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Despite attraction of for-profit work, ophthalmology needs to focus on basics
Mexico's economic problems have made lucrative refractive and cosmetic surgery appealing. Doctors are urged not to lose their "personal approach to sickness."
Ophthalmologists and their patients in Mexico stand to benefit from the coming changes in the health care system (see accompanying article). As the number of patients with coverage grows, there will be an increase in the number of ophthalmic procedures performed annually, and a need for more ophthalmologists. Further, the competition introduced by privatization will improve the quality of care.
But it is likely to be some time before the changes at the upper tiers of the system filter down to benefit patients at the SSA level. There is concern among some Mexican ophthalmologists that non-medically necessary, for-profit procedures, such as refractive surgery, are distracting doctors from Mexico's more serious ophthalmologic problems, such as untreated cataract or external corneal disease.
Refractive surgery
Refractive surgery is fairly popular in Mexico. The nation's attitude toward medicine, described as more liberal and less bureaucratic, has enabled a large number of Mexican ophthalmologists to gain experience with excimer lasers in recent years. Radial keratotomy (RK) has been largely abandoned in favor of photorefractive keratectomy (PRK) or laser in situ keratomileusis (LASIK), which account for about 90% of all refractive procedures, according to Arturo Chayet, MD, in private practice in Tijuana, Mexico.
"Although Mexican law is quite strict in terms of the training that is required for someone to become a doctor, physicians here have greater freedom to use different techniques and equipment that are not used in the United States or Europe," said Guillermo Avalos, MD,in private practice in Guadalajara, Mexico. "This allows the Mexican ophthalmologist to perform techniques that, to a certain degree, are considered experimental in other countries."
The benefit of this liberal attitude toward new techniques and technology helps them to become refined and more quickly integrated into mainstream Mexican medicine.
"Since we can do procedures without great restriction, Mexico and the other Latin American nations tend to be on the cutting edge of refractive surgery," Dr. Avalos said.
The downside is, of course, that safety can be compromised.
LASIK and PRK tend to be priced similarly in Mexico. For bilateral cases patients are typically charged between US$1,000 and US$1,500. The charge for bilateral RK, much less frequently used, is about US$800. These charges include both surgeon's fees and clinic fees. Refractive surgery is seen by many Mexican physicians as a lucrative venture with the potential to greatly supplement income.
"Refractive surgery is an area that will continue to change in Mexico," said Antonio Mendez Noble, MD,in private practice in Tijuana and Mexicali, Mexico. "In my practice, it is continuing to grow, and will become increasingly important."
Physicians who perform refractive surgery tend to be the same surgeons interested in plastic surgery - another area of medicine known for high profits. Ophthalmology departments in both public and private hospitals across Mexico are considering, or have already founded, oculoplastic groups. Tempering their enthusiasm is the fact that start-up costs for cosmetic surgery tend to be high, especially if a facility plans to offer laser blepharoplasty. Demand for the procedures is predicted to increase, but is unlikely to attain the levels it has in the United States.
Financial temptations
Ramon Naranjo-Tackman, MD, in private practice in Mexico City and a member of the ethics committee of the Mexican Board of Ophthalmology, the official accreditation agency, said that because there are potentially high profits in "non-sickness" areas of ophthalmology, it is easy for physicians to lose sight of their primary goal. Mexico's somewhat permissive attitude toward technology and its applications make harnessing it for profit relatively easy.
"Because profit-generating technology is widely and readily available across Mexico, doctors are tempted to pursue only those avenues," he said. "However, in pursing money, it is possible for doctors to lose their personal approach to sickness, and this is something that I have personally seen. A lot of technology, which seems to be flooding Mexico, may not be the best thing for ophthalmology."
The potential for ophthalmologists to pursue only potentially lucrative new technologies is indicative of Mexico's larger economic problems, he said.
"The overall economic situation in our country must be improved," Dr. Naranjo-Tackman said. "This would prevent doctors from only practicing areas of medicine where money can be made. Perhaps the health care reforms will help. Doctors must remember that their main goal is to help people."
Mexican ophthalmologists typically earn between US$3,000 and US$6,000 per month, the majority of which is derived from their private patients. Government reimbursement is usually low. Most ophthalmologists are employed by the IMSS or the ISSSTE, where they work for 6 to 8 hours each day. After working in the public sector, most then spend 2 to 4 hours in a private office.
Mostly ECCE
Extracapsular cataract extraction (ECCE), as in most other parts of Latin America, is the primary cataract procedure in Mexico, accounting for about 90% of all cataract procedures performed. Slowly, phacoemulsification is gaining popularity, but the high cost of equipment and its formidable learning curve have slowed its assimilation into mainstream medicine. There are currently about 150 phaco machines in use across Mexico, increasing by a few dozen annually. Cataract surgery was the main topic of discussion at the annual meeting of the Mexican Society of Ophthalmology, held recently in Leon, Mexico. According to Dr. Avalos, there was general consensus at the meeting that within a few years phaco will replace ECCE as the primary cataract intervention. Among wealthier patients, there is an increasing awareness of phacoemulsification, according to José Antonio Villarreal Maíz, MD, private practice ophthalmologist in Torreon, Mexico.
"One should be aware that in Mexico, the vast majority of surgeons are not doing phaco, but rather planned ECCE," Dr. Naranjo-Tackman said. "Phaco has yet to gain the popularity it has achieved in other parts of the world, but that will soon change."
For patients in the public sector, cataract surgery is covered by government insurance plans; however, certain necessities of surgery, such as IOLs and viscoelastics, are not reimbursed under the IMSS or ISSSTE plans and must be paid by the patient directly. In the public sector, procedures are reimbursed at about US$300 per eye. Patients usually pay an additional US$25 to US$50. In the private sector, a complete cataract procedure costs the patient between US$1,000 and US$1,500 per eye, and IOLs are typically included in the cost.
Of the 3,000 ophthalmologists in Mexico, 1,780 are members of the Mexican Society of Ophthalmology (SMO), based in Mexico City. In addition to the SMO, there are nine smaller organizations for subspecialists. Between 4% and 5% of medical students opt to specialize in ophthalmology annually - usually about 100.
For Your Information:
- Guillermo Avalos, MD, can be reached at Morelos 617, Guadalajara, 44100, Mexico; ++(3) 614-5727; fax: ++(3) 641-9652.
- Arturo Chayet, MD, can be reached at Paseo de Tijuana 406-4, Tijuana BC 22320 Mexico; ++(66) 83-5723; fax: ++(66) 82-9338. Dr. Chayet has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- José Antonio Villarreal Maíz, MD, can be reached at Paseo de la Rosita, 620 Col Campestre la Rosita, Torreon 27250, Mexico; ++(17) 212-211; fax: ++(17) 215-252. Dr. Maíz has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Ramon Naranjo-Tackman, MD, can be reached at Merida No. 119, Col. Roma, Mexico City, Mexico 06700; ++(5) 584-0525; fax: ++(5) 584-0557. Dr. Naranjo-Tackman has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Antonio Mendez Noble, MD, can be reached at Paseo de los Heros, 9365, CP 22320, Mexico; ++(66) 84-95-37; fax: ++(66) 84-95-38. Dr. Noble has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.