Eye Injections Cost More Than Payers Think

Marcia Frellick

July 29, 2019

CHICAGO — Specialists are losing money with every intravitreal injection they administer, regardless of the drug being injected, an investigator warns.

Each injection we do costs $127.74 — $1.60 for materials, $97.88 for labor, and $28.26 for overhead — said Christina Weng, MD, from the Cullen Eye Institute at the Baylor College of Medicine in Houston. However, Medicare reimbursement in 2018 was just $104.40, which means a loss of $23.34, or 22.36%, for every injection.

"That's shocking because it is one of the most frequently used codes in our specialty and subspecialty. We perform about 7 million injections a year in the United States," she told Medscape Medical News.

The findings, presented here at the American Society of Retina Specialists 2019 Annual Meeting, are particularly significant, Weng said, because a mid- to high-volume practice can do 20 to 50 injections each day. And small practices could be particularly hard hit because, unlike larger practices, they cannot spread overhead costs out.

Weng said she decided to do the observational activity-based cost analysis because the Common Procedural Terminology (CPT) code for intravitreal injection (67028) is closely scrutinized by regulators who are checking to make sure that physicians are not being overpaid for the very common procedure.

But what she found, when she timed each step of the procedure in her practice for 14 patients who came in for an injection-only appointment and added in the associated costs, was that they are actually being underpaid.

Part of the problem might stem from an undervaluation when physicians are asked about costs by the Relative Value Scale Update Committee (RUC), a group of physicians who make recommendations to the American Medical Association, she explained, which then makes recommendations about the value of new and revised CPT codes to the Centers for Medicare and Medicaid Services.

Physicians often think of the injection as a 2-minute process of greeting the patient, giving the injection, and washing the patient out, Weng said. But her study put the total time related to the procedure at 32 minutes and 58 seconds.

Hidden Costs

"When you add up the time between charting, ordering up the medication, getting the patient prepped — maybe not by the physician but by staff — those are all costs involved in the procedure," Weng said.

These findings are "concerning," said moderator Geoffrey Emerson, MD, PhD, from the Retina Center of Minnesota in Minneapolis.

"Doctors know running a clinic is expensive, but we forget about hidden costs, such as rent, data entry into the EHR, and time spent greeting patients," he told Medscape Medical News.

This study "shows that clinics incur a net loss when hidden costs are factored in. This is especially concerning, considering that intravitreal injection is our most common and best tool for helping patients with retinal disease," he added.

The findings point to action needed on two fronts, said Weng: re-evaluating whether the reimbursement is fair, and working to make the injection process more efficient.

For instance, a time–motion study of family physicians showed that more time is taken with electronic health record documentation than with direct patient care, as reported by Medscape Medical News. Those findings are consistent with several other studies.

"The doctor spent 6.5 minutes on the EHR and only 5.5 minutes with the patient face to face," she reported. "It's really shocking to see."

Costs likely differ by region, Weng pointed out. Rent in Houston is lower than it would be in many other large urban areas, so her calculations, which used her actual rent, are probably very conservative.

These numbers are from one physician in one practice, Weng cautioned, but she said she hopes the findings will prompt others to assess costs in their own practices so that an accurate national reimbursement figure can be arrived at.

"The last thing we want to do is get pegged to $127," she said. "We really want this to be accurate."

A re-evaluation of the code is also important because the cost of drops to numb the eye and dilating drops, for instance, have risen sharply, said John Thompson, MD, from the Greater Baltimore Medical Center.

This work "can serve as data for us to go up in front of the RUC and say, 'look, the numbers you have are outdated'," Thompson added.

Weng reports relationships with Alcon, Alimera Science, and Allergan. Emerson and Thompson report no relevant financial relationships.

American Society of Retina Specialists (ASRS) 2019 Annual Meeting. Presented July 28, 2019.

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