Reforms not reducing ophthalmologists’ numbers, but some find revenue is lower

In an era of cuts, physicians have had to choose between salaries and new medical technology. Many now earn less than before.

With 120,000 total physicians and 4.5 hospital beds for every 1,000 people, there is clearly no shortage of medical services in Argentina, and ophthalmology is not an exception. There are 3,200 ophthalmologists in Argentina, or one for every 10,600 people. The nation’s ophthalmologist-to-patient ratio is higher than that of most of its Latin American neighbors and of the United States (where there is one ophthalmologist for every 15,300 people).

Each year about 80 ophthalmologists complete their training, which consists of medical school plus a five year postgraduate qualification program, according to the national organization, Consejo Argentino De Oftalmologia. Fellowships are less common in Argentina than in Europe or the United States.

While there appears to be no shortage of ophthalmologists, there is a shortage of revenue. Argentina’s ophthalmic community has been caught in the middle of the government’s ongoing health care reform efforts (see accompanying article). Physicians, who have grown accustomed to providing their patients with top-quality, though costly, health care, have recently been forced to choose between their own salaries and the pressing need to keep up with world standards and purchase new equipment and technology. With decreases in reimbursements, many physicians have paid for new technology with money that would normally be earmarked for their salaries and those of staff members. Ophthalmologists who have chosen technology over personal earnings have experienced a decrease in income compared with years past.

Advanced ophthalmology

Compared with other countries in the region, ophthalmology tends to be more advanced in Argentina, although the level of medical sophistication varies by region. About 70% of Argentina’s ophthalmologists, or about 2,240, perform cataract surgery. According to ophthalmologists interviewed for this article, between 30% and 50% of surgeons who perform cataract surgery use phacoemulsification. (In Brazil only about 5% of cataract surgeons perform phaco.)

"Argentina is in the midst of a transition from extracapsular cataract extraction to phaco," said Roberto Zaldivar, MD, in private practice in Mendoza. "Not everyone can access phaco technology and many of those who can have not yet completed the learning curve."

Patients pay between US$2,000 and US$2,500 for phacoemulsification. Sixty percent of the cost is reimbursed by the government. Patients who opt for phaco pay the remaining 40% out-of-pocket.

According to physicians interviewed for this article, the time patients wait for cataract procedures can vary depending on where they live and the complexity of their cases. In large cities, doctors reported virtually no waiting period for non-complicated operations, but some doctors from Argentina’s interior said the wait for cataract surgery can be several months. For particularly complex procedures, Dr. Zaldivar said some patients wait as long as 10 months.

PRK disappearing

Refractive surgery in Argentina is generally popular and affordable to many; however, some doctors interviewed for this article said the subspecialty is experiencing something of a growth plateau compared with 1995 and 1996. Three years ago, refractive surgery experienced a boom in Argentina, marked by significant volume increases on the part of surgeons.

"Some growth is still evident, but the field has stabilized recently," Dr. Zaldivar reported. Photorefractive keratectomy (PRK) is becoming increasingly uncommon in Argentina. Most surgeons favor laser in situ keratolmileusis (LASIK). PRK costs patients about US$1,200 per eye.

The fee for LASIK is higher. Prices range between US$1,500 and US$1,700 per eye. There are between 65 and 70 excimer lasers currently in operation in Argentina. Dr. Zaldivar said he no longer performs PRK or radial keratotomy, opting instead for LASIK, phakic intraocular lenses and refractive phacoemulsification.

There are a large number of academic, professional, subspecialty and regional organizations for Argentine ophthalmologists. Twenty-five officially recognized societies represent ophthalmologists in Argentina, according to the national organization.

Pre-pagas, pre-paid health insurance programs similar to health maintenance organizations or managed care plans, have gained popularity according to Enrique Malbran Jr., MD, in practice in Buenos Aires. Currently, about 30% of his patients pay for treatment with private resources. At his Mendoza practice, Dr. Zaldivar reports that 50% of his patients pay privately. It should be noted, however, that both Dr. Zaldivar and Dr. Malbran are particularly well-known ophthalmologists in Argentina. The number of privately paying patients may be significantly lower for other ophthalmologists.

For Your Information:

Roberto Zaldivar, MD, is in private practice in Mendoza, Argentina. He can be contacted at the Instituto Zaldivar, Ave. Emilio Civit 685, Mendoza 5500, Argentina. +(54) 61-293-222; fax: +(54) 61-380-350.

Enrique Malbran, MD, is in private practice in Buenos Aires. He can be contacted at Parera 164, Capital Federal, Buenos Aires, 10114, Argentina. +(54) 1-815-8144; fax: +(54) 1-814-4853.

For information on Argentina’s national ophthalmology organization, contact Consejo Argentino De Oftalmologia, Las Heras 2126 12° "G" (1127) Capital Federal, Buenos Aires, Argentina. +(54) 1-807-3489; fax: +(54) 1-803-8288; e-mail: oftalmo@impsat1.com.ar.