MANAGING CHANGE IN OPHTHALMOLOGY PRACTICES

With expensive new technologies on the horizon and ageing populations already straining health services resources in many countries, European ophthalmologists will have to innovate to continue meeting patient needs, members of the ESCRS Practice Development Committee told participants at the third annual Practice Development Masterclass in Vienna last year.

“Government will no longer be able to afford to fully pay for healthcare,†said Jorge Alió MD, PhD.

Of course, reduced public funding creates opportunities for private practice, but it also requires that surgeons develop their business and management skills, said Prof Alió, of the Institute Oftalmologico de Alicante, Vissum Corporation, in Spain. Surgeons must partner with business to continue improving technologies, and with government and academic institutions to continue advancing research and meeting the human needs of the population, Prof Alió said.

At Prof Alió’s VISSUM clinics, private-paying patients are treated side-by-side with public-paying patients, with the ratio varying according to local needs. At Alicante, the ratio is about 90 per cent private to 10 per cent public; Castilla la Mancha is close to 50 per cent to 50 per cent. While VISSUM is an independent organisation owned by Prof Alió, some of his partners, and an external investor, it is associated with the Miguel Hernandez University, Alicante, as a teaching and R&D centre.

In the UK, where the government has been privatising services for years in an attempt to improve the quality and efficiency of care, two groups of surgeons are emerging, according to Paul Rosen FRCS, FRCOphth, MBA. On the one hand are entrepreneurs, who set up their own clinics and practices; on the other are those who remain in the National Health Service, said Dr Rosen, of London. Even within the NHS there is a new emphasis on bringing surgeons into leadership. “In my hospital there has been a complete reorganisation of management,†Dr Rosen explained. “It is now a clinically led organisation and the people who are in charge are doctors.â€

Budget pressure and increased demand for transparency in operations and clinical outcomes are leading to similar shifts within public and academic institutions in Austria, added Oliver Findl MD, MBA, of Hanusch Hospital in Vienna. By examining clinical processes and eliminating duplicate and unnecessary steps, his department has increased volume 35 per cent with the same staff. With healthcare costs exceeding 11 per cent of gross domestic product, Dr Findl sees innovation within the public sector as essential to keep up. “Demand will increase, but budgets won’t.â€

Innovation within academic practices will be essential to generate enough revenue to afford new technologies to compete with private clinics, said Thomas Kohnen MD, PhD, Goethe University, Frankfurt, Germany. “Private clinics are gaining in Germany but they can’t treat government patients if they do not have the licence. At the same time universities are losing patients. It used to be that people were lined up to see the university surgeons, but this has shifted somewhat into the private sector.â€

Managing private-public tensions

While the shift to private practice can improve productivity and make advanced technology more available, it can also create tensions and even conflicts of interest. Surgeons will be challenged to take the good from privatisation while maintaining their ethical commitment to serving all patients.

On the up side, private structures make it possible to offer advanced technologies such as femtosecond cataract surgery. Prof Alió estimates that this technology adds about €740 to cataract surgery plus hidden costs associated with lost productivity. But his system is flexible enough to recoup the costs, he said. “It becomes part of the overhead.â€

Countries vary in how they handle private patients. In Austria, public hospitals may treat public patients, Dr Findl said. “Hospitals like to have the private patients because it brings in extra revenue.â€

But this can cause friction with publicly insured patients, who may wait longer for service. Dr Findl noted that a consumer advocacy magazine in Austria did a “secret shopper†feature in which reporters called hospitals around the country inquiring about wait times for cataract surgery. In some hospitals, staff replied that if the patient paid privately they could have it in a week, but if they were on the public system the wait would be nine months. “And this was published,†Dr Findl said. “The minister for health stood up and said, ‘This is a disaster; we cannot allow this to be.’â€

Eventually, the ministry determined that private rooms and better food were okay for private patients, but different waiting times would not be allowed. “This has not been such a problem in Austria because waiting times are relatively short, but if your wait is six or nine months, it could be an issue,†Dr Findl said.

In the UK, differences in waiting times are permitted, Dr Rosen said. “You have to be open about it. Patients have a choice. If they pay themselves or are paid by an insurance company then the operation is done with the surgeon of their choice almost at the time of their choice. But if they go with the NHS, the service is free, but anyone can do the surgery. They are buying choice; they are buying certainty about who does it.â€

The UK NHS hospitals are keen to have the private business because it means extra revenues, he said. They will accommodate early scheduling of private patients at times the regular service is off, such as evenings and weekends, said Dr Rosen .

Other countries ban private practice in public facilities. In Germany, private clinics may not treat publicly financed patients, Prof Kohnen said. Norway requires that private practice be done in a separate facility.

Outside Europe, in Canada it is illegal to offer private services if they are covered under the public system. In New Zealand, a system of contracting public services to private surgeons has resulted in a handful of surgeons getting almost all the public business, but operating for a very low wage, with most surgeons left with no public business.

Dr Findl also cautioned against conflicts of interest that may arise from mixing public and private services. For example, offering premium IOLs to older patients who present for cataracts may not be appropriate. “We are seeing a lot of explants of these lenses. We have to keep in mind that the goal for these patients is to treat the cataract and they may not be able to tolerate multifocal lenses,†he said.