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Medicare Spending on Treatments for Ophthalmic Conditions

Summary

Avalere analysis finds that new users account for a large share of Medicare spending on opthalmic medications.

Ophthalmic conditions can significantly impair vision and lead to blindness. In 2018, physician-administered medications to treat ophthalmic conditions accounted for nearly 10% of the total Medicare Part B drug spending. The top 3 conditions — Wet Aged-related Muscular Degeneration (AMD), Diabetic Macular Edema (DME), and Retinal Vein Occlusion (RVO) — accounted for 77%, 12% and 11% of Medicare spending on ophthalmic medications, respectively (Figure 1).

Figure 1. Breakdown of Medicare Part B Spending on Physician-Administered Medications by Ophthalmic Condition, 2018
Figure 1. Breakdown of Medicare Part B Spending on Physician-Administered Medications by Ophthalmic Condition, 2018

*Other Conditions: Diabetic Retinopathy (DR), DR without DME, Macular Edema/Cystoid Macular Edema, Uvetitis.

Avalere’s analysis finds that overall 7% of Medicare Part B spending on ophthalmic medications was for new users. However, the share of drug spending for new users varied greatly by ophthalmic condition. For instance, new users accounted for nearly half (48%) of Medicare drug spending to treat DR, but new users of Part B medications to treat AMD accounted for only 6% of spending, though at a higher dollar amount (Figure 2).

Figure 2. Share of Medicare Part B Drug Spending on New Users by Ophthalmic Condition, 2018
Condition Total Medicare Part B Drug Spending
(in Millions)
Medicare Drug Spending on New Users
(in Millions)
Share of Medicare Drug Spending on New Users
DR $0.7 $0.3 48%
DME $340.1 $42.3 12%
DR without DME $7.9 $3.6 45%
Macular Edema / Cystoid Macular Edema $17.8 $3.3 18%
RVO $311.8 $33.0 11%
Uvetitis <$0.1 <$0.1 8%
AMD $2,251.6 $131.0 6%
Total $2,929.9 $213.5 7%

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Methodology

Avalere analyzed 100% Medicare Fee-For-Service (FFS) Part B claims for 2018 under a research data use agreement with CMS. We analyzed a cohort of beneficiaries representing less than 20% of total Medicare population; this cohort included beneficiaries receiving physician-administered medications in the physician office or hospital outpatient department setting for ophthalmic conditions (diabetic macular edema, cystoid macular edema,  diabetic retinopathy, uveitis, wet age-related macular degeneration, retinal vein occlusion) identified via ICD-10 diagnosis codes. For the purposes of this analysis, “new users” were defined as those who did not have the specific medication/indication/care setting combination in the prior year.

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