Medicare reimbursement for ophthalmology procedures has shifted over the past 2 decades, with changes in conversion factors, relative value units (RVUs), and practice settings affecting subspecialties differently.¹ These shifts are placing increasing financial pressure on private practices and raising concerns about patient access to essential eye care.

In this Q&A conversation with the Eye Care Network, Dustin D. French, PhD, discusses research examining Medicare payment trends across ophthalmic subspecialties, including retina and oculoplastics.¹ French outlines which subspecialties are most affected and how these trends may influence practice operations and patient access to care. French is professor of ophthalmology and medical social sciences at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Note: Transcript edited for clarity and length.

Your recent research examines Medicare reimbursement trends over time. What are the most significant Centers for Medicare & Medicaid Services (CMS) changes affecting RVUs today, and why are physicians—particularly ophthalmologists—paying close attention right now?

Dustin D. French, PhD: The most critical issue is not RVU changes. It is the conversion factor. Our study found that Medicare’s conversion factor has declined 47% after adjusting for inflation since 2003, while RVU components remained relatively stable. Ophthalmologists are paying close attention today because we are a procedure-intensive field that addresses high-volume Medicare conditions like cataracts and diabetic retinopathy. With the conversion factor driving nearly all reimbursement erosion and Medicare projected to become insolvent by 2033, there is [a] real concern about practice viability and patient access to essential eye care.

How have recent CMS updates altered the relationship between RVUs and actual physician reimbursement, and what misconceptions do clinicians often have about how RVUs translate into take-home pay?

French: A major misconception that many ophthalmologists carry is that RVUs directly translate to reimbursement, when they don't. Our study shows that even though RVU values have remained relatively stable, actual payments have dropped dramatically because of conversion factor cuts. The shift toward value-based care models and bundled payments has fundamentally changed this relationship. Under traditional fee-for-service, higher RVUs meant proportionally higher payments.

Now, bundled payments lump multiple services together at a fixed rate, and value-based programs tie reimbursement to quality metrics and cost containment rather than volume alone. This means physicians can generate the same RVUs, but receive different compensation depending on their quality scores, patient outcomes, and total cost of care.

Another critical misconception some ophthalmologists may have: many clinicians do not realize that practice setting matters enormously. Our findings show non-facility settings, where most ophthalmologists work, experienced significantly steeper declines (38.9% vs 33.5%, P < .001), meaning private practices bear a disproportionate burden of these cuts.

From your analysis, which ophthalmic subspecialties or procedure types appear to be most impacted by current reimbursement shifts, and what factors are driving those differences?

French: Retina experienced the steepest decline, with facility reimbursement dropping 44.3% and non-facility declining 47.6%. This appears driven by both conversion factor cuts and actual RVU revaluations. Our data show retina procedures experienced the largest reductions in work RVUs over the study period, compounding the conversion factor erosion that hit all subspecialties. Oculoplastics showed the widest gap between settings, with non-facility prices declining 39.6% versus facility at 29.3% (P < .001). Individual procedures reveal even more dramatic disparities.

Intravitreal injections, one of the highest volume procedures in all of Medicare, declined 86.3% in non-facility settings versus 62.1% in facility settings. Similar patterns emerged for probing of nasolacrimal duct (80.4% vs 12.1%) and foreign body removal (77.3% vs 30.6%). The driving factors are 2-fold: subspecialties relying heavily on technology-intensive procedures face compound pressure from both conversion factor cuts and periodic RVU downgrades, while those practicing predominantly in non-facility settings absorb disproportionate losses in practice expense RVUs.

How do you see ongoing CMS policy changes—such as budget neutrality and practice expense revaluations—shaping reimbursement trends over the next several years for ophthalmology practices?

French: Budget neutrality creates a zero-sum game where gains in one area must be offset by cuts elsewhere, perpetuating the decline is what we documented. Practice expense revaluations are particularly problematic for ophthalmology because they fail to account for the reality that technology costs are rising while reimbursement for technology-dependent procedures continues falling.

For example, practices face increasing capital expenses for optical coherence tomography machines, surgical microscopes, and intravitreal injection supplies, yet reimbursement for procedures using those technologies like anti-VEGF injections has dropped over 86% in non-facility settings.

The 2025 reconciliation bill proposes linking the conversion factor to 75% of the Medicare Economic Index initially, dropping to just 10% thereafter. This partial indexing won't meaningfully reverse 2 decades of erosion nor provide a stable long term plan. Unless structural reforms address both the conversion factor declines and the mismatch between rising practice expenses and falling procedure reimbursement, ophthalmology practices will face continued financial pressure that threatens both private practice viability and patient access to care.

Based on your findings, what practical steps can ophthalmologists and practice leaders take to better adapt to these reimbursement changes while maintaining financial sustainability and quality patient care?

French: The most critical step is advocacy. Ophthalmologists need to actively support organizations pushing for conversion factor reform, Medicare Economic Index (MEI) linkage, and more accurate practice expense calculations. Without policy changes, no amount of operational optimization will reverse two decades of systematic reimbursement erosion. The 2025 reconciliation bill's partial MEI indexing is a start, but it's inadequate.

Practices should also model their financial exposure between facility and non-facility settings to inform strategic decisions, but ultimately, sustained advocacy for structural payment reform is the only viable long-term solution. Otherwise, we are facing a workforce shortage crisis that will directly harm Medicare beneficiaries' access to essential eye care particularly for common chronic diseases like diabetes—11.6% of the US population (38.4 million people)—that require [an] annual eye exam and treatment for prevention of blinding disease. It becomes a perfect storm of rising cost of technology for treatment, high levels of vision threatening disease, a growing number of Medicare beneficiaries, and an unstainable financial model to meet the expanding vision needs of Americans.

Dustin D. French, PhD
E: [email protected]
French is professor of ophthalmology and medical social sciences at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Reference

1. Bhatt AN, Brower D, Pan E, et al. A blurry bottom line: the economics of declining Medicare payment trends in ophthalmology subspecialties, 2003 to 2024. Inquiry. 2025;62:469580251399357. doi:10.1177/00469580251399357