The Cost of Treating Diabetic Macular Edema

Estimated reading time: 5 minutes

Medically reviewed and verified by Kate Burke, MD, MHA

If you or a loved one has been diagnosed with diabetic macular edema (DME), one of the first things that might come to mind is: what is the cost of treatment? How much should I expect to pay in order to manage this disease? Cost is one of the most common concerns when it comes to treating any health condition. DME has a number of effective available treatments. Here, PatientsLikeMe will explore why cost matters, why it is rising, and what patients starting treatment need to know.

Cost as a Concern

Health care costs in the United States are a major financial burden. As a country, we spend more than any other nation on our healthcare, both per capita and as a percentage of total GDP. In 2022, health spending in the United States increased to over $4.5 trillion, or $13,493 per capita. That total was 17.3% of our total GDP. According to surveys from the Kaiser Family Foundation, half of U.S. adults find it hard to afford health care, and one in four have faced financial difficulty in paying medical bills within the past year. These costs lead many to delay or skip care completely.

The rising cost of treatments, paired with high insurance premiums, deductibles, and out-of-pocket expenses, is a major concern for families! For those with DME, the financial burden is especially high. Studies show that managing DME can cost over twice as much as managing diabetes alone. This includes the cost of doctor visits, diagnostic tests, and medications. These can add up quickly, especially for treatments that need ongoing care.

Why Cost Is Increasing

There are a few factors that have led to the growing cost of health care, and DME in particular.

1. High Drug Prices: Many DME treatments need intravitreal injections, which are medications given directly into the eye. While some options cost as little as $50 per dose, others can cost between $1,200 and $1,800 per injection. Since these treatments may need to be repeated monthly, costs can rise quickly.
2. Frequent Visits: If you have DME you need regular monitoring and follow-up appointments. These include dilated eye exams and imaging tests. These add to the overall cost.
3. Insurance Limitations: Even with insurance, patients often face high out-of-pocket costs. For instance, Medicare Part B typically covers 80% of the cost of an eye exam, where the patient pays the remaining 20%. However, some patients may carry supplemental insurance covering this additional amount. Patients with a Medicare Advantage plan may have different benefits with an entirely different cost structure. Check with your doctor to determine the best strategy for obtaining your eye exams and medications..

Why the Cost of Treatment Matters

The financial impact of treatment goes beyond just medical bills! It affects quality of life and your ability to access care. High costs often lead people to delay or skip treatments, which can result in worsening vision and more expensive care in the future. If you need an injection but feel like you can't afford it this month, your condition could worsen to the point where you require more care the following month. Many people also take on debt to pay for their care. Studies show that 41% of U.S. adults have medical debt, with women, low-income families, and minorities disproportionately affected. Early and consistent treatment is the best way to preserve your health! Without it, you face greater risks of vision loss, which could lead to job loss and higher long-term expenses.

What Someone Starting Treatment Should Know

If you are just beginning a treatment for DME, here are some tips to help manage the costs.

1. Ask About Lower-Cost Options: Talk to your doctor whether the cost-effective treatments are suitable for you. While they might recommend branded drugs in some cases, many people see great results with less expensive alternatives.
2. Understand Your Insurance Coverage: Insurance is complicated! Review your plan to know what it covers and how much you will need to pay out of pocket. If you are on Medicare, think about supplemental coverage or a Medicare Advantage Plan to help with costs.
3. Look Into Financial Assistance Programs: Many drug manufacturers offer co-pay assistance programs for expensive brand medications. These programs can really help reduce or eliminate out-of-pocket costs.
4. Plan for Long-Term Costs: DME treatment requires multiple injections and follow-up visits over time. Budgeting for these expenses and understanding your maximum out-of-pocket limits can help you prepare.
5. Advocate for Yourself: Ask your doctor or insurance company about cost-saving measures, like generic drugs or alternative treatments. Some clinics also offer payment plans to help spread out costs.

Living with DME is challenging, but there are effective and affordable treatments out there. While the cost of care can be overwhelming, understanding your options and getting financial assistance can make it more manageable! Work closely with your doctor and explore cost-saving strategies. You can protect your vision without breaking the bank. Remember, early and consistent treatment is the key to preserving your eyesight and quality of life.

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