Cataract surgery: It’s by far the most common surgery done in the country and it’s almost entirely focused on older adults because they are the ones who get cataracts. Because of the demand, access has always been a problem and now, new research out of Ontario shows that economic disparity has also come into play.

The study, published in the Canadian Medical Association Journal and undertaken by Queen’s University, the Institute for Clinical and Evaluation Services and the University of Toronto’s Temerty Faculty of Medicine, found that lower-income patients are less likely to access services at for-profit clinics that receive government funding to cover their surgeries than are those in higher-income brackets.

Ontario’s Ford government increased funding to private, for-profit cataract surgery clinics to address the long wait times, but it seems low-income Ontarians have been less likely to access their services.

“The COVID-19 pandemic exacerbated what was already a long wait for some people,” says lead author and cataract surgeon, Robert Campbell. “So the move in Ontario has been to fund more and more cases to be done in private, for-profit centres, using more public funding.”

Campbell felt that that policy change came with a risk that the “practice patterns or business models” of such clinics may still cater to more wealthy Ontarians by upselling them on extras over and above their publicly funded surgery. That hypothesis was borne out in the research.

“Essentially, our results confirmed that concern, and shockingly so, really,” Campbell says. “The big increase [in funding] over the last period, the vast majority has gone to the wealthiest people in the top 20 per cent or so and there are actual decreases in lower socio-economic status brackets compared to sort of baseline trends before the pandemic. So, it’s concerning and disappointing, but not a complete surprise.”

Campbell says the fact that we’re “pouring more and more public money into something that’s getting worse, not better,” is the most startling finding.

A report by the Ontario Health Coalition found patients who ended up at for-profit eye surgery clinics were faced with extra charges ranging from $50 to $8,000. The report found that some patients were told they had to pay for medically necessary surgeries that were, in fact, covered by OHIP. Others were told they’d face extreme wait times of two to five years if they didn't opt for the upsell options — this when actual wait times for even lower-priority patients is only seven months from referral to surgery. Some reported not receiving “vital information about the effectiveness of OHIP-covered eye surgery” in trying to make their decisions.

Similar approaches across the country

Cataracts occur when proteins break down in the natural lens in the eye and vision becomes cloudy. Symptoms, according to the Canadian Ophthalmological Society, include blurred vision, glare at night, frequent eyeglass prescription changes, decreasing colour intensity or a yellowing of colour, among others.

Cataract surgery policy differs across the country although the Canada Health Act provides for the basic surgery’s coverage and provinces just have jurisdiction as to how they deliver those services.

In Newfoundland, the province agreed to provide funding to private clinics that did the surgeries for the public, but some people ended up paying out of pocket, resulting in the federal government threatening to cut off its transfer payments by those amounts. In the end, the province invited those who’d paid out of pocket to bill it and then found a way for private clinics to bill basic cataract surgery directly to the province’s medical care plan.

Nova Scotia allows private clinics to do the surgeries, which has reduced wait times, but it’s unclear what demographics are being helped the most. Federal Retirees’ member Ken Chaddock did have a good experience, however.

“I have a little bit of astigmatism in one eye and my surgeon noted that ‘This isn’t Toronto, we’re not going to try to upsell you on a $2,500 lens because it’s not going to do you any good,’” Chaddock says. “In Nova Scotia, the ophthalmologists are all private practice [doctors], but the government covers the cost of pretty much everything.”

Quebec, meanwhile, outsources several surgeries to private clinics, including cataract surgery. The practice met with some controversy in the early stages as hospital ophthalmologists were questioning the quality of the work at the clinics vying for the work as their per-surgery quotes were lower than they expected.

Manitoba, Alberta and B.C. also engage private clinics to do some of their cataract surgeries, partly because they all face backlogs as baby boomers age. And there’s a battle over fees in B.C., which the government proposes to lower and doctors have been fighting.

The Yukon government appears to do all such surgeries in hospitals, sometimes with visiting ophthalmologists. The Northwest Territories does all cataract surgeries in a hospital in Yellowknife and also takes care of cases from Nunavut.

Like Ontario, New Brunswick’s government has provided public funds to private clinics, but the health authority still controls the wait lists and that’s one of the policy recommendations Campbell made in his study.
 

Policy changes for public good

Campbell likes the New Brunswick wait list approach because it’s fair and transparent.

“Right now in Ontario, a surgeon or a centre can pick and choose and change their wait lists and that allows them to manipulate things,” Campbell says. “Whereas, if you had a centralized wait list that's controlled transparently and publicly and there's no way to get around that list. Some places already do this to be fair, but it could solve the problem in terms of [limiting the ability] to charge people to jump the queue.”

The other policy change he would make would address a “fundamental conflict of interest” issue.

“Centres and surgeons shouldn't make more for doing the surgery one way versus another way,” he says. “It's still the same operation, whether you'll use lens A versus lens B, so take away the profit incentive and say, ‘This is what you get paid’. Surgeons shouldn't make double, triple, quadruple pay arbitrarily for doing it in a slightly different way. I think you would see the interest in doing extra things plummet.”

Campbell says once a patient opts for the non-OHIP covered lens, the price can then become whatever the market will bear.

“It’s like buying a car where you can shop around to different places,” Campbell says. “You're really stuck in a system and you've got [few] options. And if you want to go back onto somebody else's wait list, [you’re back to waiting again.]”