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OPHTHALMOLOGY'S FISCAL CRISIS EuroTimes looks at the diverse effect of the current economic crisis in Europe on all aspects of ophthalmologyby Sean Henahan "The economic crisis
has created a new 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 environment in continent producing trillion euro bailout Europe which has schemes, austerity budgets and even riots already influenced "We are facing the biggest challenges and will continue to that this union has ever had to face influence healthcare throughout its history – a financial crisis, in general and an economic and social crisis, but also ophthalmology in a crisis of confidence," proclaimed Jose Manuel Barroso, president of the EU Commission in his EU 2012 state of Union Ioannis Pallikaris MD, PhD
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, "I believe that rationalise the benefit packages and
the impact of the implement wide-reaching reforms in the economic crisis pharmaceutical market. Ophthalmology has not escaped the fiscal tsunami. on healthcare and in some parts of Europe, cataracts director of the Vardinoyannion Eye upfront in cash for supplies. ophthalmology in are not operated as early as in the past, institute of Crete, noted that in some cases Conversely, medical professionals in the particular has not and when patients are considered good patients who previously would have used private sector will experience a decrease fully emerged candidates, they may have to wait private resources to address their needs in their surgical load and consequently to considerably longer before they can be are now obliged to use public healthcare their incomes, Dr Pallikaris observed.
operated. The volume of elective refractive systems, creating an overload. This "Taken together, these factors will Argyrios Tzamalis MD
surgeries, often considered an unofficial overload in the public healthcare system cause a decrease of the quality of provided leading economic indicator, including produces a series of complications such as medical services. The final consumers, the LAsiK and presbyopic iOL procedures, delaying the provision of services such as patients, will be the ones that will suffer the has declined in many regions as disposable cataract surgery. most due to this situation." income has diminished. he noted that the economic crisis is "The economic crisis has created a new causing further shrinkage in government Global financial crisis Greece
environment in Europe which has already spending for the public healthcare system, has perhaps been hit harder than most influenced and will continue to influence which raises the spectre of hospitals being countries in Europe, notes Argyrios healthcare in general and ophthalmology unable to offer high-quality services such Tzamalis MD, 2nd Department of in particular. These effects will be greater as premium lenses cataract surgery due Ophthalmology, Aristotle University of in countries that suffer the worst, mainly to the expensive consumables such as the southern European countries," ioannis iOLs, and viscoelastics. This was seen in "The global financial crisis has had a Pallikaris MD, PhD, told EuroTimes. Greece very recently, where international tremendous impact on Greece's economy, Dr Pallikaris, professor of companies, fearful they would not be exacerbating existing problems. The ophthalmology, school of Medicine, reimbursed, refused to extend credit, health sector has been seriously affected University of Crete and founder and demanding that Greek providers pay by the economic situation, and the three EUROTIMES Volume 18 Issue 2
Memorandums of Understanding that to patients in many areas. The public Greece has signed since 2010 dictate healthcare system is expected to absorb a series of measures that focus on the significant budget cuts, meaning longer reduction of public expenditure. A broad waits for surgery. As fewer spanish citizens range of healthcare reforms and policies are able to afford private insurance, the have been implemented, which represent insurance companies have had to reduce the biggest shakeup of the healthcare the coverage they provide, reduce access system in decades. irrespective of their to some surgeries, reducing physician positive policy goals, these measures payments, and increasing the portion of have started to affect public access to the the cost expected from the patient, noted healthcare system and to increase the financial burden on patients," he told "i can only hope that this will not last too long, that things will improve. The economic hard times in Greece Meanwhile, i suggest to residents that they have had a measurable effect on the focus on medicine and ophthalmology, delivery of ophthalmology services. Many and remember it is not about focusing public hospitals and eye clinics have had on making money, we are here to serve problems providing ophthalmic surgical people, with or without the crisis." services due to lack of essential materials. indeed, in the last two years some Subtle effects The impact of the
ophthalmology departments have had to recession in Europe has not affected suspend even cataract surgery services all areas equally. in general, the more because companies declined to provide northern countries, while not unaffected, iOLs unless they were first compensated are faring better. in the Netherlands for by the government, which did not have example, the effects have been more subtle, the financial ability to do so, Dr Tzamalis notes Leigh spielberg MD, a resident at the Rotterdam Eye hospital.
