OPHTHALMOLOGY TRENDS

European ophthalmologists will need to overcome a combination of economic, organisational and regulatory hurdles to ensure that their patients fully benefit from the latest advances in ophthalmic technology, according to a panel of experts at the XXXth Congress of the ESCRS. “While high-volume and low-cost cataract surgery is now standard, we have seen that product selection of some newer technologies is being limited due to increased costs in public healthcare systems,†Dr Matteo Piovella told delegates attending a joint ESCRS/Italian Society of Ophthalmology symposium on the future of healthcare in Europe.

Dr Piovella argued that doctors in Italy and some other European countries no longer have the freedom to choose the best technology for their patients. One possible solution, he said, might be to introduce a system of co-payments, with the government paying for a “standard†cataract procedure with implantation of a monofocal IOL and the patient picking up the tab for any “extrasâ€, such as a toric or multifocal IOL. Panellists agreed that advances in technology have resulted in improved outcomes for patients and spurred manufacturers to continually upgrade their product lines.

“I think there is no doubt that we have improved our results when we consider the evolution from intracapsular and extracapsular extraction through to phaco, microincision cataract surgery and now femto cataract,†said Ulf Stenevi MD. “When the results are better and when patients request these technologies and the doctor sees that they actually do improve outcomes, then they are usually incorporated into our practices. But the cost factor is also important. If we accept that certain technologies are very good then the taxpayers and the clinics will buy them. If they are not accepted by the patients, however, and it is just the doctors who think they are good, then it will take more time,†he added.

The improvements in technology have also helped to reduce costs for cataract surgery, pointed out Richard Lindstrom MD. “Back in the late 1970s I was doing intracapsular cataract extraction, which took one hour per procedure with a five per cent complication rate, at a cost of just over $5,000 dollars an eye. Today we are doing three to four procedures an hour and the cost is around $1,600 dollars an eye and the outcomes are extraordinarily better,†he said. Moderator Peter Barry FRCS asked the panel why so-called “premium†IOLs – accommodating, multifocal and toric lenses – represented less than one per cent of the market in Europe compared to 14 per cent in the US.

“We welcome many American colleagues to our European meeting and many of them tell us that they come here in order to develop what is new in terms of innovation and technology because the FDA system won't allow them to even try out what is being developed in Europe. Now we have the paradox that our American counterparts are performing more premium IOL implantations over there than we are in Europe. Is this because European citizens don’t have the money to spend on these lenses?†said Dr Barry.

For Paul Rosen FRCS, FRCOphth, the main problem resides in the absence of a co-payment system for many European countries. “In the United States co-payments are an accepted part of the healthcare system, whereas in countries such as Italy and the UK they are not allowed and therefore the premium IOL technology has not migrated into the public system as expected,†he said. Roberto Bellucci MD noted that technology is often developed for specific cases and only becomes more widely used if its efficacy and safety are proven over time.

“We are forced to some degree to use new technology, because in cases involving complications legal problems may arise if the surgeon has been shown not to have used the best available technology for every patient,†he said. Dr Bellucci also voiced doubts about whether a voucher or co-payments system could be successfully introduced in Italy.

“I can see potential problems with a voucher system where the patient is able to choose the centre where he or she wants to have surgery. With this approach, public hospitals will see a reduction in the number of procedures and there will be an impact on employment for nurses and medical staff, leading to protests from trade unions, so there are potential political problems as well,†he added. Dr Barry also took issue with the term “premium IOLs†which he said implied that some intraocular lenses were somehow sub-premium.

“The term is essentially based on the premise that multifocal or toric IOLs are the perfect IOL for everybody. And I would suggest that that idea is an absolute nonsense. There are a lot of patients out there for whom the premium IOL is in fact the monofocal lens. We would have a far better chance of convincing health providers, insurance companies and patients if we did not suggest that we are selling these lenses for everybody and creating an artificial twotier system,†he said. Thomas Kohnen FEBO said it was important for each country to define the standard of care in order to avoid confusion surrounding the issue of premium IOLs.

“We have to be careful of these ‘premium’ lenses because they are not good for everybody and not everybody should have a multifocal lens – if the patient has an endothelial problem for example. We have to define the standard of care either nationally or internationally. It is something that is evolving all the time as technology progresses. So we need a standard and then we need to have an ‘extra’ situation as well that takes account of additional services that the patient might want to pay for,†he said. Given the emphasis on reducing costs for national healthcare systems, Dr Barry asked whether a case might be made for moving cataract procedures from the hospital environment into dedicated cataract centres.

Dr Rosen pointed out that the concept of “cataract factories†had already been tried in the UK with mixed results. “The government introduced 'independent sector treatment centres' in the UK over a decade ago and they were a political move to break what the government saw as the doctors’ stranglehold on the system. They spent £3bn on developing these centres and to some extent they worked because they dealt with waiting lists. The other good thing that came out of it was the fact that it introduced competition so a lot of departments raised their game,†he said. On the debit side, however, the new centres threatened the viability of existing health facilities rather than complementing them, said Dr Rosen.

“What tended to happen is that things drifted towards the lowest common denominator with a lot of potential for disruption in the healthcare system. For example, in the UK if you do a cataract procedure there is small profit made and that money goes to cross-subsidise a lot of other services like psychiatry. That principle is lost if the work is farmed out to a private contractor,†he said. The result in Oxford was that the government sought to transfer a large number of cataract operations from the Oxford Eye Hospital to the private centre, undermining the financial viability of the hospital and compromising the training of ophthalmic surgeons, explained Dr Rosen.

“In the end, Oxford Eye Hospital successfully competed against the private centre and performed the majority of the scheduled cataract operations. It ended up costing the government a fortune, reported to be £12,000/cataract treated due to the nature of the contract, and was deemed a total disaster in Oxford,†he said.