Brazil’s ophthalmologists strive to ensure fair payment

With a sufficient number of ophthalmologists to provide adequate eye care, one challenge is assuring access.

Global Notebook In Brazil, as in other Latin American countries, public and private health care have separate objectives, strategic planning and actions. As in most countries, the public sector is responsible for providing universal health care coverage. But limited funds, old-style bureaucratic and political administration and continual changes of objectives are responsible for variation in the quality of services delivered. Brazil is facing the challenge of applying programs for more cost-effective delivery of health care services.

Additionally, health care reform cannot be separated from other economic and political changes occurring concurrently. One year ago, Brazil was dealt an economic blow with the devaluation of its currency. Jobs and living standards were threatened, unemployment rose and real wages fell.

In Brazil and several other Latin American countries, governments are relying on national and international health care insurance companies to uphold and increase the delivery of health care to a larger proportion of their population. Additionally, advances in medicine and technology and their associated costs are prompting patients in the higher social classes, formerly private patients, to buy private health care insurance. At the same time, some governments are taking a second look at their involvement in this situation, redefining themselves more as regulators and defenders of public interests. Conversely, the private market is becoming more aggressive.

Public health services in Brazil cover 75% of the population, according to the Pan American Health Organization. Most inpatient hospital services are provided under a system of public reimbursement for services provided by private entities; 80% of hospitals that provide services within the Unified Health System are private. In contrast, public establishments provide 75% of the outpatient care within the Unified Health System. In 1995, 20% of the Brazilian population was covered under private health insurance plans at a total cost of US$6,400 million.

Insurance

According to Marcos Pereira de Avila, MD, PhD, president of the Conselho Brasileiro de Oftalmologia (CBO), in Brazil, most people are insured through government health insurance companies. The health care provided by these plans is reasonably good, he said. But there are also independent insurance companies from which patients can purchase a plan through their employers to cover themselves and their families. It is these plans that are causing adversity for physicians in Brazil, Dr. Avila said.

“These types of insurance plans are beating hard on physicians,” he told Ocular Surgery News. “They pay physicians and hospitals less and less. And the patients are paying more and more.” Dr. Avila commented that it is sometimes difficult to differentiate whom the insurance companies are benefiting, other than themselves.

Many Brazilian individuals do not have government or private insurance. According to Dr. Avila, people in this group are forced to rely on the public health system, which he said is not in good shape. Dr. Avila estimated that perhaps 60% of the Brazilian population must rely on the public system of care.

“I’ll say it is getting better, but it still isn’t sufficient to give a reasonably good standard of care,” Dr. Avila said of the public system. “It is far below average care.”

A fourth group is made up of Brazilians who pay out of pocket for surgery, eye exams and other health care. This group represents 2% to 3% of the Brazilian population, he estimated.

Fair reimbursement

“From a physician standpoint, we are facing the problem of getting good plans for ourselves, where the insurance company would pay us what we deserve,” Dr. Avila said. “We are getting insufficient funds to cover our basic expenses.”

According to Dr. Avila, the CBO is working to draft a document that specifies the real costs associated with performing cataract surgery and other ophthalmic procedures. The hope is that these costs will be reflected in reimbursement levels.

Levels of payment have been an ongoing area of disagreement between ophthalmologists and insurance companies. Currently, according to Dr. Avila, with the reimbursement supplied by insurance companies, ophthalmologists are just breaking even.

“We [the CBO] have calculated what the real costs are of specific ophthalmic procedures in all regions of Brazil, since the cost varies from one region to another,” Dr. Avila said. “Then we add a profit of say 15, 20, 25% on the cost and this is the real price. We hope to have an agreement on cost calculated on a technical basis, not on a political calculation.”

Sufficient manpower

There are now about 9,000 ophthalmologists in Brazil, which is more than enough to supply adequate care to the 165 million population, Dr. Avila said.

“According to the World Health Organization we need one ophthalmologist to every 20,000 people,” Dr. Avila said. “If we have 10,000 ophthalmologists we are able to treat 200 million people. In Brazil there are only 165 million people, so we have a sufficient number of ophthalmologists.”

According to the Pan American Health Organization, there are 12.6 physicians per 10,000 people and 34.9 hospital beds per 1,000 population in Brazil.

Currently there are no optometrists in Brazil, according to Dr. Avila, and ophthalmologists there want to keep it that way. He said ophthalmologists are doing whatever is necessary to prevent optometrists from gaining a foothold in Brazil.

Brazilian ophthalmologists feel that eye care provided by an ophthalmologist is better than that given by an optometrist. Dr. Avila argues that optometrists will not detect diseases that are commonly diagnosed by ophthalmologists. “In Brazil, where we have a very poor population, the only chance that [patients] have to get a preventative eye exam is when they go for glasses. If they don’t have a physician taking care of their eyes, they may lose sight and vision, since they didn’t have prevention.”

A country-wide blindness prevention program was recently instituted. With this year’s program, in conjunction with Brazil’s Ministry of Health, ophthalmologists performed cataract surgeries on 130,000 poor Brazilians. (See interview on facing page.) In addition, 3.5 million Brazilian children in the first grade were screened for their vision correction needs. About 300,000 glasses were donated to children who needed them.

Since 1994, the Brazilian Ministry of Health has been carrying out a program of family health incorporating health promotion into traditional medical care.

Universities

Dr. Avila asserts that Brazil has one of the best teaching systems in the world.

“We have some of the best standards of teaching in the residency programs in the world,” Dr. Avila said. “We have 50 affiliated residency programs, from which 500 new ophthalmologists emerge yearly.” Dr. Avila is also proud of the CBO meeting, which is now the second largest ophthalmology meeting in the world, he said, with about 4,000 ophthalmologists attending in 1999.

Failed experiment

Health care reform efforts are ongoing, but some have been unsuccessful.

About 4 years ago, Sao Paulo remodeled its health care system. A conservative populist, Paulo Maluf, the mayor at that time, set out to change the health care system by handing over care to co-operatives of doctors, nurses and administrators that would manage resources. Patient involvement with local co-ops would be comparable to having a private health plan, only free, promised Mr. Maluf. But this system was soon crippled by corruption, according to a report in The Economist. Political associates rewarded over-generous deals for supplies and services to firms, which in turn made campaign donations to the politicians.

But fraud wasn’t the only problem. Brazil’s 1988 constitution commands that federal and state governments transfer most health care services to city councils. But Mr. Maluf’s scheme did not coincide with Brazil’s constitution and so disqualified itself from federal grants of $100 million a year, equivalent to about a fifth of Brazil’s budget, which has been cut by a third because of the city’s financial crisis.

Some 12,000 doctors and associated health staff refused to join the co-ops and remained on the dwindling city payroll. In the meantime, the state government continued to operate almost 200 clinics and hospitals within the city borders, duplicating the efforts of the 142 clinics run by the co-ops.

Since last year, about 50 investigations have been orchestrated against suspicious suppliers.

Report Card: Brazil
Population	165.1 million
Gross domestic product (GDP)	US$1 trillion
Percentage of GDP spent on health care	7.6%
National health care expenditure per capita	US$280
Number of ophthalmologists	10,000
Physicians per 10,000 population	12.6
Hospital beds per 1,000 population	34.9
SOURCE: PAN-AMERICAN HEALTH ORGANIZATION

For Your Information:
Marcos Pereira de Avila, MD, PhD, can be reached at Av T-2 #401Setor Bueno, Boiania, Brazil 74.210-010; +(55) 62-285-5566; fax: +(55) 62-251-8110; e-mail: dbco.ret@internetional.com.br. Dr. Avila has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.