Cutting doctor’s fees: penny wise, but pound foolish

As a recent ophthalmology and retina surgery graduate, I was shocked by the dramatic unilateral healthcare cuts announced in May. This left me with a poor first impression of the relationship between the health care profession and government. Although the OMA and government are back at the bargaining table, I am concerned that the best interests of the patient may not be represented. It is increasingly frustrating to hear the same myths perpetuated by government officials.

One myth is that the quality of health care services will not be affected. In reality, compromising essential services will threaten patients’ vision and quality of life. One example from my specialty is that payment for optical coherence tomography (OCT) tests is now limited to 4 tests per patient per year. OCT technology allows for high-resolution images of retinal tissue structure – essentially providing a biopsy of the retina without requiring any invasive procedure.

Multiple clinical trials have proven that blindness can be prevented in patients with wet macular degeneration. Some trials suggest that intraocular drug injections, when given monthly, are superior to injections given on an “as needed” basis.  However, a more popular approach is a compromise between the two, known as “treat and extend”, which reduces the costs and complications associated with monthly treatment. This requires that OCTs be performed more than 4 times per year. Without doing the OCT, doctors may instead provide injections more often than required.  What is the cost of limiting $25 OCT tests? More patients may require injections costing up to $1700 per shot, while also increasing the risk of complications. Penny wise, but pound foolish.

Another myth is that the breadth of services provided in healthcare will not be affected. These cuts de-incentivize technology, so in the future ophthalmologists in Ontario will no longer be able to invest in the most up to date diagnostic equipment. Patients may have to travel outside the province to receive imaging that ophthalmologists have established as the standard of care.

The most pernicious myth is that there were no fee cuts, just freezes. The reality is that some of the most commonly performed ophthalmological procedures and diagnostic tests were cut substantially.  For example, compensation for OCT was cut from $63 to $25, which along with the reduction of from 6 tests per year down to 4 amounts to a 74% cut.  In June, Ontario retina specialists in an informal survey reported a 34% reduction in income as a result of the cuts – clearly not just a freeze in compensation. Some have self-reported a 50% drop in income since. This comes on the heels of our voluntary offer and implementation of a 16% cut in reimbursement in 2011.

To date, the Ontario government has refused to declare how they came to their decisions on the implementation of these cuts and who was advising them. As a member of the Canadian Retina Society and the Ontario Society of Retina Specialists, this was discussed at our meetings in June and September. Other provincial governments have sought out retinal subspecialists to understand the services they provide in an effort to make well-informed decisions on budgetary amendments. The fact that the Ontario government has not also taken this step has been troubling, considering the solid record we have of working with government to seek out cost savings that are not detrimental to patient care. The profession recognizes the current economic situation and is willing to find ways of reducing public health care spending with the least impact on patient care, but we have not been allowed meaningful input.

Retina specialists have been fortunate to witness exceptional advances in their field in the last decade. Patients with wet macular degeneration can now be saved from blindness. Intraocular injections of Avastin and Lucentis (see chart below) can dramatically improve vision in 30% of patients and can stabilize the vision of another 60% of the population. This is very different from 2004, where the majority of patients lost vision. Injections also help improve the quality of life for patients with diabetic retinopathy who can more quickly re-enter the workforce. The cost of any of these indicated diagnostic tests or treatments is not even comparable to the cost of social services for a blind patient (e.g., disability payments, transportation, home services, etc.).

Since 1991, the Ontario population has increased by 31%. The number of ophthalmologists has only increased by 8%.  The number of procedures performed has increased by 18% since 2006. This has led to fitting in an extra day of work into an ophthalmologist’s schedule. This increase in workload actually stemmed from the request of the government to decrease wait times.

I have only been in practice for two years, but I was drawn to this profession because ophthalmologists are passionate about their work, adapt to ever-changing technology, and are appreciative of the opportunity to provide better healthcare with every passing year. I am extremely grateful to my colleagues and for the privilege to provide retina care in Ontario. But I do fear how our practice will change if the government continues to ignore our clinical recommendations and evidence-based medicine, and deprives patients of the diagnostic and therapeutic technology that makes our specialty so fascinating.