Faculty Bibliography

Importance/UNASSIGNED:The Merit-Based Incentive Payment System (MIPS) is intended to promote high-value health care through quality-related Medicare payment adjustments. Objective/UNASSIGNED:To assess the economic evaluation of MIPS scoring and reporting on ophthalmologists. Design, Setting, and Participants/UNASSIGNED:In this retrospective, cross-sectional, multicenter economic evaluation conducted from October 10 to November 30, 2021, MIPS performance and related payment adjustments were evaluated using the US Centers for Medicare & Medicaid Service (CMS) public data files for ophthalmologists. Participants were stratified by reporting affiliation. Analysis of variance and summary statistics were used to characterize and compare total and subcategory MIPS scores and adjustments received by participants. Reported CMS methodology and performance year (PY) 2019 payment percentages were used to estimate payment adjustments for the following categories: positive MIPS adjustment plus potential additional adjustment for exceptional performance, positive MIPS adjustment, neutral payment adjustment, negative MIPS payment adjustment, and maximum negative MIPS payment adjustment. Study participants included ophthalmologists registered for Medicare Part B with participation in the Quality Payment Program (QPP) in PY 2019. Main Outcomes and Measures/UNASSIGNED:Proportion of ophthalmologists qualifying for payment adjustments and payment adjustments. Results/UNASSIGNED:For PY 2019, 76.5% of ophthalmologists (13 621) who registered for Medicare participated in the MIPS pathway of the QPP. Ophthalmologists practiced in a predominantly large metropolitan area (12 302; 90.3%). Roughly 99% of participants (11 182) received nonnegative reimbursement adjustments, and 92.6% (10 367) received positive adjustments. Ophthalmologists filing as individuals were less likely to achieve exceptional performance scores compared with those who had a filing category of advanced alternative payment model (APM; odds ratio [OR], 0.0003; 95% CI, 0.00002-0.00481) or group (OR, 0.21013; 95% CI, 0.19020-0.23215). When analyzing participating ophthalmologists with available Medicare payment data (11 193), a total of 8777 (78.4%) achieved exceptional MIPS scores corresponding to mean (SD) adjustments per physician of $244.60 ($217.36) to $4864.78 ($4323.08), or 0.07% ($2 146 835.21 of $3 212 011 252.88) to 1.33% ($42 698 166.89 of $3 212 011 252.88), of the total nondrug Medicare payment. Conclusions and Relevance/UNASSIGNED:Results of this economic evaluation showed that although 78.4% of ophthalmologists received exceptional positive payment adjustments, roughly 84% (798916 of 954615) of all health care professionals nationally achieved this benchmark. Exceptional MIPS was associated with filing as group or APM, resulting in, on average, a relatively small additional payment per participant; this suggests that ophthalmologists who file as individuals should consider an alternative filing approach. Changes in MIPS methodology may disproportionately affect certain ophthalmologists, which warrants further study.

PURPOSE/UNASSIGNED:To study the nature of crowdfunding campaigns for common ophthalmologic procedures. METHODS/UNASSIGNED:Cross sectional, retrospective study of campaigns on GoFundMe.com from January 1st, 2021 to July 31st, 2021. All domestic and international campaigns referring to cataract and intraocular lens placement or LASIK procedures, excluding those with non-ophthalmologic conditions or campaigns for multiple conditions. Descriptive analysis of campaigns including condition, country of origin of patient, total and median value raised, total and median value sought, age of the patient, funding goal met, insurance status when possible. Total and median funds raised and sought, international versus domestic campaigns, success rate for campaigns, percent of campaigns involving children, percent of campaigns mentioning insurance. RESULTS/UNASSIGNED:137 campaigns were identified, 67.9% (93/137) were for cataract and 32.1% (44/137) were for LASIK. 13.1% (18/137) of campaigns were international. 7.3% (10/137) campaigns were successful at reaching funding goals. Of successful campaigns, 70.0% (7/10) were for cataract and 30.0% (3/10) were for LASIK. Total value raised (in USD) was $131,763, where $106,593 was for cataract and $25,170 was for LASIK. The median value sought overall was $5,000, where the median sought for cataract procedures was $5,000 and the median for LASIK was $4,000. The median value raised was $395. 5.8% (8/137) of campaigns mentioned minors. 12.5% (1/8) of campaigns for children or minors successfully met funding goals compared to 7.0% (9/129) adult campaigns. The total funds raised for children or minors was $9,224 with a goal of $41,050. The total funds raised for adults was $122,539 out of a goal of $775,617. 14.6% (20/137) campaigns mentioned insurance coverage, of which 85% (17/20) were for cataract and 15.0% (3/20) were for LASIK. Premium lenses (toric, multifocal, etc.) were mentioned in 1.1% of cataract campaigns (1/93) as being cost prohibitive. CONCLUSIONS/UNASSIGNED:Crowdfunding is ineffective as a means for patients to raise funds for ophthalmic procedures. The broad range of financial requests within campaigns indicates a large patient knowledge gap in cost for procedures.

