Healthcare in Europe

Politicians and patients put Italian ophthalmologists under pressure

Like their colleagues throughout Europe, Italian ophthalmologists are under increasing pressure from politicians and patients alike.

For Roberto Bellucci MD, the political pressure manifests itself in the government demanding a higher return on its health services investment.
"The most pressing problem, in my opinion, is the decreased amount of money allocated by the government to health care in general, and to ophthalmology in particular," says Dr Bellucci, who serves as chief of the Ophthalmic Unit at Verona Major Hospital.
Demographics reveal the extent of pressure on Italy's health funding: Italy has the highest proportion of elderly in the world - some 24.1% of Italians are aged 65 years or older.

The financial consequences of such pressure are readily apparent in cataract surgery, Dr Bellucci says. For example, cataract surgery is the most popular surgery in Italy, but its value is decreasing. In fact, the reimbursement to hospitals decreased by 40% in some parts of Italy during the last five years.

"In addition, there is a proposal to consider cataract surgery as an ambulatory procedure only, which will decrease its reimbursement further," Dr Bellucci adds.
Cataract surgery isn't the only loser in the battle for funding. "Reimbursements for other types of surgery too, like retinal surgery, is much lower than expected according to the time and the skill required to perform it," he says.

For instance, private ophthalmology helps to:

• Reduce the public waiting lists by siphoning off patients who can afford to pay
• Provide a service that is often of a higher standard than the public service
• Provide laser and other refractive surgery that is not available in the public service
• Provides visits and surgery in locations not reached by the public service.

"Italy is full of small villages with less than 10,000 inhabitants, and most of them have only private-practice ophthalmologists," he explains.

Against such a background, ophthalmic care for the vast majority of Italians is improving, says Matteo Piovella MD, Secretary of the Italian Society of Ophthalmology.
For instance, waiting lists for cataract surgery have shortened, Dr Piovella notes. In the last three years, all the waiting lists have been reduced dramatically. He credits such a 'revolution' to widespread ophthalmologist support for improving the quality of patient care. The Society, too, has taken up the cause for quality improvement by building systems to certify quality in ophthalmic practice, he adds.

Also, Italy's international leadership in organising live surgery meetings over the last 15 years has also helped increase quality and aided in the diffusion of new surgical techniques throughout the country, Dr Piovella explains.
In time, such developments may help relieve the pressure that ophthalmologists are now feeling from disgruntled patients. According to Dr Piovella, Italian ophthalmologists are facing ever-more litigious patients who increasingly turn to the country's courts to resolve their complaints.

Delay compounds the problems, he adds. For instance, five years can elapse between the time a patient sues an ophthalmologist and the time the malpractice case reaches a court.

And when an ophthalmologist gets to court, judges are often more sympathetic to the patient than to the ophthalmologist.

"They think it is right to reimburse a patient who had bad results even if that complication was impossible to avoid. For example, judges are moving to the concept that a capsule rupture is a mistake, even if you have only one rupture for every 1,000 cataract operations," Dr Piovella said.

He adds that judges are awarding more money because they know it is the physician's insurance company - and not the physician personally - that compensates the patient.
The Italian malpractice system - particularly its cost - is also leading physicians' insurance companies to settle cases that they should fight. "Often, the insurance company decides to make a settlement out of the court, even if you are innocent, to avoid the cost and the risk of a precedent," he says.

"In this way, good doctors without liability are written in the black list of the guilty, without the chance of defending themselves."

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