By Dr D Ramamurthy
Motivation is the cornerstone of excellence and achievement. It drives innovation and fuels competitiveness. An athlete striving for gold in the Olympics, a scientist dreaming of the next big discovery or invention, a doctor battling an affliction, or a teacher imparting knowledge—motivation is as important a determinant of outcome as is skill and competence. But the converse holds equally true—there is a tipping point that flips motivation and clarity into de-motivation and enervation, affecting organisational behaviour and individual action both. In the case of doctors and healthcare professionals, the urge to be part of this profession is often guided by an altruistic purpose or driving force to heal people and be of service. A great example are the doctors who join Médecins Sans Frontières, or Doctors Without Borders, and volunteer their time all over the world. In the medical field, motivation is also linked to the strenuous process it takes to become a certified doctor. An American physician, for example, has to undergo about 14 years of training for the job—four years of college, four years of medical school, and residencies and fellowships. In the UK, it takes a would-be GP between 10-12 years before being fully qualified. In India, the process lasts 10-13 years, depending on the specialisation. Correlate this with the time taken to specialise in fields such as management, engineering, academia or aviation. Becoming a specialist in the medical field takes perseverance and motivation. So, what is that tipping point that can threaten to derail a doctor’s work and his commitment to offering his patients the best possible care?
I believe ‘price control’ could be that tipping point for the intra-ocular lenses (IOL) industry, of which I am a part (as an ophthalmologist). For the layman, the human eye has a natural crystalline clear lens, which focuses the rays of light on the back of the eye (retina). With age and certain diseases, this lens opacifies, blocking light from going into the eye. This condition is called cataract. The only treatment is to surgically remove this opaque lens and replace it with a clear artificial lens, which is referred to as the IOL. Price control, if undertaken in the IOL segment by the government, will seek to place price-caps on the market cost of IOLs (as has already been done in the case of heart stents and orthopaedic implants). However, correlating the IOL industry with stents and orthopaedic implants is not an apples-to-apples comparison. Not only would the benefits of such an act be far and few, it might even be counterproductive for doctors and patients alike. Let me explain how. Cataract surgery, while being one of the commonest surgical procedures performed on the human body, is also the most delicate (involving not just the IOL, but also expensive surgical equipment).
The operation is truly life-changing: though it does not add years to life, it adds life to years of an individual. With the current cataract technology and IOLs available, cataract surgery is not just vision-restorative, but also is vision-enhancing. In India, the conquest of reversible blindness caused by cataracts has truly been a success story. This has largely been possible because of the government and NGOs working in tandem and the robust contribution of Indian ophthalmologists. Although 1 in 5 of the world population is an Indian, every third cataract operation in the world is performed in India. Approximately 6.5 million cataract surgeries are performed in India each year, which is more than the total done in the US, China and Western Europe combined. Most of these surgeries lessen or completely negate the need for thick glasses post the operation. A successful surgery using high-end and specialised multifocal or Toric lenses can ensure that even an 80-year-old can enjoy the quality of vision that s/he had at the age of 20, without the use of glasses. Such high-end medical technology comes at a price, as many millions of dollars are spent on developing these lenses along with the surgical technologies that go with it.
Price control adds to the list of other limitations already being faced by the medical ecosystem, such as a big gap between supply and demand of good and qualified doctors, for example, and threatens to impact the symbiotic relationship between patients and doctors. Price control in the IOL segment would limit, for example, my ability to provide the best possible treatment to my patients as it would take away my operational freedom of choice. By forcing me to choose from a limited set of device providers—basis cost rather than quality also—it would foster an uncompetitive ecosystem that benefits a few companies at the cost of many. Unlike in the case of heart stents or orthopaedic devices, where the issue leading to price control was that of a shortage of Indian-made devices, the case is quite the reverse in the IOL segment. The market is dominated by Indian players across all price ranges, so the question of Indian patients not having ‘access’ to high quality IOLs across a wide price range does not arise. In fact, IOLs are available from the very affordable to the very expensive, depending on choice and function both.
In such a situation, doctors would appreciate the freedom to choose the right device for their patients. To have that taken away from them is not only unfair, but also does not make sense because patients are never denied treatment because of the cost of a lens. In fact, the problem in the IOL sector is totally different—that of a huge shortage of capable doctors, which both private and public healthcare service providers need to address. In such a situation, implementing a price cap on IOLs will only be a short-sighted move limiting the wide variety of choices patients and doctors have today. Solving medical problems requires the right tool, not a convenient tool. The real effect of price control in healthcare has been bluntly but accurately summed up by the Stanford University professor Alain Enthoven as more similar to “bombing from 35,000 feet, where you don’t see the faces of the people you kill.”
(The author is Immediate Past President, All India Ophthalmological Society and Chairman of The Eye Foundation)