Differences in characteristics of Medicare patients treated by ophthalmologists and optometrists.

PURPOSE: To quantify differences in the age, gender, race, and clinical complexity of Medicare beneficiaries treated by ophthalmologists and optometrists in each of the United States. DESIGN: Cross-sectional study based on publicly accessible Medicare payment and utilization data from 2012 through 2017. METHODS: For each ophthalmic and optometric provider, demographic information of treated Medicare beneficiaries was obtained from the Medicare Provider Utilization and Payment Data from the Centers for Medicare and Medicaid Services (CMS) for the years 2012 through 2017. Clinical complexity was defined using CMS Hierarchical Condition Category (HCC) coding. RESULTS: From 2012 through 2017, ophthalmologists in every state treated statistically significantly older beneficiaries, with the greatest difference (4.99 years in 2014) between provider groups seen in Rhode Island. In most states there was no gender difference among patients treated by the providers but in 46 states ophthalmologists saw a more racially diverse group of beneficiaries. HCC risk score analysis demonstrated that ophthalmologists in all 50 states saw more medically complex beneficiaries and the differences were statistically significant in 47 states throughout all six years. CONCLUSIONS: Although there are regional variations in the characteristics of patients treated by ophthalmologists and optometrists, ophthalmologists throughout the United States manage older, more racially diverse, and more medically complex Medicare beneficiaries.

Influence of Age, Sex, and Generation on Physician Payments and Clinical Activity in Ontario, Canada: An Age-Period-Cohort Analysis.

PURPOSE: To compare the effect of age, sex and generation on physician practice patterns in Ontario, Canada. DESIGN: Retrospective cohort study. METHODS: Physician and patient data from 1992-2013 were used to calculate the yearly number of physicians, distinct patients seen, patient visits, government payments, physician age, sex, specialty, and year of birth. Age-period-cohort models were used for analysis. RESULTS: There was a negligible change in the number of distinct patients for all physicians and family physicians and a 20.6% decrease for ophthalmologists. There were small declines in yearly visits for all physicians (14.2%) and family physicians (17.3%) and a 10.0% increase for ophthalmologists. There were a lower number of visits (and patients for ophthalmologists) in each succeeding recent birth cohort. For all groups and birth cohorts, male physicians had a significantly greater number of visits and patients. Median payments increased over time in all groups and were less for women with an average women-to-men ratio of 0.64 for all physicians, 0.75 for family physicians, and 0.59 for ophthalmologists. After adjusting for the number of visits and patients, sex differences in payments remained significant for all physicians and ophthalmologists but were no longer significant for family physicians. CONCLUSION: Younger cohorts of Ontario physicians have greater yearly payments compared with older cohorts at the same age despite similar or a slightly lower number of visits and patients. The sex gap of payments was mostly explained by differences in the number of patients and visits for family physicians but remained significant for all physicians and ophthalmologists.

Differences in practice of ophthalmology by gender in Australia.

IMPORTANCE: The number of females practising ophthalmology is rising. It is known that practice patterns between female and male ophthalmologists differ. Understanding the differences will help to inform future workforce planning. BACKGROUND: To investigate the differences in clinical practice between female and male ophthalmologists in Australia. DESIGN: Cross-sectional study. PARTICIPANTS: Ophthalmologists participating in the Royal Australian & New Zealand College of Ophthalmologists workforce survey, and/or Medicine in Australia: Balancing Employment and Life survey, and those who made claims from Medicare Benefits Schedule Australia. METHODS: Combined analysis of de-identified 2014 data from the surveys and Medicare Benefits Schedule. MAIN OUTCOME MEASURES: Hours worked, service provision, remuneration and social circumstances. RESULTS: Female ophthalmologists provided 35% fewer services per ophthalmologist per year (2834 vs 4328) than male ophthalmologists. Female ophthalmologists received approximately half the annual income of male ophthalmologists; median self-reported net personal annual income was AUD122 500 (interquartile range [IQR] 96 000-225 000) for females compared to AUD245 000 (IQR 180 000-365 000) for males (P = .01). The median self-reported hours worked per week was 35.0 (IQR 28.0-46.0) for females and 41.8 (IQR 36.5-48.5) for males (P = 0.04). A higher proportion of females practise in medical subspecialties, while a higher proportion of males practise in surgical subspecialties. CONCLUSIONS AND RELEVANCE: Female ophthalmologists earn less compared to male ophthalmologists after accounting for lower service provision and hours worked. Difference in income may be partially accounted for by higher total number of services and procedural services provided by male ophthalmologists. Understanding differences between female and male ophthalmologists will help to inform future medical workforce planning.

An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013.

PURPOSE: To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013. DESIGN: Retrospective, cross-sectional study. METHODS: A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services. RESULTS: In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013. CONCLUSION: Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement.

Refractive Surgery: Malpractice Litigation Outcomes.

