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Despite dwindling ophthalmology rolls, France seeks to cap eye care services
Four key ophthalmic organizations have joined forces to better represent themselves in Paris.
[SIDEBAR: French academy has international goals]
In the face of likely budget cuts, an aging population and a dwindling number of practitioners to care for them, organized ophthalmology in France has just become better organized. Four specialty groups have jointly formed a French academy to represent their views to the government.
Until recently, there has been little need in France for a politically active arm of the ophthalmic community. Reimbursement rates were predictable and the Ministry of Health’s system reliable. Academics, clinicians and the trade union that represents the interests of ophthalmologists had no formal relationship with one another. This laissez faire environment could be found in other areas of medicine, as well. The French government put little pressure on the medical community to monitor expenses or limit activities.
Eventually, however, the cost of the national health system began to surge. Beginning in the early 1980s, spending on government health care grew by more than 5% annually. The growth, driven by both demographic changes and high utilization, continued for more than 15 years. The government now worries that soon it may not be able to afford the national health care system — which provides 99% of the French population with cradle-to-grave benefits.
According to the National Center for Policy Analysis, an international nonprofit organization based in the United States, the French system invites high rates of utilization. Because the government will reimburse up to 70% of a physician’s fee and 100% for certain medications, the health system encourages physicians to see patients and prescribe medicines. As a result, according to the National Center for Policy Analysis, the French take more medications than any other people on earth.
Other statistics affirm that medical spending may be out of line in France. The nation has the highest rate of combined public and private health spending in Europe, and the second highest in the world, yet it ranks ninth among the “healthiest” countries in Europe, falling behind Greece and Slovenia, according to the Economist Intelligence Unit. In 1995, the country had a US$8 billion health spending deficit, despite spending nearly 11% of its gross domestic product (GDP) on health care. In 1997, the government spent FF728.5 billion on health care (about US$123 billion) for a population of 57.7 million.
France is now trying to overhaul its system. The government plans to trim budgets and reduce inefficiencies, but plans have met with resistance from the medical community. Health care professionals claim that in its rush to remake the system, the government is not looking carefully enough at the services it seeks to limit or the methods with which it hopes to accomplish its goals. One government strategy takes a two-pronged approach that would cap annual growth and freeze reimbursement rates. Since talk of the cuts began, medical trade unions have organized strikes and, in the most dramatic cases, briefly taken some state hospital directors hostage. Medical specialists of different backgrounds have joined together to oppose cuts.
Ophthalmology mobilizes
Ophthalmology, considered a large target for budget reductions, is now organizing itself as well. At the 105th Congress of the French Society of Ophthalmology (SFO) meeting in Paris, representatives from that organization, as well as from the French Syndicate of Ophthalmologists (an ophthalmic trade union) the Association of French Ophthalmic Professors and the College of Non-university Ophthalmologists, voted to form the French Academy of Ophthalmology. The new organization, its founders say, will be better equipped to represent the views of the ophthalmic community to the nation’s health ministers. The four component bodies will retain their individual identities, but the French Academy hopes to help the member bodies better coordinate efforts both academic and political.
The creation of a pan-ophthalmic professional organization in France is in part a response to the health ministry’s policy of dealing with each medical specialty separately. Rather than require all reimbursable specialties to reduce expenditures by a uniform amount, the ministry makes separate budget deals with specialties it has identified as being particularly costly.
“The government finds that it is easier to divide the medical population,” said Georges Baïkoff, MD, an ophthalmic surgeon in private practice in Marseille. “The government is always trying to put pressure on us. They have not yet succeeded in making the cuts they want to make, but we are very anxious.”
Marc Y. Weiser, MD, an ophthalmic surgeon in Paris, told Ocular Surgery News that he agrees the government would prefer to deal with each subspecialty separately, rather than the medical community as a whole.
“They try to cut down the solidarity between the specialties so they can dictate policy,” Dr. Weiser added.
