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Driving forces and current trends in private equity acquisitions within ophthalmology

Del Piero, Juliet; Parikh, Ravi; Weng, Christina Y
PURPOSE OF REVIEW/OBJECTIVE:Private equity investment in ophthalmology has dramatically increased over the past 20 years. Despite a massive influx in private equity investment in ophthalmology, little is known regarding if and how private equity investment might affect practice behavior. This review seeks to discuss why private equity investment may be expanding in ophthalmology and explore recent data on demographic and billing trends before and after private equity acquisition. RECENT FINDINGS/RESULTS:Recent publications have identified ophthalmology and optometry practices acquired by private equity from 2012 to 2021. Practice demographics and provider billing habits before and after private equity acquisition were analyzed from 2012 to 2019 and 2012 to 2017, respectively, using Internal Revenue Service, United States Census, and Medicare fee-for-service data. SUMMARY/CONCLUSIONS:Private equity investment in ophthalmology is increasing and may be because of a growing demand from an aging population, fragmented network of healthcare practices, and potential for ancillary billable services. Private equity practices acquired between 2012 and 2019 were mostly in metropolitan areas with higher proportions of private insurance coverage. Ophthalmologists and optometrists in practices acquired between 2012 and 2016 showed increased utilization of diagnostic testing and cataract surgery in the year following private equity acquisition compared with the year prior to private equity acquisition.
PMID: 35838270
ISSN: 1531-7021
CID: 5269432

Malpractice Cases Arising From Telephone Based Telemedicine Triage in Ophthalmology

Kahan, Elias H; Shin, Joshua D; Jansen, Michael E; Parker, Rebecca Hughes; Parikh, Ravi
PURPOSE/UNASSIGNED:To determine the allegation, precipitating medical issue, and outcome of telephone triage focused malpractice litigation among ophthalmologists. METHODS/UNASSIGNED:The WestLaw Edge database was reviewed using terms pertaining to ophthalmology and telemedicine. The search ranged from 4/7/30 to 1/25/22. RESULTS/UNASSIGNED:Of the 510 lawsuits, 3.5% (18/510) met inclusion criteria. 94.5% (17/18) alleged delays in evaluation and/or treatment. 61.1% (11/18) alleged incorrect diagnoses, 38.9% (7/18) claimed improper discussion of risks or informed consent, and 5.6% (1/18) alleged delayed referrals. The precipitating medical issues included retinal detachment in 33.3% (6/18) of cases, post-procedure and post-trauma endophthalmitis in 33.3% (6/18) of cases, ocular trauma without endophthalmitis in 22.2% (4/18) of cases, and bilateral acute retinal necrosis and allergic reactions each accounting for 5.6% (1/18) of cases. CONCLUSION/UNASSIGNED:Telephone triage creates potential malpractice litigation. Delay in in-person clinical evaluation and alleged failure to inform patients of possible irreversible vision loss may lead to potential malpractice litigation. We suggest offering the option of same day in person evaluation and informing the patient how delay may lead to irreversible vision loss.
PMID: 35980308
ISSN: 1744-5205
CID: 5300092

The Effect of Sample Medication Use on Subsequent Anti-VEGF Agent Selection for Neovascular Age-Related Macular Degeneration

Wai, Karen M; Begaj, Tedi; Patil, Sachi; Chen, Evan M; Miller, John B; Kylstra, Jan; Aronow, Mary E; Young, Lucy H; Huckfeldt, Rachel; Husain, Deeba; Kim, Leo A; Vavvas, Demetrios G; Eliott, Dean; Mukai, Shizuo; Gragoudas, Evangelos S; Patel, Nimesh A; Sobrin, Lucia; Miller, Joan W; Parikh, Ravi; Wu, David M
PURPOSE/UNASSIGNED:Medication samples of anti-VEGF agents can represent a good option for retina specialists to provide timely treatment for newly converted neovascular age-related macular degeneration (nvAMD) while prior-authorizations (PA) are pending. Our study examines the effect of medication sample use (ranibizumab or aflibercept) on future anti-vascular endothelial growth factor (VEGF) agent selection in nvAMD. DESIGN/UNASSIGNED:Retrospective cohort study. PARTICIPANTS/UNASSIGNED:nvAMD patients who underwent an initial anti-VEGF injection with a sample medication were compared to nvAMD control patients who never received a medication sample. METHODS/UNASSIGNED:Charts from 2017 through 2020 were reviewed for data regarding demographics, anti-VEGF agent selection, and visual acuity outcomes for both groups. The utilization of different anti-VEGF agents in each group was compared at various time points using chi-square tests for independence of proportions. MAIN OUTCOME MEASURES/UNASSIGNED:Anti-VEGF agent selection for the first four injections and at one year were examined. RESULTS/UNASSIGNED:injection, and 1 year) in sample (96.2%, 95.9%, 91.9%, 93.4%, respectively), and control groups (98.1%, 94.2%, 94.9%, 87.8%, respectively). Bevacizumab usage was significantly lower among eyes receiving samples relative to controls at the second (1.9% vs. 38.7%, p < .001), third (3.1% vs. 41.3%, p < .001), fourth injections (4.7% vs. 40.4%, p < .001), and at 1 year (0% vs. 33.8%, p < .001). Aflibercept usage was significantly higher in sample eyes relative to controls at the second (78.3% vs. 43.4%, p < .001), third (76.3% vs. 41.5%, p < .001), and fourth injections (76.7% vs. 43.4%, p < .001), and at 1 year (77.0% vs. 52.7%, p < .001). CONCLUSIONS/UNASSIGNED:Sample medications in nvAMD may be initiated for many reasons, including awaiting PA approval. Our study found that eyes receiving a sample anti-VEGF agent (ranibizumab or aflibercept) for their initial injection were less likely to receive bevacizumab at future visits relative to eyes that did not receive an anti-VEGF sample, even after one year of treatment. Given the persistent use of more expensive medications at subsequent injections for patients who were initiated on samples, insurance payors may consider waiving PA requirements for bevacizumab to avoid a paradoxical increase in health-care costs.
PMID: 35923110
ISSN: 1744-5205
CID: 5288152

