THE NETHERLANDS FACES CHALLENGES

“The financial crisis didn’t dominate my decision-making when I was looking for a job,” says Sharmila Boekhoorn MD, who finished her ophthalmology residency in 2012. “My goal was to work in a large, high-quality, non-academic hospital with pleasant and engaging colleagues. And if I had to pay a members’ fee to join this type of partnership, then so be it.”

Dr Boekhoorn found full-time employment immediately after graduation. “I’m happy with ophthalmologists’ current situation, financially,” she continued, “but it’s widely known that finances will become tighter in the near future.” With this in mind, the Dutch Ophthalmic Society has embarked on a wide scale policy of reorganisation over the past decade. The goal was to increase efficiency and reduce costs without compromising on quality or patients’ access to care, and also without drastically increasing the number of ophthalmologists per capita.

This reorganisation was initiated with the knowledge that the ageing of the population would lead to an increased demand for eye care while money available to pay for this care was unlikely to increase. It was achieved by transferring many non-invasive tasks from ophthalmologists to optometrists, orthoptists, opticians, ophthalmic technicians and even general practitioners.

The consensus is that this reorganisation was generally successful. Peter van Etten MD, has experienced the advantages of this reorganisation from two different positions. He is currently an ophthalmology resident in Rotterdam, but before going to medical school, he completed the optometry training and worked full-time as an optometrist for six years.

“The reorganisation was beneficial for us as optometrists because it expanded our role within the frame of patient care. We were brought right into the ophthalmology clinics to screen patients, participate in diagnostics, see patients postoperatively and follow up patients with chronic diseases. Our work became more interesting due to the broader scope of responsibilities that we have assumed.”

And now, as an ophthalmologist-in- training, Dr van Etten is again experiencing the benefits of the reorganisation. “Treating standard conditions like cataracts, advanced diabetic retinopathy, glaucoma and age-related macular degeneration has become more interesting and efficient for the ophthalmologist, because we can now focus our knowledge and energy on diagnostics, serious pathology and surgery. We can allow others to perform refraction, fundus photography, contact lens fitting and screening procedures. For example, optometrists do an excellent job screening fundus photographs for diabetic retinopathy.”

Although the Netherlands spends a relatively high percentage of its GNP on health care, relative to other countries, these costs come primarily from nursing homes and retirement homes rather than from hospital care. Further, quality is high and the patients’ financial contributions remain relatively low, notes Kees Sol, the Chief Financial Officer of the Rotterdam Eye Hospital.

This has all allowed the Netherlands to continue providing top-quality care despite having relatively few ophthalmologists per capita. There are approximately 740 ophthalmologists serving a population of nearly 17 million. Besides the reorganisation, ophthalmology started out with a built-in advantage prior to the financial crisis based on two situations. First, the amount of money allocated to ophthalmology in medical budgets in

the past was very low, so efficiency has long been a priority. Second, with the introduction of a market system within the past few years, in which insurers and hospitals bargain amongst themselves to determine the level of payments for clinical activities, payment levels in ophthalmology became more reasonable, so that the financial crisis did not hit ophthalmology particularly hard in comparison with other medical specialties.

This has allowed the Netherlands to avoid having to decrease the number of residency training positions. Further, in contrast to many other European counties, every resident is surgically trained and emerges from residency theoretically able to perform standard ophthalmic surgeries independently. Research funding, however, has suffered somewhat due to the crisis, according to Willem van den Bosch, MD, PhD, director of the Rotterdam Ophthalmic Institute.

“Lower interest rates have decreased the funds available from both governmental and private sources.” Besides the reorganisation of care, modern developments will make an impact on the delivery of care. “Technology will continue to change the face of ophthalmology,” says Mr Sol. “Eye care will be delivered closer and closer to the consumer. Digital screening will continue to increase, and patients will require fewer visits to the hospital. And when patients do come to the hospital, they can expect high-quality care as well as short waiting lists and anxiety reduction measures.”

What the future holds for young ophthalmologists, however, is difficult to predict. Recent developments have suggested that all medical residents might have to help pay for their training. Physicians’ salaries have been sharply reduced in recent years by around 20 per cent across the board, with more cuts likely. Further, working in private practice will likely become more difficult, as the government works to force all physicians into salaried positions. Physicians’ freedom to work as they please has always been vastly more restricted than their counterparts in the United States, and this freedom will likely continue to diminish.