An anonymous complaint to a health authority has rekindled concerns about the potential for conflict of interest and the limits on access to care imposed by a treatment protocol that creates a lucrative practice for a small number of retinal specialists.
About two dozen designated ophthalmologists in B.C. are making hundreds of thousands of dollars in addition to their regular billings by treating the specific condition of wet macular degeneration, an affliction that strikes elderly people and is treated by injections into the eye.
The complaint letter to the Provincial Health Services Authority in December said the B.C. protocol limits access for elderly patients to a select few ophthalmologists who are approved to administer the treatment, most in metro Vancouver. It alleges there is discord between the retinal specialists and other ophthalmologists who are trained and capable of administering the treatment.
The system "sequesters" the treatment to an elite group within small geographic areas, barring other ophthalmologists from having approved drug coverage for their patients.
Although the treatment was widened geographically to make it more available, there are concerns people who can't afford to travel miss treatment and lose their vision, the letter alleges, because of unfair restrictions.
The writer said it's an "inappropriate" use of public funds that rewards a select few doctors by limiting the treatment for the condition.
The writer said the reason for anonymity is that the author works in the industry and doesn't want to raise interpersonal tensions.
The retinal specialists bill the Medical Services Plan in the seven-figure range for their work. The figures are gross amounts, from which office, staffing and ancillary costs are deducted.
PHSA said the specialists bill MSP for the diagnostic and injection services. A capped administrative fee of $125 is provided by the provincial program to cover the cost of monitoring the safety and effectiveness, data reporting, participating in visiting clinics, quality assurance and other costs.
About 58,000 treatments were provided last year at a cost of $11 million. The budget is developed by an accountability committee of people from the retinal specialists group, the PHSA and the Health Ministry.
The government agreed to start funding treatment for macular degeneration in 2009. Coverage included an expensive drug designated for the condition (Lucentis) and another much cheaper one that wasn't specifically approved but was deemed effective (Avastin).
The fee structure prompted concerns that doctors had an improper financial consideration in deciding which drug to use, given they made far more money if they opted for the cheaper drug.
Access for Sight Impaired Consumers, an advocacy group, wrote to the government in 2013 saying that if the cheaper Avastin were used, it would lead to a robust pool of funds for the administration-fee payments. The group said Ontario was reducing the procedure fees and B.C. specialists were making far more money than elsewhere.
"Why are physicians in B.C. being remunerated significantly more than their counterparts in other provinces?" asked the group.
The ministry told ASICBC that B.C. is the only province that tracks effectiveness of each injection. Both drugs had similar efficacy and safety. If there are no specific clinical factors, then it was considered entirely appropriate for them to use the cheaper drug. The ministry said it was accountable stewardship of limited resources and not a financial incentive.
Some advocates say the findings about efficacy and safety are based on voluntary reporting of side-effects by the doctors using the cheaper drug.
The PHSA said there is no financial incentive for the specialists to use the cheaper drug. "The aggregate annual drug utilization rate recommended by the retinal specialist group allows for sufficient flexibility to treat all patients in the program."
Advocates say there are ophthalmologists in B.C. who are willing and able to do the procedures but aren't admitted to the "club," so they are precluded from including it in their practices.
