The Prevalence of Diagnosis of Major Eye Diseases and their Associated Payments in the Medicare Fee-for-Service Program

Abstract

Purpose: To estimate the prevalence of diagnosis of major eye disorders and their associated payments, in total and per-person diagnosed, among Medicare fee-for-service (FFS) beneficiaries in 2018.

Methods: We analyzed 100% Medicare Part B FFS claims and Part D Events among beneficiaries continuously enrolled for 12 months in 2018 to calculate the proportion of beneficiaries with ≥1 claim indicating age-related macular degeneration (AMD), cataract, diabetic retinopathy (DR), or glaucoma, and their associated payments, including Medicare and patient out-of-pocket. Eye disease and eye care services were identified using case definitions from the Centers for Disease Control and Prevention's (CDC) Vision & Eye Health Surveillance System (VEHSS). Outcomes are reported by disease overall and by age group (0-39, 40-64, 65-84, 85+ years), sex, race/ethnicity, and U.S. state.

Results: Among nearly 30 million Medicare Part B FFS beneficiaries in 2018, over 41% (12.4 million) had a claim containing a diagnosis of at least one of the four eye disorders; 33.7% with cataract, 13.3% with glaucoma, 9.2% with AMD and 3.2% with DR. Payments for eye care services and drugs associated with these four conditions were $10.1billion; $3.6 billion for cataract, $3.5 billion for AMD, $2.2 billion for glaucoma and $0.8 billion for DR. The average cost per beneficiary diagnosed was $816: $1,290 for AMD, $781 for DR, $543 for glaucoma, and $360 for cataract.

Conclusions: Major eye disorders are common among Medicare FFS beneficiaries and account for approximately 4.3% of Medicare Part B and 1% of Medicare Part D spending.

Keywords: AMD; age related macular degeneration; cataract; cost; diabetic retinopathy; eye; glaucoma; medicare; ophthalmic; payment; preva lence; vision.