DOC takes a role in ophthalmic advocacy, education

The president of the DOC discusses its dual role as political entity and educational resource.

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At this year’s Kongress der Deutschen Ophthalmochirurgen (DOC), Dr. med. Armin Scharrer, president of the meeting, took time to talk with Ocular Surgery News International Edition about topics ranging from the current status of health care funding in Germany to the organization of the meeting itself.

Dr. Scharrer is head of the ophthalmology department in Fürth. He has been involved in the organization of the DOC congress, along with Prof. Dr. med. Thomas Neuhann, from its beginning 12 years ago, and has been president of the meeting for the past decade. He also is head of the surgical section of the professional association of German ophthalmologists (AK Ophthalmochirurgie), the Berufsverband Augenärzte (BVA).

The DOC and German health care

Ocular Surgery News: You have been president of the DOC for a long time.

Dr. med. Armin Scharrer: For 10 years now. The first 2 years, Thomas Neuhann ran the meeting, and for the past 10 years, I have been president.

OSN: But the DOC is not actually an organization with a membership, it is an annual meeting?

Dr. Scharrer: Yes, it is an annual meeting. But we do some things like a society. People think we are a society. We work together with other societies, but officially we have not the status of a society.

OSN: But you do have an influence on health care policy.

Dr. Scharrer: Yes, I think we have a lot of influence. Besides my job here as president of the meeting, I head the German professional association of ophthalmologic surgeons, the BVA. So the organizer of this meeting is in personal union with the head of the German ophthalmic surgeons’ professional association.

OSN: There has recently been a proposal by the new government in Germany to cap spending on health care. Are you involved in negotiations regarding that issue?

Dr. Scharrer: Yes. Unfortunately, I am involved in it. It is never good being involved in negotiating in decreasing markets, which is what the health care market in Germany is, no doubt about it.

We have a rather good status here in Germany concerning the fees for hospitals. You get a good fee, a quite reasonable fee, for cataract surgery in the hospital. You get a good fee concerning the stay of patients in the hospital for glaucoma or retinal surgery. But the fees for ambulatory surgery — for cataract, glaucoma, penetrating keratoplasty, lid surgery — all these prices are going down.

But that is not the only problem. Another is that we really do not know what the fees are. We get the figures about 6 to 9 months after we have done the work.

OSN: That is the point system.

Dr. Scharrer: Yes, the point system. We do surgery throughout the year, and perhaps at the end of July or the beginning of August we get an idea what the fees will be for work we did 6 months ago.

You must imagine this. If you go to the physiotherapist for a massage, he gets DM 21, and you know that. But we are doing cataract surgery, glaucoma surgery, keratoplasties and ambulatory retina, and no one has an idea what we will get for it. I think that is unbelievable.

OSN: It is probably unique in the world. Is that only for ambulatory surgery?

Dr. Scharrer: It is not only for ambulatory surgery, but also for all we do in an ambulatory wing, including diagnosis and treatment by the conservative approach. And it is not only ophthalmology of course, but in all medicine.

So we have stable fees in the hospitals, not very high, not very low — fair prices. But we do not have set fees in the ambulatory sector, for either conservative or surgical care. No one knows what we will get for what we are doing, and the only thing that we really know is that the prices are going down continuously. So we are very angry.

OSN: How much of cataract surgery in Germany is done on an outpatient basis?

Dr. Scharrer: About 75% of surgeries are done in ambulatory settings or in the hospital but by private physicians, and about 25% are done in town hospitals and university hospitals.

OSN: The surgeries done in hospitals would be the more complicated cases?

Dr. Scharrer: It depends on the surgeon. If they have access to both settings, then yes, you would have the normal cataract cases in the ambulatory surgical center, and the complicated cases such as combined cataract with keratoplasty, combined cataract glaucoma and such cases would be done in the hospital. But a lot of surgeons do not have the choice. Some have only one facility, so they do all either ambulatory or in the hospital. If you look at university eye hospitals and town hospitals, only about 20% of this group are doing ambulatory surgery in reasonable numbers.

