Not infrequently, an ophthalmologist or optometrist receives a critical letter that informs the recipient that their utilization rate for a procedure is higher than the norm. The letter implies that the procedure is performed too frequently and perhaps unnecessarily. Unfortunately, there is no comparable letter informing them that a procedure is not performed often enough. 

According to CMS data,¹ laser trabeculoplasty (CPT 65855) is performed about 150,000 times per year on Part B Medicare beneficiaries, who numbered 37 million enrollees in 2020.² The prevalence of open-angle glaucoma (OAG) in the United States in 2020 is estimated to be 3.36 million people,³ and 65% of those are ≥65 years old and likely Medicare beneficiaries. The US population was 331 million in 2020;⁴ OAG affects 1% of them, but 78% of those are undiagnosed and untreated.⁵ Using enrollment data and prevalence of OAG, we can estimate there are 1.3 million Part B Medicare beneficiaries with OAG, and about 79% have a bilateral affliction.⁶ Approximately 40% of all eyes with OAG have advanced disease⁶ that might not benefit from laser trabeculoplasty. If we could only identify and treat these beneficiaries, about 1.4 million eyes with mild-to-moderate OAG would likely benefit from laser trabeculoplasty; that is 9 times more procedures than are currently performed in this population.  

The investigators of the Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial found “...selective laser trabeculoplasty (SLT) to be clinically and cost-effective as a primary treatment of open-angle glaucoma (OAG) and ocular hypertension (OHT) … providing better long-term disease control than initial drop therapy, with reduced need for incisional glaucoma and cataract surgery over 6 years.”⁷ As a point of reference, US ophthalmologists prescribe an average of 3.6 antiglaucoma medications for OAG.⁸ A survey of US ophthalmologists found a preference for treating their own glaucoma disease with SLT rather than medications. 

“The cost of treating and preventing glaucoma is about $5.8 billion per year in the US with the annual medical cost of glaucoma projected to be as high as $12 billion by 2032 and $17.3 billion by 2050.”^9-11 “The annual direct cost of glaucoma treatment in the US ranges from $623 to $2,511, depending on disease severity.”¹² In comparison, 2024 Medicare national payment rates for laser trabeculoplasty (per eye) are $199 for the surgeon in a facility and $133 for the ambulatory surgery center.

It is fair to conclude that ophthalmologists and some licensed optometrists should reevaluate SLT due to its effectiveness, fewer side effects than antiglaucoma medications, and cost-effectiveness. This is one procedure that deserves to be performed more often. GP

Kevin J. Corcoran, COE, CPC, CPMA, FNAO, is principal of Corcoran & Corcoran in Las Vegas, Nevada.

 References

1. CMS. Utilization data for CPT 65855 but excluding data for physicians who did ≤10 (2020).

2. Kaiser Family Foundation. Total number of Medicare beneficiaries by type of coverage. Accessed April 14, 2024. https://www.kff.org/medicare/state-indicator/total-medicare-beneficiaries/?currentTimeframe=1&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D   

3. Friedman DS, Wolfs RC, O’Colmain BJ, et al. Prevalence of open-angle glaucoma among adults in the United States [published correction appears in Arch Ophthalmol. 2011 Sep;129(9):1224]. Arch Ophthalmol. 2004;122(4):532-538. doi:10.1001/archopht.122.4.532

4. US Census Bureau 2020. Accessed April 14, 2024. www.census.gov  

5. Shaikh Y, Yu F, Coleman AL. Burden of undetected and untreated glaucoma in the United States. Am J Ophthalmol. 2014;158(6):1121-1129.e1. doi:10.1016/j.ajo.2014.08.023

6. Seth PK, Senthil S, Das AV, Garudadri C. Prevalence of glaucoma types, clinical profile and disease severity at presentation: Tertiary Institute based cross-sectional study from South India. Indian J Ophthalmol. 2023;71(10):3305-3312. doi:10.4103/IJO.IJO_3305_22

7. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial: six-year results of primary selective laser trabeculoplasty versus eye drops for the treatment of glaucoma and ocular hypertension. Ophthalmology. 2023;130(2):139-151. doi:10.1016/j.ophtha.2022.09.009

8. Charters L. The magnificent 7: how many glaucoma medications are too many?  Ophthalmology Times. November 13, 2019. Accessed April 14, 2024. https://www.ophthalmologytimes.com/view/magnificent-7-how-many-glaucoma-medications-are-too-many   

9. Allison K, Patel D, Alabi O. Epidemiology of glaucoma: the past, present, and predictions for the future. Cureus. 2020;12(11):e11686. doi:10.7759/cureus.11686

10. Lawler T, Liu Y, Christensen K, Vajaranant TS, Mares J. Dietary antioxidants, macular pigment, and glaucomatous neurodegeneration: a review of the evidence. Nutrients. 2019;11(5):1002. doi:10.3390/nu11051002

11. Feldman RM, Cioffi GA, Liebmann JM, Weinreb RN. Current knowledge and attitudes concerning cost-effectiveness in glaucoma pharmacotherapy: a glaucoma specialists focus group study. Clin Ophthalmol. 2020;14:729-739. Published 2020 Mar 6. doi:10.2147/OPTH.S236030

12. Schlenker MB, Trope GE, Buys YM. Comparison of United States and Canadian glaucoma medication costs and price change from 2006 to 2013. J Ophthalmol. 2015;2015:547960. doi:10.1155/2015/547960