Ophthalmology suffers in Iceland from insufficient government funding

The private sector is investing in innovation but faces restrictions on the number and types of procedures.

Issue: October 2013

A long economic crisis and a government that is slow to foster and finance innovation are threatening the exemplary but delicate balance of ophthalmology in Iceland, according to ophthalmologists interviewed by Ocular Surgery News.

“Ophthalmological examinations and treatment modalities paid for by the government are unchanged since 1990. Since then, a lot of innovation has come to the scene in ophthalmology. We are suffering from lack of funding for ophthalmological equipment at the national hospital and for advanced ophthalmological evaluation or treatment outside the hospital setting,” Johannes Kristinsson, MD, said. “In addition, the salaries of doctors have gone down as compared to the rising cost of living.”

With a surface area of 103,000 km² and a population of approximately 320,000, Iceland is the most sparsely populated country in Europe. Most settlements are located along the coast because the interior — about 80% of the territory — consists of uninhabitable volcanic mountains, glaciers and lava fields.

Reykjavik, the capital city, is home to more than two-thirds of the population. Thirty-one of the country’s 33 ophthalmologists live and practice there or in the surrounding area. Two are in the north in Akureyri, and six or seven travel once or twice a month to the smaller towns in the east and west to visit local patients, according to Kristinsson.

“It’s a delicate balance that we mostly manage to keep. As there are very few of us trained for each subspecialty, crises can obviously rise if one specialist — for example, in glaucoma, cornea or pediatrics — has to take a leave of absence or quits,” he said.

The medical workforce has been stable until recently. Because specialty training in ophthalmology is not available in Iceland, graduates typically study abroad for their specialties, mainly in Sweden, Norway and the United States, and then go back to their country to practice.

“We are quite well known for the fact that we study abroad but like to go back,” Kristinsson said.

However, the economic crisis and bubble burst of 2008 produced a decline in gross domestic product and employment, which also affected the health care sector.

“Our standard of living, which ranked amongst the highest in the world, has gone down. This has reduced doctors’ salaries, who usually are heavily in debt from years of studying both home and abroad, and there is a trend amongst physicians in the country to work abroad part of the time, mainly in Sweden, to top up their income. It’s something new and quite alarming that was almost unthinkable 10 years ago,” he said.

A difficult balance

Health care in Iceland is universal. The government generally pays for the majority of the services rendered by ophthalmologists, but patients’ co-pays vary according to age, disability and other factors.

“It doesn’t go above a certain amount, but it has become increasingly difficult for some people in recent years to afford the rising extra cost,” Kristinsson said.

Early in the 20th century, ophthalmology was the first medical specialty to implement the concept of private practice, mainly to deal with general ophthalmology and outpatient procedures. Even though ophthalmological procedures were performed in a hospital setting, it was not until 1969 that a formal eye department was established. For almost a century, almost all cataract operations were performed in a hospital setting, mostly at the National Hospital of Iceland (Landspitali), with a small portion performed in the smaller hospital center of Akureyri. In 2008, two private clinics were allowed to perform cataract surgery through a contract with the Health Administration.

“It was a good thing because it took off some of the burden from our national hospital. However, they are only allowed a fixed number of procedures per year, which is not sufficient to cover the current needs,” Kristinsson said. “The waiting list for cataract surgery at the hospital has been getting longer in the last few years and is starting to be long in the private clinics, too.”

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The budget restrictions recently imposed by the government are preventing the national hospital from keeping up with the growing demand for cataract surgery; there is a limited number of working ORs that have to be shared with other procedures, which are also on the rise.

“Intravitreal injection procedures have increased sharply in the last few years and have pushed elective cataract surgeries aside, making the waiting list even longer,” Kristinsson said.

Allowing private practices to perform intravitreal injections could be a helpful next step, but the idea has been met with resistance. Because government funding for all hospital departments is based on the number of procedures performed, funding would potentially decrease with a large portion of vitreous injections moving from hospitals into the private sector, according to Kristinsson.

With the increase in intravitreal injection therapies has come a growing number of optical coherence tomography examinations.

“A few private clinics have invested in OCT equipment but have to ask patients [to pay] the full amount because OCT examinations are not reimbursed by the government outside hospitals. We are in the odd situation of being able to perform OCT examinations and yet not being able to do the injections,” Kristinsson said.

Keeping pace with innovation

The ophthalmology department at the national hospital has suffered from slow and limited investment in modern technologies. It takes years to obtain what is needed and most of the instruments are donated by nonprofit organizations, such as Odd Fellows, Lions and Kiwanis, according to Kristinsson.

“We try to keep our private practices updated, but it is difficult because costs are increasingly high and there has been no support from the government for whatever came to the scene after 1990. The health authorities have made clear that all examinations or treatments added to the list of what is currently reimbursed will be reimbursed from the fixed reimbursement allotment, thereby making it the responsibility of ophthalmologists to deal with this amongst themselves. This is entirely unfair as this leads to growing antagonism amongst the physicians. This ultimately comes down hardest on the patients themselves. If I perform topography or OCT or place punctal silicone plugs, the patient has to pay this entirely out of pocket,” he said. “Many people feel that they are being double-taxed, as they rightly feel that they should be getting modern-quality ophthalmological examinations and treatments without having to pay them totally out of pocket. For example, they have to pay 55 for corneal topography, which is difficult for low-income families and many of the elderly.”

After his specialty training at the Duke Eye Center, U.S.A., Kristinsson was working on the idea of implementing refractive surgery in the public sector within the national hospital.

“I was quickly informed that the national hospital did not perform any surgeries paid entirely out of pocket. Since this route was blocked, I was literally pushed towards the private sector, and I opened my own private practice in 2001,” he said.

Although entirely paid out of pocket by the patients, refractive surgery has gained an increasing popularity in the country.

“Many Icelandic ophthalmologists were skeptical toward the procedure, and still several are. However, there are no less than three centers providing refractive surgery care, which is extraordinary given the fact that the population is a little above 300,000. The number of surgeries is unknown, but since 1,100 to 1,200 surgeries a year are performed at my center, the total number in the country probably exceeds 2,000 a year. This would be more than twice the number of surgeries performed in the U.S., corrected for the number of country inhabitants,” Kristinsson said.

Such a high level of popularity is even more surprising because a ban on medical advertising was lifted only at the beginning of this year.

“The low investment in advertising may in fact play a part in allowing surgeons to keep the price of refractive surgery low compared with neighboring countries, such as a LASIK price of 800 per eye,” Kristinsson said. “Word of mouth is still the most powerful form of advertising.” – by Michela Cimberle

Reference:
Johannes K. Kristinsson MD, PhD, can be reached at Augljos Laser Refractive Surgery Center, Alfheimar 74, Vesturhus, 2nd floor, 104 Reykjavik, Iceland; email: johannes@augljos.is.

Disclosure: Kristinsson has no relevant financial disclosures.