"it is a real vicious cycle! And you can "in the Netherlands, the residents imagine what the impact could be on themselves aren't particularly having the patients' health levels. in fact, many problems. Our contracts are guaranteed patients keep coming to big university eye for the whole of the five-year training clinics just to have a simple ophthalmic period. We are reasonably paid, despite procedure done since this may not be the relatively high cost of living in performed anywhere else or maybe because holland. Further, the job market for they cannot afford it going privately. Even ophthalmologists happens to be quite good eye drops are in short supply." here, so finding a job after graduation has The economic crisis has also put the not been a problem for anyone who has squeeze on residents looking ahead to graduated during the period that i've been their first career post. Dr Tzamalis noted here, since mid-2010." that every ophthalmology resident at however, he notes that "further up the his institution in the past two years has ladder" there have been some big changes. moved to more prosperous countries, with The Dutch government is trying to get all Germany and the UK being the favourites. physicians to become essentially salaried Even though many residents would prefer employees on the payrolls of hospitals. Image courtesy of Eoin Coveney to stay in their home country, because of The physicians' rights in The Netherlands Across countries hit hard by the crisis, countless vulnerable sections of society are forced to postpone vital treatment and even surgery the dire economic situation in Greece, have always been very restricted: specialists there has been a hiring freeze, with no (as opposed to GPs/family doctors) have hospital positions expected to be available always been essentially required to work the difference it makes or can make, for for many years to come. in hospitals. Although they could work example, to do wet refractions before "i believe that the impact of the "privately" within these hospitals, they had surgery or to refract several times and to economic crisis on healthcare and to have some sort of connection with the provide post-op care," he said.
In my own country ophthalmology in particular has not fully hospital. Only recently have specialists he remains optimistic in the long term, I can see the effects emerged. i think that in the next few years discovered a loophole or financial noting that ophthalmology is in a good of the crisis both as the insurance funds won't be able to bear construction to allow them to work position as patients age and become aware a consumer and as a the burden of covering ophthalmic needs, separately from hospitals, but this is quite of the many options for them. he predicts provider. It is affecting which are continuously increasing with the an ordeal. The government is trying to that while refractive surgery will probably all ophthalmologists, evolution of technology," he said.
eliminate this across the board. not increase much in volume, demand those working in both "Also, there has been a general, across- for presbyopic options such as the Kamra Economic storm spain is also being
the-board reduction in fees paid for corneal inlay does have growth potential.
public as well as in buffeted strongly by the economic storm. medical services, up to about 30 per cent private care it has had a real estate meltdown, a capital in the past few years! The doctors are not Dual approach Ophthalmology in the
crisis and has record unemployment. happy about this," he said.
UK, which pioneered the idea of national José Güell MD
Under these circumstances it is not health insurance after the second World surprising that ophthalmology would feel More providers Germany also seems
War, is now experiencing a number of to be holding up pretty well. Refractive challenges related in part to the global "i am concerned about the effects surgeon Kaweh schayan-Araghi MD, of recession, notes Richard Packard MD, of the European economic crisis on the ARTEMis Eye Clinic, Dillenburg, FRCs, FRCOphth, Windsor, England.
ophthalmology. in my own country i Germany, says his office has not noticed a The UK currently has a dual approach We do see a trend can see the effects of the crisis both as a drop in demand for refractive surgery, but to healthcare delivery funding. The vast towards low-cost consumer and as a provider. it is affecting that patients now have more providers to majority is done through the National providers for all ophthalmologists, those working in choose from. he did see some sign of the health service (Nhs), with the rest both public as well as in private care," José times in pricing, however.
