Study examines reimbursement differences between the sexes

By Robert Stoneback, associate editor

Female ophthalmologists were reimbursed a median of $0.56 for every Medicare dollar that was reimbursed to a male ophthalmologist, according to a new study published this March in JAMA Ophthalmology.

The JAMA paper, titled “Differences in Clinical Activity and Medicare Payments for Female vs Male Ophthalmologists,” reviewed the CMS database for Medicare payments to ophthalmologists from Jan. 1, 2012, to Dec. 31, 2013. The research took place from February to May 2016.

With this reimbursement disparity, the authors estimated that female ophthalmologists would be reimbursed $1.5 million less over a 30-year career, before considering interest and investment returns.

No evidence in the study, led by Ashvini K. Reddy, MD suggested that women were less competent or motivated than their male counterparts.

A look at the 2017 annual physician salary survey conducted by Medscape shows that women ophthalmologists have made significant income gains since 2013. In its 2013 study, Medscape suggested that women specialists, of all kinds, earned much less than their male counterparts because so few were in high paying specialties.

Medscape’s 2017 Physician Compensation Report finds that salaries for full-time male ophthalmologists averaged $370,000; for females, it was $267,000. In 2013, the numbers were $294,000 for men and $220,000 for women.

CMS data

For 2012, according to the study, the mean reimbursement amount for female ophthalmologists was $106,932; for male ophthalmologists, it was $185,405. The mean number of charges per ophthalmologist was 2,811 for men and 1,631 for women. Women accounted for 19.8% of ophthalmologists receiving Medicare reimbursement payments, and 12.3% of the total payments collected via Medicare. The mean payment charge in 2012 was $66 for both women and men.

For 2013, the study reported the mean reimbursement for female ophthalmologists was $106,846, and $184,310 for males. The mean number of charges per ophthalmologist was 2,860 for men and 1,660 for women. That year, women accounted for only 12.8% of the total Medicare submissions, and received only 12.5% of the payments. The mean payment was the same for both sexes, at $64.

The authors noted in the study that it was not designed to explain why women submitted fewer submissions than men to CMS.

Women also reported 24% fewer patient visits, but worked only 5% fewer hours than men; the study actually found that increased work time was associated with lower income among women.

Dr. Reddy wrote that there were limitations to the study’s analysis. These included not measuring payments from non-CMS sources, as they are not reported, and physician ages and specialty status not being uniformly available, meaning that seniority or subspecialization could not be factored into earnings.

Due to these limitations, the study could not recommend corrective action for the reimbursement inequality, though it found strong evidence of it.

In a statement issued after the paper’s publication, Dr. Reddy said, “Policies that justify hiring women at a lower base salary than men are not supported by these data. Such practices would be not only unethical and ill-advised, it would be illegal in most states under ‘equal pay’ legislation.” Dr. Reddy added that she welcomes “further rigorous research” on the topic.

By the numbers

While Medscape’s reports list an upward trend in ophthalmologists’ income, the greater increase is still seen among men.

Comparing Medscape data, which covered all income, to the period for which Dr. Reddy and her colleagues collected the Medicare data, full-time ophthalmologists earned an average of $295,000 in 2012 and women earned $216,000.

Medscape also said one factor keeping women’s salaries lower was that more women worked part-time. The 2017 Medscape report listed 15% of men working part-time, and 85% full-time. Of the women responders, 76% worked full-time compared to 24% part-time.

The 2016 data stated that 14% of men worked part-time, versus 31% of women.

Part-time and full-time statistics were not available for the 2012 and 2013 reports. OM

Where does femto fit?

Two studies compare femto’s clinical effectiveness against manual surgery.

By Michael Patterson, DO

Debate continues over whether the use of femto in cataract surgery is more effective than manual removal of the lens. The discussions around the technology are highlighted by two recent studies, one of which finds femto does not yield better visual or refractive outcomes than traditional phaco cataract surgery, and the other which finds femto-assisted cataract surgery is associated with a reduction in Nd:YAG capsulotomy rates compared to manual cataract surgery.

Phaco vs femto

In the first study, a group of researchers compared 2,814 prospective femtosecond-assisted cases and 4,987 retrospective phacoemulsification cases. Data for the study, which were obtained from Europe and Australia, compared intraoperative and postoperative complications, postoperative CDVA and refractive outcomes. The eyes chosen for the phacoemulsification cases were from the European Registry of Quality Outcomes for Cataract and Refractive Surgery.¹

Existing data indicate that femtosecond cataract surgery is safer, more efficient and predictable than manual surgery.² Constructing a cataract wound with three, four or five hinges via a laser with self-sealing abilities seemingly has an advantage over a manual incision. However, the results from this study reveal the opposite.

Common perceptions

Complications regarding the posterior capsule were 0.7% for femtosecond vs 0.4% for phacoemulsification. Postoperative complications such as corneal edema, early PCO, uncontrolled IOP, uveitis requiring treatment, and others were 3.4% in the femtosecond group vs 2.3% in the traditional phacoemulsification group. Compilation of the data showed that the refractive outcomes were similar between the two procedures. The percentage of patients with worse CDVA was 1% with femtosecond and 0.4% with the traditional phacoemulsification group. The biometry prediction error was similar between the two groups at 0.43 diopters for femtosecond and 0.40 diopters for traditional phacoemulsification.¹

The data conflict with the perception that femtosecond technology is superior when used in cataract surgery. While intraoperative complications were low in both groups, postoperative complications were lower in conventional cataract surgery.¹

It’s important to note that, in the femtosecond group, there were more cases of prior corneal refractive surgery.¹ Most prior studies comparing the two procedures have excluded prior corneal refractive surgery.³ It would be hard to say this put the femtosecond group at a disadvantage, though, as the phaco group had more eyes with mature, white cataracts.¹

