SOCIOECONOMICS OF OPHTHALMIC SURGICAL CARE IN THE NEW MILLENNIUM

The socioeconomic forces that are changing the face of medical care delivery are, among others, rationing, limited resources, rising costs, rising numbers of the underinsured and uninsured, changing population demographics, new technology, new medications and care options, capitation, aging baby boomers, impending bankruptcy of the medicare trust fund. All of these factors and more will change the availability (both perceived and actual), and the delivery of both medical and surgical care in the coming millennium. Continued technologic advances, together with rising incomes and an aging population, have accounted for a significant portion of the rising medical care cost. Much of this increase has gone for increasing the effectiveness of diagnostic and therapeutic devices, but a growing share of these dollars continue to go toward the purchase of services that, although the basis of all care, are not perceived as having great societal value. Socioeconomic considerations for surgical care (i.e., who will pay, who will have access, what type of care treatments will be available, and so forth) will closely mirror those for all medical care in the United States. They involve moral and economic considerations. We are constantly barraged with reports that health care costs are out of control and that, in the next millennium, we will be unable to afford to pay for health care as we know it today. Although we cannot predict the future, we know that health care will be different in the years to come. Many problems that plague us today will no longer exist in the coming years, but they will be replaced by new problems and challenges, along with a new set of medical and ethical issues. Health care resources have always been in limited supply. These resources vary tremendously, depending upon location. Broadly speaking, the resources are less limited in larger communities, especially when a university or major clinic is present. In the past, the major limited resources were well-qualified, trained health care professionals. Recently, however, the resource that is causing the most limitation of delivery of health care is financial. There is always the question of whether we should be spending our tax revenues on defense, the environment, schools, or health care. How much of private employers' gross revenue should be spent on providing health care to their employees? No country spends as much of its gross national product (GNP) on health care as the United States. The reasons for this are beyond the scope of this particular article. Health care expenses are curtailed in such countries as Britain, Canada, and Germany by the government controlling how health care dollars will be spent. Limiting physical resources, that is, the number of hospital beds, the number of operating rooms, the availability and supply of health care workers including physicians, automatically limits the type and availability of health care provided. Subtle long delays in allowing care and surgery to take place will serve to decrease expenses. Some patients will get tired of waiting for care, some will get better without it, and others will progress to the point where care is no longer necessary, especially when the delay directly or indirectly leads, ultimately, to the death of the patient. Society has been given a not-so-subtle message as to who will receive certain types of services as provided by the state. Acceptable or not, the government has made a number of moral and ethical decisions that will decide how to rank the types of medical care by importance. Priorities are given to life-threatening medical conditions, but even within that group priority is given to treating children and young adults who have the greatest possibilities of survival first. Physicians may have to learn, in a way that is acceptable to both themselves and their patients, how to deny care that they consider to provide only a marginal chance of clinical improvement. There has always been a natural selection process, based upon the limited number of patients that can be cared for by a physician and the judgment calls made by every physician as to whether or not to offer certain types of care regimens or surgical procedures. Medical judgments always must made regarding whether or not an individual may benefit from or survive a procedure or a treatment, before recommending this procedure or treatment. In the future, many of these judgment calls may have to be made on economic as well as medical, moral, and ethical considerations. Although elective surgery for problems such as cataracts, lid abnormalities, and prostate disease is available in other countries, patients may wait months or years before they have these problems remedied because of the limited resources available. This delay, by itself, is a subtle way of decreasing the cost of medical care. Even though the technology is available and the surgeons are just as good as they are in the United States, the population learns to live with their 20/40 (or worse) cataracts and their droopy eyelids while scarce resources such as operating rooms, nurses, doctors and ambulatory surgery centers (if they are available) are used to treat more socially pressing needs, such as life-threatening issues as cancer, trauma, diabetes and vascular disorders, and severe degenerative diseases that make it difficult to be self-sustaining and independent. In countries with extremely limited resources, it is not unusual for a patient to wait for blindness before seeking care (if it is even available) for their cataracts (patients believe that it is as normal for cataracts to turn white as for the hair to turn white.) For those who choose not to wait, if they can afford it, they have the option to leave the system and to seek their care elsewhere in the private sector (often in another country). Some may see this as discriminatory, but no one who really needs care, as defined by the state or in this country by the managed care plan, is officially denied care. There have been no studies to show that, overall, the outcomes of these systems in European countries significantly impact on the longevity or quality of life as we know it today, but it must affect those individuals who do not get the needed care. The heart of the debate on health care in the United States today is driven by a number of factors, such as: (1) a capital intensive economy, (2) a perceived oversupply of physicians and healthcare resources, (3) a significant variation in the distribution and availability of resources, (4) an aging population, (5) a robust economy, (6) a market-informed health care community, (7) a surging demand for all health care services, and (8) the realization that surgery to change ourselves and our perceived image is available and safe. The problem—and question that needs to be asked—is whether it is the role of the society to control the distribution, availability, and funding of these services.