Ophthalmology may benefit from Spain's recent economic gains

Leaders of Spain's cataract and refractive surgery society acknowledge problems but are generally upbeat about the future.

[SIDEBAR: Decentralization is the major component of Spain's national health care system]

Economic indicators suggest that Spain’s often-troubled economy is beginning to show signs of recovery — good news for its underfunded health care system, and for ophthalmology.

Gross domestic product (GDP), according to The Economist, is up 3.6% over last year, and industrial production also is on the rise. Though official unemployment is still the highest in Western Europe, at 17.4%, it has decreased from 19.2% in mid-1998. The nation’s economic problems are not over, but minor improvements have led economists to predict that Spanish economic growth will outpace the rest of Europe, the United States and Japan through 2000.

The effects of economic recovery may already have been felt to some degree in ophthalmology. When Ocular Surgery News last reported on Spain in March 1998, refractive surgery was underperformed. Although formalized analysis of procedure volume is not available in Spain, the president of the country’s cataract and refractive surgery society reports that today volume is at an “all-time high.” Anecdotal reports suggest waiting periods for cataract surgery have decreased as well. A year ago, physicians reported that many public sector patients waited up to 1 year for treatment. Today, the average wait is reportedly about 3 months.

Ocular Surgery News sat down with Luis F. Vega, MD, president of the Sociedad Española de Cirugia Ocular Implanto-Refractiva (SECOIR), and José Angel Cristóbal Bescós, MD, president of the organizing committee for the 14th SECOIR Congress in Zaragoza, to discuss the current state of ophthalmology in Spain.

They report that limited health care budgets and an abundance of ophthalmologists mean that many young physicians are out of work, but they say the problems vary by region. Private sector care, however, is doing well, and growth in the sales of private insurance continues, they say.

Ocular Surgery News: Describe the biggest challenges facing Spanish ophthalmology, in both the private and public sectors.

Dr. Luis F. Vega: The public social security system has a lot of economic problems, and generally there is not a lot of money available to purchase new equipment with modern technology for every public hospital in Spain. Nevertheless, ophthalmology here is at an average level when compared with other countries of similar size and wealth.

Also, ophthalmologists are facing unemployment in the public sector. Once an ophthalmologist has finished his residence training, he would like to work in the national health system, which of course is already full of ophthalmologists.

OSN: So there are too many ophthalmologists in Spain? Does this apply to the private sector as well?

Dr. Vega: Yes, there are too many, and yes, it affects private physicians, too.

OSN: How many ophthalmologists are there in Spain?

Dr. Vega: About 3,500. There are more ophthalmologists than there is a need for.

OSN: About how many ophthalmologists graduate from medical school each year?

Dr. José Angel Cristóbal Bescós: Between 100 and 120. In Spain, ophthalmologists work until they are 65 years old. We never retire! So the profession becomes more crowded every year.

Public vs. private care

OSN: Despite the large number of ophthalmologists, do patients in the public system still sometimes have to wait for care?

Dr. Cristóbal: Yes.

Dr. Vega: But it depends on the region. It is different from one region to another.

OSN: What accounts for the regional differences?

Dr. Vega: Some regions have a large number of hospitals; others have a smaller number. In some urban areas, for example, there are seven large hospitals for only 1 million people.

OSN: How long does the typical public sector patient wait before he or she can receive cataract surgery?

Dr. Vega: At this moment, less than 3 months.

OSN: And is that true across the country?

Dr. Cristóbal: That is the average. We try to not have them wait for more than 3 months.

Dr. Vega: Some others are waiting 4 or 5 months, but that is not the normal waiting period.

OSN: The private patients receive care immediately?

Dr. Vega: Yes, of course, within a few weeks of initial presentation.

OSN: Most ophthalmologists have both public and private practices. About how much of their time do they spend in the private office versus the public facility?

Dr. Cristóbal: Usually they spend the morning in the public hospital and the afternoon in the private hospital. More or less, 7 hours in the morning in the public, and 5 hours in the afternoon.

OSN: It is a very long workday.

Dr. Vega: Yes.

Private insurance

OSN: Because of the waiting lists, a growing number of patients are beginning to purchase private insurance.

Dr. Cristóbal: Yes, some are. Its popularity in our specialty depends on the individual ophthalmologist. For example, there are a lot of ophthalmologists who work with this type of insurance. Others will not accept private insurance.

OSN: Will the number of privately insured patients in Spain continue to grow in the coming years?

Dr. Cristóbal: Yes. I think that this is going to increase because the public system is experiencing problems with meeting the demand.

OSN: Is the technology in private offices in Spain considered superior to that in the public centers?

