages the use of Lucentis by offering discounts to heavy users, which further increases the margin on the drug. The doctors interviewed refused to talk about reimbursements.

The volume of injections can be high. Dr. Frederick Reeser in Milwaukee, which is near the top of Medicare’s reimbursement list, performed more than 6,000 eye injections in 2012, according to Medicare data.

“We can do 25 injections a day; it’s not an unusual day,” said firm administrator Jim Mortell. “A lot of people are kept on medication and never stop it.”

Lucentis injections accounted for $7.0 million of Dr. Reeser’s total Medicare reimbursement of $8.6 million.

Nationally, drug choice can make a big difference to Medicare. A 2011 report from the Office of Inspector General of the Department of Health and Human Services stated that if Avastin had been used completely in place of Lucentis to treat macular degeneration in 2008 and 2009, Medicare would have saved 1.1 billion dollars. Conversely, if only Lucentis and no Avastin had been used, Medicare would have spent an additional $1.5 billion over the two-year period.