At Press Time

PBS to Salute Dr. Charles Kelman

Documentary on Phaco Inventor to Air in January.

By Jerry Helzner, Senior Editor

■ When former Houston Oilers football coach Bum Phillips was asked if legendary running back Earl Campbell was in a class by himself, Phillips replied: "I don't know if he's in a class by himself but whatever class he is in, it sure doesn't take long to call the roll."

Dr. Charles Kelman occupies a similarly exalted position in the ophthalmology community. More than five years after his death from lung cancer at age 74, the inventor of phacoemulsification is remembered not just as a brilliant medical innovator, but also as a first-rate musician, a talented entertainer, a wit, a helicopter pilot and a caring father and husband.

Now, thanks to the efforts of his widow Ann and some longtime friends and colleagues, early next year the rest of the country will get to see the magnetic Charlie Kelman personality that veteran ophthalmologists still talk about while treasuring his wit and wisdom.

"This documentary is the result of an effort that a group of us has been involved in for more than three years," says Deanna Morton, a longtime friend and principal in InfiniTech Public Relations in Great Neck, NY. "We were able to interest the New York PBS affiliate WLIW in presenting Charlie's story to the country and they have handled the production."

Ms. Morton says the 58-minute docu mentary consists of a great deal of footage of Dr. Kelman himself, along with interviews with friends and colleagues. The film, titled "Through My Eyes: The Charlie Kelman Story," was previewed at the American Academy of Ophthalmology meeting in San Francisco in October.

Sponsors that helped make the film possible include Alcon, Bausch & Lomb, the AAO, Wills Eye Institute, The International Retinal Research Foundation, Ophthalmic Associates of Long Island, Aker Kasten Eye Center and individual contributors such as Jerre Minor Freeman, MD, and James B. Carty, MD.

Dr. Kelman was always comfortable with a microphone in his hands.

Almost a Teen Idol

For those readers not totally familiar with Brooklyn-born Dr. Kelman, his original goal was to become a band-leader but his father insisted that he first become a physician.

While doing his residency at Wills Eye Hospital in Philadelphia in the late 1950s, he became acquainted with a record company executive who handled teen heartthrobs. Dr. Kelman was, among other things, an aspiring songwriter. He wound up recording one of his own songs, "Telephone Numbers," under the name Kerry Adams. It started to move up the charts. However, when the record company scored with a huge new Chubby Checker hit called "Do the Twist," it stopped pushing "Telephone Numbers" and the song disappeared from the airwaves. The end of Dr. Kelman's stint as a teen idol marked the beginning of a spectacular medical career.

Some colleagues have called Dr. Kelman ophthalmology's equivalent of Babe Ruth, both for his outsize personality and his huge achievements. Like Babe Ruth, Dr. Kelman developed prodigious skills, accumulating more than 100 patents in his lifetime. He also had a larger-than-life presence that made him many friends but also caused him to be a controversial figure early in his medical career.

Dr. Kelman became a pioneer in cryosurgery and he revolutionized cataract surgery. He got the idea for phacoemulsification in the late 1960s while having his teeth cleaned with an ultrasonic device. Before Dr. Kelman, cataract surgery was a difficult procedure that required immobilized patients to be in the hospital for more than a week, followed by weeks of recovery and the wearing of thick, image-distorting glasses for the rest of their lives.

Controversy Over Phaco

"The fact that he played the saxophone and did stand-up comedy didn't endear him to the ophthalmology establishment," colleague and friend Robert Sinskey, MD, told Ophthalmology Management in a 2004 tribute to Dr. Kelman. "From the beginning, the establishment was skeptical about the value of phacoemulsification. When Charlie couldn't get his papers published in the peer-reviewed journals, he went to the lay press to get his ideas out."

"Probably no one who's made a major contribution to medicine took more abuse than Charlie Kelman," added renowned cataract surgeon I. Howard Fine, MD, in the 2004 article. "Some doctors were practically making a career of saying that Charlie Kelman was a dangerous man offering patients a dangerous procedure. In reality, it was a great procedure that had to be learned and mastered by skillful surgeons."

The situation got so bad that at one important ophthalmology meeting a man was allowed to sit by the entrance wearing a sign that read: "I was blinded by phaco."

