June 2007




Perspectives in Lens & IOL Surgery

The view from Canada

by Steve Arshinoff M.D., F.R.C.S.C.


Steve Arshinoff, M.D., FRCSC, is an internationally renowned surgeon, innovator, teacher, researcher, and clinician. He has designed surgical procedures, instruments, and is best known internationally for his unique understanding of and education in the field of viscosurgery. Steve is a founding member and past president of the Canadian Society of Cataract and Refractive Surgery, and is currently secretary of the International Intraocular Implant Club. In this month's column, Steve paints a very frightening picture of what happens in a fully-socialized system of healthcare that deprives physicians of any ability to advocate for their patients' better healthcare, their own practice patterns, and their personal incomes. Every American surgeon should read this month's column and reassess the direction in which healthcare appears to be going in the United States.

I. Howard Fine, MD, Column Editor


To adequately appreciate and improve the health care system in the U.S., it is vital to understand what systems are in place globally

The vast majority of Canadian ophthalmologists who are active in cataract and refractive surgery are members of the ASCRS. We have a Canadian CSCRS, and yet Canadians still find it essential to belong to a foreign organization. I know of no other country where this happens to the same extent. Is it because Canada, being a sparsely populated country (about 32 million inhabitants in an area much greater than the U.S.), simply does not have the breadth of experience to create a fully functional society like the ASCRS or ESCRS? Undoubtedly, this is a contributing factor, but I believe that our health care system plays a large contributory role in restricting innovation and development, and thereby constrains the available academic exchange locally available.

Health care in Canada comes under uncontested provincial jurisdiction according to the Canadian constitution (British North America Act, 1867). The federal government sets broad guidelines. Tommy Douglas, of Saskatchewan was the revered father of Canadian socialized health care. He was undoubtedly a socialist, and a very skilled politician. By about 1972 all 10 Canadian provinces had followed the lead of Saskatchewan in adopting some variant of totally encompassing socialized health care. They were induced to jump in by the federal government, which offered financial incentives for provinces which met broad national standards for public health care delivery. (Medical Care Act 1966; Canada Health Act 1984). All ten provincial health care plans are different, with Saskatchewan’s being the most socialist and Alberta’s the least. Canada also has three territories, which come under purely federal jurisdiction, and so have different schemes again. Indigenous Canadians also come variably under federal jurisdiction. To discuss cataract surgery in all jurisdictions would be confusing and incredibly tiresome for the reader, so I will stick to the one I know best: my home—the somewhat middle of the road province of Ontario.

1970 to mid 1990s 

Ontario, as the stalwart of the Canadian industrial economy, containing the largest population, and the home of the largest Canadian stock market (Toronto Stock Exchange) entered the Canadian Medicare scheme with some reluctance and conservatism. The government initially reimbursed patients for their medical bills at a rate related to the prevailing Ontario Medical Association recommended fees. Doctors were given the option to bill patients directly, and have the government reimburse the patient, or to join the system completely, and bill the government, receiving reimbursement directly. Doctors were not allowed to be in both systems simultaneously.

