Commercial Price Variation in Ophthalmology.

Abstract

Objective: To assess the variation in commercial insurance payment rates for common ophthalmology procedures across major national insurers and identify patterns in professional and facility fees.

Design, setting, and participants: This cross-sectional study used January 2025 Transparency in Coverage data, payment rates negotiated between insurers and health care professionals from 4 large national insurers (Blue Cross Blue Shield, United Healthcare, Cigna, and Aetna) for 10 common ophthalmology procedures. Data included approximately 684 506 professional fee price points from 15 788 physicians and 55 930 facility fee price points from 4697 facilities. Data were analyzed January through March 2025.

Main outcomes and measures: The primary outcomes were the distribution of negotiated prices (mean, median, percentiles), coefficients of variation, and volume-weighted price indices by payer for professional and facility payments by commercial insurers. Geographic variation in pricing was also assessed.

Results: Negotiated facility fees showed substantially greater price variation than professional fees across all ophthalmology procedures, with facility coefficients of variation exceeding professional coefficients by factors of 2 to 4. Blue Cross Blue Shield maintained consistently higher payments (14% above market average for professional fees; 13% above for facility fees), while Aetna demonstrated dramatic variation with professional fees 54% below average but facility fees 45% above average. Geographic analysis revealed substantial state-level variability, with facility prices for standard cataract surgeries showing up to 5-fold differences between upper and lower bounds across states.

Conclusions and relevance: This study reveals substantial variability in commercial insurance payment rates for ophthalmology procedures, particularly in facility fees. These findings indicate that market dynamics, insurer-health care professional negotiations, and geographic factors substantially influence price variation, which has important implications for health care affordability and access to ophthalmologic care.