An Uncertain Future

Alun Evans

As you may be aware, five of the US Medicare administrative contractors (MACs) are withdrawing their local coverage determinations (LCDs) for a number of microinvasive glaucoma surgery (MIGS) procedures. Though this announcement has been welcomed by companies that would have been negatively impacted by the potential changes to Medicare coverage, the need for the U-turn does not diminish a sense of uncertainty.

Sudden turnarounds are not new. Only a couple of years ago – driven by mounting pressure from the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) – Aetna rescinded its policy of requiring preauthorization for cataract surgeries (in every state except Georgia and Florida) after only one year.

It would be remiss, of course, to suggest that all ophthalmologists were against the proposed MIGS coverage changes taking place. Admittedly casting his view from the other side of the Atlantic, Power List alumnus Gus Gazzard, Consultant Ophthalmic Surgeon at Moorfields Eye Hospital, and UCL Professor of Ophthalmology at the Institute of Ophthalmology UCL and the NIHR Biomedical Research Centre, UK, told The Ophthalmologist earlier this year: “While many see this LCD ruling as terrible, I personally see it as a step towards common sense distribution of resources and the limiting of patients to risk of harm only when we know the device works. The designation of treatments as ‘investigational’ until there is randomized controlled trial (RCT) evidence is, in my view, long overdue, and moreover is precisely how we manage things at Moorfields in the UK.”

However, Gazzard did append his statement with a reservation about what the ruling could have meant for ophthalmic development: “I do worry that this will limit innovation – slow it down, but not stifle it – but that may be the price we have to pay for keeping patients safe and using funds wisely.” Whether or not you agree with this view, it’s one that could be reiterated in the months and years to come – both in the US and abroad.

Whatever the future, the unfolding drama of MIGS coverage has cast a shadow on the glaucoma care landscape. Will it influence developers and investors interested in dipping their toes in the MIGS market? Will ophthalmologists-in-training reconsider their career options? Well, with glaucoma cases increasing to an estimated 112 million people by 2040 (1), ophthalmologists who specialize in glaucoma are likely to be in demand like never before – whatever the treatment options available to them.