Payment for premium treatments, needs-based planning at issue for Italian ophthalmologists

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Matteo Piovella

While hospital funding is insufficient to cover the cost of new treatments and technologies in Italy, a potential future shortage in the medical work force raises concern.

To continue providing the highest standard of care, the Italian National Health Service, or NHS, must increase the budgetary allocation for ophthalmology or be open to new forms of co-payment, according to Matteo Piovella, MD.

“Although ophthalmology has always been struggling with low budgets, patients until recently were guaranteed the best available care under NHS coverage. The revolutionary advances in pharmacotherapies as well as in diagnostic and therapeutic technologies have changed the scenario: Hospitals have insufficient funds to keep pace with what is now the highest standard of care,” Dr. Piovella, president of the Italian Society of Ophthalmology (SOI), said.

Premium IOLs are a significant example. The NHS covers the cost of basic cataract surgery with standard monofocal IOLs but not the additional cost of premium technologies. Because no bill-sharing system is permitted, patients are forced to either accept basic cataract surgery or pay the entire cost of the operation in a private clinic for implantation with a premium lens.

“Very few Italians have complementary insurance. If they go private, they usually pay out of their own pockets,” Dr. Piovella said.

Intravitreal injections pose a similar problem. Although the injections have been fully approved as a treatment option, insufficient funding imposes limitations on their use, according to Dr. Piovella.

“Hospitals face the impossible challenge of meeting the high costs of repeated injections, getting the money out of a budget that has remained substantially unchanged for many years. They can treat these patients, but then there will be no money left for other treatments,” he said.

With the Italian population aging, Dr. Piovella advocates that government and health authorities become aware of the cost-effectiveness of new technologies and sight-preserving treatments.

Demographics

With 7,000 ophthalmologists in a population of 60 million, Italy is currently in the privileged position of having a good doctor-patient ratio. It also has sufficient work opportunities for all eye care specialists. Of the total number of ophthalmologists, 40% are employed by the NHS, while 60% work mostly or exclusively in private practices. Currently, 69% of Italian ophthalmologists are men and 31% are women, but the ratio of women is rising quickly, and women are expected to outnumber men in future years.

The highly populated and wealthy northern regions of Italy employ 41% of the country’s ophthalmologists. The remaining 59% are more or less equally distributed between the center and the south and islands. A higher concentration is also seen in metropolitan areas, with 10% of Italian ophthalmologists practicing in Rome, 5% in Milan and, on the whole, 25% in the six largest cities of Italy.

“Number and distribution meet, perfectly, the current needs of our population. However, numbers are stagnating and the average age of practicing ophthalmologists, which has grown from 40 to 48 in the last 15 years, raises concern for the future,” Dr. Piovella said.

The introduction of enrollment caps at Italian medical schools and the drastic 10-fold reduction of residency positions in ophthalmology in the last 30 years have eliminated the surplus of physicians, overlooking the need for long-term planning. As in the rest of Europe, the number of ophthalmologists graduating in Italy each year will soon be insufficient to guarantee full replacement of the retiring work force.

SOI takes on challenges

Another challenge to Italian ophthalmology is that of fully reinstating the right for hospital physicians to also work in private practices. A provision enforced by the Ministry of Health 12 years ago forced physicians to choose between working for the NHS or in the private sector and dictated any private professional activity outside hospital premises.

The provision, Dr. Piovella said, gave rise to heated debate. Hospital physicians’ salaries were, and still are, grossly inadequate and disproportionate to what ophthalmologists can earn privately.

It also raised concern about the “brain drain” from public hospitals, he said.

“Some amendments were introduced, but this law still leaves a lot up to interpretation. Basically, what happens now is that regional authorities decide whether NHS-employed doctors can or cannot work outside hospital premises. This means that if you work in a hospital in Milan, you can also have your own private practice; if you work in a hospital in Bologna, you cannot. It is a fact, however, that regions that forbid private practice have a higher rate of early retirement amongst specialists,” Dr. Piovella said.

Another goal of the SOI is to prepare, in collaboration with education authorities, a needs-based plan of admissions to residency positions in ophthalmology, in order to adjust for future demand.

The SOI has played a key role in representing the interests of the profession and has been actively involved in the dialogue with the government and others to improve health care standards, he said.

“In all the challenges we have been discussing, the SOI is actively involved. We are asking to have premium IOLs available in hospitals, where 93% of cataract procedures are performed. We are fighting to have a bigger share of the total health expenditure allocated for ophthalmology, because eye health is a priority that is systematically underrated,” Dr. Piovella said. – by Michela Cimberle

• Matteo Piovella, MD, can be reached at Centro Microchirurgia Ambulatoriale, Via Donizetti 24, 20052 Monza, Italy; +39-039-389498, fax: +39-039-2300964; e-mail: piovella@piovella.com.
• Disclosure: No companies or products are mentioned that would require financial disclosure.