According to Joseph Colin, MD, a professor of ophthalmology and the head of the CHRU Morvan Ophthalmology Service in Brest, the government has successfully leveraged its weight and its negotiating power against smaller medical specialties.
In response to this tactic, medical specialists, including ophthalmologists, are forming a lobby so that they may be more forceful in negotiations with the government. Even if the ministry insists on making individual deals with separate specialties, a show of solidarity on the part of specialists may help everyone, Dr. Colin said.
Until now, arm-twisting of smaller specialties has allowed the government to strike advantageous deals with medical groups that lack the resources to muster much opposition. Physicians interviewed for this article said the deal the government made with the nation’s radiologists was particularly bad.
“They were small and they could not do much to defend themselves,” one physician said.
Uncertainty on cuts
While the government has already made reimbursement reduction deals with French cardiologists and radiologists, there is no deal with ophthalmologists, so no one is certain by what amount the health ministry’s budget for ophthalmic reimbursement will be cut. French ophthalmic surgeons are anxious because cataract surgery, as in many other nations, is the most common surgical procedure in France.
About 320,000 cataract procedures will be performed in France this year, surgeons interviewed for this article estimate. Physicians are reimbursed a surgical fee of 1,700 FF (about US$300) per procedure. Other costs related to surgery, such as the cost of the surgical suite and that of the IOL, are reimbursed separately. In all, cataract surgery costs the ministry of health about US$2,500 per eye. Patients typically wait no longer than a month to receive cataract surgery, sources said.
“For years, the government has been telling us that cuts are coming, but for 3 years, they have done nothing,” Dr. Baïkoff said. “We don’t know when the cuts are coming or how.”
The government has not said it will actually reduce the amount it reimburses physicians per procedure, but a proposed two-pronged approach may accomplish similar goals. This plan would freeze the amount of reimbursements at the previous year’s level. Then it would limit expenditure further by reducing the amount of money each physician would be reimbursed. That amount, for example, might be limited to 1% or 2% more than the reimbursement the physician received in the previous year. (No one is certain, at this point, what the caps might be. Physicians estimate that they would likely be about 2%. French health ministers in 1997 sought an overall budget reduction of 1.7%.)
Targets high-volume?
Under this proposal, high-growth (typically also high-volume) surgeons would be penalized most. Physicians would have to return reimbursements in excess of the cap to the ministry.
French ophthalmologists say this aspect of the budget reduction proposal is wrongheaded. High-volume surgeons, they argue, tend to be the most efficient, and therefore have the lowest costs per procedure. By refusing to reimburse these surgeons if they exceed by more than a few percent the number of cases performed last year, the government is encouraging both inefficiency among surgeons and waiting lines for patients, they say.
“Our representatives do not disagree totally with the need to reduce costs and control health care spending, but we recommend that the government investigate each individual practice before it decides how caps should be levied,” Dr. Weiser said. “In many cases, there is no reason why a high-volume surgeon with lower costs per procedure should be penalized.”
One reason for concern that future cuts will single out high-volume surgeons is that, if recent trends continue, all ophthalmic surgeons may become “high volume” in coming years. The number of ophthalmic surgeons is shrinking.
Coming shortage
Nearly 500 new ophthalmologists began practicing in 1988, the final year of 15 years of growth in the number of ophthalmologists, according to an article by José Alain Sahel, MD, published in the October 1998 Archives of Ophthalmology. Currently, the number of new ophthalmologists who enter practice annually has decreased to 50 or 60. According to physicians interviewed for this article, significantly more than that retire each year, which means that as the population of France ages, the number of ophthalmologists is decreasing.
“A major drawback is already felt in general and university hospitals, where the lack of ophthalmologists in training puts a drain on the clinics at the expense of research and teaching activities,” wrote Dr. Sahel. “Moreover, within 10 years, the need for new ophthalmologists might not be met and many tasks performed by clinicians will be performed by other health care specialists at lower costs.”
