One drug, administered by injection into the eye, collected more Medicare dollars in 2023 than the entire psychiatric workforce did in 2022. That's not a rounding error. It's a structural feature of how Medicare values care.

A 10-to-1 Gap That Has Held for a Decade

In 2013, ophthalmology received $5.8 billion in total Medicare payments. Psychiatry received $808 million. The ratio was roughly 7 to 1, and psychiatry actually had more providers: 21,677 versus ophthalmology's 17,215. More doctors, less money, by a wide margin.

That gap has only widened. By 2021, ophthalmology's 17,024 providers generated nearly $7.0 billion in Medicare payments. Psychiatry's 19,316 providers generated $682 million. Payment per provider tells the starkest version of this story: in 2018, the average ophthalmologist collected $388,945 from Medicare while the average psychiatrist collected $36,728, a ratio of more than 10 to 1. By 2019, those figures were $408,298 and $36,574, respectively.

For patients, this arithmetic has real consequences. A reimbursement structure that pays procedural specialists ten times more per provider than behavioral health clinicians shapes where physicians train, where they practice, and which patients get seen.

One Drug Doing the Heavy Lifting

The concentration of ophthalmology spending is striking. In 2023, a single drug, aflibercept (J0178), an injection used to treat macular degeneration and diabetic eye disease, accounted for $2.35 billion, or 32.39% of all ophthalmology Medicare payments. The second-largest line item, faricimab-svoa (J2777), added another $965 million, or 13.32%. Together, two injectable drugs represented nearly half of everything Medicare paid to ophthalmology.

Cataract removal with prosthetic lens insertion, the procedure most people associate with ophthalmology, ranked third at $578 million, or 7.98% of the total.

This concentration matters because it means ophthalmology's spending advantage over psychiatry isn't primarily about the volume of patient encounters or the breadth of services. It's substantially driven by the reimbursement rates attached to a handful of biologics. Aflibercept alone, in 2023, collected more than three times what all of psychiatry received from Medicare in 2022.

Psychiatry's Shrinking Footprint

While ophthalmology's total payments grew from $5.8 billion in 2013 to $7.2 billion in 2023, psychiatry's trajectory moved in the opposite direction. Total psychiatric payments fell from $808 million in 2013 to $607 million in 2022. The provider count dropped too, from 21,677 in 2013 to 18,760 in 2022.

Payment per psychiatrist has been essentially flat in nominal terms for a decade, hovering between $32,000 and $42,000. In real terms, that's a pay cut. The Medicare mental health workforce is contracting at exactly the moment demand for behavioral health services is rising.

No one convened a committee to decide that treating a senior's retinal disease should be reimbursed at ten times the rate of treating their depression. That outcome emerged from decades of fee schedule decisions, drug pricing policy, and specialty-specific coding structures. But the cumulative effect is an implicit triage: Medicare's payment architecture systematically directs resources toward procedural and pharmaceutical interventions and away from behavioral health.

Given that aflibercept injections alone accounted for 32.39% of all ophthalmology Medicare payments in 2023, the question worth sitting with is how much of ophthalmology's entire spending advantage over psychiatry is attributable to a single drug's reimbursement rate.