Private, public practices face different challenges

Issue: February 2008

Evolving technology, a growing need for cataract and diabetic retinopathy treatment and an emerging interest in elective procedures mark the unique challenges that private and government practices face in providing appropriate care.

Kamal Jeet Singh

Of the nearly 5 million cataract surgeries performed in India in 2006, 80% were performed in the private sector or a nongovernment organization, according to Vision 2020: Right to Sight India.

Private ophthalmologists face challenges, such as a lack of government funding, high cost of technology and a high level of competition.

Surgeons must strike a balance between offering the newest treatments and technologies and providing affordable, quality care, according to experts.

Ocular Surgery News conducted e-mail interviews with three ophthalmologists — Amod Gupta, MD, P.N. Nagpal, MD, and Kamal Jeet Singh, MS — who commented on forces that affect practices amid social change and booming economic growth.

“There are so many eye problems and a dearth of hospitals so that not one or two but hundreds of big centers are required,” Dr. Singh said.

Technology: a dilemma

New surgical methods and technologies are becoming widely available, Dr. Gupta said, but they force some private practices to increase fees and possibly even operate unethically.

Amod Gupta

“With rapidly evolving technologies and expectations of the middle class in India, most of the private practices are coming under pressure to invest, at the cost of increasingly unaffordable eye care,” he said.

High patient expectations also fuel the rapid adoption of expensive technologies such as LASIK, YAG laser and optical coherence tomography (OCT), even in small towns that may not have enough patients to make such technology cost-effective, Dr. Gupta said.

“Often it leads to an unhealthy competition, and sometimes the practice may verge on the border of unethical practices,” he said. “A patient walking into a clinic may be suspected of having glaucoma and be advised to have automated perimetry, OCT, GDx (VCC scanning laser perimetry, Carl Zeiss Meditec) or some such investigation, irrespective of whether the patient needs these investigations or not.”

Dr. Singh said public and private hospitals lack state-of-the-art technology.

“Technology-wise, all hospitals are lagging behind,” he said.

Dr. Gupta agreed, saying, “While technology is first to arrive in the private sector, in the public sector, on the other hand, it perhaps never arrives or does so at the tail end.”

Large surgical centers

The Indian government should invest in large, local surgical centers, Dr. Gupta said.

“There is indeed a need for large surgical centers at the district level, funded by the government that should have all the technologies available for use by both the private and the public sectors and should become self-sustainable,” he said.

However, providing subsidized care for those in need is important, he said.

Pran N. Nagpal

“Money should not be a decisive factor either in the quality of care or even the person’s right to sight,” Dr. Gupta said. “A large majority of Indians cannot afford care in private clinics and need the heavily subsidized or even free care available in the public sector.”

Dr. Singh was less optimistic about the results gained by government-funded surgical centers.

“Government in India does a lot of charity, but unfortunately, it does not bear fruit,” he said. “There are big cities where still basic IOL surgery is not being performed. The role of the private sector is always there.”

Dr. Nagpal supports ophthalmologists practicing privately to create group practices so as to increase their benefit from investments in technology.

“Larger hospitals with multiple surgeons should be encouraged in urban and metro cities,” he said. “Even in the private sector, group practice should be encouraged to reduce the investment in ever-changing technology. Individual private practices should be encouraged in the rural sector, where the surgeons do not like to go. The encouragement to group practices and private practices in the rural sector could be in the form of soft bank loans and or some direct subsidy in investment.”

Dr. Gupta said, “The concept of surgical centers where in these facilities could be shared by a number of ophthalmologists is still new and few such centers exist in India.”

Continued medical education

Dr. Gupta called for the Indian government to invest in continued medical education, not just technology.

“The need of the day is for the government to invest heavily not only in technology but in continued medical education,” he said.

Dr. Gupta cited a lack of systematic training facilities for ophthalmologists in the private sector. Also, many practitioners do not have the time or incentive to upgrade their clinical skills, he said.

“The only source of learning may be attending general or specialty meetings,” Dr. Gupta said. “There are no benchmarks or surgical guidelines available.”

Dr. Singh said the Indian government funds continuing education in ophthalmology, but the funding has not kept up with rapidly developing technology.

“The government has been doing a lot in the field of medical education,” he said. “But presently, the medical science has developed so fast that government is unable to keep pace.”

For more information:

Amod Gupta, MD, can be reached at Department of Ophthalmology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012; e-mail: eyepgi@sify.com.

P.N. Nagpal, MD, can be reached at the Retina Foundation, Near Shahibag, Underbridge, Rajbravan Road, Ahmedabad 380004; +792-865-537; e-mail: pran@drnagpal.com.

Kamal Jeet Singh, MS, can be reached at State Institute of Ophthalmology, Allahabad 211003; +941-521-4108; e-mail: kamaljs2@rediffmail.com.

Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.