The system worked very well for about 15 years, because the “free market” effect of allowing opted out doctors to bill patients directly assured that when opted-out doctors “overcharged” patients, they could go to an opted-in doctor, and when government hospitals failed to keep up with modern technology or practices, patients could seek out “private” care. Thus, the two groups acted as checks and balances on each other. In 1987 the Ontario government, as all governments do, sought increasing budgetary control, and legislated all doctors into the system. They began to set firm annual health care budgets (replacing previous estimates), and restrict training of doctors, nurses and other health care workers, in an effort to contain the cost of what was now a completely government controlled system. Predictions were coming in that by the mid 21st century, unrestrained growth in health care would consume 100% of GDP, and government decided to act. Future medical fee increases were to be “negotiated” between the Ontario Medical Association (physician membership in the OMA is compulsory by legislation) and the government. This is problematic under the BNA Act, because nobody has the right to “bind the crown” in British democracies. Therefore, it was soon discovered that only the doctors’ side was bound by agreements, and government was free to change the agreement post hoc, at will, usually by reducing fees, clawing back past payments, etc. Doctors’ incomes were capped by governments, to remove any incentive to work harder, and cataract (and other) fees have only minimally increased for 20 years, while office overhead (the doctor’s responsibility) steadily climbed. Waiting lists became a fact in Canadian medicine, and served to keep operating rooms and hospitals working at planned maximum capacity. Booking any urgent patients became a challenge. Progressive restrictions upon the freedom of doctors to control their own practices, use hospitals, etc. gradually ensued, as they have in every centrally controlled system in the world. The value of a medical practice rapidly went to zero, because the government controlled the budget of every hospital. Hospitals became reluctant to take on new medical staff, because every new staff person impacted upon the budget, and new money was rarely forthcoming to increase any department’s capacity. Consequen-tly selling the practice of a retiring physician to a new graduate, in no way guaranteed the new graduate the ability to practice at the hospital next door. It became apparent to hospital administrators that they could gain by appointing somebody other than the purchaser of a retiring physician’s practice, if anybody, to replace a retiring physician, and simply force the retiring doctor to give away or dismantle his practice, giving the hospital more control of the type and scope of practice that the new young doctor would have, thus slowly molding hospital departments to the will of administrators and government budgetary dictates. This trend was facilitated by government severely restricting training of new physicians, resulting in a severe shortage of all types of doctors, and thereby destroying any value of a loyal patient base. The effect of all this has been to level all ophthalmologists into a relatively mediocre, but equal, status. Because medical practices had no value, and reimbursements were stagnant, ophthalmologists became reluctant to purchase new technology for their offices.

The next step was for hospitals to review every item used in operating rooms (and everywhere else), and to purchase them primarily by competitive bidding rather than by medical merit. Any device or drug that doctors considered to be essential for good practice became the subject of extended battles, with doctors in most hospitals simply giving in. Everything is now tendered, and line by line arguing ensues. Often the cost of the staff committees to fight over purchases far outweighs any potential economic benefit of buying the cheapest device or drug. Generic drugs, the cheapest available, usually made by a few local companies, are mandated by law for hospitals. Some of these have been found to cause TASS (e.g. Generic Canadian Pharmaceutical Partners vancomycin for intracameral use) or other problems.

Mid 1990s to present

In the mid 1990’s things were looking pretty dismal for Canadian ophthalmology, with the governments progressively squashing things that we had considered our rights. Then, refractive surgery, which governments completely opted out of, offered us a wedge into regaining some freedom. Many Canadian ophthalmologists jumped into laser refractive surgery as a way to escape the Medicare tyrant. As everywhere else, most eventually discovered that refractive corneal surgery has its own complexities and issues, and requires a minimum volume and effort to continue, and so about 70% of those who were in the field in Canada have now dropped out. Nevertheless, the advent of refractive surgery did encourage us to venture further into refractive lens exchanges, and to begin to consider some cataract procedures primarily refractive, and therefore exempt form the Medicare system.

Refractive cataract surgery has allowed Canadian ophthalmologists to embrace refractive IOLs and has permitted a number of private cataract and laser centers to arise, as government hospitals were initially reluctant to allow non-government procedures to be done. Surgeons must exercise great caution, because if one is found to be performing government covered cataract surgery privately, but calling it something else, severe fines or prosecution may ensue. However, recently, even government hospitals have permitted, and even encouraged cataract surgeons to embrace and sell their patients alternative or “better” IOLs, thus allowing surgeons to bill for the lenses, and simultaneously permitting the hospitals to save the cost of an IOL for that patient. This practice has the negative effect of causing a reduction in the hospital IOL budget for the next year, for every refractive IOL used. If the government one day legislates that IOLs cannot be charged for as an extra uncovered fee (as they have in the past when foldable IOLs were new, and just stated they are saying again now for current “enhanced and presbyopic” IOLs) the hospital will find itself with an almost zero budget for IOLs. Furthermore the practice of doctors charging for IOLs, while the hospital diverts the government funding for another unused IOL does, cross the line of the Medicare legislation, and some provinces and hospitals have demanded to have the exclusive right to sell patients “better” refractive IOLs and limit any additional charge a surgeon may levy for using these IOLs, and counseling patients about available IOLs. The issue is currently undergoing debate again and is in a state of flux.

