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Cover Focus | Sep 2015

Copayments Don’t Really Matter in Public Health Care

Fixed incomes for surgeons often mean limited use of premium IOLs.

My experience implanting multifocal IOLs is nil, and I have used toric add-on lenses in only a few patients who were unsatisfied with their refractive outcomes. Before I share my explanation, consider this fact: I work in a national public health care system, with a fixed salary that mandates I get paid the same amount regardless of whether I do 10 or 100 cataract surgeries in a month and of what type of IOLs I implant. Further, my salary is financed by tax money, which includes the taxes that I pay to the government.

Public health care in Sweden is provided by about 20 independent county councils, some but not all of which allow patient copayment in various forms. Until recently, almost all cataract surgeries were carried out in the public health care sector. In the past few years, however, a growing number have been performed in the private health care sector, and these providers get reimbursed approximately €550 per standard IOL operation from the public health care system. Private patients may also choose to pay for a whole premium IOL procedure out of pocket (or with private health insurance)—a much higher price than the copayment procedure.

St Erik Eye Hospital, a public health care unit in Stockholm, started offering multifocal and toric IOLs with copayment in 2007. In addition to the normal hospital fee (about €35), patients are responsible for the additional cost of the IOL and extra preoperative examination, administration, and counseling, which is up to €800 for a toric and €1,500 for a multifocal toric IOL. In the past 8 years, only a small fraction of patients—perhaps 100 of the 4,000 to 5,000 patients undergoing cataract surgery annually—have used this option.

As Swedish laws state that health care should be equal regardless of in what part of the country a patient is treated, public health care providers should work together with our profession to equalize copayment terms among the county councils. Therefore, in May 2015, the Swedish Ophthalmological Society organized a national workshop to discuss copayments for multifocal and toric IOLs. During the workshop, some cataract surgeons voiced concerns about implementing multifocal IOLs in a publicly financed center, mainly because these lenses require extra chair time and come with increased risk of unhappy patients. As public health care has a responsibility to the entire population of a covered area as well as to individual patients, a balance must be found between the struggle to keep high availability of appointments with short waiting times for surgical scheduling and the aim to treat the individual needs of each patient.

Attendees of the workshop argued that, because of the trade-offs with most if not all multifocal IOLs (eg, loss of light energy and contrast sensitivity), and because accommodating IOLs are still under development, presbyopia-correcting IOLs are less probable to enter into a nationwide copayment arrangement for cataract patients treated in the public health care system. However, because toric IOLs provide some patients with significant benefits (ie, corneal astigmatism correction), workshop attendants seemed less reluctant to use them in a copayment arrangement, even considering the extra pre- and intraoperative workup and investments in equipment necessary. Implantation of toric IOLs in public-financed eye care without any extra charge was also considered, especially in eyes above a certain amount of astigmatism; however, the amount of cylinder remains to be decided.

 The Swedish Ophthalmological Society continues to work on suggestions for a nationwide policy regarding copayment for toric and presbyopia-correcting lens solutions for cataract patients.

Björn Johansson, MD, PhD, FEBO
• Department of Ophthalmology, Linköping University, Sweden
• Member, CRST Europe Editorial Board