OPHTHALMOLOGY'S FISCAL CRISIS

The global economic crisis born in 2008 has reached into almost every corner of the world. Europe has been particularly hard hit, as the fiscal crisis has spread across the continent producing trillion euro bailout schemes, austerity budgets and even riots in the streets. “We are facing the biggest challenges that this union has ever had to face throughout its history – a financial crisis, an economic and social crisis, but also a crisis of confidence,†proclaimed Jose Manuel Barroso, president of the EU Commission in his EU 2012 State of Union Address.

As a result, governments are desperate to reduce expenditures, particularly in healthcare. The most common reforms across European countries – and especially Greece – have endeavoured to moderate the growing budgets for health services, rationalise the benefit packages and implement wide-reaching reforms in the pharmaceutical market. Ophthalmology has not escaped the fiscal tsunami. In some parts of Europe, cataracts are not operated as early as in the past, and when patients are considered good candidates, they may have to wait considerably longer before they can be operated. The volume of elective refractive surgeries, often considered an unofficial leading economic indicator, including LASIK and presbyopic IOL procedures, has declined in many regions as disposable income has diminished. “The economic crisis has created a new environment in Europe which has already influenced and will continue to influence healthcare in general and ophthalmology in particular. These effects will be greater in countries that suffer the worst, mainly the southern European countries,†Ioannis Pallikaris MD, PhD, told EuroTimes.

Dr Pallikaris, professor of ophthalmology, School of Medicine, University of Crete and founder and director of the Vardinoyannion Eye Institute of Crete, noted that in some cases patients who previously would have used private resources to address their needs are now obliged to use public healthcare systems, creating an overload. This overload in the public healthcare system produces a series of complications such as delaying the provision of services such as cataract surgery. He noted that the economic crisis is causing further shrinkage in government spending for the public healthcare system, which raises the spectre of hospitals being unable to offer high-quality services such as premium lenses cataract surgery due to the expensive consumables such as IOLs, and viscoelastics. This was seen in Greece very recently, where international companies, fearful they would not be reimbursed, refused to extend credit, demanding that Greek providers pay upfront in cash for supplies. Conversely, medical professionals in the private sector will experience a decrease in their surgical load and consequently to their incomes, Dr Pallikaris observed. “Taken together, these factors will cause a decrease of the quality of provided medical services. The final consumers, the patients, will be the ones that will suffer the most due to this situation.â€

Global financial crisis

Greece has perhaps been hit harder than most countries in Europe, notes Argyrios Tzamalis MD, 2nd Department of Ophthalmology, Aristotle University of Thessaloniki, Greece. “The global financial crisis has had a tremendous impact on Greece’s economy, exacerbating existing problems. The health sector has been seriously affected by the economic situation, and the three Memorandums of Understanding that Greece has signed since 2010 dictate a series of measures that focus on the reduction of public expenditure. A broad range of healthcare reforms and policies have been implemented, which represent the biggest shakeup of the healthcare system in decades. Irrespective of their positive policy goals, these measures have started to affect public access to the healthcare system and to increase the financial burden on patients,†he told EuroTimes.

The economic hard times in Greece have had a measurable effect on the delivery of ophthalmology services. Many public hospitals and eye clinics have had problems providing ophthalmic surgical services due to lack of essential materials. Indeed, in the last two years some ophthalmology departments have had to suspend even cataract surgery services because companies declined to provide IOLs unless they were first compensated by the government, which did not have the financial ability to do so, Dr Tzamalis confirmed. “It is a real vicious cycle! And you can imagine what the impact could be on the patients’ health levels. In fact, many patients keep coming to big university eye clinics just to have a simple ophthalmic procedure done since this may not be performed anywhere else or maybe because they cannot afford it going privately. Even eye drops are in short supply.â€

The economic crisis has also put the squeeze on residents looking ahead to their first career post. Dr Tzamalis noted that every ophthalmology resident at his institution in the past two years has moved to more prosperous countries, with Germany and the UK being the favourites. Even though many residents would prefer to stay in their home country, because of the dire economic situation in Greece, there has been a hiring freeze, with no hospital positions expected to be available for many years to come. “I believe that the impact of the economic crisis on healthcare and ophthalmology in particular has not fully emerged. I think that in the next few years the insurance funds won't be able to bear the burden of covering ophthalmic needs, which are continuously increasing with the evolution of technology,†he said.

Economic storm

Spain is also being buffeted strongly by the economic storm. It has had a real estate meltdown, a capital crisis and has record unemployment. Under these circumstances it is not surprising that ophthalmology would feel some effect. “I am concerned about the effects of the European economic crisis on ophthalmology. In my own country I can see the effects of the crisis both as a consumer and as a provider. It is affecting all ophthalmologists, those working in both public as well as in private care,†Jose Guell MD, professor of ophthalmology at Autonoma University of Barcelona and director of the Cornea and Refractive Surgery Department at IMO, Barcelona, told EuroTimes. As in other parts of Europe, there has been a notable decline in demand for elective refractive surgery. But it has affected access to care and options available to patients in many areas.