In the past few years, year-long waiting lists for cataract, orthopedic, cardiac and other procedures have become a hot political issue in Canada. Government has moved to remove doctors’ income caps, and created considerable additional operating room capacity. As the waiting lists are now shrinking, government is stating that it now intends to drastically reduce hospital funding of cataract surgery per case, and then to reduce surgical fees, and to make ophthalmologists compete economically for cases. They have begun to institute cataract referral clinics, where the government will advertise the clinic to the public, employ optometrists to assess the patients, and refer the patient to the next available surgeon on their roster, who has agreed to go along with the optometric run referral clinic plan. This practice threatens to initiate the death of private independent practice for ophthalmologists in Ontario. We may be entering a period of government corporate style medicine, where surgeons become the employees of government funded clinics and work by roster, in rotation.

All ophthalmologists are now being requested to use the exact same pre- and post-operative eye drop regimen, and do their procedures in a standard manner with exactly the same instruments. This will supposedly make things “more efficient” for a government run system. There will be no room for innovation, research, or individual variation in practice. Complex cases are not considered for their additional needs, and there is no plan to care for them. No funding for research is attached to the proposals for efficient cataract centers. Actually, policies are being put in place to prevent any surgeon from trying out new equipment, drugs, IOLs, or anything that is not already standard at the institution. The surgeons may get to try out a few new things at the times of tendering every few years, but nothing in between tenders. After moving to strip us of independent surgical practice, the government next will strip us of the ability to perform any independent research of significance.

When one considers the above story, it is not surprising that we look to the American Society of Cataract & Refractive Surgery as an escape where we can see what happens in a country that has always vigorously resisted any restrictions to freedom, and has made other sacrifices in order to preserve academic and practice freedoms. All countries are struggling to cope with endlessly increasing demands for medical services as new drugs and technology emerge. In Canada everybody is covered, whereas in the U.S., many have no health care coverage. Instead Canada has sought to minimize costs by instituting standardization, restricting doctors’ incomes and doctors’ and patients’ choices and freedoms. It is nice to be able to see patients, and not have to discuss the cost of their needed treatment with them. But more and more, I feel that in many ways, we are paying excessively for this benefit. I understand that Cuba is the only other jurisdiction with a health care system that is as controlling and restrictive as Ontario’s. In Canada we must all be round pegs and fit into the same round holes. Neither Canada, nor the U.S. is “right” in making these different choices. Either way, somebody in society pays the price for the choices made. Hopefully, but not likely, we will move to a system embracing the best of both countries, but unless somebody sees political gain for that, I cannot be hopeful or see it as a likely outcome. Throughout my career, I have been an ardent supporter of the ASCRS, and have attended every meeting for about 25 years, and presented my thoughts and ideas there, where they are considered and criticized by my American and international peers solely on merit. I will keep my membership to the ASCRS, so I can feel freedom, at least in my thoughts about what is best for my patients. 

Editors’ note: Dr. Arshinoff reported no financial interests related to his comments.

The author would like to thank Jeffrey Sher M.D. F.R.C.S.C., chair, Department of Ophthalmology, McMaster University, Hamilton, Ontario, for his thoughtful review and comments with respect to this article.

Contact Information

Arshinoff: saaeyes@idirect.com

The view from Canada The view from Canada
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