Balance of public, private health care seeks to meet population needs in Spain

Official recognition of subspecialty training is a goal that should be dealt with at the European level, a clinician says.

Jorge L. Alió

Ophthalmic care meets population needs in Spain, with a good balance of public and private service delivery, according to Jorge L. Alió, MD, president of the Spanish Association of Technology and Implant Surgery, Refractive and Cornea.

Ophthalmology, like health care in general, in Spain is under a national health system (NHS), which is managed by 17 autonomous regional governments. Overall spending on health care amounts to 15% of the national budget, Dr. Alió said. Of that, 95% comes from income tax and 5% comes from social security contributions made by workers and employers.

All Spanish workers have access to free health care, regardless of their type or level of employment. About 20% of Spanish residents, mainly in large cities such as Madrid and Barcelona, prefer to purchase private health insurance coverage rather than using the NHS. Approximately 5% of health care services are provided solely on a private basis — mainly procedures, such as refractive surgery, that might not be covered by the NHS or some insurance companies because they are considered nonessential.

“The NHS provides high-level, efficient services to cover all the basic needs of medical assistance. In the case of ophthalmology, it provides primary care as well as standard medical and surgical treatment for all ocular pathologies and age-related disabilities,” Dr. Alió said. “However, services are area-based, meaning that the hospital and doctors you are referred to depend on your place of residence, and you have no choice in who will take care of your needs.”

This lack of physician choice drives some people in Spain to pay for private insurance schemes, which usually require patients to obtain care from a list of specialists and public or private centers. Patients seeking premium and elective procedures, such as refractive surgery and cosmetic oculoplasty, must pay for private treatment.

Distribution

There are 3,200 ophthalmologists in Spain, 3,000 of whom belong to the Spanish Ophthalmological Society. Only 25% work full time in public hospitals. Approximately 60% have appointments in the public system as well as part time in private practices, and about 15% work exclusively for private practices.

Private practices have been growing steadily due to the increasing market for refractive procedures, including lens surgery with premium IOLs. These procedures are in the domain of private insurance and private care, where they are likely to remain. Most ophthalmologists in Spain, including Dr. Alió, agree with this arrangement.

“The standard for everybody has to be provided by the government, but if you go beyond standard, you should provide for yourself,” he said. “However, we expect private practices to become more accessible in future years. There is a growing competition, and these procedures will become cheaper.”

The ratio of men to women among ophthalmologists is currently 50-50. Female medical students already outnumber their male counterparts, so the proportion of women will grow in future years.

The geographic distribution of ophthalmologists corresponds well to population needs. No area is unattended, although 60% of ophthalmology residents are trained in Madrid, 20% in Barcelona and the remaining 20% elsewhere.

“We train about 120 ophthalmologists per year. They undergo a 4-year program where, unlike in some other European countries, surgery is done from the first year and there is no separation between medical and surgical ophthalmology,” Dr. Alió said. “Like everywhere else in Europe, there is no subspecialty degree, and this is a limitation that is becoming increasingly evident in our system.”

Challenges

Spanish ophthalmology faces challenges on three levels, Dr. Alió said. The first is financial, due to Spain’s looming economic crisis that will likely affect the health care budget in the next 5 to 10 years.

“Because of financial constraints, hospitals will offer fewer contracts to ophthalmologists, which means fewer options for the patients, decreased efficiency and level of services. Also, there will be less money to spend on technological equipment, and there is a risk that public health will be unable to keep pace with the fast evolution of modern ophthalmology,” he said.

The influx of optometrists into medical practice is the second main challenge that will create controversy in the future. Currently 10,000 certified optometrists practice in Spain. Because job opportunities for them are scarce, they sometimes encroach into ophthalmology’s field of expertise, some ophthalmologists say.

“Wherever there are optometrists, they are fighting to expand their scope,” Dr. Alió said. “Drawing a line is mandatory, to prevent unlawful intrusions and malpractice. Medical care and surgical procedures, including laser, must remain strictly beyond the scope of optometrists.”

Obtaining official subspecialty certification within university training programs is the third major challenge that needs to be dealt with at the European level.

“Ophthalmology subspecialties have never been formally introduced in our system. Most of us are in fact trained in specific subspecialty areas, but there is no official certification to guarantee the level and quality of our training and to clearly direct patients’ choices,” Dr. Alió said.

One of the consequences is that patients may receive a suboptimal level of eye care because they do not know where to go for their specific pathology. They often go to the general ophthalmologist who is nearest to them but might not have the specific competence or the appropriate technological equipment to care for their condition.

“There is no way to identify subspecialties by the average patient. At the same time, not all ophthalmologists are so professionally and ethically correct to give up a patient and redirect him or her to the colleague who can best deal with his or her specific condition,” Dr. Alió explained. “It’s a major problem in Europe. ‘Hidden’ subspecialties should have visibility for the patient and official recognition by education authorities.” – by Michela Cimberle

• Jorge L. Alió, MD, PhD, can be reached at Vissum Corporation, Avenida de Denia, s/n, 03016 Alicante, Spain; +34 965150025; fax: +34 965151501; email: jlalio@vissum.com.
• Disclosure: No products or companies are mentioned that would require financial disclosure.