Michael Antonietti, MD and Mak Djulbegovic, MD
Mass Eye and Ear, Boston, MA; Wills Eye Hospital, Philadelphia, PA
This session, moderated by Drs. Basil Williams, Camille Palma, and Mercy Kibe, focused on structural barriers, socioeconomic disparities, and systemic challenges in retinal healthcare delivery.
Dr. Ravi Parikh opened the first block of presentations by sharing findings recently published in Ophthalmology evaluating real-world anti-VEGF utilization patterns between Medicare Advantage (MA) and Medicare Fee-for-Service (FFS) beneficiaries using the IRIS® Registry. The study revealed that MA beneficiaries were significantly less likely to receive higher-cost, on-label branded anti-VEGF agents like aflibercept or faricimab, and experienced significantly higher rates of bevacizumab use compared to FFS patients. Dr. Parikh highlighted these insurance-driven step-therapy restrictions as a major barrier to care and urged CMS to mandate greater transparency regarding MA step-therapy rules, especially as novel modalities such as gene therapies and tyrosine kinase inhibitors emerge. Next, Dr. Ella Leung, conducted a financial analysis that evaluated Medicaid versus Medicare reimbursement across the ten most common vitreoretinal surgical procedures. Across a weighted national average, Medicaid reimburses vitreoretinal surgeries at approximately 88% of Medicare rates, with substantial state-by-state and procedural variability that directly impacts access to surgical care for Medicaid beneficiaries. Closing the first block, Dr. Judy Kim conducted a big-data analysis of ~10,000 patients using the TriNetX database to evaluate diabetic retinopathy (DR) outcomes among unhoused individuals. Unhoused patients presented with a 3- to 5-fold higher baseline prevalence of severe complications—including proliferative diabetic retinopathy (PDR), vitreous hemorrhage, and tractional retinal detachment—compared to stably housed controls and also, significantly worse longitudinal follow-up beyond six months.
In the First Discussion Period, Dr. Parikh and panelists noted that Medicare Advantage enrollment is particularly common among socioeconomically disadvantaged populations. The panel emphasized the role of retina specialists as advocates, with Dr. Kim highlighting the necessity of bringing data-backed evidence directly to lawmakers to advocate for appropriate reimbursement and protect patient access. To address high loss-to-follow-up rates in vulnerable groups like unhoused patients with PDR, the panel recommended pragmatic, individualized treatment strategies such as same-day bilateral panretinal photocoagulation.
The second block shifted toward structural access and disease presentation across subspecialties. Dr. Bivek Wagle investigated whether social determinants of health (SDOH)—including zip code median household income, distance to hospital, age, gender, and race—impacted visual outcomes in endophthalmitis. Analyzing 59 patients over four years at the University of Nebraska, the study concluded that SDOH metrics were not significantly associated with presenting or 3-month visual acuity, though the authors noted limitations due to sample size and zip code-level income data, recommending larger multi-center trials. Dr. Hong-Uyen Hua then detailed the national landscape of pediatric retinal care, noting that while retinal disease causes 50% of childhood blindness, formal pediatric retina fellowships remain rare, leaving over half of U.S. states without a single practicing pediatric retina specialist. Geographic mapping demonstrated that the nation’s 83 pediatric retina specialists are heavily concentrated in higher-income counties with higher adult education levels, higher insurance rates, and greater internet connectivity. Finally, Dr. Milam Brantley evaluated 191 patients undergoing genetic testing for inherited retinal diseases (IRDs), demonstrating that socioeconomic disadvantage and family history correlated with disease severity in peripheral IRDs, while age and marital status correlated with severity in macular IRDs. Quantitative imaging metrics detected these socioeconomic disparities more consistently than visual acuity alone.
During the Second Discussion Period, participants addressed strategies to improve subspecialty capacity given that only 83 pediatric retina specialists practice nationwide. Panelists suggested integrating foundational pediatric retina exposure into general retina fellowships to ensure broader comfort with basic management. Advocacy and increased funding were central themes, with calls to expand access to IRD genetic testing and address lower reimbursement rates for lengthy, complex pediatric care. The session concluded with a call to action for the retina community to adopt a holistic care model, dedicate time to teach trainees at safety-net and county hospitals, and foster cross-organizational partnerships (such as ASRS collaborating with AAPOS) to expand care access for all patients.