OSN: This point system has been in place for some time. How will the proposal by the new government change it?

Dr. Scharrer: The point system started in 1992 in Germany. At that time, for one point we got 10.9 pfennige, pennies. Now it varies from Bundesland to Bundesland [state to state] in Germany; that is, it is different from Berlin to Frankfurt, say. But on average for surgical maneuvers it is about five to six pennies, 50% of what we had in 1992. But no one knows exactly. There are some states that get 3.9 pennies, and that is what makes it so difficult in Germany. It is not one rule for the whole country. There is a pre-rule made by the government, but then a second rule is made by the states, so payment varies from state to state.

OSN: Do you have a voice in negotiating these fees, or are they simply imposed upon you?

Dr. Scharrer: They are negotiated. The problem is that for the entire ambulatory medicine system in Germany, there is a capitated amount. The government says, 2 years ago you had 1 billion for the entire system. So next year, 2 years later in 1999, you will get just the same amount for the entire system. It does not depend on how many operations are performed or how many people are ill. It does not depend on how many drugs are prescribed for patients. All of these things are changing in the market. So the 1 billion is divided by what? No one knows. They will figure it out afterward.

But the other problem is that there is no separation between, for instance, ophthalmology and internal specialists. If there were, we could conceivably say, “Well, we ophthalmologists will try to not operate on more patients this year.” But ophthalmology is only about 5% of the entire ambulatory market in Germany, so it does not depend on what we alone are doing. The internal specialists might say, “Okay, let us have 20% more gastroscopies because patients need it.” That will affect us, as well.

What we are trying to get are stable fees. We are going to have prices in euros now in Germany, and we want to know the fee, let us say 1,000 or 1,500 euros per surgery. And we want a contract for the next 1 or 2 years. That is what we are looking for.

But we will not have it this year because, as you know, we got a new government in Germany and they have decreed this global budget. Our new Minister of Health, Andrea Fischer, said essentially, I am not interested in how many people are ill, how many people are operated or how many people are going to the physician. I will give you the money and you are responsible for how it is spent.

No businessperson would tolerate this situation. We have our costs. We are investing millions of marks, founding clinics and surgery centers. We have nurses that have to be paid 2% more every year. We have our costs concerning materials, lenses, viscoelastics and so on. We have to pay for it, not in points but in DM. So we want to have a DM amount for what we are doing, as well.

Working toward change

OSN: Do you think that by working together you may be able to change this next year?

Dr. Scharrer: We will try to do it. If things do not change within the next 6 months, I think we will stop ambulatory surgery in ophthalmology completely all over the country.

OSN: Just start doing everything inpatient? Or a strike of some kind?

Dr. Scharrer: We will go back to doing everything in the hospital, because that will cost the social security about two or three times more than ambulatory surgery. They will have to pay 3,000 DM again for cataract surgery if we do it in the hospital. So it will be a combination of a strike and a change of some procedures back to the hospital for a definite time.

Patients will not like it. Social security companies will not like it because they will have to pay more than now. But all things now are political. You have to cause political stress, show political power, otherwise you will not get one penny more.

The only society that has a chance of changing things is the one that integrates all ophthalmic surgery. Together with Prof. Anselm Kampik — the general secretary of the German scientific society DOG (Deutsche Ophthalmologische Gesellschaft) — we have to go to the Ministry of Health. We have to demand, “Okay, we want reasonable fees for the hospital surgeons, but we also want to have reasonable fees for ambulatory surgery.” We hope they will listen.

The DOC meeting

OSN: Can we talk about the DOC meeting? You have a unique structure of short presentations followed by longer panel discussions that seems very effective. Is there a particular thinking behind that?

