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Editors Selection IGR 16-4

Forms of Glaucoma: Health Economics of Exfoliation Galucoma

Comment by Tony Realini on:

80016 A Comparison of Resource Use and Costs of Caring for Patients With Exfoliation Syndrome Glaucoma Versus Primary Open-Angle Glaucoma, Rathi S; Andrews C; Greenfield DS et al., American Journal of Ophthalmology, 2019; 200: 100-109

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Rathi and colleagues have conducted a retrospective study evaluating resource utilization and costs of therapy in eyes with primary open-angle glaucoma (POAG) and exfoliation glaucoma (XFG). Drawing from a data set including a 20% representative sample of Medicare beneficiaries between 2008-2014, they estimated the total two-year costs of care as well as rates of specific services (office visits, surgery, etc.) performed in both existing (prevalent) and new (incident) cases. Costs to care for patients with XFG were significantly greater than for POAG, as were the frequency of office visits, cataract surgery, and glau-coma surgery; this was true in both incident and prevalent cases. These findings are not surprising - it is generally accepted that XFG is a more aggressive form of glaucoma than POAG and would thus require more aggressive (i.e., more expensive) care. The significance of this study, however, transcends its specific findings. As the authors point out, the US healthcare system is ripe for a revamp of its reimbursement model, and one possible replacement for the current fee-for-service model is a bundled payment approach in which the reimbursement for care will be a standard annual amount based on diagnosis and severity. Rathi and colleagues rightly point out that the devil is in the details: what constitutes a diagnosis? Their broader point is that a bundled payment approach will only be viable if diagnosis has the appropriate level of granularity.

There were significant differences in costs of care between specific forms of glaucoma (POAG vs PXF)

A diagnosis of 'glaucoma' may be inadequate to estimate annual care costs with the necessary precision for such a system to work; in this case, there were significant differences in costs of care between specific forms of glaucoma (POAG vs PXF). It follows that costs may vary with other forms of glaucoma as well, including pigmentary glaucoma, steroid-induced glaucoma, traumatic glaucoma, etc. Rathi and colleagues are to be congratulated for making this broader point and beginning the process of clarifying realistic care costs for the various forms of glaucoma in advance of any potential reimbursement policy changes.

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