PURPOSE: To review data on malpractice claims related to refractive surgery to identify common allegations and injuries and financial outcomes. METHODS: The WestlawNext database was reviewed for all malpractice lawsuits/settlements related to refractive eye surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes. RESULTS: A total of 167 cases met the inclusion criteria, of which 108 cases (64.7%) were found to be favorable and 59 cases (35.3%) unfavorable to the defendant. A total of 141 cases were tried by a jury with 108 cases (76.4%) favorable and 33 cases (23.6%) unfavorable to the defendant. Laser in situ keratomileusis was performed in 127 cases (76%). The most common allegations were negligence in treatment or surgery in 127 cases (76%) and lack of informed consent in 83 cases (49.7%). For all cases, the need for future surgery (P = 0.0001) and surgery resulting in keratoconus (P = 0.05) were more likely to favor the plaintiff. In jury verdict decisions, cases in which failure to diagnose a preoperative condition was alleged favored the defendant (P = 0.03), whereas machine malfunction (P = 0.05) favored the plaintiff. After adjustment for inflation, the overall mean award was $1,287,872. Jury verdicts and settlements led to mean awards of $1,604,801 and $826,883, respectively. CONCLUSIONS: Malpractice litigation in refractive surgery tends to favor the defendant. However, large awards and settlements were given in cases that were favorable to the plaintiff. The need for future surgery and surgery leading to keratoconus increased the chance of an unfavorable outcome.

Differences in Clinical Activity and Medicare Payments for Female vs Male Ophthalmologists.

IMPORTANCE: The number of women in ophthalmology is rising. Little is known about their clinical activity and collections. OBJECTIVE: To examine whether charges, as reflected in reimbursements from the Centers for Medicare & Medicaid Services (CMS) to ophthalmologists, differ by sex and how disparity relates to differences in clinical activity. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of the CMS database for payments to ophthalmologists from January 1, 2012, through December 31, 2013. The dates of the analysis were February 1 through May 30, 2016. After exclusion of J and Q codes, the total payments to and the number of charges by individual ophthalmologists were analyzed. The mean values were compared using a single t test, and the medians were compared by the nonparametric Wilcoxon rank sum test. MAIN OUTCOMES AND MEASURES: Primary outcome measures were the mean and median CMS payments to male and female ophthalmologists in outpatient, non-facility-based settings. Secondary outcome measures included the number of charges submitted by men and women and the types of charges most commonly submitted by men and women. RESULTS: This study included 16 111 ophthalmologists (3078 women [19.1%] and 13 033 men [80.9%]) in 2012 and 16 179 ophthalmologists (3206 women [19.8%] and 12 973 men [80.2%]) in 2013. In 2012, the average female ophthalmologist collected $0.58 (95% CI, $0.54-$0.62; P < .001) for every dollar collected by a male ophthalmologist; comparing the medians, women collected $0.56 (95% CI, $0.50-$0.61; P < .001) for every dollar earned by men. Mean and median collections were similar when comparing female vs male ophthalmologists in 2013 (P < .001). The mean payment per charge was the same for men and women, $66 in 2012 and $64 in 2013. There was a strong association between collections and work product, with female ophthalmologists submitting fewer charges to Medicare in 2012 (median, 1120 charges; difference -935; 95% CI, -1024 to -846; P < .001) and in 2013 (median, 1141 charges; difference -937; 95% CI, -1026 to -848; P < .001) than male ophthalmologists. When corrected by comparing men and women with similar clinical activity, renumeration was still lower for women. In both years, women were underrepresented among ophthalmologists with the highest collections. CONCLUSIONS AND RELEVANCE: Remuneration from the CMS was disparate between male and female ophthalmologists in 2012 and 2013 because of the submission of fewer charges by women. Further studies are necessary to explore root causes for this difference, with equity in opportunity and parity in clinical activity standing to benefit the specialty.

Open Payments Database: Anti-Vascular Endothelial Growth Factor Agent Payments to Ophthalmologists.

PURPOSE: To analyze anti-vascular endothelial growth factor (anti-VEGF) agent-associated industry payments to ophthalmologists using the Centers for Medicare and Medicaid Services (CMS) Open Payments and Provider Utilization and Payment data. DESIGN: Retrospective database review using 2 national databases. METHODS: Payments from 2013 to 2014 were analyzed by anti-VEGF agent, payment category, and dollar amount. Ranibizumab and aflibercept usage was correlated by performing log-ratio analysis. RESULTS: A total of 3207 ophthalmologists received 13 449 payments totaling $4 454 325 associated with ranibizumab and aflibercept. As 7% of ophthalmologists received 90% of payments, the Gini index was 0.92, demonstrating unequal distribution of payments. Consulting fees and speaker fees were associated with highest payment amounts to fewest providers. For 2383 providers (74%), greater than 90% of the anti-VEGF payments were associated exclusively with either ranibizumab or aflibercept. A total of 1382 ophthalmologists were matched in both databases. Providers receiving >90% of payments from ranibizumab were more likely to use ranibizumab, and those receiving >90% of payments from aflibercept were more likely to use aflibercept over bevacizumab as compared to those who received no payments. CONCLUSIONS: The distribution of all anti-VEGF payments is unequal. Ophthalmologists who received aflibercept or ranibizumab payments were more likely to receive the majority of payments from one source or the other, but not both. Those who received anti-VEGF payments were more likely to use ranibizumab or aflibercept, as compared to off-label bevacizumab, than those who did not receive any payment.