covered either through private insurance or Güell MD, professor of ophthalmology at "We do see a trend towards low- self pay by the patient or a combination of Autonoma University of Barcelona and cost providers for refractive surgery. both these. While Dr Packard said the euro director of the Cornea and Refractive Unfortunately, they have to cut corners crisis does not appear to have had a large Kaweh Schayan-Araghi MD
surgery Department at iMO, Barcelona, to meet the price expectations of patients. impact on the Nhs to date, the amount of told EuroTimes. We experience more patients trying to funding available to commissioning bodies, As in other parts of Europe, there has negotiate about the price since these like primary care trusts (PCTs), has not been a notable decline in demand for providers advertise more. Quality seems kept up with inflation. As a result these elective refractive surgery. But it has to be of minor importance to patients, or PCTs are trying to save money. affected access to care and options available we seem not to be able to communicate "One of the ways that they are doing EUROTIMES Volume 18 Issue 2
Ioannis Pallikaris[email protected]
Argyrios Tzamalis[email protected]
José L Güell[email protected]
tacts Kaweh Schayan-Araghi[email protected]
artemiskliniken.de Richard Packard[email protected]
con Peter Barry[email protected]
this is to try to restrict cataract surgery by specifying visual thresholds for surgery and also not paying in some instances The number of for second eye surgery. The number of cataract surgeries cataract surgeries performed in the UK performed in the UK has thus come down. in the private sector, insurers and most particularly the largest has thus come down one, BUPA (British United Provident Association), has tried by other means to reduce its spend on cataract surgery. Richard Packard MD, FRCS, FRCOphth
BUPA the largest insurer with more than 40 per cent of the market has slashed the reimbursement for its subscribers by over Dr Packard notes that this reimbursement reduction has not been Ophthalmology will accepted by the majority of surgeons. have to fight hard in response, BUPA has tried to redirect to preserve its slice its subscribers to a chain of high street of the health budget and fight very hard REFORM In PRACTICE opticians who do refractive surgery and are now offering cataract surgery. Patients are less than happy, he emphasised.
to increase it, which More patients, electronic records, lower pay it will need to do Postoperative discontent
under Obama changes if it is to embrace president Peter Barry FRCs of Dublin, toric and multifocal by Howard Larkin ireland, echoed Dr Packard's concerns.
lenses, anti-VEGF "i am concerned that in parts of the agents and other long-term effects of drugs and devices. United Kingdom second eye cataract new treatments Come 2014, about 14 million Americans will gain health About 35 to 40 per cent of Us practices surgery is not permitted for economic insurance, rising to about have converted to EMR.
reasons and i am also concerned that 30 million by 2022, thanks to health From state-run insurers, ‘clinical care pathways' effectively preclude Peter Barry FRCS
reforms passed by the Obama ophthalmologists can expect a variety the surgeon from seeing the patient administration. But since reform is of managed care approaches, Dr Mosier until the time of surgery and likely not largely a joint project of the federal said. Most feature greater involvement afterwards. This trend will result in more Looking to the future, Dr Barry said: and state governments, the details of primary care physicians in controlling patients having unnecessary surgery "Ophthalmology will have to fight hard of coverage and how they will affect specialist service use, and restrict patient and postoperative discontent even if the to preserve its slice of the health budget ophthalmologists will vary greatly choice of physicians.
surgery itself was uncomplicated. Cataract and fight very hard to increase it, which it by location.
