Use of, and Medicare Expenditure on, Sutureless Amniotic Membrane Grafts Soared — and Maybe Not for a Good Reason
Summary: A new analysis reveals a steep rise in the use and Medicare costs of sutureless amniotic membrane grafts (AMGs) between 2011 and 2020. These grafts, often used in ophthalmology for conditions like dry eye, were reimbursed based on wholesale acquisition cost (WAC), not the provider’s true purchase price. This created significant profit margins that may have fueled overutilization. Experts call for reimbursement reform to prevent misuse while ensuring patient access when clinically appropriate.
Key Highlights:
- Sharp increase in use: Procedures billed for sutureless AMGs jumped from 319 in 2011 to more than 8,000 in 2020.
- Cost escalation: Medicare payments grew from $3.6 million in 2011 to $95.6 million in 2020.
- Profit-driven incentives: Providers could profit up to $600 per graft due to the gap between WAC and actual acquisition cost.
- Concerns of misuse: Utilization patterns suggest many applications may not have been clinically justified, echoing past controversies around skin substitute billing.
- Policy suggestions: Researchers recommend aligning reimbursement with real costs and enforcing oversight to balance access with responsible use.
Read the full article on Managed Healthcare Executive
Keywords:
sutureless amniotic membrane grafts,
Medicare expenditure,
reimbursement incentives,
overutilization,
ophthalmology grafts,
Managed Healthcare Executive