New research from Queen’s University, the Institute for Clinical Evaluation Sciences (ICES), and the University of Toronto’s Temerty Faculty of Medicine shows that people of lower socioeconomic status are less likely to receive cataract surgery at for-profit surgical centres that have received public funding, compared to those in high socioeconomic status groups. 

A cataract is a medical condition where the lens of the eye becomes cloudy or opaque. When a cataract forms it prevents light from passing through the lens properly, causing blurred or distorted vision. Cataract surgery involves removing and replacing the cloudy lens with a clear artificial lens.

Like many other surgical procedures during the COVID-19 pandemic, cataract surgery rates declined. To make cataract surgery more accessible, the Government of Ontario funded private for-profit surgical centres to reduce the backlog.

Robert Campbell, a clinician-scientist and deputy head of the Department of Ophthalmology at Queen's University and a senior adjunct scientist at ICES, was the lead author of a study investigating the effectiveness of public funding in achieving equitable access to cataract surgery. 

The study was published in the Canadian Medical Association Journal (CMAJ). 

“Cataract surgery is the most common operation in Canada and access has always been an issue,” says Dr. Campbell. “There is a clear need for new ways to approach surgical funding, especially in the post-COVID world. This means continuously exploring new ideas, and adapting practices based on evolving evidence. It is important to be innovative and open-minded in searching for the best approach to health care.”

Identifying inequalities in surgical access

Dr. Campbell’s team analyzed more than 900,000 cataract surgeries in Ontario between 2017 and 2022 and explored the effect of socioeconomic status on access to surgery at public hospitals versus the private for-profit surgical centres. The researchers also compared data from before and after the funding changes, which were implemented in response to the COVID-19 pandemic's impact on surgical availability.

The results showed that the proportion of cataract surgeries conducted at private for-profit centres increased from 16 per cent before the pandemic to 23 per cent after receiving public funding. However, the increased rate of cataract surgeries at for-profit centres did not impact all demographics equally, with surgical rates for the wealthiest patients rising by 22 per cent, while the rate for the least affluent patients fell by 9 per cent.

“Despite an infusion of public funding into private for-profit surgical centres that was designed to cover facility overhead running costs and enable access to care regardless of ability to pay, rates of cataract surgery at these private for-profit centres have improved mainly for those with the highest socioeconomic status,” says Dr. Campbell.

The findings raise important questions about the effectiveness of contributing public funding towards for-profit surgical centres to achieve equitable access to healthcare services and highlights a troubling trend where funding aimed at improving accessibility has instead widened the gap between affluent and lower-income patients.
“The current model has led to improved access for wealthier patients but has not sufficiently addressed the needs of those with lower socioeconomic status,” says Dr. Campbell.

Removing barriers to surgical care 

Dr. Campbell notes that while the results are unexpected, one potential explanation is that surgeons and for-profit centres have financial incentives to prioritize patients who pay for extra services. Extra services are uninsured and can include intraocular lenses with specific features, and procedures designed to decrease the need for glasses. These services are charged to patients to offset overhead facility costs, generate profit, and can lead to private facilities prioritizing affluent patients over those with low socioeconomic status.  

Dr. Campbell acknowledges that more research is needed on the topic, but that a possible solution is a unified surgical waitlist system where patients are not penalized based on their ability to pay, suggesting that such measures could help mitigate the observed disparities.

“A unified waitlist, in its simplest model, would consist of one waitlist for an area or region where patients would see the first surgeon available, regardless of their ability to pay for extra services,” he says. “Ensuring that financial conflicts of interest do not influence patient care decisions remains a priority.”
  
To learn more, the full journal article, “Impact of expanding private for-profit cataract surgery on lower socioeconomic status patients: an Ontario population-based study,” is available in the CMAJ.