Ophthalmic Medication Expenditures and Out-of-Pocket Spending

An Analysis of United States Prescriptions from 2007 through 2016


      To estimate temporal trends in total and out-of-pocket (OOP) expenditures for ophthalmic prescription medications among adults in the United States.


      Retrospective, longitudinal cohort study.


      Participants in the 2007 through 2016 Medical Expenditure Panel Survey (MEPS) 18 years of age or older. The MEPS is a nationally representative survey of the noninstitutionalized, civilian United States population.


      We estimated trends in national and per capita annual ophthalmic prescription expenditures by pooling data into 2-year cycles and using weighted linear regressions. We also identified characteristics associated with greater total or OOP expenditures with multivariate weighted linear regression. Costs were adjusted to 2016 United States dollars using the gross domestic product price index.

      Main Outcome Measures

      Trends in total and OOP annual expenditures for ophthalmic medications from 2007 through 2016 as well as factors associated with greater expenditures.


      From 2007 through 2016, 9989 MEPS participants (4.2%) reported ophthalmic medication prescription use. Annual ophthalmic medication use increased from 10.0 to 12.2 million individuals from 2007 and 2008 through 2015 and 2016. In this same period, national expenditures for ophthalmic medications increased from $3.39 billion to $6.08 billion and OOP expenditures decreased from $1.34 to $1.18 billion. Per capita expenditure increased from $338.72 to $499.42 (P < 0.001), and per capita OOP expenditure decreased from $133.48 to $96.67 (P < 0.001) from 2007 and 2008 through 2015 and 2016, respectively. From 2015 through 2016, dry eye (29.5%) and glaucoma (42.7%) medications accounted for 72.2% of all ophthalmic medication expenditures. Patients who were older than 65 years (P < 0.001), uninsured (P < 0.001), and visually impaired (P < 0.001) were significantly more likely to have greater OOP spending on ophthalmic medications.


      Total ophthalmic medication expenditure in the United States increased significantly over the last decade, whereas OOP expenses decreased. Increases in coverage, copayment assistance, and use of expensive brand drugs may be contributing to these trends. Policy makers and physicians should be aware that rising overall drug expenditures ultimately may increase indirect costs to the patient and offset a decline in OOP prescription drug spending.

      Abbreviations and Acronyms:

      AHRQ (Agency for Healthcare Research and Quality), CI (confidence interval), FPL (federal poverty level), MEPS (Medical Expenditure Panel Survey), OOP (out-of-pocket), PBM (pharmacy benefit manager)
      To read this article in full you will need to make a payment