What drove the eventual acceptance of phaco was the realization by individual eye surgeons across the country and around the world that the outcomes could be much better than with any other procedure for extracting cataracts.

Once phaco achieved acceptance, Dr. Kelman received numerous honors. His wealth enabled him to indulge his hobbies, including flying his own helicopter and renting out Carnegie Hall for a night to put on his own show. OM

Good Test, Uncertain Reimbursement

Corneal Hysteresis May Have Benefits, but Payment is a Challenge.

By Jerry Helzner, Senior Editor

■ Will ophthalmologists perform tests for which they see a benefit even if reimbursement is problematic or non-existent?

Corneal hysteresis is a case in point. This diagnostic test measures the biomechanics of the cornea, possibly providing insight into a potential new metric for evaluating glaucoma.

Malik Kahook, MD, a Denver glaucoma specialist, believes that corneal hysteresis per formed with Reichert's Ocular Re sponse Analyzer (ORA) could have important benefits in understanding why some patients experience glaucoma progression despite what appears to be satisfactory IOP control.

However, when he submitted claims for the test under the Category III code for corneal hysteresis (0181T), he was continually denied payment. The Category III code is almost always given to new procedures for which more validating data is needed and means that reimbursement is decided by the local Medicare carrier or independent insurer.

"I have been using the ORA in low-tension glaucoma patients to see if corneal-compensated IOP is different from what we are getting with Goldmann applanation," says Dr. Kahook, who feels it might help explain disease progression despite what appears to be excellent IOP control. "When we find a corneacompensated IOP that is significantly higher than a Goldmann IOP, it might alert us to the fact that IOP control might not be as good as we think it is. Again, we are not sure what these data mean and need to do larger clinical trials to better understand how to use this machine."

Dr. Kahook says that problematic reimbursement means that his use of corneal hysteresis will be limited for the time being. He can use the test "only in an experimental or research setting. It is not practical in today's economic reality to do repeated testing for which we get no reimbursement." The burden of proof remains, he says, to show that this test provides information that is of value and worthy of reimburse ment. "To date, and for glaucoma specifically, these data are lacking."

For its part, Reichert is working toward better reimbursement in two ways. The company is building a reference base of peer-reviewed articles supporting the value of the ORA, especially for corneal hysteresis. It is also gaining more evidence of reimbursement being obtained, especially when practices are persistent in submitting claims and appealing denials.

"Keep billing [for this test]. Do not give up," advises Mitsugu Shimmyo, MD, of New York City. "They deny, keep billing. If the insurers ask questions, answer them and explain why we do this and what information we get. Medicare still does not pay, but many of the commercial insurances pay for it in the New York area now."

Adds Nathan Radcliffe, MD, also of New York, "Our office appealed every denied claim. In terms of appeals, we have been pleased with the response as we went from three to 12 insurance plans paying in about six months. Writing appeal letters is an investment, but the return in this case has been very reasonable."

Andrew Rabinowitz, MD, a Phoenix glaucoma specialist, finds what could be a parallel in what initially was problematic reimbursement for pachymetry.

"Prior to the publication and proliferation of the Ocular Hypertension Treatment Study (OHTS) data in 2002, corneal pachymetry was done rarely by doctors who diagnosed and treated glaucoma," Dr. Rabinowitz says. "The OHTS data, which revealed that corneal thickness was indeed related the severity of glaucoma, brought the pachymeter into the exam rooms of general ophthalmologists and glaucoma specialists alike."

Pachymetry was once only considered a billable test when performed on glaucoma suspects. It was deemed unnecessary once a diagnosis of glaucoma was made. The OHTS results brought the realization that pachymetry was a valuable data point for glaucoma suspects and glaucoma patients alike. It was not until the OHTS results were widely accepted that pachymetry was deemed a billable test for all patients who were being evaluated or treated for glaucoma.

Dr. Rabinowitz says that physicians who are familiar with corneal hysteresis suggest that it has major value in the assessment of glaucomas.

Some practices may currently be hesitant to file claims for corneal hysteresis because of the fear of being audited for a high volume of denied claims. Coding expert Riva Lee Asbell says that practices should not be deterred in submitting claims under code 0181T. "If there is a legitimate use for the code, there is no reason it should raise a red flag," she says.