Dr. Cristóbal: Only in refractive surgery.

OSN: So do you think that as there is an increase in the number of privately insured patients, the money that physicians are earning privately actually could improve the equipment in the public sector, as well? Will it trickle down?

Dr. Cristóbal: It is possible. Because private physicians accept private insurance, their practices are growing. As they become larger, they can purchase better equipment. Eventually, that equipment finds its way to the public centers. The role of public and private hospitals, because of insurance, may level out in coming years.

Cataract surgery

OSN: How many cataract procedures are performed each year in Spain?

Dr. Vega: We don’t have formal studies to tell us the exact amounts, but we estimate there are about 200,000.

OSN: Do most ophthalmologists perform cataract surgery?

Dr. Vega: Probably 75% to 80% perform cataract surgery.

OSN: Is extracapsular cataract extraction still used?

Dr. Vega: Sometimes. Personally, I use phacoemulsification in 99% of my cases.

OSN: What about for the whole country?

Dr. Vega: Maybe 50% phaco, 50% extracap.

Dr. Cristóbal: Yes, I would agree with that.

OSN: Are there a large number of phaco machines in Spain?

Dr. Cristóbal: Yes, there are phaco machines in every hospital.

OSN: How much does the government reimburse for a cataract procedure?

Dr. Cristóbal: Normally, the government does not pay for medical procedures. In the private hospital, cataract surgery costs about $1,800, which includes the IOL.

Refractive surgery

OSN: Please describe the popularity of refractive surgery in Spain.

Dr. Vega: It’s very popular; more popular than it has been in the past.

OSN: Are physicians performing mostly laser in situ keratomileusis (LASIK)?

Dr. Vega: Yes, at this moment LASIK is most popular. The use of photorefractive keratectomy (PRK) is now coming down.

OSN: Do you ever perform PRK for low myopes?

Dr. Vega: Some, but mostly everyone who is doing refractive surgery uses LASIK.

OSN: And about how many procedures are you performing yourself a year?

Dr. Vega: In my office [in Oviedo], there are seven surgeons and we perform about 400 LASIK procedures per month, so that’s 4,800 each year.

Dr. Cristóbal: My team performs 200 LASIK procedures per month in Zaragoza.

OSN: Are any physicians in Spain using radial keratotomy (RK)?

Dr. Cristóbal: No, I don’t think so. No one I know of is doing RK at the moment.

OSN: Do the underemployed or unemployed ophthalmologists you described earlier see refractive surgery as a way to increase income? Is it seen by physicians as a way to earn more in a system that may limit one’s earnings potential?

Dr. Cristóbal: The ophthalmologists who would stand to benefit most from increased income are the young physicians. However, the young physicians are in the public system where refractive surgery is not practiced.

So the answer then is no. The growth in refractive surgery in Spain is attributable to increased volume among established, experienced surgeons.

Language barrier

OSN: Many Spanish ophthalmologists speak French as a second language, rather than English. Some say this has been a problem when Spanish ophthalmologists participate in large, English-language international meetings. Has it limited their participation?

Dr. Cristóbal: Yes, it has and does. A problem in ophthalmology is that not many ophthalmologists here speak English well. It poses a big problem when they go to other meetings.

Dr. Vega: In Spain, it is traditional in the academic institute to speak French, but now, they are introducing English. Twenty years ago, it was all French. But now, English is more important if Spanish physicians are to participate in the international arena.

Report Card: Spain

Population	40 million
Percentage of gross domestic product spent on health care	7.6%
Percentage of population covered by national health system	99%
Unemployment rate	17.4%
Life expectancy	78 years
Number of ophthalmologists	about 3,500*
Annual number of cataract procedures	about 200,000*
Number of phaco machines	about 200*
*Source: Sociedad Española de Cirugia Ocular Implanto Refractiva.

For Your Information:

• José Angel Cristóbal Bescós, MD, is a private practice ophthalmologist in Zaragoza and the president of the organizing committee of the Sociedad Española de Cirugia Ocular Implanto-Refractiva He can be reached at Paseo Sagasta, 60, entlo. D., 50006 Zaragoza, Spain; phone and fax: +(34) 976-25-22-33. Dr. Cristóbal has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
• Prof. Luis F. Vega, MD, is a private practice ophthalmologist in Oviedo and the president of the Sociedad Española de Cirugia Ocular Implanto-Refractiva. He can be reached at Uría 3-2.°, 33003 Oviedo, Spain; +(34) 985-24-15-12 or +(34) 985-24-01-41; fax: +(34) 985-27-33-60; e-mail: ioftalmologic@omc.telprof.es. Dr. Vega has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.