Femto and posterior capsulotomy

In the study examining posterior capsulotomy operations, 1,534 eyes were analyzed from two separate clinical sites and surgery facilities between August 2011 and August 2014. Individuals chosen for the study needed to have CDVA of 20/25 or better one to three months after surgery. Patients with prior ocular pathology unrelated to the surgery were excluded.⁴

This study concludes that femtosecond laser-assisted cataract surgery helps reduce the rate for Nd:YAG capsulotomy compared to manual cataract surgery; the rate of Nd:YAG capsulotomy was 11.6% in the femtosecond group and 15.2% in the manual cataract surgery group. Data also found that the time from surgery to a Nd:YAG capsulotomy was hastened in the femtosecond group compared to the manual.⁴

IOLs and capsulotomy

Another finding from the study revealed a higher Nd:YAG capsulotomy rate for silicone hydrophilic acrylic IOLs compared to hydrophobic acrylic lenses. All silicone lenses in this study were accommodating lenses, which have a higher PCO rate.⁴

Whether this information about capsulotomies is applicable to changing clinical decisions regarding femtosecond cataract surgery is unknown. New capsulotomy devices that don’t require femtosecond laser-assistance, like the Zepto (Mynosys) and CAPSULaser (Excel lens), both still pending FDA approval, could result in very interesting data from future studies. OM

REFERENCES

1. Manning S, Barry P, Henry Y, et al. Femtosecond laser–assisted cataract surgery versus standard phacoemulsification cataract surgery: Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2016;42:1179-1790.
2. Nagy Z, Kránitz K, Takacs A, et al. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg. 2011;27:564-569.
3. Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsification time using femtosecond laser pretreatment. Ophthalmology. 2013;120:942-948.
4. Tran DB, Vargas V, Potvin R. Neodymium:YAG capsulotomy rates associated with femtosecond laser–assisted versus manual cataract surgery. J Refract Surg. 2016;42:1470-1476.

A (mini) tome on Trabectome

New book helps surgeons make the most of a MIGS device, and more.

By René Luthe, senior editor

With every new innovation comes questions, and glaucoma specialist Constance Okeke, MD, MSCE, an early adopter of minimally invasive glaucoma surgery (MIGS), found herself on the receiving end of many MIGS queries. Especially for Trabectome, NeoMedix’s surgical device for use in ab interno trabeculotomy, “I was repeatedly asked how do I choose patients for Trabectome surgery,” says Dr. Okeke, a consultant and speaker for NeoMedix. As she set about answering that question, the waters got a bit murkier as other MIGS techniques and tools were being developed. “Then I was asked, ‘How do you decide this one versus that one?’ I said, ‘That’s a good question!’”

The search begins

To find the answers, Dr. Okeke examined a database of her own patients. She also looked at NeoMedix’s database that contains the names of physicians who had used Trabectome, mining for characteristics of success.

“What was interesting was that the things I was finding were directly correlated with what I was seeing clinically,” says Dr. Okeke, who has performed more than 1,000 Trabectome surgeries, according to her website.

One such direct finding: Patients who had pseudoexfoliation glaucoma had more success as compared with primary open-angle glaucoma. Further, “Good results occur with both Trabectome and cataract combined with Trabectome, but the results seem to last longer when the combined procedures were done.” Those results included reduction in IOP; additionally, whatever medications patients were on at the time of surgery stayed at that level or were reduced for a longer period of time.

Hot off the press: A how-to

The result of her research is The Building Blocks of Trabectome Surgery Volume 1 — Patient Selection. Launched in March by Kugler Publications, the book offers guidance on how to improve Trabectome outcomes through a step-by-step approach for patient selection, as well as tips on pre-, intra- and postoperative care. The reason she chose to write about Trabectome specifically, rather than the broader category of MIGS, Dr. Okeke explains, is because in her eight years of experience with it, she has found the device to produce consistent pressure reduction in patients. “It’s not 100% — unfortunately, there isn’t any glaucoma surgery that is 100% successful, but with the device, I’ve been able to reduce the number of traditional glaucoma surgeries that carry with them higher risks of complications, both perioperative and in the future,” she says.

But Dr. Okeke cautions that neither Trabectome nor MIGS in general will crowd out other glaucoma therapies.

But a one-size-fits-all approach is still out

“One cannot knock the efforts of trying to find new medical therapies, because when we talk about surgery, yes, it’s less invasive with micro-incisions, but the reality is, it’s still surgery,” she says. “It’s not always going to be the first option we go for when addressing a patient’s need. It’s easy to talk about MIGS when someone has a cataract and you’re going to be in the patient’s eye anyway.” However, she points out, when an ophthalmologist informs a patient he or she has glaucoma, the doctor will not then launch into the MIGS option. “There’s still a plethora of glaucoma patients, and they are not going to see the surgeon first; they are going to see the optometrist, or a general ophthalmologist, who will offer the patients drops first.”

In the MIGS space, Dr. Okeke notes, glaucoma specialists are seeing an explosion of new techniques and devices with new mechanisms of action for treating glaucoma and achieving pressure lowering. “As we are approaching these multiple techniques and devices, one of the things we are seeing is that combination therapy can lower pressures in some of those moderate to advanced glaucomas,” she says. “I am a full proponent of doctors learning multiple techniques, because what I find is that glaucoma is not a one-size-fits-all disease. Our patients are individuals, and the more tools you have in your pocket, the better you can address an individual patient’s needs.” OM

Dr. Okeke is assistant professor of ophthalmology at Eastern Virginia Medical School and a glaucoma specialist and cataract surgeon at Virginia Eye Consultants. She is a consultant and speaker for NeoMedix and speaker and research investigator for the Glaukos iStent inject and iStent Supra.