At Press Time

Ophthalmologists' Pay is Average for MDs

By Samantha Stahl, Assistant Editor

■ In 2010, the median earnings for an ophthalmologist in the US was $248,500, according to a survey recently conducted and published by Medscape. Compensation was defined as salary, bonus and profit-sharing contributions only (speaking engagements, consulting fees and other non-patient care activities were not included).

The online survey gathered information from 15,794 physician-respondents across 22 specialties. Of these, 333 (approximately 2%) were ophthalmologists — 77% were men and 23%, women. Most were MDs (96%) and board-certified (88%).

The majority of respondents (48%) earned between $100,001 and $299,999 a year. Approximately 31% earned at least $350,00. This put ophthalmology at 12th place of the 22 specialties surveyed. The top three earners were orthopedic surgery, radiology and anesthesiology. Primary care practitioners and pediatricians had the two lowest median salaries.

Ophthalmologists that earned the most (median salary of $330,000) worked in small cities with populations of 50,000 to 99,999. Suburban and rural ophthalmologists had similar salaries — $255,000 and $249,500, respectively. Those in metropolitan areas with 500,000 people or more had the lowest median salary — $225,000.

Practice setting varied amongst respondents, with most in solo practice (25%), a single-specialty group (23%), a partner in private practice (14%) or in a multi-specialty group (12%). Single-specialty group physicians had the top earnings, with a median salary of $360,000, while independent contractors had the lowest ($160,000). Women earned significantly less on average than men, with the median salary for a female ophthalmologist standing at $200,000, compared to $285,000 for males.

2010 also saw widespread salary increases for ophthalmologists, with 35% reporting that they earned more in 2010 than in 2009 and 8.5% saying they experienced an over 20% raise. Conversely, 10.5% reported a decline in salary, 4% of whom said their salary decreased by 20% or more.

According to the Bureau of Labor Statistics, the ranks of US ophthalmologists are expected to grow at least 20% by the year 2018, thanks to the aging population in need of ophthalmic care.

Judge: PAs Can Perform Some Surgical Tasks

St. Luke's Eye wins a key case.

■ In what might become a milestone decision, a federal judge has ruled that a properly trained, experienced and properly supervised physician assistant (PA) can perform a number of surgical tasks that are a part of cataract surgery.

The ruling went in favor of James P. Gills, MD, the director of the St. Luke's Cataract & Laser Institute in Tarpon Springs, Fla., after a cataract surgery patient who underwent a successful procedure sued under the federal False Claims Act. The suit alleged that billing for the procedure included only the name of Dr. Gills although a PA performed some of the steps in the surgery. Dr. Gills does perform the phacoemulsification and implants the IOLs for every cataract surgery patient in his care.

Dr. Gills has long been known as a pioneer in using PAs as part of his cataract surgery team.

“Dr. Gills' model is highly unusual and not widely accepted in ophthalmology communities in the United States,” noted US District Judge James D. Whittemore in his ruling. However, he wrote that the lawsuit's evidence did not “provide a basis for finding that the billing certifications were knowingly false or fraudulent.”

The judge went on to state that federal law allows physicians to bill Medicare for supervised PA services under specific circumstances, and that Florida medical rules define direct supervision as “immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.”

As part of his defense, Dr. Gills furnished a signed a consent form authorizing Dr. Gills “and/or associates or assistants of his choice” to perform the surgery. In his ruling, the judge did not address the informed consent process followed by Dr. Gills.

Asked for a comment on the case by Ophthalmology Management, St. Luke's responded that “Dr. Gills has been exonerated in connection with his billings to Medicare for cataract surgery. The Court recognized that it was appropriate, and not a false claim, for a surgeon to bill to Medicare the physician's fees for a cataract surgery even when some of the surgical tasks are delegated to a properly supervised physician assistant.”

St. Luke's said the Court also observed that there was “no evidence controverting that Dr. Gills and his associates ensured that the physician assistants were knowledgeable and highly skilled” in performing the procedures delegated to them and supervised by the surgeons. “In fact, Dr. Gills and his colleagues have consistently successful cataract surgery outcomes,” St. Luke's concluded.

New Studies Highlight DMEK, DSAEK Outcomes

DMEK excels in study of transplant techniques.

By Jerry Helzner, Senior Editor

■ A large study conducted by the Cornea Research Foundation of America and the Price Vision Group, both in Indianapolis, found that DMEK corneal transplant procedures resulted in far fewer rejections than either DSAEK or PK procedures. In fact, only one out of 141 eyes treated with the DMEK procedure, which uses only the endothelial layer, experienced a rejection episode in the median 13-month DMEK follow-up period. The DMEK technique, which presents more challenges to the surgeon because it involves thinner tissue, on average also produced better visual outcomes.

Comparing only individuals whose transplant was performed by the Price Vision Group, 54 out of 598 DSAEK patients (9%) experienced a rejection episode and five out of 30 PK patients (17%) experienced a rejection episode. A DSAEK graft includes some stromal tissue and PK is a full-thickness graft.

Because all of the procedures were performed by Price Vision Group, the postoperative steroid regiment and the rejection criteria were the same for all patients in the study. Ninety percent of all the patients in the study received a transplant as a result of Fuchs' dystrophy.

The results were first published in the January 2012 issue of the journal Ophthalmology.