Medical Malpractice Lawsuits Involving Urology Trainees

Golan, Roei; Kuchakulla, Manish; Watane, Arjun; Reddy, Raghuram; Parikh, Ravi; Ramasamy, Ranjith
OBJECTIVES/OBJECTIVE:To distinguish the various characteristics of medical malpractice lawsuits involving trainees to prevent future litigation. METHODS:LexisNexis, an online legal research database containing legal records from the United States, was retrospectively reviewed for malpractice cases involving urology interns, residents, or fellows from January 1, 1988, to December 31, 2020. RESULTS:A total of 16 cases were included, of which 7 (43.8%) involved urological allegations while 9 (56.2%) involved non-urological allegations. Five of the cases consisting of non-urological adverse outcomes led to mortality. Procedural error was claimed in 12 (75.0%) cases, negligence in 7 (43.8%), delayed evaluation in 6 (37.5%), lack of informed consent of procedure or complications in 5 (31.2.%), failure to pursue treatment in 4 (25.0%), inexperienced trainee in 2 (12.5%), failure to supervise trainee in 2, lack of informed consent of trainee involvement in 1, incorrect diagnosis in 1, and prolonged operative time in 1 case. CONCLUSIONS:Malpractice education, careful supervision, awareness during perioperative care, and detailed communication between patients and physicians should be highlighted in training programs to improve patient outcomes and mitigate risk of future malpractice.
PMID: 35093401
ISSN: 1527-9995
CID: 5153272

Cost of Ranibizumab Port Delivery System vs Intravitreal Injections for Patients With Neovascular Age-Related Macular Degeneration

Sood, Shefali; Mandell, Jordan; Watane, Arjun; Friedman, Scott; Parikh, Ravi
Importance/UNASSIGNED:The study team investigated costs associated with the ranibizumab port delivery system (PDS) for neovascular age-related macular (nAMD), an alternative to conventional intravitreal anti-vascular endothelial growth factor (VEGF) injections. Objective/UNASSIGNED:To investigate costs of intravitreal anti-VEGF injections vs ranibizumab PDS for patients with neovascular AMD (nAMD). Design, Setting, and Participants/UNASSIGNED:This cost analysis used trial data and Medicare reimbursement rates and included patients with nAMD who were receiving ranibizumab, aflibercept, bevacizumab injections, or ranibizumab PDS. Main Outcomes and Measures/UNASSIGNED:The number of intravitreal ranibizumab, aflibercept, and bevacizumab injections to break even with costs of ranibizumab PDS. Total direct medical costs over 1 year and 5 years for the ranibizumab PDS arm with refills at fixed 6-month intervals compared with monthly or bimonthly injections were calculated using Medicare rates. Scenario and sensitivity analyses accounted for uncertainty and variation. Results/UNASSIGNED:The mean (SD) number of ranibizumab, aflibercept, and bevacizumab injections to break even with the cost of ranibizumab PDS with 1 refill was 10.8 (1.3), 9.3 (1.1), and 34.5 (4.2), respectively. Ranibizumab PDS with fixed 6-month refills over 1 year cost $21 016 ($2102). Comparatively, monthly intravitreal ranibizumab cost $1943 (95% CI, -$3047 to $6932; P = .34) more, aflibercept cost $5702 (95% CI, $253-$11 151; P = .04) more, and bevacizumab cost $16 732 (95% CI, -$20 170 to -$13 294, P < .001) less. For bimonthly injections, aflibercept cost $7658 (95% CI, -$11 649.52 to -$3665.61; P = .006) less. Over 5 years, monthly intravitreal ranibizumab projected to cost $25 581 (95% CI, $2275-$48 887; P = .04) more, aflibercept cost $44 374 (95% CI, $18 623-$70 125; P = .008) more, and bevacizumab cost $67 793 (95% CI, -$82 501 to -$53 085; P < .001) less than PDS with fixed refills (mean [SD] cost, $89 218 [$8921]). For bimonthly injections, aflibercept cost $22 422 (95% CI, -$40 287 to -$45,56; P = .03) less. In scenario analyses, ranibizumab PDS with refills as needed offered cost savings compared with real-world intravitreal ranibizumab or aflibercept use at 5 years but not at 1 year. Conclusions and Relevance/UNASSIGNED:In this cost analysis, ranibizumab PDS with 1 refill cost more than intravitreal ranibizumab or aflibercept injections if less than or equal to approximately 11 or 10 injections, respectively, are required within the first year. Long term, if less than 4.4 and 3.8 injections are needed per refill, intravitreal ranibizumab and aflibercept is lower cost. Ranibizumab PDS costs more than intravitreal bevacizumab injections throughout scenarios.
PMID: 35708679
ISSN: 2168-6173
CID: 5250232

