Comparison of Medicaid vs Medicare Reimbursement Rates for Vitreoretinal Surgeries in the United States.

Purpose: To compare the Medicaid and Medicare physician reimbursement rates for the top 10 most common vitreoretinal surgeries.

Methods

The Medicaid-to-Medicare reimbursement ratios were compared for the most frequently used Common Procedural Terminology (CPT) codes, adjusted for each state's proportion of Medicaid enrollment in the United States.

Results

The most used CPT codes were 67042 (26%), 67036 (20%), 67108 (17%), 67041 (11%), 67113 (11%), 67040 (6.5%), 67039 (4.1%), 67121 (2.8%), 67218 (0.44%), and 67107 (0.43%). The weighted average (±SD) of the Medicaid reimbursement rate was 88% ± 2.3% of the Medicare rates. New Jersey had the lowest Medicaid-to-Medicare ratio (52% ± 2.33% of all Medicaid enrollees). Thirty-six states, comprising 80% of all US Medicaid enrollees, had lower Medicaid than Medicare rates; 30 of those states had lesser-of policies, under which physicians would be reimbursed at the lower Medicaid rates despite patients being dually enrolled in both Medicaid and Medicare.

Conclusions

There were significant variations between states, but Medicaid reimbursements were on average 12% lower than Medicare rates. In most states, there was a significant opportunity cost for the physician performing the same surgery on a patient with Medicaid compared with Medicare. State governments should work to improve patient access to care, match the Medicaid and Medicare rates, and eliminate lesser-of payment policies.