Of the 6,700 ophthalmologist members of the SFO, the 50% to 60% who are ophthalmic surgeons are most concerned with the proposed cuts. Ophthalmologists who do not perform surgery mostly prescribe medicine or spectacles and are not considered targets for budget reductions.
“Very soon, there will not be enough ophthalmologists to provide eye care to everyone, and we will need help,” Dr. Colin explained. “We will need technicians, opticians, orthoptists and assistants if we are to continue providing high-quality care.”
No optometrists
There are almost no optometrists in France, but there are about 1,500 orthoptists and 6,500 opticians. If the roles of these eye health providers are expanded, more French ophthalmologists would be able to concentrate on surgery without compromising the level of care currently available.
Most French ophthalmologists — some 96% according to data published in 1996 — are in private practice. One-third spend at least some of their time in a public hospital, but only 2.4% are employed full time in general or university hospitals. There are few subspecialists in France, and no specific subspecialty training exists. Sixty percent of French ophthalmologists are surgeons, and 50% are cataract surgeons specifically. Twenty percent practice refractive surgery, 43% perform strabismus surgery and 44% perform eyelid surgery. Seventy-two percent of ophthalmic surgeons practice laser surgery, while only 6% perform retinal surgery.
Refractive surgery is popular in France. Laser in situ keratomileusis is the most common refractive procedure, and according to Dr. Baïkoff the annual number of cases and the number of physicians who perform it is increasing.
No managed care
| France's Ophthalmology Society |
| Société Française d'Ophtalmologie President: Dr. Jean-Paul Adenis 9, rue Mathurin Reginer Paris 75015 France Tel.: +(33) 1-47-34-20-21 Fax: +(33) 1-40-56-39-48 |
While the French ophthalmic community has expressed serious concern over the proposal to limit growth and freeze rates, most agree this option is preferable to another that has gained some support among legislators. The second option is the introduction of a managed care style system in which general practitioners would act as gatekeepers, referring for treatment by specialists only patients who meet certain criteria. This style of medicine is common in the United States, but even after a decade remains controversial and fairly unpopular there.
“If many private companies enter the health care system, the danger is that we will end up with some type of health maintenance organization-based system,” Dr. Weiser said. “We have the American experience on which to base our perceptions, and we don’t think it works so well. If given the choice, we’d prefer the other option.”
Dr. Weiser doubts the French people would accept a managed care style system anyway. “The French are not prepared for a very rigid system for health care,” he said, prompting a comment from Dr. Baïkoff. “French patients want open access to the physician of their choice. To them, anything else would not be acceptable.”
Report Card: France
Population 57.7 million Percentage of gross domestic product spent on health care 11% Number of ophthalmologists (members of the SFO) 6,700 Ratio of ophthalmologists to population 8:100,000 Number of new ophthalmologists annually 50-60 Number of ophthalmic surgeons 3,100 Number of cataract surgeons 2,600 Annual number of cataract procedures 320,000 Average health system reimbursement per cataract procedure US$2,500
For Your Information:
- Joseph Colin, MD, professor of ophthalmology and the head of the CHRU Morvan Ophthalmology Service, can be reached at CHRU Morvan Service D’Ophtalmologie, 29200 Brest, France; +(33) 2-98-22-34-40; fax: +(33) 2-98-46-49-70.
- Prof. Georges Baïkoff, MD, is a private practice ophthalmologist. He can be reached at Clinique Monticelli, 88 Rue du Commandant Rolland, 13008 Marseille, France; +(33) 4-91-16-22-28; fax: +(33) 4-91-16-22-25.
- Marc Weiser, MD, is in private practice in Paris. He can be reached at 61 rue de Rennes, 75006, Paris, France; +(33) 1- 45-48-31-13; fax: +(33) 1-45-44-56-44. None of the doctors has a financial interest in the products mentioned in this article, nor are they paid consultants for any companies mentioned.
- Reference: Sahel, JA. On French ophthalmology. Arch Ophthalmol. Oct 1998; 116:1364-1465.