Public Funding for Cataract Surgery Helped Wealthy Patients

A policy change meant to reduce a backlog for cataract surgery in Ontario appears to have benefited wealthy patients, while reducing access to this critical treatment for those with a lower socioeconomic status.

Following the policy change, the rate of cataract surgeries at private, for-profit eye surgery centers rose 22% for patients with the highest socioeconomic status, while decreasing 8.5% among those with the lowest socioeconomic status, Robert J. Campbell, MD, David Barsky chair in Ophthalmology and Visual Sciences at Queen’s University in Kingston, Ontario, Canada, told Medscape Medical News.

Ontario had long paid surgeon fees for cataract surgeries performed in private centers but not extra fees for other services (such as procedures designed to reduce the need for glasses). The COVID-19 pandemic worsened existing backlogs for cataract surgeries. In 2020, the province began paying facility fees along with surgical costs.

The researchers had suspected that the initial results of a new provincial policy would not deliver the expected gains for Ontarians in need of cataract surgery, said Campbell. But the declines they discovered were more than they had anticipated.

“It’s startling, shocking, disappointing to see that,” said Campbell, adding that these are early results for the policy change. “Maybe things will improve,” he said. “Certainly, so far, it’s not working the way it was intended. It was intended to help everybody equally.”

The research was published on August 26 in CMAJ.

Disparity Increased

To track how well the policy change was working, Campbell and the researchers reviewed population-based, administrative healthcare databases via ICES.

They compared data on cataract surgeries performed from January 2017 to February 2020, which they defined as the pre-funding change period, vs from March 2020 to March 2022, which they defined as the funding change period. They also used the Ontario Marginalization Index, which considers income, education, housing, and family structure to classify patients into five groups based on their socioeconomic status.

“Unexpectedly, despite new public funding for operations provided in private, for-profit surgical centers, which was intended to fully cover all overhead costs and remove the need to charge patients, this disparity did not decrease but instead grew during the funding change period,” wrote the researchers. “In contrast, in public hospitals, the rate of surgery decreased similarly among patients of all socioeconomic status quintiles.”

The percentage of cataract operations performed in private, for-profit centers increased from 15.5% before the funding change to 22.5% in the funding change period. During the funding change period, the rate of cataract surgeries at public hospitals decreased by 22.3%, compared with the expected rate, whereas the rate at private, for-profit centers remained stable.

The researchers recommended the creation of common wait lists that incorporate all surgical centers in a region, rather than maintaining different wait lists for private, for-profit centers and public hospitals. Under the current system, physicians may have an incentive to steer patients with more money toward private centers where they then may pay for additional services, the researchers wrote.

“I’m definitely not anti-innovation, and we need creative solutions,” said Campbell. “But there needs to be certain safeguards put in place” to prevent conflicts of interest.

A Beta Test

Commenting on the study for Medscape Medical News, Nina Ahuja, MD, chair of the Council on Advocacy for the Canadian Ophthalmological Society, suggested that the initial findings suggest that the policy change should be considered a “beta test.”

“The goal was to increase access to surgery, and I think that this really gave us an opportunity to see what something like that could do,” said Ahuja, who was not involved with the research.

The Canadian Ophthalmological Society and governmental bodies are continuing to work to expand access to cataract surgery, said Ahuja. No one should see the initial results from the policy change as the final word, she said.

“Our goal is to work collaboratively to make sure that these disparities are addressed,” she said. “People shouldn’t feel alarmed at the data or offended by the data. This is all knowledge and information we need to bridge gaps for our patients and for our providers.”

The study was funded by the Ontario Health Data Platform and a Canadian Institutes of Health Research operating grant. Campbell reported no relevant financial relationships. Ahuja is a board member of St. Joseph’s Healthcare Foundation and performs surgery at a private center.

Kerry Dooley Young is a freelance journalist based in Washington, DC.