The United States’ elderly population is increasing; by 2030, one in five Americans will be of retirement age.1 Both the incidence and prevalence of two common eye diseases—age-related macular degeneration (AMD) and diabetic retinopathy (DR)—continue to increase with an aging population.2,3 Consequently, the demand for eyecare is growing, with projections expected to increase by 24% by 2035.
However, the supply of ophthalmologists is expected to decline by 12%, resulting in a workforce shortage of 30%.4 This shortage not only includes ophthalmologists but also extends to primary care and subspecialties in medicine, which are further exacerbated by a regional maldistribution of physicians across the United States.5
Collectively, the aging population and potential decline of the physician workforce represent a growing public health crisis that, without sustained policy reform, will place greater strain on the US healthcare system.
Growing health expenditures in the United States
The national health expenditures (NHE) have been increasing yearly since 2005.6 In 2024, health expenditures grew 8.2% to $5.3 trillion USD, accounting for 18% of the US gross domestic product (GDP).7
Over the next decade, the average growth of the NHE is projected to outpace that of the GDP, increasing the health spending share of GDP to 20.3% by 2033.8,9 Despite the increase in health expenditures, US life expectancy has declined,9-11 with significant deterioration from 1983 to 2021.12-14
Furthermore, Americans face a large US healthcare debt liability, as 41% of US adults (100 million individuals) have medical debt. In 2021, 58% of all debt collections were for medical bills.14,15
Evolving insurance policies in retina care
The insurance landscape has changed significantly in recent years, including in the realms of prior authorization, reimbursement, and restrictions.
Prior authorization
Various insurance payers may require prior authorization for anti-vascular endothelial growth factor (VEGF) injections. A recent multicenter study found that 96.2% of prior authorization requests for anti-VEGF drugs were ultimately approved, but 59.6% of these approvals were delayed by more than 24 hours.16
In practice, this means administrative burden with paperwork and patients waiting to be treated, often requiring a second visit before authorization is approved. Some plans also impose step therapy, forcing trials of lower-cost drugs (e.g., bevacizumab) before covering newer agents.17
Although outright denials are modest (~3% of requests), this policy can delay use of optimal therapies.18
Reimbursement cuts
Unlike most other specialties, which typically have only a handful of CMS-designated complex procedures, ophthalmology has a comparatively large number. Roughly 20 to 50 of procedures are classified as higher complexity across CMS coverage and payment frameworks.19,20
Despite performing highly complex procedures, payer reimbursement for retina procedures and surgeries continues to shrink. Medicare’s conversion factor has been cut in recent rules, leading to roughly a 1 to 2% annual decrease in ophthalmology fees.19,20
Even routine office imaging platforms such as optical coherence tomography (OCT) and fundus photography have suffered reimbursement cuts.19 Medicare’s global surgery policy bundles payment for pre-operative, intra-operative, and routine post-operative care, typically covering 90 days.21
Diagnostic tests and in-office procedures are only separately billable if medically necessary and not part of routine post-operative care.21 The combined effect of declining reimbursement and bundled payments reduces practice revenue.
Coverage restrictions
Coverage restrictions have narrowed approved indications for advanced retinal imaging. Medicare requires documentation of medical necessity for fluorescein or indocyanine angiography and limits these tests to nine per eye per year.22 Insurers often deny coverage for tests deemed redundant, such as same-day OCT and fundus photography.
However, they image different aspects of the retina and may be critical for modern-day management. Additionally, procedures such as anti-VEGF injections that were once routine now require pre-authorization, which can delay care.23
Workflow and practice impact
Retina practices report more extended visits due to additional coordination tasks, with staff tracking prior authorization requirements before scheduling necessary treatment.25 Appeals and peer-to-peer reviews consume physician time, diverting specialists from patient care.
These policy shifts overall disrupt clinical workflow and decision-making. Insurance dictation of medical care through withholding and manipulating payments sometimes influences treatment choices, such as favoring off-label bevacizumab over newer drugs when prior authorizations or step therapy block access.26,27
Emerging practice models and physician responses
Under pressure from insurers, some ophthalmologists are exploring alternative practice models. A minority of physicians are opting out of Medicare entirely to regain control over pricing and avoid payer restrictions.
A 2024 analysis found a rising trend of Medicare opt-outs; while many were in specialties like oculoplastics or refractive surgery, other specialties were also opting out, reflecting broader discontent among ophthalmologists, including retina specialists.28
Concierge medicine and office-based surgery
New models of care are rapidly expanding, with concierge medicine standing out for its emphasis on personalized, high-quality services and broad access to care. Evidence supports its positive effects on patient satisfaction, involvement in care, preventive practices, and early disease detection, yet research remains insufficient to link concierge medicine to improved health outcomes clearly.29,30
These practices inherently serve a wealthier subset of patients willing to pay extra.31 Thus, while concierge retina is promising for those who can afford it, it does not address access for the general population, and alternative solutions must be explored.
Office-based surgery is another model that streamlines the surgical process. In recent years, the rising cost of retina surgery and the decline in its volume have made block time less available to retina specialists.
These crippling financial factors are extending into surgical care. Data show that complex retinal detachment repairs are declining significantly.32 Although office-based surgery represents a possible new frontier, not all patients are eligible or candidates for office-based surgery.
Strategies to navigate the obstacles retina practices face
- Optimize prior authorization processes:
- Assign a dedicated specialist to track payer rules.
- Maintain an internal guideline summarizing payer requirements, step-therapy protocols, and diagnosis criteria.
- EHR alerts can flag procedures needing prior authorization and remind staff to verify benefits.
- Submit complete documentation upfront and escalate denials through peer-to-peer reviews and timely appeals supported by published guidelines and outcome data.
- Streamline coding and billing:
- Stay current with CPT updates, payer policies, and modifier requirements.
- Consider using professional coders or consultants to audit claims and prevent revenue loss from incorrect billing.
- Enhance practice efficiency:
- Delegate administrative tasks, employ digital pre-authorization software, and consider team-based care where optometrists or physician assistants handle routine follow-ups.
- Advocate collectively:
- Engage with organizations such as the American Medical Association, the American Academy of Ophthalmology, the American Osteopathic Colleges of Ophthalmology and Head and Neck Surgery, and the American Society of Retina Specialists to push for policy reforms.
- Locally, work with hospitals or payers to negotiate streamlined protocols.
- Explore new care models:
- Selective concierge or cash-fee services may generate revenue to support uncompensated care.
5 key takeaways
- Aging US demographics are increasing AMD and DR rates while the ophthalmologist supply is shrinking, which could lead to epidemic demand.
- Rising costs may lead to stagnant outcomes. US NHE accounts for 18% of GDP without proportional gains in longevity, and insurers remain highly profitable, reflecting a system where financial incentives may outweigh patient outcomes.
- Insurance hurdles, such as prior authorizations and step-therapy rules, delay retina care. Meanwhile, advanced diagnostics face coverage limits.
- In addition, Medicare and commercial payers have lowered many retina-related reimbursement fees. The surgical global periods and bundling rules further restrict billable services.
- Appeals, peer-to-peer reviews, and extra documentation consume substantial resources, causing an administrative burden. Delays tied to insurer policies can result in reduced optical patient care, increased burnout, and reduced clinical time.
- It is imperative to develop adaptive strategies. Successful centers employ dedicated prior authorization specialists, maintain updated internal guidelines, leverage support staff and technology, and appeal denials with clinical evidence.
- Some practices use concierge services or opt out of Medicare for select cases. Professional societies advocate for policy reforms and fair reimbursement. Sustaining retina care will require both efficient practice management and policy changes that align incentives with patient outcomes.
