Ophthalmology commercial prices vary enormously

July 10, 2025

Summary: Prices paid by commercial health plans for common eye surgery procedures varied substantially, showing the importance of health plan contracted rates. Facility fees varied more than professional fees.

Source: Philips and Whaley, JAMA Ophthalmology July 3, 2025. This shows the ratio of the 75th and the 25th percentile.

Research published in JAMA Ophthalmology demonstrated the impressive differences in how much commercial health plans paid for common eye surgery procedures. The researchers used transparency data published by the carriers as required by federal law, as compiled by a data company, Clarify Health. They did not correlate these with hospital transparency data. The data sample was large, including over 684,000 professional fees from almost 16,000 physicians and almost 56,000 facility fee prices paid to almost 5,000 facilities in January, 2025.

The researchers compared the 25th and 75th percentiles of payment, which eliminates very low and very high prices that could be due to claims or data processing errors. Separately, they also provided mean and median allowed prices. In every instance for professional and facility fees the mean (average) was higher than the median (50th percentile). This “skew to the right” means that averages were driven by especially high prices, which might be due to professionals and facilities with high leverage getting exceptionally high prices.

A 2024 paper by one of the authors demonstrated that hospital outpatient departments charged about 44% more for cataract removal than freestanding ambulatory surgery centers.

I expected the lowest allowable prices on average would be from the largest commercial payers, but this data showed the lowest prices in both professional and facility charges were from the two smallest payers.

Implications for employers:

• Allowable prices vary widely, especially for facility fees.

• Moving elective procedures out of hospital outpatient departments and into freestanding ambulatory surgery centers likely would lead to large cost savings.

• Companies and their consultants can use transparency data to determine which carriers are able to obtain the lowest allowable prices. Beware, though, that these can change as carriers and providers renegotiate multi-year contracts.