INTRODUCTION/BACKGROUND:Private equity firms have recently acquired several large urology practices in the United States. As little is known about these acquisitions, we sought to characterize trends in urology practice consolidation. METHODS:We compiled urology practice acquisition data via financial databases, news outlets, practice websites, and Internet keyword search for the time period January 1, 2011 through March 15, 2021. For each acquisition, we determined the acquiring group, number of employed urologists, practice locations, and status of ancillary services (pathology, radiology, or surgery centers). We estimated workforce effects based on the 2019 American Urological Association workforce census. RESULTS:We identified 69 independent practice acquisitions in the study period, including 19 (28.4%) by hospital systems, 7 (10.4%) by multispecialty physician groups, 23 (34.3%) by urology practices, and 20 (29.9%) by private equity-backed platforms. Private equity firms initially targeted large urology practices (mean of 60.8±32.6 urologists) with ownership of ancillary services and consolidated local market share through acquisitions of smaller practices (mean of 15.9±14.5 urologists). As of March 2021, we estimate that 7.2% of private practice urologists in the U.S. were employed by one of 5 private equity-backed platforms; over 25% of all urologists practicing in New Jersey and Maryland are employed by a private equity-backed platform. CONCLUSIONS:Private equity acquisitions have accelerated to become a dominant form of urology practice consolidation in recent years and have achieved significant market influence in certain regions. Future research should assess the impact of private equity investment on practice patterns, health outcomes, and expenditures.

Neovascular age-related macular degeneration (AMD) is a progressive eye disease and is a leading cause of vision loss in the Western world. Vascular endothelial growth factor inhibitors have become a mainstay of treatment for this disease. Currently, treatment options include three originator biologics with approvals for neovascular AMD (aflibercept, ranibizumab, and brolucizumab-dbll) and one biologic that is commonly used off-label for the condition (bevacizumab). In the USA, Medicare spending on these drugs consistently surpassed $4 billion per year between 2015 and 2019, driven by high prices and varying off-label use of bevacizumab, which is substantially cheaper than the other biologics used to treat neovascular AMD. In this article, we discuss how legal reform can improve market competition for biologic drugs, using AMD therapies as a case study. We chose this group of drugs for their significant contribution to Medicare spending, the price difference between approved therapies and intravitreal bevacizumab, and because there currently exists a large biosimilar pipeline with many drug candidates in the final stage of development. We propose mechanisms for anticipating and facilitating the market introduction of biosimilars, as well as changes to the pricing model in Medicare that can promote use of cost-effective therapies. Reforms such as empowering Medicare to negotiate drug prices may help ensure that introduction of new biologics and biosimilars for AMD will lower spending and increase patient access.

PURPOSE/UNASSIGNED:The COVID-19 pandemic has had a profound effect on the delivery of healthcare in the United States and globally. The aim of this study was to evaluate the impact of COVID-19 on common ophthalmic procedure utilization and normalization to pre-pandemic daily rates. METHODS/UNASSIGNED:Leveraging a national database, Clinformatics™ DataMart (OptumInsight, Eden Prairie, MN), procedure frequencies and daily averages, defined by Current Procedural Terminology codes, of common elective and non-elective procedures within multiple ophthalmology sub-specialties were calculated. Interrupted time-series analysis with a Poisson regression model and smooth spline functions was used to model trends in pre-COVID-19 (January 1, 2018-February 29, 2020) and COVID-19 (March 1, 2020-June 30, 2020) periods. RESULTS/UNASSIGNED:< .001) all declined significantly. All procedures except laser iridotomy returned to pre-COVID19 rates by June 2020. CONCLUSION/UNASSIGNED:Most ophthalmic procedures that significantly declined during the COVID-19 pandemic were elective procedures. Among these, the majority returned to 2019 daily averages by June 2020.