      Subscribe to Ophthalmology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Keehan S.P.
        • Cuckler G.A.
        • Sisko A.M.
        • et al.
        National health expenditure projections, 2014–24: spending growth faster than recent trends.
        Health Aff (Millwood). 2015; 34: 1407-1417
        • Kesselheim A.S.
        • Avorn J.
        • Sarpatwari A.
        The high cost of prescription drugs in the United States: origins and prospects for reform.
        JAMA. 2016; 316: 858-871
        • Cubanski J.
        • Swoope C.
        • Damico A.
        • Neuman T.
        How Much Is Enough?.
        Out-of-Pocket Spending among Medicare Beneficiaries: A Chartbook. Kaiser Family Foundation, Menlo Park, CA2014
        • Goldman A.L.
        • Woolhandler S.
        • Himmelstein D.U.
        • et al.
        Out-of-pocket spending and premium contributions after implementation of the Affordable Care Act.
        JAMA Intern Med. 2018; 178: 347-355
        • Park T.
        • Jung J.
        The effect of Medicare Part D on prescription drug spending and health care use: 6 years of follow-up, 2007–2012.
        J Manag Care Spec Pharm. 2017; 23: 5-12
        • Sarna D.
        • Squires D.
        • Bishop S.
        Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier?.
        The Commonwealth Fund, New York, NY2017
        • Kamal R.
        • Cox C.
        • McDermott D.
        What are the recent and forecasted trends in prescription drug spending? Peterson-KFF.
        (Accessed March 17, 2020)
        • Paez K.A.
        • Zhao L.
        • Hwang W.
        Rising out-of-pocket spending for chronic conditions: a ten-year trend.
        Health Aff (Millwood). 2009; 28: 15-25
        • Javitt J.C.
        • Zhou Z.
        • Willke R.J.
        Association between vision loss and higher medical care costs in Medicare beneficiaries costs are greater for those with progressive vision loss.
        Ophthalmology. 2007; 114: 238-245
        • Wittenborn J.S.
        • Zhang X.
        • Feagan C.W.
        • et al.
        The economic burden of vision loss and eye disorders among the United States population younger than 40 years.
        Ophthalmology. 2013; 120: 1728-1735
        • Gong D.
        • Chang J.S.
        • Barbany M.
        • et al.
        Comparison of United States and international ophthalmic drug pricing.
        Ophthalmology. 2019; 126: 1358-1365
        • Parikh R.
        • Feng P.W.
        • Tainsh L.
        • et al.
        Comparison of ophthalmic medication prices between the United States and Australia.
        JAMA Ophthalmol. 2019; 137: 358-362
        • Newman-Casey P.A.
        • Woodward M.A.
        • Niziol L.M.
        • et al.
        Brand medications and Medicare Part D: how eye care providers’ prescribing patterns influence costs.
        Ophthalmology. 2018; 125: 332-339
        • Newman-Casey P.A.
        • Robin A.L.
        • Blachley T.
        • et al.
        The most common barriers to glaucoma medication adherence: a cross-sectional survey.
        Ophthalmology. 2015; 122: 1308-1316
        • Stein J.D.
        • Shekhawat N.
        • Talwar N.
        • Balkrishnan R.
        Impact of the introduction of generic latanoprost on glaucoma medication adherence.
        Ophthalmology. 2015; 122: 738-747
        • Galor A.
        • Zheng D.D.
        • Arheart K.L.
        • et al.
        Dry eye medication use and expenditures: data from the medical expenditure panel survey 2001 to 2006.
        Cornea. 2012; 31: 1403-1407
        • Lam B.L.
        • Zheng D.D.
        • Davila E.P.
        • et al.
        Trends in glaucoma medication expenditure: Medical Expenditure Panel Survey 2001–2006.
        Arch Ophthalmol. 2011; 129: 1345-1350
        • Agency for Healthcare Research and Quality. MEPS HC-197A
        2017 Prescribed Medicines.
        Agency for Healthcare Research and Quality Center for Financing, Access, and Cost Trends, Rockville, MD2019
        • Martin B.I.
        • Deyo R.A.
        • Mirza S.K.
        • et al.
        Expenditures and health status among adults with back and neck problems.
        JAMA. 2008; 299: 656-664
        • Salami J.A.
        • Warraich H.
        • Valero-Elizondo J.
        • et al.
        National trends in statin use and expenditures in the US adult population from 2002 to 2013: insights from the Medical Expenditure Panel Survey.
        JAMA Cardiol. 2017; 2: 56-65
        • Agency for Healthcare Research and Quality
        Medical Expenditure Panel Survey: MEPS-HC response rates by panel.