Distinct characteristics of central serous chorioretinopathy according to gender

Yoneyama, Seigo; Fukui, Ayumi; Sakurada, Yoichi; Terao, Nobuhiro; Shijo, Taiyo; Kusada, Natsuki; Sugiyama, Atsushi; Matsubara, Mio; Fukuda, Yoshiko; Kikushima, Wataru; Parikh, Ravi; Mabuchi, Fumihiko; Sotozono, Chie; Kashiwagi, Kenji
To investigate the differences in clinical and genetic characteristics between males and females with central serous chorioretinopathy (CSC). Consecutive 302 patients (mean age; 56.3 ± 11.7, male/female: 249/53) with CSC were evaluated on the initial presentation. All CSC patients underwent fluorescein angiography and indocyanine green angiography (FA/ICGA), swept-source or spectral-domain optical coherence tomography (OCT), and fundus autofluorescence (FAF) to confirm a diagnosis. All patients were genotyped for rs800292 and rs1329428 variants of CFH using TaqMan technology. On the initial presentation, female patients were significantly older (p = 2.1 × 10-4, female 61.6 ± 12.4 vs male 55.1 ± 11.3) and had thinner subfoveal choroidal thickness (p = 3.8 × 10-5) and higher central retinal thickness (p = 3.0 × 10-3) compared to males. A descending tract was more frequently seen in males than in females (p = 8.0 × 10-4, 18.1% vs 0%). Other clinical characteristics were comparable between the sexes. The risk allele frequency of both variants including CFH rs800292 and CFH rs1329428 was comparable between males and females (CFH rs800292 A allele male 51.2% vs female 47.2%, CFH rs1329428 T allele male 56.2% vs 52.8%). On the initial presentation, age, subfoveal choroidal thickness and central retinal thickness differ between males and females in eyes with CSC. A descending tract may be a strong male finding in CSC.
PMID: 35732691
ISSN: 2045-2322
CID: 5266022

Economic Evaluation of the Merit-Based Incentive Payment System for Ophthalmologists: Analysis of 2019 Quality Payment Program Data

Berkowitz, Sean T; Siktberg, Jonathan; Gupta, Arulita; Portney, David; Chen, Evan M; Parikh, Ravi; Finn, Avni P; Patel, Shriji
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.
PMID: 35420641
ISSN: 2168-6173
CID: 5219092

Utilization of Crowdfunding for Cataract and LASIK Procedures

Patil, Sachi A; Luu, Amanda; Vail, Daniel G; Watane, Arjun; Levine, Russell; Hafler, Brian; Parikh, Ravi
PURPOSE/UNASSIGNED:To study the nature of crowdfunding campaigns for common ophthalmologic procedures. METHODS/UNASSIGNED:Cross sectional, retrospective study of campaigns on 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.
PMID: 35353643
ISSN: 1744-5205
CID: 5201152

Urology Practice Acquisitions by Private Equity Firms from 2011e2021

Nie, James; Demkowicz, Patrick C.; Hsiang, Walter; Umer, Waez; Chen, Evan M.; McMahon, Gregory; Kenney, Patrick A.; Breyer, Benjamin N.; Parikh, Ravi; Leapman, Michael S.
Introduction: 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.
ISSN: 2352-0779
CID: 5144122

Competition law and pricing among biologic drugs: the case of VEGF therapy for retinal diseases

Van de Wiele, Victor L; Hammer, Maximilian; Parikh, Ravi; Feldman, William B; Sarpatwari, Ameet; Kesselheim, Aaron S
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.
PMID: 35211322
ISSN: 2053-9711
CID: 5175182