March 2009

 

OPHTHALMOLOGY NEWS

 

Universal healthcare: the Asia-Pacific experience


by Michelle Dalton EyeWorld Contributing Editor

 

 

As part of an ongoing series, EyeWorld spoke with ophthalmologists about their countries’ health care policies

Across the Asia-Pacific region, variations in health care abound. Australia has both public and private insurance. Japan and Taiwan’s systems incorporate nearly every citizen in government-funded health care. In India, there are essentially two tiers of public insurance as well as private insurance. Throughout the region, however, is one common theme: Governments alone are ill-equipped to fund health care for entire nations.

Australia

Surgeon choice falls by the wayside for patients who opt for government-funded Medicare, said Noel Alpins, M.D., associate fellow, University of Melbourne, Australia. Territories vary widely in the percentage of patients who choose private insurance instead of public health care. In some territories, such as Victoria, about 46% of inhabitants opt for private insurance, he said, but in the Northern Territories, where most of the Aboriginals reside, an overwhelming majority use Medicare. Health care budgets in Australia are state-run, with a Medicare levy of 1.5% of every working person’s income. To curb costs, the government is trying to move more people into private health care; for single people earning less than $100,000 and married couples earning less than $150,000, they can opt out of private insurance and move into the public system without paying a penalty. If income rises above those levels and the patient(s) still opt for public health care, they are surcharged 1% in addition to the mandatory 1.5%, Dr. Alpins said. Surgical fees are non-negotiable, with the government funding about 75% and private insurance about 25%, but the surgeon is free to charge a higher fee the patient would pay out of pocket. “Everyone’s covered, and we have outstanding health care,” he said. “If patients want to pay extra money for private insurance, they then have the ability to choose their physicians, their hospitals, et cetera.” They also have the choice of premium lens implantation, whereas those in the public system will typically receive monofocal lenses. While ophthalmology has the longest wait times of all specialties, on average it’s between three to six months in the public system. “In the private sector, it’s about a two to three week waiting time,” Dr. Alpins said. Which health care system is used determines how long a patient may wait for care; the rate of cataract surgery in Australia is about 9,000 per million inhabitants, among the highest in the world, Dr. Alpins said.

According to the Australian Health & Welfare statistics, the average wait for cataract surgery was 71 days, compared to 50 days for orthopedic surgery and 15 days in other specialties.

“To look at all ophthalmic procedures, 90% are admitted by 318 days,” Dr. Alpins said, “compared to 66 days in urology in the public system.”

As a general rule, he said, private surgeons are also more likely to perform advanced procedures, such as refractive cataract surgery, limbal relaxing incisions, phaco incision placements (temporal with two opposing limbal relaxing incisions), or inserting toric lenses. Patients outside major cities typically present much later; Dr. Alpins noted a study that found a majority of the Aboriginal patients who present for cataract surgery are legally blind. Phaco is still the preferred surgery, although it is not uncommon for extracap to be performed in the Northern Territories, he said. “There is also the issue that neither public nor private systems realize high refractive errors are visually debilitating,” Dr. Alpins said. “

India

Like Australia, India has multiple healthcare systems, said Abhay R. Vasavada, M.D, director, Iladevi Cataract and IOL Research Centre, Raghudeep Eye Clinic, India. Because the majority of the country’s residents are at poverty levels, they are covered completely by the National Health Policy, implemented in 1983, he said. A secondary public system allows patients to pay a nominal fee; few can afford private insurance. Dr. Vasavada said in some of the more rural locations “health care delivery may be appalling,” but that more and more people are opting for private insurance, at least in the major cities. “The challenges of availability and quality are different in each area,” he said. The cycle of poor quality and expensive care is continued by the elderly population who knows the services are lacking and, as a result, present much later in the course of a disease, Dr. Vasavada said. “Not only do we have long waiting lists, but the elderly just don’t come to the clinics,” he said. Most physicians are allowed to work in both the public and private sector, but each state regulates that, he said. All surgeons are paid a standard fee in the public system, he said, irrespective of the number of surgeries they perform. “We perform lots and lots of surgeries, but the quality of care in general is not very good,” he said. In the bigger cities, private sector is flourishing with people who can afford to go to private clinics, Dr. Vasavada said. “Surgeons who are trained in phaco don’t have an incentive to stay in the government system because the money they’re paid is not enough, the working environment is not conducive to advanced technologies,” he said.

The government does recognize its dilemmas, Dr. Vasavada said, and is working with private sector providers to manage some village-based clinics. “Progress is slow,” he said. “We’re not making much of a difference today in quality of care than what it was 10 years ago. I don’t think I’ll see that kind of change in my lifetime.”

Japan

Public health care in Japan has been available since the late 1920s. Japanese health care is highly regulated by the government, with both National Health Insurance and employees’ insurance, and membership is compulsory. Employee health insurance covers those who work for medium to large companies, national or local government, or the education system. Premiums are based on monthly salaries, and the average contribution is about 4% of a person’s salary. The country spends about 8% of its gross domestic product on health care. There is no restriction, however, to supplementing with private insurance, said Hiroko Bissen-Miyajima, M.D., professor of ophthalmology, Tokyo Dental College, Suidobashi Hospital, Tokyo. “In some rare cases, people don’t have to pay anything towards insurance,” she said. About 20% of the hospitals in Japan are government-run, with the majority being private and physician-owned.

