Ophthalmology

Timo Tervo

Competition from a widely expanding private sector and the pressure of foreign investors imperil fairness and efficiency of the public health care system in Finland.

“When I started my career at the University Hospital of Helsinki, everyone was working full time there. Now 90% are part-time workers, and this applies to all the public hospitals in the country. For-profit clinics absorb a lot of the medical working force and working time because they pay more,” Timo Tervo, MD, said.

Specialists keep one foot in the public sector because “they learn in the hospital and make their money outside the hospital,” he noted. However, this creates problems for hospital administration and causes concern about the future of health care for the more vulnerable segments of society.

“Full-time hospital doctors are paid a monthly salary and nothing else,” Lasse Lehtonen, MD, PhD, chief administrative physician at Helsinki University Hospital, said. “Only night duties are paid extra. Outside, they have a chance to earn three times more. Keeping the interest and loyalty to serve in public hospitals alive is a challenge.”

Multinational corporate control

Finnish ophthalmology departments have been unable to meet the growing demand for services in recent years. Cataract and glaucoma patients, for instance, have increased by 20% to 30%. Because by law treatment must be provided to all patients within 6 months from diagnosis, hospitals buy a certain number of services from private clinics to accommodate the overflow beyond their treatment capacities. Thus, the national health system occasionally covers treatment in private clinics.

“This and the high quality of our services has made Finnish health care a lucrative target for multinational investment companies such as Bridgepoint and Triton,” Dr. Tervo said. “They are buying ownership of private clinics, including the three largest private clinics in Finland, and have become an awkward presence in our country for a number of reasons.”

The companies refuse to give information on who their investors are, offering no guarantee that their money comes from legal sources, Dr. Tervo said.

In addition, because they hold such a large share of the private health care market, the investment companies have caused an increase in costs and a decrease in quality of care.

“The ethics of ophthalmology is changing,” Dr. Tervo said. “Patients are becoming customers, and for-profit clinics are attempting to create demand for unnecessary procedures. Cataract operations are often ‘sold’ to people who are 20/20 and should not have their refraction corrected by lens surgery. There is a lot of flagrant cheating on visual acuity, and when patients come to us for secondary cataract, we often find no information on preoperative visual acuity on their records, so we don’t know if there was an indication for surgery in the first place. This is not patient care but market strategy.”

Another issue is the lobbying of these for-profit, investor-owned chains against recent efforts to provide private services within hospital facilities.

“At Helsinki University we have recently developed an ambitious project which would help us keep our working force and avoid buying services from external outsourcers. The project is that of setting a private center within the university hospital of Helsinki, a sort of clinic in the clinic where specialists will offer private consultations and services utilizing hospital facilities,” Dr. Tervo said.

“We are encountering fierce opposition by private health care service providers and their multinational investors. However, we are not going to give up our battle. All we want is to compete better with private companies, with the same rules, and not be a giant bigger than they are but with our head cut,” Dr. Tervo said.

Health care organization

The Finnish health care system provides universal coverage to all citizens, independent of social status or income. About 80% of its funding comes from income tax, with the remainder derived from parallel social health insurance schemes.

Lasse Lehtonen

“The Ministry of Social Affairs and Health is the highest national authority for health care policies, but health administration is decentralized,” Dr. Lehtonen said, “and municipalities, which collect a large proportion of their citizen’s income tax, have the responsibility to establish priorities and allocate funds on the basis of their need for services. Municipalities also have the freedom to merge, collaborate or contract with other municipalities to optimize resources.”

There are 597 active ophthalmologists in Finland. Roughly 50% are employed in the public sector but also practice in private clinics.

There are no optometrists in Finland, but there are a large number of opticians for fitting spectacles and contact lenses. In rural areas, ophthalmologists often practice within optical shops.

“Population needs are reasonably well covered,” Dr. Lehtonen said. “Most of our population is in the south, where there are also our larger cities and university hospitals.”

However, more specialists are needed in fields such as retinal surgery, pediatric ophthalmology and ocular tumor, he said.

“We need a better planning at source. There is no lack of ophthalmologists, but most of them tend to converge in certain subspecialties and neglect other areas,” Dr. Lehtonen said. – by Michela Cimberle

For more information:

Timo Tervo, MD, can be reached at Helsinki University Eye Hospital, P.O. Box 220, FI-00029 HUS, Finland; email: timo.tervo@hus.fi.

Lasse Lehtonen, MD, PhD, can be reached at Helsinki University Central Hospital, HUS Group, Stenbäckinkatu 9, Helsinki PO Box 100, FI-00029 HUS, Finland; +358-9-471-71240; email: Lasse.Lehtonen@hus.fi.

Disclosures: No products or companies are mentioned that would require financial disclosure.