Canada's Wait Time Strategy, a program aimed to reduce the time adults wait for medical services and treatment, has allowed approximately 60,000 more operations for sight restoration, cancer, heart, and joint replacement since 2004, according to a report released by the Canadian Institute for Health information.¹ Provincial governments are funding increases in the number of surgeries and procedures being performed in these therapeutic areas. The initiative also includes MRI and CT exams. Despite the increased funding and surgeries, long wait times continue to plague Canadian patients, including those with visual impairments.

Nadeem Esmail, Director of Health System Performance Studies at The Fraser Institute (Toronto, Ontario), recently reported that the wait time across Canada, from a general practitioner's referral to the time treatment is provided by a specialist, decreased 1 week, from 18.3 weeks in 2007 to 17.3 weeks in 2008.² "Canadians are generally proud of their universal access health insurance program, which provides access to care regardless of ability to pay," Mr. Esmail wrote in a Canadian newspaper.³ "However, [as others have stated], 'Access to a waiting list is not access to health care.'"

In November 2008, an experimental program was implemented in Eastern Ontario to reduce patients' wait for cataract surgery. The medically acceptable waits for cataract surgery is 182 days; under this program, cataract patients who do not receive surgery within 120 days of seeing a specialist can contact the Community Care Access Center, the provincial agency that coordinates health services, and either choose to be assigned to another surgeon with a shorter waiting list or stay with their current specialist. This system is intended to target the 6% of cataract patients who do not undergo surgery within the acceptable 182 days, according to the Champlain Local Health Integration Network.

When the wait-list strategy was initiated in Ontario in 2004, the average wait time for cataract surgery was 311 days. Currently, cataract surgery patients wait an average of 113 days, or 69 days less than the medically acceptable 182 days and 198 days less than the initial wait time in 2004.⁴

Two changes in the health care system are responsible for this significant decrease, according to George Beiko, BM, BCh, FRCSC. Dr. Beiko is an Assistant Professor of Ophthalmology at McMaster University, a Lecturer at the University of Toronto, and a private practitioner in St. Catharine's, Ontario.

The first change has to do with Ontario's reimbursement policy. "In the 1990s, the government limited reimbursement to doctors by capping the number of services for which physicians could be reimbursed. This resulted in a decreased numbers of surgeries being performed. Wait times decreased when the cap on reimbursement was lifted and doctors could be paid fully for all services rendered," Dr. Beiko wrote in an e-mail to CRST Europe.

The second change relates to increased surgical quotas for hospitals. "A baseline number of cataract cases for each hospital was determined, and if the hospital contracted to do more, then the hospital received additional funding based on each additional case that was done," Dr. Beiko explained. "This enticement resulted in hospitals actively recruiting doctors to do more cataracts; some hospitals opened the operating rooms at night and on weekends."

Although the average wait for cataract surgery has significantly decreased, Dr. Beiko is concerned that a segment of the cataract patient population is being excluded from treatment. "Yes, more cases are being done, and surgeons are being reimbursed fully. But this encourages surgeons to do easy cases—to concentrate on cataract surgery to the exclusion of other patients, specifically diabetes, glaucoma, and pediatric cases. In fact, the wait for these cases has increased dramatically, from 114 to 141 days on average," Dr. Beiko wrote. "Because hospitals are interested only in numbers, easy cataract cases are preferred. Patients with kyphosis, on supplemental oxygen, wheelchair ridden, or those requiring general anesthesia are discouraged."

Rosa Braga-Mele, MD, FRCSC, recognizes that the strategy has effectively lowered wait times and that the government funding has increased operating time for cataract surgeons. Nonetheless, Dr. Braga-Mele, an Associate Professor at the University of Toronto and Director of Cataract Unit and Surgical Teaching at Mount Sinai Hospital in Toronto, said the strategy is imbued with "inherent obstacles and expenses."

"It became more time-consuming for my booking secretary to input all the variables," Dr. Braga-Mele wrote to CRST Europe. "Since doctors' wait times are reported online for patients' reference, we are required to input even more variables as this initiative continues. Now, doctors in Canada are fighting the possibility that we will be required to document our postoperative outcomes online."

Although Canadian provincial governments have good intentions to increase cataract patients' access to care, Dr. Beiko worries that "the government has an agenda to render ophthalmology as a cataract-only specialty." He questions whether ophthalmologists will see noncataract patients if reimbursements are medically and politically associated predominately with cataract surgery and who will treat complicated cataract cases if they are excluded from this strategy.

According to Dr. Beiko, Canada, with a population of 33 million, trains only 25 new ophthalmologists per year. "In a medical system in which there is a shortage of ophthalmologists, it is incumbent on the government, which claims to provide universal access to health care, to ensure timely and quality health care," Dr. Beiko said. "Decreasing wait times, although laudable as it addresses timeliness for the majority, has resulted in a decline of access to care to an already deprived minority requiring nonsurgical ophthalmic care or surgery other than routine cataract surgery."

George Beiko, BM, BCh, FRCSC, is an Assistant Professor of Ophthalmology at McMaster University, a Lecturer at the University of Toronto, and a private practitioner in St. Catharine's, Ontario, Canada. Dr. Beiko may be reached at tel: +1 905 687 8322; e-mail: george.beiko@sympatico.ca.

Rosa Braga-Mele, MD, MEd, FRCS(C), is anAssociate Professor of Ophthalmology at the University of Toronto and Director of Cataract Unit and Surgical Teaching at Mount Sinai Hospital in Toronto. Dr. Braga-Mele may be reached at tel: +1 416 4620393; e-mail: rbragamele@rogers.com.

1. Ogilvie M. Study bolsters surgery wait-time strategy. thestar.com. June 26, 2008. http://www.thestar.com/comment/columnists/article/449466. Accessed December 8, 2008.
2. Esmail N. Hold the applause, please. Okanagan Sunday. October 14, 2008.
3. Esmail N. Why are Canadians still waiting for health care? The Fraser Forum. February 5, 2008.
4. Ministry of Health and Long Term Care. Ontario wait times. http://www.health.gov.on.ca/transformation/wait_times/wait_mn.html. Accessed December 8, 2008.