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Is for-profit the right path?
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To the Editor:
I read, with great interest and considerable concern, the comments of Dr. Richard Lindstrom in his regular editorial (Substantial changes likely in eye banking, corneal transplantation community, Lindstrom’s Perspective, July 25, 2017).
Dr. Lindstrom does, indeed, have a long history of involvement in eye banking and has made important contributions to the science of corneal preservation. Nonetheless, those of us who have also been active at the epicenter of organized eye banking in this country and abroad for the last four decades share serious concerns about the course being taken by eye banks with commercial, for-profit subsidiaries or partners in the United States following a trajectory that is perceived as inevitable by Dr. Lindstrom.
I agree completely with Dr. Lindstrom’s observation that the only constant is change, and as a leader of organized eye banking, I have both witnessed and been part of constant change in the eye banking system. This change includes, among others, the development of ever-evolving medical standards, the appearance of eye bank collaboratives and tissue sharing organizations, and the growing involvement of eye banking in corneal surgery through tissue preparation for lamellar procedures (DSAEK, DMEK, femtosecond laser-assisted corneal grafts). This most recent change has truly revolutionized the relationship between the eye bank, the corneal surgeon and the patient.
Yet, in this ongoing kaleidoscopic evolution of tissue acquisition, storage, preparation and distribution processes, there are some overarching and enduring principles that have been violated by an eye bank with a for-profit motivation.
The first of these principles is the important relationship between the eye bank and its regional community. An eye bank driven by a for-profit entity that does not support and moves aggressively to supersede this relationship moves against the very foundation of eye banking. Even with the contraction of the number of eye banks in the country, there is a distinct covenant of trust between community surgeons and their local eye banks. Tissue imports from other banks are filtered through the local screening processes, giving the surgeon trust in the quality of the tissue that he or she is about to implant in the patient. In a publicly stated, noble quest to eliminate corneal blindness worldwide, the for-profit entity can lose an appreciation of this important community link. Indeed, one practice has been to move into regions and wrest participating hospitals from their allegiance to the local eye bank, all in the name of greater efficiency and better service.
The second principle that appears to be violated is the departure from the donated cornea as a gift. Linking tissue donation to a for-profit enterprise essentially renders the graft a commodity. While the stated rationale of the for-profit entity is to pour profits into the donor-driven eye bank, there is concern that the steady stream of profits will flow decreasingly into the eye banking nonprofit effort and increasingly into the coffers of the business stakeholders.
I hope that Dr. Lindstrom’s vision of the brave new world of eye banking is inaccurate. We embrace constant change, but the abiding humanitarian principles of what we do as eye bank professionals and using surgeons should not be lost by those who would profit from the system by linking it to the business practices of the industry. We cannot bury our heads in the sand; we must be vigilant and responsive to change; but we must also be true to our principles, accept our stewardship responsibilities, and realize that it is not the industry that will solve the issue of global corneal blindness. We will accomplish the eradication of blindness through aggressive and widespread public education, efforts at the local and regional level, and the development of a price structure that supports the needs of our patients rather than the demands of our medical establishment or the industry.
Mark Mannis, MD, FACS
Fosse Endowed Chair in Vision Science Research
Department of Ophthalmology & Vision Science
University of California Davis Eye Center
Sacramento, California
Dr. Lindstrom responds:
I would like to thank Dr. Mannis for his thoughtful response to my commentary on eye banking. I appreciate his concerns and have great respect for his decades of tireless work on behalf of eye banking, we corneal surgeons and our patients. I believe we both have a great love for the field of corneal transplantation and the eye banks that support the wonderful gift of sight a corneal surgeon in collaboration with an eye bank provides to both the patient in need and the donor family. I suspect we both also share a significant nostalgia for the way things were in eye banking in the U.S. when it was primarily a community-based Lions-supported “cottage industry.” The goal of my commentary was to offer some thoughts on the challenges eye banks are facing and some possible, or perhaps inevitable, changes these challenges will almost certainly catalyze. I remain convinced that external pressures will result in consolidation in the eye banking community.
In my home area of Minnesota and North and South Dakota, we have already consolidated from four eye banks to two, with local eye banks at the Mayo Clinic and in North Dakota closing. These eye banks served a local community of surgeons and patients with all the positive attributes Dr. Mannis describes as desirable yet no longer existing. So, consolidation has already occurred in my region of the country. I believe similar consolidation will occur nationwide and accelerate. This consolidation will occur in many forms, starting with creation of collaborative networks and ending with mergers and acquisitions. Many of the surviving organizations a decade from now will continue to be not-for-profit, but I predict some will also work collaboratively with for-profit organizations. In addition, increasing collaboration and integration with organ procurement organizations, feared by many eye banks, is likely and good. In my opinion, neither collaboration with a for-profit organization nor an organ procurement organization is in and of itself evil. They should both be judged by the quality of products and services they provide the corneal surgeon, their patients and the donor community.
For most corneal surgeons and their patients, the primary goal is access to high-quality donor corneal tissue customized to their individual patient’s need on the surgery day desired. I believe there is good, perhaps irrefutable, evidence that competition promotes enhanced service and catalyzes innovation. It is rare that protectionism in support of entrenched monopolies is truly in the best interest of those being served. While a donor cornea is a gift from the donor family, we all appreciate the fact that significant expense is involved in procuring, processing and placing a donor cornea, and that a fee is paid to the eye bank for delivering a transplantable cornea, and that fee is significant.
Because it is a fact that in the U.S. we have an ever increasing supply of transplantable corneas that is in excess of U.S. demand, it seems a truism that competition among eye banks for placement of transplantable corneal tissue is inevitable. I expect this competition, while threatening to some, will result in improved service and encourage innovation in a field that is in great need of both, along with meaningful investment.
Dr. Mannis, you and I agree that change is inevitable. No doubt about it, change is threatening to those who currently enjoy and benefit from the status quo. Fortunately, in a free and capitalistic country like ours, change is still primarily incubated in a system that supports entrepreneurial effort and innovation. Those eye banks, regardless of affiliation or tax-exempt status, that respond to the challenges of the future by providing great value through ever better products and service for surgeons, their patients and the donor community will survive and thrive. Those that do not will likely fail. If my comments encourage even one still-active classical community eye bank to thoughtfully develop a 1-, 5- and 10-year business plan that assures their success, I will have achieved my goal.
Richard L. Lindstrom, MD
OSN Chief Medical Editor