In 2000, the government called for reforms of the current system, including a review of drug pricing, methods of evaluating medical technologies, and the ideal combination of fee-for-service and fixed-fee payment systems. All physicians are paid the same in the public system, regardless of how many surgeries they perform weekly, Dr. Bissen-Miyajima said. The government does not yet recognize the difference in quality, so general physicians are paid the same as specialists and sub-specialists. “Our doctors are working very hard,” she said. “We see as many patients as possible every day. Waiting times are three to four hours. There’s no appointment system here, so patients can come and see doctors whenever they want.”

Surgeons are not allowed to advertise any additional services, Dr. Bissen-Miyajima said, but they can speak to the patient about those services in the office.

For patients who do want additional services, such as premium lenses or other new technology in lieu of monofocal IOLs, the cost is fully borne by the patient, including the hospital stay and anesthesia. Hospital stays in Japan average twice as long as those in Western countries, according to local newspapers. Ophthalmologists are concerned that if the government continues to disallow co-payments for premium lenses, “it will limit the growth of multifocal lenses in our market,” Dr. Bissen-Miyajima said.

Taiwan

Taiwan’s public health care coverage was established about a decade ago and is compulsory, said David C. Chang, M.D., chief executive officer, Taiwan Nobel Medical Group, Taipei Nobel Eye Institute, Taipei. By 1997, 99% of people had enrolled. By 2000, the government was forced to introduce global budgeting in an effort to contain costs. This involved an expenditure cap method “to improve the service quality of primary care,” Dr. Chang said. Global budgeting was phased in, beginning first with dental outpatients, then Chinese medicine outpatient, then Western medicine primary care, and finally hospital services in 2002. The National Health Insurance works with medical organizations to deliver its programs and to supervise those providers in the system “to provide the highest quality health services,” Dr. Chang said.

“We only pay $5 for registering with the system,” he added. Unlike some other countries, the number of ophthalmologists for the aging population is completely adequate, Dr. Chang said. “We can arrange cataract surgery the day after your first visit,” Dr. Chang said. “If you’re insured, it takes about a day. Those who want to self-pay can have both eyes operated on the same day.”

The one problem with the system, Dr. Chang said, is that some physicians do not perform a lot of procedures because the number allowed (40 eyes/month) is dictated by the government. “Your salary as a surgeon will be inhibited unless you also perform a lot of self-pay procedures. You’ll be monitored if you go too far over the limit,” he said. Monitoring physicians is now a peer-review process, to ensure needless surgeries are not being performed and to ensure surgeons do not exceed the limits. Dr. Chang is one of the peer reviewers in his region. In refractive surgery, physicians are obligated to give a full explanation of all potential options. “Myopes with astigmatism might not need refractive lens exchange; LASIK will solve their problems,” he said, who first began performing LASIK in 1998 in his private clinic, and then in the hospital, in 2001. “The government gave permission for primary clinics to perform LASIK in 1999,” he said. From 1999–2001, he estimated about 120 eye centers opened. In 1999, conventional LASIK was about $1,500/patient. “There was an incremental increase in laser machines until 2002, when there was a peak in volume,” he said. Prices decreased to around $1,000/patient. Wavefront-guided technology once again pushed prices up to $1,500. “In 2006, pricing was still down a bit. Those without wavefront-guided technology could only charge around $800, and even those with wavefront-guided technology were charging $1,200,” he said. With the introduction of femtosecond lasers, however, another price increase ensued. Now, surgeons with both femtosecond and wavefront-guided abilities are able to charge close to $2,500/patient, he said. “Fewer than 10% of the surgeons have these advantages,” he said. “Nearly half don’t make any money anymore. You don’t have to do a lot of marketing if there’s good word of mouth. About 10% of the clinics here are successful, 30% are balanced, and another 50% really don’t have enough patients to do the procedures.”

In his group, about 90% of the patients self-pay.

“Socialized welfare is good, but in some parts of the country, some patients don’t receive quality or quantity healthcare as before because of limits set by global budgeting. Some patient quality may be sacrificed,” he said. In short, Dr. Chang said, as a patient himself “it’s convenient and accessible to be insured in Taiwan, and the quality is very good.” As a physician, though, “global budgeting will impact the ability of medical facilities to improve or elevate technology. They’ll spend lots of money, but still have no more patients to treat.”

Editor’s note: None of the physicians interviewed have a direct financial interest in their comments. Dr. Chang is one of the medical peer reviewers for Taiwan.

Contact information

Alpins: +61 408 343 977, nalpins@unimelb.edu.au

Bissen-Miyajima: +81 3 5275 1912, bissen@tdc.ac.jp

Chang: + 886-2-23705666, chaokai@ms17.hinet.net

Vasavada: icirc@abhayvasavada.com

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