PURPOSE/OBJECTIVE:To describe resolution of a subfoveal choroidal cavern after half-dose verteporfin photodynamic therapy for persistent central serous chorioretinopathy. METHODS:Case report. RESULTS:A 43-year-old man was referred for treatment of chorioretinopathy in his left eye. On presentation, swept-source optical coherence tomography demonstrated a serous retinal detachment and a 161-μm-thick subfoveal choroidal cavern showing a characteristic tail of hypertransmission extending posteriorly. Subfoveal choroidal thickness measured 456 μm in the affected eye. Complete resolution of subretinal fluid and the subfoveal choroidal cavern were observed 3 months after half-dose verteporfin photodynamic therapy. Twelve months after treatment, subfoveal choroidal thickness had decreased further to 276 μm, and visual acuity had improved to 20/15. CONCLUSION/CONCLUSIONS:After half-dose verteporfin photodynamic therapy for chorioretinopathy, resolution of subretinal fluid was accompanied by resolution of a subfoveal choroidal cavern at 3 months and a 39.5% reduction in subfoveal choroidal thickness at 1 year.

Importance/UNASSIGNED:Telemedicine has been shown to have had reduced uptake among historically marginalized populations within multiple medical specialties during the COVID-19 pandemic. An evaluation of health disparities among patients receiving ophthalmic telemedical care during the pandemic is needed. Objective/UNASSIGNED:To evaluate disparities in the delivery of ophthalmic telemedicine at Massachusetts Eye and Ear (MEE) during the COVID-19 pandemic. Design, Setting, and Participants/UNASSIGNED:This retrospective, cross-sectional study analyzed clinical visits at a single tertiary eye care center (MEE) from January 1 to December 31, 2020. Patients who had ophthalmology and optometry clinical visits at the MEE during the study period were included. Exposures/UNASSIGNED:Telemedicine vs in-person clinical encounters. Main Outcomes and Measures/UNASSIGNED:Variables associated with use of ophthalmic telemedicine during the study period. Results/UNASSIGNED:A total of 2262 telemedicine ophthalmic encounters for 1911 patients were included in the analysis. The median age of the patients was 61 (interquartile range, 43-72) years, and 1179 (61.70%) were women. With regard to race and ethnicity, 87 patients (4.55%) identified as Asian; 128 (6.70%), as Black or African American; 23 (1.20%), as Hispanic or Latino; and 1455 (76.14%), as White. On multivariate analysis, factors associated with decreased receipt of telemedical care included male sex (odds ratio [OR], 0.86; 95% CI, 0.77-0.96), Black race (OR, 0.69; 95% CI, 0.56-0.86), not speaking English (OR, 0.63; 95% CI, 0.48-0.81), educational level of high school or less (OR, 0.83; 95% CI, 0.71-0.97), and age (OR per year of age, 0.99; 95% CI, 0.989-0.998). When comparing telephone- and video-based telemedicine visits, decreased participation in video-based visits was associated with age (OR per year of age, 0.96; 95% CI, 0.94-0.98), educational level of high school or less (OR, 0.54; 95% CI, 0.29-0.99), being unemployed (OR, 0.28; 95% CI, 0.12-0.68), being retired (OR, 0.22; 95% CI, 0.10-0.42), or having a disability (OR, 0.09; 95% CI, 0.04-0.23). Conclusions and Relevance/UNASSIGNED:The findings of this cross-sectional study, though limited to retrospective data from a single university-based practice, suggest that historically marginalized populations were less likely to receive ophthalmic telemedical care compared with in-person care during the first year of the COVID-19 pandemic in the US. Understanding the causes of these disparities might help those who need access to virtual care.

RATIONALE/BACKGROUND:Brolucizumab is a novel anti-vascular endothelial growth factor agent with clinical trials demonstrating excellent efficacy for neovascular age-related macular degeneration (AMD) in both visual and anatomic outcomes. However, there is concern of intraocular inflammation (IOI), and we propose concurrent subtenon triamcinolone acetonide (STTA) to prevent IOI. PATIENT CONCERN/UNASSIGNED:A 73-year-old man was treated with aflibercept for neovascular AMD in his right eye. Despite 11 months of monthly intravitreal aflibercept injections, optical coherence tomography demonstrated persistent exudation. Ten days following his second brolucizumab injection, the patient presented with decreased vision due to vitritis in his right eye. DIAGNOSIS/METHODS:Brolucizumab-related IOI in neovascular AMD refractory to aflibercept. INTERVENTIONS/METHODS:A combination therapy involving of intravitreal brolucizumab and STTA. OUTCOMES/RESULTS:The anti-vascular endothelial growth factor inhibitor was changed back to aflibercept; however, exudation persisted. Therefore, a combination therapy involving STTA (5 mg/0.5 mL) and intravitreal injection of brolucizumab (6.0 mg/0.05 mL) was performed to treat the exudation and as prophylaxis to recurrent IOI. Combination therapy achieved no recurrent IOI and resolution of exudation with 8-week treatment intervals. LESSONS/CONCLUSIONS:This case might indicate that STTA is not only an optimal treatment option for brolucizumab-related IOI but also a preventive agent for this condition.