Dr. Scharrer: When Thomas Neuhann and I thought about founding a new meeting 12 years ago, our idea was, first of all, education for the average ophthalmic surgeon. We wanted to ensure two things; first, people should not spend too much money or too much time to get a very good education.

So we try to be well organized. We try to give solid education in a short time. That means we invite well reputed, international lecturers. They have 20-minute lectures and after that, we have discussions and roundtables. All the speakers on Saturday and Sunday are invited speakers. We think about what would be interesting for the auditors and then who would be the best person to present it.

The second thing is that we wanted every year to set the gold standard for ophthalmic surgery here in Germany. That means we have a lot of instruction courses, wet labs and free papers for innovations. In the free papers, people have the chance to have 5 minutes to say what is really new.

These two things, education and the gold standard, are the philosophy behind the meeting.

OSN: It seems in recent years that you have been pushing more to make this an international meeting.

Dr. Scharrer: Basically we did not push it. It happened. The first year, 12 years ago in Munich, we were about 85 colleagues, German people, friends. The second year, there were about 200 people, including some from Switzerland and Austria, and people were going home and touting the meeting.

After 6 or 7 years, we had people from 30 countries here. We thought that perhaps it would be good to give people from all over the world a chance to come here.

You know, I have great respect for the wonderful American Society of Cataract and Refractive Surgery (ASCRS) meeting, and for Manus Kraff, the program chair for about 25 years now. Certainly some ideas from the ASCRS have been adapted for this meeting. Ours is a national meeting like the American meeting, but we give people the chance, if they are interested, to come from all over the world — from Japan, from European countries, from the United States. And if you want to do this in Europe, you have to be bilingual. Now, you see, about 60% or 70% of the presentations here are in English. But we have simultaneous translation from German to English and English to German.

OSN: Which is, by the way, very good.

Dr. Scharrer: It is very good because they have been doing it for 10 years. They are the best in Germany at translating this material. They are the most expensive too, I can tell you.

That continuity is the same philosophy as Thomas and me remaining in our roles here. I have chaired the meeting for 10 years now, and have done the program with Thomas from the beginning. Like Manus Kraff at ASCRS — after 25 years you have a feeling for what is going on. I think stability in the organizers is not a bad thing for meetings.

OSN: That relates to another question I was going to ask. You have had the same translators every year for 10 years, and you have also had the same location. Obviously, if you have 2,500 people coming to Nuremberg, they have not yet gotten tired of coming to the same spot.

Dr. Scharrer: We ask the attendees every 2 years, “Would you like to change from Nuremberg to Munich, to Berlin or Hamburg?” The last time we asked, 2 years ago, about 75% chose Nuremberg. People are accustomed to everything here; they do not need a warming-up period. People like it very much in the same place. If they want to change, we will change.

This goes back again to stability. I think the quality of the organization becomes better from year to year if you stay at the same place. It is hard to rebuild each year in different places. You have to start over. But we do not. We continue at the level we had and improve another 5%. So that is the philosophy behind it.

OSN: Other than location, do you have any changes planned for the future?

Dr. Scharrer: No basic changes. After the meeting I get really good feedback from a few people, and we think about what we could optimize, what we could change. But there are no basic changes planned.

We have a good situation among the German congresses. There are three large meetings in Germany. We are the surgical meeting. There is a pure scientific meeting, the DOG, and there will be a meeting mainly for conservative ophthalmologists in Dusseldorf next year — the AAD. I think we can live together wonderfully.

Report Card: India

Population	81.1 million
Number of ophthalmologists	6,900
Percentage of ophthalmologists who perform cataract surgery	20%
Annual number of cataract surgeries performed	250,000
Average cataract reimbursement	DM1,500*
Number of new ophthalmologists annually	300-400
*US$975

For Your Information:

• Dr. med. Armin Scharrer can be reached at Moststrasse 12, Fuerth, 90762, Germany; +(49) 911-779-820; fax: +(49) 911-779-8251; e-mail: oberscharrer@t-online.de.