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Originally published April 9, 2014 at 9:12 PM | Page modified April 9, 2014 at 9:40 PM

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Eye specialists get big chunk of Medicare payments

More than any other specialists, ophthalmologists — not cardiologists, cancer doctors or orthopedic surgeons — were the biggest recipients of Medicare money in 2012.


The New York Times

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Although consumers and health experts will be poring over the newly released Medicare data for months, maybe years, one startling piece of information has already emerged, demonstrating some of the complexity inherent in the long-fought-over information on 880,000 health-care providers across the country.

More than any other specialists, ophthalmologists — not cardiologists, cancer doctors or orthopedic surgeons — were the biggest recipients of Medicare money in 2012. The 17,000 providers, mostly concentrated in Florida, Texas, California and New York, accounted for 7 percent — $5.6 billion — of the reimbursements to doctors and other providers.

Included in the amount is $929 million for cataract surgery, about $1 billion for an expensive eye drug and $707 million for eye exams.

Put another way: Of the 100 physicians who receive the largest payments from Medicare, nearly half are eye specialists.

The reasons say volumes about an aging population and a specialty that does many procedures, some involving a very expensive drug, all of which are well-reimbursed by Medicare. They also speak to the difficulty of interpreting the data and what the numbers do and don’t reveal.

In ophthalmology, for example, a small number of doctors are able to perform high numbers of well-paid cataract surgeries or give numerous injections to patients with a serious eye disease known as macular degeneration, a condition that, if left untreated, leads to blindness.

They are also likely to treat a large share of Medicare patients in their practices.

“There are just these pockets of profitability within the system,” said Dr. Lisa Bielamowicz, executive director and chief medical officer for research at the Advisory Board Co.

Ophthalmologists say much of what Medicare pays them goes to the cost of the drugs they administer to patients in their offices, that and the bulk of that money ultimately goes to the drug companies.

The most expensive drug, Lucentis, which is used to treat macular degeneration, as well as 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 per injection into the eye, with at least one injection a month. A Genentech cancer drug, Avastin, can also be used off label to treat eye disease, at a cost of only about $50 per injection — although that choice is not without its own issues.

Many of the cancer specialists who are also highly reimbursed are also purchasing chemotherapy drugs, the cost of which is also included in what Medicare pays them.

Experts say the payments also do not reflect the cost of expensive equipment that a doctor may use in treating patients.

“If an internist admits someone to the hospital with pneumonia and they go to the ICU and have a $300,000 bill, that is not tagged to the physician,” said Dr. John Thompson, president of the American Society of Retina Specialists. “But when we treat someone for macular degeneration, that gets attributed to the physician.”

Eye doctors also say that compared with many other specialties, they treat mainly older people.

“You would expect ophthalmology to be heavily represented in a payment system that is for age 65 and up,” said Dr. Michael X. Repka, medical director for government affairs at the American Academy of Ophthalmology.

Doctors make a markup when they buy a drug and use it.

Medicare is supposed to pay 6 percent over the drug’s average price. That percent represents a larger number of dollars for an expensive drug than for a cheap one.

Retina specialists talk of colleagues who earn huge amounts of frequent-flier miles by buying Lucentis using credit cards.

Genentech encourages the use of Lucentis by offering big users rebates, which further increases the markup on the drug. Doctors questioned declined to talk about the rebates.

On a national scale, the choice of drugs can make a big difference to Medicare.

A 2011 report by the Office of Inspector General of the Department of Health and Human Services said 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.



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