In another study, also published in the January 2012 issue of Ophthalmology, DSAEK graft rejection was linked to endothelial cell loss. Researchers led by Jennifer Li, MD and Mark Terry, MD, of the Devers Eye Institute in Portland, Ore., did a retrospective analysis of 615 eyes that had undergone DSAEK at Devers and that had endothelial cell counts measured at regular intervals by specular microscopy. Percentage endothelial cell density (ECD) declines were calculated at each time point for all patients.

The researchers identified 45 cases of graft rejection, with the greatest number of rejections occurring between 12 and 18 months postop. Eyes that experienced graft rejection had a higher median percentage decline in ECD at all time points compared with eyes that did not have graft rejection episodes. The difference in ECD between the two groups became statistically significant at the two- and three-year postop measurements.

The researchers concluded that a linkage exists between ECD and DSAEK graft survival.

Genentech Ends Dispute; Will Get Eylea Royalties

Regeneron reports strong initial sales.

■ Regeneron Pharmaceuticals has entered into a non-exclusive license and partial settlement of a patent dispute with Genentech relating to US ophthalmic sales of the recently approved wet AMD drug Eylea. The settlement, which removes a cloud over the future of Eylea, was arrived at in early January and involves royalty payments to Genentech in return for patent licenses.

Genentech is Regeneron's chief competitor in the treatment of wet AMD, with Genentech's Lucentis the branded market leader in this area, with US sales of about $1.5 billion in 2010.

Regeneron received a non-exclusive license to certain patents relating to VEGF receptor proteins, known as the Davis-Smyth patents, and other technology patents. Patent litigation is continuing with respect to matters not covered by the announced agreement. The agreement does cover any and all ophthalmic indications for Eylea.

Under the terms of the agreement, Regeneron will make payments to Genentech based on US sales of Eylea through May 7, 2016, starting with $60 million upon cumulative US sales of Eylea reaching $400 million.

Regeneron said it has not infringed on any Genentech patents but said it made the financial agreement to avoid the uncertainty and risk of further litigation.

The unsettled portion of the patent dispute involves potential non-ophthalmic future uses for Eylea.

In related news, Regeneron said that Eylea had a highly successful US launch, with sales of $24 to $25 million in the initial launch, encompassing the period from November 21 through December 31. Analysts had estimated sales in the $3 to $5 million range. For 2012, Regeneron is estimating US Eylea sales in the range of $140 to $160 million, or about a 10% share of the branded wet AMD market.

Research Digest

New & Noteworthy Journal Articles

Compiled by Andrew E. Mathis, PhD, Medical Editor

► Glaucoma and corneal cell loss. Loss of corneal endothelial cells due to chronic angle-closure glaucoma is a known risk of the disease, and acute angle-closure attacks have been reported to be related to permanent corneal endothelial cell loss. In the January 2012 issue of the Journal of Glaucoma, ophthalmologists in Taiwan have published the results of a trial to determine the long-term effects of acute angle-closure attacks on these cells.

The study enrolled 174 eyes divided into four groups: 40 eyes from patients with primary angle-closure glaucoma (PACG) with earlier documented acute angle-closure attacks; 40 fellow eyes of patients who had experienced such attacks; 44 eyes of patients with chronic PACG who had not experienced such attacks; and 50 eyes from age-matched normal patients. All participants underwent gonioscopy, central corneal pachymetry and ocular measurements including IOP and visual acuity.

The mean endothelial cell density in the PACG patients who had experienced acute attacks was 2,271 ±80 cells/mm², compared to 2,458 ±79 cells/mm² in the fellow eyes, 2379 ±50 cells/mm² in the chronic PACG eyes and 2,559 cells/mm² in the controls. While the difference in cell density between the eyes that had experienced acute attacks and the controls was significant, other comparisons did not yield statistical significance, nor did the mean central corneal thickness of the acute attack eyes differ from the other eyes significantly.

However, corneal endothelial cell density was negatively correlated with the duration of acute attacks. The authors state that more rapid resolution of acute attacks is needed to prevent damage to the corneal epithelial cells.

► Who pays for eye emergencies? To what extent do public health insurance funds bear the expense for emergency room visits due to eye emergencies? Doctors in Florida and Texas collaborated on a study to determine trends in coverage and reimbursement over a five-year period at emergency departments in Florida. Their findings appear in the January 2012 issue of Archives of Ophthalmology.

Examining data from the Florida Agency for Health Care Administration, the study authors identified nearly 750,000 emergency department visits due to eye emergencies between 2005 and 2009. These patients included both children and adults, so the data were stratified according to age younger than 18 and 18 or older. The data were also analyzed for type of insurance coverage, and negative binomial regression was applied to draw statistical conclusions.

The study authors found that the largest proportion of emergency outpatient services were paid for by commercial insurance (31.1%). Out-of-pocket payments accounted for 26.2% and Medicaid for another 22.0%. For pediatric patients, out-of-pocket payments accounted for 67.7% of principal payments applied. For all patients, Medicare expenditures increased by 5.9% for each calendar year of the study, while commercial coverage decreased each year by 4.5%, but during the entire period, Florida residents received less Medicaid coverage than the national average.

The study authors draw the conclusion that Medicaid and private payments are accounting for a substantial portion of eye emergencies in Florida. They are curious to discover what effects, if any, the healthcare reform passed in 2010 will have on these trends. OM