Physician-Industry Interactions and Anti-Vascular Endothelial Growth Factor Use Among US Ophthalmologists.

IMPORTANCE: The publication of the US Physician Payments Sunshine Act provides insight into the financial relationship between physicians and the pharmaceutical industry. This added transparency creates new opportunities of using objective data to better understand prior research that implicates pharmaceutical promotions as an important factor in a physician's decision-making process. OBJECTIVE: To assess the association between reported industry payments and physician-prescribing habits by comparing the use of anti-vascular endothelial growth factor (VEGF) intravitreal injections by US ophthalmologists to the industry payments these same physicians received. DESIGN, SETTING, PARTICIPANTS: This study reviews data from the Centers for Medicare & Medicaid Services (CMS) 2013 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File and the CMS-sponsored August through December 2013 Open Payments program (Physician Payments Sunshine Act). Ophthalmologists who prescribe anti-VEGF injections for all indications were analyzed. MAIN OUTCOMES AND MEASURES: Association between industry payments reportedly received and the number and type of anti-VEGF injections administered. RESULTS: A total of 3011 US ophthalmologists were reimbursed by CMS for 2.2 million anti-VEGF injections in 2013. Of these physicians, 38.0% reportedly received $1.3 million in industry payments for ranibizumab and aflibercept. Analysis revealed positive associations between increasing numbers of reported industry payments and total injection use (r = 0.24; 95% CI, 0.22-0.26; P < .001), aflibercept and ranibizumab injection use (r = 0.32; 95% CI, 0.29-0.34; P < .001), and percentage of injections per physician that were aflibercept or ranibizumab (r = 0.27; 95% CI, 0.25-0.29; P < .001). A smaller association was noted between greater number of industry payments and bevacizumab injection use (r = 0.07; 95% CI, 0.04-0.09; P < .001). Similar associations were found between the total dollars of reported industry payments received to injection use. Subgroup analysis further revealed that physicians receiving $1 to $25 in reported industry benefits were more likely than those not receiving industry payments to perform a greater percentage of their injections with aflibercept and ranibizumab. CONCLUSIONS AND RELEVANCE: Among ophthalmologists who prescribe anti-VEGF medications, there is a positive association between reported pharmaceutical payments and increased use of aflibercept and ranibizumab injections. As is inherent to the design of correlation studies, this analysis cannot determine whether the payments reported caused the increased use, are a result of the increased use, or are merely associated with some other factor that causes the increased use.

Representation of Women With Industry Ties in Ophthalmology.

IMPORTANCE: Women in ophthalmology are growing in number and have made strides in traditional metrics of professional achievement. Professional ties to industry represent another potential means of career advancement, recognition, and income. OBJECTIVE: To report the representation of women among ophthalmologists receiving industry remuneration for research, consulting, honoraria, grants, royalties, and faculty/speaker roles. DESIGN, SETTING, AND PARTICIPANTS: In this observational, retrospective study, the Centers for Medicare and Medicaid Services Open Payments database for payments to ophthalmologists by biomedical companies was reviewed for representation, median payments, and mean payments by women and men for industry relationships in 2013 and 2014. The analysis was performed from July 2015 to November 2015. MAIN OUTCOMES AND MEASURES: The primary outcome measures were percentage representation of women vs men overall and in industry research, consulting, speaking roles, royalties and licenses, grants, services other than consulting, and honoraria. Secondary outcome measures included mean and median payments from industry to female vs male ophthalmologists. RESULTS: In 2013, 4164 of 21 380 (19.5%) ophthalmologists were women, and of 1204 ophthalmologists analyzed for industry payments, 176 (4.2%) women had industry ties compared with 1028 (6%) men (P < .001). Mean payments to women were $11 419 compared with $20 957 for men (P = .001), and median payments to women were $3000 compared with $4787 for men (P = .007). In 2013, women were underrepresented among ophthalmologists receiving industry payments for research (49 of 462 [10.6%]), consulting (96 of 610 [15.7%]), honoraria (3 of 47 [6.4%]), industry grants (1 of 7 [14.3%]), royalties and licenses (1 of 13 [7.7%]), and faculty/speaker roles (2 of 48 [4.2%]). In 2014, 4352 of 21 531 (20.2%) of ophthalmologists were women. Of 1518 ophthalmologists analyzed for industry payments, 255 (6%) women had industry ties compared with 1263 (7.4%) men (P < .001). Mean payments to women were $14 848 compared with $30 513 for men (P = .004), and median payments to women were $3750 compared with $5000 for men (P = .005). Women remained underrepresented among ophthalmologists receiving industry payments for research (25 of 241 [10.4%]), consulting (145 of 921 [15.7%]), honoraria (14 of 11 [12.6%]), industry grants (3 of 25 [12.0%]), royalties and licenses (1 of 22 [4.6%]), and faculty/speaker roles (21 of 189 [11.1%]) in 2014. CONCLUSIONS AND RELEVANCE: Women make up a minority of ophthalmologists with professional industry relationships, and the average woman partnering with industry earns less than her male colleagues. The reasons for differences are multifactorial and could not be determined by this study.