The most common is a surgery should not become a commodity," will need to do if it is to embrace toric and "Decisions made in Washington DC comprehensive risk-based plan, in which Dr Barry told EuroTimes. multifocal lenses, anti-VEGF agents and and in state capitals today will have a contracted network is at risk for care Dr Barry noted that in ireland the other new treatments," he said.
an impact on how we care for our quality and outcomes. Plans support debate over new contracts for consultants This raises the greater issue, that even patients," said susan K Mosier MD, members with health assessment and was having a very serious adverse effect if and when the current economic crisis MBA, an ophthalmologist and Medicaid care coordination, and must report on morale both amongst consultants passes, ophthalmology is facing an ongoing program director for the state of Kansas. performance and quality measures and themselves and specialist registrars at the crisis of sorts, involving factors of access however, the overall direction is clear. submit to external quality reviews to end of their training who would become to care, including providing sufficient Payment will move away from fee-for- obtain payment. Nearly half of state-run the next tranche of consultants. This numbers of surgeons and the programmes service reimbursement toward managed programmes already use this model, anxiety for the future is causing more stress to train them to meet the coming demand care approaches. "There is a lot more and they will likely be greatly expanded than the current economic downturn, suggested by the demographics of the performance monitoring and recording under reform, Dr Mosier said. she also ageing population. But perhaps the most expects private insurers to follow suit.
ireland has also seen a reduced vexing question is, who will cover the cost The federal Medicare program, which Driving it all is reduced funding, said demand for elective refractive surgery, as for not only standard services, but for covers those 65-years-of-age and older, Michael X Repka MD, MBA, AAO's prospective patients have less surplus cash the remarkably effective, but expensive, already has adopted strict performance- medical director of governmental spend, a trend Dr Barry said he expected new treatments becoming available for all based payment rules, said William L affairs. For decades, total government would continue for some time. manner of eye diseases? Rich MD, medical director of health expenditures on ophthalmology have policy for the American Academy grown year to year, but they are about to of Ophthalmology (AAO). in 2015, level off even as patient demand grows. practices that fail to meet quality and he noted, for example, that the advent COMING SOON IN MARCH EUROTIMES.
medical record use requirements will of intravitreal injections for AMD lose up to 3.5 per cent of Medicare and other retinal conditions has revenues, rising to 7.0 per cent or more dramatically increased procedure volume in retinal offices.
The EuroTimes March Cover Story will provide a retrospective on
AAO is developing a registry that Technological advances such as the ways the prophylaxis of endophthalmitis after cataract surgery
is designed to enable participating implants that reduce the number of has changed over the 10 years since the publication of the ESCRS
practices to meet the quality reporting injections required may help relieve requirements, which will tie payments to this particular problem, Dr Repka said. That study showed that the rate of endophthalmitis among those
indicators such as providing screening however, the larger issue is finding ways receiving intracameral cefuroxime was only 0.05 per cent compared
and prevention services, Dr Rich said. to deliver services more efficiently and to 0.35 per cent among those who did not receive the antibiotic.
While switching to electronic records effectively. "We have to find savings in The article will include a review of the history and inspiration of
can be costly, participating in registries healthcare delivery. More quality and the study and the impact it has had on cataract surgery around
has clinical benefits, including auditing less cost is no longer a mantra, it is the world as well as reports from several leading surgeons on their
practice performance and monitoring current views on the topic of endophthalmitis prophylaxis.
EUROTIMES Volume 18 Issue 2

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Cornerstones 1-1.indd

Practice-Based Research Syntheses of Child Find, Referral, Early Identifi cation, and Eligibility Practices and Models Volume One, Number One September 2005 Educational Outreach (Academic Detailing) and Physician Prescribing Practices Carol M. Trivette The use of an educational outreach procedure called academic detailing for changing physician pre-scribing practices was the focus of this research synthesis. The practice is characterized by brief, repeated, face-to-face, informal educational outreach visits to physicians by knowledgeable profes-sionals (academic detailers) in physicians' offi ces or other practice settings to provide information and materials to change prescribing behavior. The synthesis included 38 studies of more than 5,000 physicians and other health-care providers. Results showed that a number of academic-detailing characteristics were most associated with hypothesized or expected changes in prescribing prac-tices. Characteristics include collecting baseline information on physicians' current prescribing prac-tices, establishing a motivation to change, establishing the credibility of the message and messenger, repeating a highly focused message, and providing positive reinforcement for changes in prescribing practices. Implications for using these practice characteristics for child fi nd are described.

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