Evidence-based medicine key to allocation of resources

Montréal-Ophthalmologists can direct and shape the future of medicine with changes in the health policy paradigm and commitment to more active involvement in the evolution and the efficacy of services, according to William L. Rich III, MD.

He spoke about the tragedy of the commons as it relates to ophthalmology and society. The tragedy of the commons refers to the fate of the commons in English society. Towns had a common grazing area for livestock and the citizens had the right to allow a certain number of animals to graze there. When the grazing areas were depleted, the towns failed.

"Within medicine, we can look at our commons, i.e., our resources, as what society allocates for the delivery and maintenance of society's health and the provision of care. In the United States, we have had interesting evolving relationships since the early 20th century with government and payers assuming more and more responsibility for the provision of that care," Dr. Rich said.

History of U.S. healthcare

Before 1929 and health-care insurance, physicians were paid in cash or by barter arrangements. Because many patients were too poor to pay for services, they did not have access to healthcare. This in turn led to problems with biomedical resources, because of the absence of money invested in it, Dr. Rich recounted.

"The response to societal pressures was the creation of commercial insurance in 1929, first in Texas to attract teachers and 1 year later in the Northwest in the timber industry to attract a workforce. Prepaid insurance also was a reflection of economic pressures. Kaiser initially was a construction company in California that opted to share the cost of medical care with insurers and hospitals," Dr. Rich explained.

From 1930 and thereafter, however, the U.S. population, specifically the poor and the elderly, was at continued risk of adverse health outcomes because of lack of financial and geographic access to health services.

"As late as 1964, only 54% of the elderly had access to health insurance compared with 75% in commercial markets," Dr. Rich emphasized.

"This meant bad news for ophthalmologists, who had restricted revenue streams because most elderly individuals lived below the poverty line. Compared with other medical specialties, ophthalmology was not an eminent specialty," he said.

Society began to address health-care problems in 1934, when as part of The Great Society, President Roosevelt proposed national health insurance, followed by President Truman in 1945. However, the concept was too costly to implement. In 1952, Truman, in an attempt to make healthcare more affordable, targeted the poor and elderly, and devised Medicare, which also failed to pass into law. Medicare and Medicaid finally passed in 1964.

"After this, ophthalmology grew rapidly in prestige and fresh capital started to flow into ophthalmic research because of the exponential growth in people who were eligible for insurance coverage. As Medicare spending grew exponentially, Congress tried several methods to distribute and control the costs more equitably. From 1964 to 1992, ophthalmologists were paid on average the actual charge to the patient. Those were the halcyon days," Dr. Rich explained.

The concept of resource-based relative value scale then was developed with three goals: to pay physicians in a more rational way based on the inputs they needed to supply a particular service, to redistribute the flow of income into cognitive services to increase the application of primary care services, and to slow the growth of expenditures.