The public healthcare system is expected to absorb significant budget cuts, meaning longer waits for surgery. As fewer Spanish citizens are able to afford private insurance, the insurance companies have had to reduce the coverage they provide, reduce access to some surgeries, reducing physician payments, and increasing the portion of the cost expected from the patient, noted Dr Guell. “I can only hope that this will not last too long, that things will improve. Meanwhile, I suggest to residents that they focus on medicine and ophthalmology, and remember it is not about focusing on making money, we are here to serve people, with or without the crisis.â€

Subtle effects

The impact of the recession in Europe has not affected all areas equally. In general, the more northern countries, while not unaffected, are faring better. In the Netherlands for example, the effects have been more subtle, notes Leigh Spielberg MD, a resident at the Rotterdam Eye Hospital. “In the Netherlands, the residents themselves aren't particularly having problems. Our contracts are guaranteed for the whole of the five-year training period. We are reasonably paid, despite the relatively high cost of living in Holland. Further, the job market for ophthalmologists happens to be quite good here, so finding a job after graduation has not been a problem for anyone who has graduated during the period that I've been here, since mid-2010.â€

However, he notes that “further up the ladder†there have been some big changes. The Dutch government is trying to get all physicians to become essentially salaried employees on the payrolls of hospitals. The physicians' rights in The Netherlands have always been very restricted: specialists (as opposed to GPs/family doctors) have always been essentially required to work in hospitals. Although they could work 'privately' within these hospitals, they had to have some sort of connection with the hospital. Only recently have specialists discovered a loophole or financial construction to allow them to work separately from hospitals, but this is quite an ordeal. The government is trying to eliminate this across the board. “Also, there has been a general, acrossthe- board reduction in fees paid for medical services, up to about 30 per cent in the past few years! The doctors are not happy about this,†he said.

More providers

Germany also seems to be holding up pretty well. Refractive surgeon Kaweh Schayan-Araghi MD, of the ARTEMIS Eye Clinic, Dillenburg, Germany, says his office has not noticed a drop in demand for refractive surgery, but that patients now have more providers to choose from. He did see some sign of the times in pricing, however. “We do see a trend towards lowcost providers for refractive surgery. Unfortunately, they have to cut corners to meet the price expectations of patients. We experience more patients trying to negotiate about the price since these providers advertise more. Quality seems to be of minor importance to patients, or we seem not to be able to communicate the difference it makes or can make, for example, to do wet refractions before surgery or to refract several times and to provide post-op care,†he said. He remains optimistic in the long term, noting that ophthalmology is in a good position as patients age and become aware of the many options for them. He predicts that while refractive surgery will probably not increase much in volume, demand for presbyopic options such as the Kamra corneal inlay does have growth potential.

Dual approach

Ophthalmology in the UK, which pioneered the idea of national health insurance after the Second World War, is now experiencing a number of challenges related in part to the global recession, notes Richard Packard MD, FRCS, FRCOphth, Windsor, England. The UK currently has a dual approach to healthcare delivery funding. The vast majority is done through the National Health Service (NHS), with the rest covered either through private insurance or self pay by the patient or a combination of both these. While Dr Packard said the euro crisis does not appear to have had a large impact on the NHS to date, the amount of funding available to commissioning bodies, like primary care trusts (PCTs), has not kept up with inflation.

As a result these PCTs are trying to save money. “One of the ways that they are doing this is to try to restrict cataract surgery by specifying visual thresholds for surgery and also not paying in some instances for second eye surgery. The number of cataract surgeries performed in the UK has thus come down. In the private sector, insurers and most particularly the largest one, BUPA (British United Provident Association), has tried by other means to reduce its spend on cataract surgery. BUPA the largest insurer with more than 40 per cent of the market has slashed the reimbursement for its subscribers by over 60 per cent.†Dr Packard notes that this reimbursement reduction has not been accepted by the majority of surgeons. In response, BUPA has tried to redirect its subscribers to a chain of high street opticians who do refractive surgery and are now offering cataract surgery. Patients are less than happy, he emphasised.

Postoperative discontent

ESCRS president Peter Barry FRCS of Dublin, Ireland, echoed Dr Packard’s concerns. “I am concerned that in parts of the United Kingdom second eye cataract surgery is not permitted for economic reasons and I am also concerned that ‘clinical care pathways’ effectively preclude the surgeon from seeing the patient until the time of surgery and likely not afterwards. This trend will result in more patients having unnecessary surgery and postoperative discontent even if the surgery itself was uncomplicated. Cataract surgery should not become a commodity,†Dr Barry told EuroTimes.

Dr Barry noted that in Ireland the debate over new contracts for consultants was having a very serious adverse effect on morale both amongst consultants themselves and specialist registrars at the end of their training who would become the next tranche of consultants. This anxiety for the future is causing more stress than the current economic downturn, he said. Ireland has also seen a reduced demand for elective refractive surgery, as prospective patients have less surplus cash spend, a trend Dr Barry said he expected would continue for some time. Looking to the future, Dr Barry said: “Ophthalmology will have to fight hard to preserve its slice of the health budget and fight very hard to increase it, which it will need to do if it is to embrace toric and multifocal lenses, anti-VEGF agents and other new treatments,†he said.

This raises the greater issue, that even if and when the current economic crisis passes, ophthalmology is facing an ongoing crisis of sorts, involving factors of access to care, including providing sufficient numbers of surgeons and the programmes to train them to meet the coming demand suggested by the demographics of the ageing population. But perhaps the most vexing question is, who will cover the cost for not only standard services, but for the remarkably effective, but expensive, new treatments becoming available for all manner of eye diseases?