German ophthalmology is united through adversity

Specialists pull together to maintain high standards despite shortfall in Government medical expenditure

By Stefanie Petrou Binder MD

Heidelberg - Germany's national health budget is finding itself shortchanged after years of overspending, longer life expectancy, costly treatment programs, and patients' increasing demands - and doctors, particularly ophthalmic surgeons, are taking the brunt of it.

Between low funding for university research projects and the beginnings of changes that could see a major shift in the dynamics of healthcare delivery, Germany's ophthalmologists are under pressure.

A panel of the country's leading surgeons addressed the increasingly uncomfortable political climate in their country during the annual meeting of the DGII (German-Speaking Organisation of Intraocular Lens Implantation and Refractive Surgery).

German citizens have enjoyed excellent healthcare for generations. Over the long prosperous years, the Krankenkasse (the German federal insurance establishment), physicians and patients alike began to take things for granted.

People paid their monthly bills and the doctors thrived. Now suddenly, the future of both patients and ophthalmologists appears to hang in a precarious balance.

After years of universal health coverage and a flood of developments in eye surgery and patient care, patients have come to expect that they will profit from recent advances in medicine and surgery - without drastically upping their premiums.
It is precisely these advances in medicine in general and eye surgery in particular, however, that threaten the healthcare budget. The response has been the emergence of new rules and quality assurance measures.

Quality assurance from above?
The issuing of an "externally comparable quality assurance" form in early 2002 is one such effort, according to Ulrich Schönherr MD PhD, University Eye Clinic, Erlangen.
Quality assurance experts claim that this new form which documents cataract surgery through electronic databases will allow experts to review individual cases for quality indicators.

The form allows doctors and quality specialists to compare data regarding a patient's basic documentation, preoperative findings, patient history, surgery and postoperative findings.

Quality assurance is carried out on three basic levels - hospital, state and national level, according to Volker Mohr MD, of the Bundesgeschäftsstelle Qualitätssicherung in Düsseldorf (National Quality Assurance Centre).
Specialists on each level interact for an integrated quality assurance. The system breaks down into 12 specialised areas of medicine, each with a certain number of quality indicators.

Ophthalmology currently brings up the rear, with only nine established quality indicators compared to other specialties such as orthopedics, which has 125 indicators. The quality goals of cataract surgery include a low rate of repeat surgery and reaching planned refraction.

Although most eye surgeons would agree that any additional forms to complete from insurance companies - or any other bureaucracies - would drive them through the roof, the quality assurance form not only helps draw the line in deciding which patient needs a particular procedure, but also for once disregards the "cost" aspect.
According to Dr Mohr, <the system has dwelled long enough on finances and now needs to set its sights on the very relevant issue of quality.>

Concentrating on finances is something German ophthalmologists and surgeons do a lot lately. The mid 90s, which brought a tremendous change in the healthcare budget, has left its mark on today's surgical practices.
Alf Reuscher MD, a private eye doctor and surgeon, and an active member of the Ophthalmo-Surgical Working Division of the BVA (Berufs Verband der Augenärzte), loosely translated as the Professional Association of Ophthalmologists, shared some of his predictions at the DGII meeting.

His hunch is that outpatient procedures will dominate the future of cataract surgery in Germany. More than half of all cataract operations were performed at outpatient centres in 2001.

Dr Reuscher says this shift towards outpatient treatment has occurred despite the fact that outpatient reimbursement in the past has been very low and has continued to fall. The majority of outpatient operations are performed by private physicians in their own operating suites. Their reimbursement from the insurance companies came out of the so-called capped red-budget; higher operation frequencies result in lower reimbursement fees per procedure.

In many regions of Germany, the health insurance companies realised the enormous potential for saving money by promoting outpatient procedures. A cataract operation as an inpatient procedure costs approximately E1,500 while an outpatient procedure can be done for less than half that amount - and now pay a flat rate fee, Dr Reuscher explained.

For private practitioners with additional hospital beds, the curious result is that the reimbursement for their implants is less than half the amount they would receive if the operation had been done on an outpatient basis.

Dr Reuscher predicts this will spell the end of inpatient operations by private practitioners.

This is having a huge impact on hospital dynamics. Patient numbers have slowed to a trickle as patients are examined - and perhaps operated on - by their local ophthalmologists.
German surgeons performed 500,000 cataract surgeries in 2001 - making the implications of this switch colossal.

According to Dr Reuscher, hospitals will soon be luring those same eye surgeons to operate in their facilities, offering them all the advantages of the hospital infrastructure, and thereby filling up their operating rooms again, without letting off staff or wasting equipment.
University clinics may soon feel the pinch as well. Although widely recognised as trusted centres of learning and innovation, without the proper funding, university clinics may find themselves with empty beds, to the chagrin of university heads like Prof Christian Ohrloff of Frankfurt's University Eye Clinic.

A mere 2.3% of the gross national product is allotted to research from private and public sectors.

What's left over for the rest if government-subsidised health care costs run as high as they do?
It seems ironic that the health care system should now allocate more money for outpatient operations, when, according to Prof Ohrloff, modern operating techniques were first practiced and improved in universities.

The age of unenlightenment
Low research funding is especially unenlightened, according to Prof Ohrloff, in light of the knowledge that most future developments in German medical research will have been wrought from university-inspired ideas and will undoubtedly change the face of some facet in medical practice.

Developments in medicine are, after all, for everyone's benefit. On an up-note, the universities are bouncing back. As necessity is the mother of invention, so are the universities managing with reduced means.

"We believe that it is achievement that counts in the end," Dr Ohrloff said.
The direct effects of the ever-changing health system and poor job opportunities are reflected in Dr Reuscher's anticipated intern shortage. The deficit is already evident and destined to radically worsen by 2004.

There are 23% fewer medical school graduates and 25% fewer first-year interns than six years ago. An estimated 50% of graduates will not pursue a medical career in a clinic or private practice.

At the same time, patient options are increasing and procedures are becoming less risky. Dr Reuscher therefore expects an increasing demand for ophthalmic surgeons in the near future, reinstating ophthalmology as a highly-regarded surgical specialty.
Ophthalmologists may well go over the heads of the KV (Kassenärztliche Vereinigung) - a state-level institution charged with the responsibility of dividing evenly whatever funds the Krankenkasse allocates to a specialty group.

As some believe the KV to be superfluous, it came as no surprise when ophthalmologists opted to deal personally and individually with the Krankenkasse, to their mutual satisfaction.
Adversity has managed to unite German ophthalmologists. While communication and common goals were practically non-existent just a decade ago, most ophthalmologists are now interested in joining together for their welfare and for the welfare of their patients.
The tug-of-war in the German healthcare system sees a strong social consciousness with the residues of an antiquated social idealism meeting the budgetary demands of modern technology.

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