Study Finds Wide Pay Gaps in Eye Care

Medscape

08-07-2025

Commercial insurance payments for common ophthalmology procedures vary widely across the US, with facility fees showing far greater variability than professional fees, a new study showed.
The findings come from an analysis of January 2025 Transparency in Coverage data from four major insurers — Blue Cross Blue Shield, UnitedHealthcare, Cigna, and Aetna — and highlight the inconsistent nature of pricing in eye care.
'Facility prices are negotiated by hospitals, health-system outpatient departments, and large ambulatory surgery centers that wield substantially more market clout than individual ophthalmologists,' said Alexander P. Philips of the Center for Advancing Health Policy Through Research at the Brown University School of Public Health in Providence, Rhode Island. 'Those institutions fold a wide range of fixed costs — real estate, equipment, around-the-clock staffing, and community-benefit obligations — into their rates, so the starting point for negotiation differs dramatically from one organization to the next.'
Philips and Christopher Whaley, PhD, also of the Center for Advancing Health Policy Through Research at Brown University School of Public Health, published their findings on July 3 in JAMA Ophthalmology .
For the analysis, Philips and Whaley looked at more than 740,000 price points for 10 high-volume ophthalmology procedures such as intravitreal injections, iris revision surgery, treatment for severe retinopathy, and laser surgery for postcataract treatment. They found facility fees paid by insurance companies often exceeded professional charges by factors of two to four.
For example, median facility prices for standard cataract surgery ranged from $1521 (Cigna) to $4274 (Aetna), a spread of $2753. In contrast, professional fees for the same procedure showed a much narrower interquartile spread of just $439, from $581 to $1020.
'What a physician can charge is anchored to well-known relative-value schedules that leave less room for maneuver,' Philips said. 'The moment a hospital acquires a previously independent office, the exact same cataract extraction can suddenly carry a separate facility component, widening the gap even further.'
For patients, the result can be unpredictable out-of-pocket costs that can skyrocket depending on where they undergo the procedure. 'Independent clinicians, meanwhile, find it harder to compete, and insurers ultimately load those higher facility payments into premiums,' Philips said.
Blue Cross Blue Shield consistently paid above-market rates, 14% higher for professional fees and 13% higher for facility fees, whereas Aetna showed the most dramatic divergence, with professional fees 54% below average and facility fees 45% above, the researchers found.
'Aetna appears to drive a hard bargain with individual physicians, who usually have limited leverage, while conceding more to large hospital systems that control valuable operating rooms and imaging equipment,' Philips told Medscape Medical News . 'That strategy allows the plan to advertise a lean physician fee schedule to employers, keeping the most visible line item in check, yet still maintain broad hospital networks by paying the premiums those systems demand on the facility side.'
'This pattern can look different across specialties; insurers often deploy distinct, specialty-specific tactics depending on whether hospitals, physician groups, or ancillary providers hold the upper hand,' he added. 'For example, UnitedHealth Group's deep vertical integration through Optum gives it the leverage to align professional and facility payments within its own physician and ambulatory-surgery platform, which produces a negotiation dynamic unlike what we see with Aetna in ophthalmology.'
Geographic Analysis
The study's geographic analysis revealed up to fivefold differences in median facility prices for cataract surgery across states. Outlier states like Connecticut and Alaska had significantly higher prices, potentially due to academic centers or Medicare payment policies, the researchers reported.
Philips and Whaley suggest market dynamics such as insurer-provider negotiations, selective contracting, and vertical integration play a major role in shaping these disparities. For instance, UnitedHealthcare's lower facility fees may reflect its ownership of care delivery assets through Optum, while Cigna's lower prices suggest a strategy of selective contracting with providers willing to accept lower reimbursement in exchange for volume.
The commentary also highlighted the potential of publicly available, insurer-posted data on negotiated prices to empower smaller practices. 'Transparent prices can empower smaller groups or solo practitioners with data for fair negotiations,' the authors wrote. 'Facility revenue can be indirectly critical for ophthalmologists in large departments.'
Still, both the study and commentary stress price alone is not a proxy for value. 'These prices are administrative constructs and may not reflect patient responsibility or the actual cost of care delivery,' the commentary noted.
'Patients should resist the reflex to equate a higher bill with better care. What matters far more is choosing the right setting: The same surgeon can perform a cataract extraction in a physician-owned ASC [ambulatory surgery center] for half of what it would cost in a hospital outpatient department, with no difference in clinical outcome,' Philips said. 'That said, both clinicians and patients have limited leverage to shift markets on their own; real progress depends on policy interventions that rein in unwarranted price dispersion across the system. Awareness helps individuals avoid the worst surprises, but meaningful change will flow from site-neutral payment reforms, tighter antitrust oversight, and transparency rules that expose and discourage outlier prices.'
Transparency Reforms
In an invited commentary, Sean T. Berkowitz, MD, MBA, of the Department of Ophthalmology at Vanderbilt University Medical Center in Nashville, Tennessee, and his coauthors from Cleveland Clinic, Cleveland, emphasized that ophthalmology is uniquely positioned to benefit from transparency reforms due to its high volume of standardized procedures.
However, they cautioned the data may not fully capture the nuances of care delivery. 'Site of service may impact findings,' they wrote. 'The proportion of hospital or ambulatory surgical centers in each network or geographic area may explain the larger variation in facility fees.'
They also warned that increased transparency could have unintended consequences. 'More data on local price variation may incentivize upward price pressure, consolidation, and vertical integration,' according to the authors of the commentary. 'Transparency must be paired with policies that promote competition and protect access.'
The authors of the paper and commentary reported no relevant financial conflicts of interest.