Utilization Patterns and Costs of Ocular Amniotic Membrane Grafts in the Medicare Population.
Dry eye was associated with nearly half of all ocular amniotic membrane graft use in 2020.
Utilization Patterns and Costs of Ocular Amniotic Membrane Grafts in the Medicare Population.
Recent investigations from the Office of the Inspector General and The New York Times have raised concerns about the costs to Medicare of skin substitutes, documenting pervasive fraudulent billing practices outside of ophthalmology.
Nationally representative 20% sample of Medicare Part B claims for sutureless AMGs between 2011 and 2020.
Charges for ocular sutureless AMGs increased from $3.5 million in 2011 to $95.6 million in 2020; charges for AMGs used to treat dry eye increased from $250 000 to $41.4 million over this period.
Some 28% of all claims for AMGS were submitted by 1% of providers.
Patients are more likely to receive an AMG when seen by an optometrist (hazard ratio, 1.16; P < 0.001).
The annual costs to Medicare for a patient with dry eye have increased dramatically among providers who use AMGs.
The costs to Medicare for skin substitutes are inflated by reimbursement models that encourage their use even when there is little clinical indication.
These concerns may be applicable to eye care as well, where spending on amniotic membrane grafts has increased dramatically, particularly for indications where clinical benefit may be limited.
By requiring AMG manufacturers to report accurate sales prices, policymakers could reduce costs without limiting coverage of AMGs for appropriate clinical indications.