        (Accessed 04.03.20)
        • Hill S.C.
        • Roemer M.
        • Stagnitti M.N.
        Outpatient Prescription Drugs: Data Collection and Editing in the 2011 Medical Expenditure Panel Survey.
        Agency for Healthcare Research and Quality, Rockville, MD2014
        • Hill S.C.
        • Zuvekas S.H.
        • Zodet M.W.
        Implications of the accuracy of MEPS prescription drug data for health services research.
        Inquiry. 2011; 48: 242-259
        • Schakel W.
        • van der Aa H.P.A.
        • Bode C.
        • et al.
        The economic burden of visual impairment and comorbid fatigue: a cost-of-illness study (from a societal perspective).
        Invest Ophthalmol Vis Sci. 2018; 59: 1916-1923
        • United States Senate Homeland Security & Governmental Affairs Committee Minority Office
        Manufactured Crisis: How Devastating Drug Price Increases Are Harming America’s Seniors.
        (Accessed February 21, 2020)
        • Papanicolas I.
        • Woskie L.R.
        • Jha A.K.
        Health care spending in the United States and other high-income countries.
        JAMA. 2018; 319: 1024-1039
        • The Pew Trusts
        The prescription drug landscape, explored: a look at retail pharmaceutical spending from 2012 to 2016.
        (Accessed February 3, 2020)
        • Kaiser Family Foundation
        Examining high prescription drug costs for people with employer-sponsored health insurance.
        Kaiser Family Foundation, San Francisco, CA2016
        • Blumberg D.M.
        • Prager A.J.
        • Liebmann J.M.
        Variation in prescription drug coverage enrollment among vulnerable beneficiaries with glaucoma before and after the implementation of Medicare Part D.
        JAMA Ophthalmol. 2016; 134: 212-220
        • Gotanda H.
        • Jha A.K.
        • Kominski G.F.
        • Tsugawa Y.
        Out-of-pocket spending and financial burden among low income adults after Medicaid expansions in the United States: quasi-experimental difference-in-difference study.
        BMJ. 2020; 368: m40
        • Blumberg D.M.
        • Prager A.J.
        • Liebmann J.M.
        • et al.
        Cost-related medication nonadherence and cost-saving behaviors among patients with glaucoma before and after the implementation of Medicare Part D.
        JAMA Ophthalmol. 2015; 133: 985-996
        • Klein R.
        • Klein B.E.
        The prevalence of age-related eye diseases and visual impairment in aging: current estimates.
        Invest Ophthalmol Vis Sci. 2013; 54: ORSF5-ORSF13
        • Merck & Co., Inc
        Merck Helps: Trusopt.
        (Accessed 10.03.20)
        • Novartis Pharmaceuticals Corp
        Patient assistance foundation enrollment.
        (Accessed 08.03.20)
        • Allergan, Inc
        Patient assistance programs.
        (Accessed 07.03.20)
        • Dusetzina S.B.
        • Jazowski S.
        • Cole A.
        • Nguyen J.
        Sending the wrong price signal: why do some brand-name drugs cost Medicare beneficiaries less than generics?.
        Health Aff (Millwood). 2019; 38: 1188-1194
        • Dafny L.S.
        • Ody C.J.
        • Schmitt M.A.
        Undermining value-based purchasing—lessons from the pharmaceutical industry.
        N Engl J Med. 2016; 375: 2013-2015
        • Ross J.S.
        • Kesselheim A.S.
        Prescription-drug coupons—no such thing as a free lunch.
        N Engl J Med. 2013; 369: 1188-1189
        • Ubel P.A.
        • Bach P.B.
        Copay assistance for expensive drugs: a helping hand that raises costs.
        Ann Intern Med. 2016; 165: 878-879
        • Sood N.
        • Ribero R.
        • Ryan M.
        • Van Nuys K.
        The Association between Drug Rebates and List Prices.
        Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, CA2020
        • Roy A.
        Drug companies, not ‘middlemen,’ are responsible for high drug prices.
        (Accessed 15.03.20)
        • Warraich H.J.
        • Salami J.A.
        • Khera R.
        • et al.
        Trends in use and expenditures of brand-name atorvastatin after introduction of generic atorvastatin.
        JAMA Intern Med. 2018; 178: 719-721
      1. Wilson D. Facing generic Lipitor rivals, Pfizer battles to protect its cash cow. The New York Times. November 29, 2011; Section B, Page 1.

        • Agency for Healthcare Research and Quality
        Medical Expenditure Panel Survey: precision standards guidelines for reporting MEPS-HC descriptive statistics.
        (Accessed 08.03.20)