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.