This study investigated the costs of cataract surgery from four different graded providers in two provinces of China and analyzed the variation in costs. The results of this study may not be necessarily representative of patients presenting in the other regions of China. The mean total cost for one cataract surgery episode from two hospitals in capital cities, ZOC and UH, was more than 1,000 US$. The lowest cost was from JCH, approximately 536 US$. In all providers except for JCH, the cost was more than annual disposable income of local rural residents. Especially in the UH, the cost was twice as many as annual disposable income of local rural residents.
Except the proportion of patients with reimbursement in UH was at only 36%, the proportion in the other three hospitals was more than 60%. There were significant variations in reimbursement ratio from different regions. The mean reimbursement ratio was higher in ZOC than in three hospitals in Hubei province. The more economy develops, the higher reimbursement ratio is. Urban patients can be reimbursed at about 40-95% from social medical insurance. Seven years ago, rural patients must pay the cost all by themselves[15
], but at present, more than 90% rural residents can be reimbursed due to the attendance of NCMS. However, the ratio of reimbursement for rural patients was approximately 30%, which was significantly lower than urban patients[16
China's economic development is characterized by wide geographic disparities between the coastal regions and the central/western regions. Two thirds of China's population, or around 900 million people, live in rural regions that are largely under-developed and have received few medical services. China had developed a successful health insurance system (Cooperative Medical Scheme, CMS) in the rural areas since the 1950s. Unfortunately, CMS collapsed during the shift towards a market economy at the end of the 1970s[17
]. The New Cooperative Medical Scheme (NCMS) is a 'voluntary' and heavily subsidized program established in 2003 to reduce the risk of catastrophic health spending for rural residents in China [15
]. The scheme coverage was 95.9% in Shandong province and 88.0% in Ningxia province in 2006[19
], and 85.9% of the total rural population by the end of 2007[16
]. However, the reimbursement ratio of the scheme was only around 30% of inpatient expenditure.
The relatively poor economic condition in rural areas is a major issue influencing the feasibility of performing cataract surgeries [20
]. In 2001, Helen Keller International (HKI) initiated free cataract testing and a low-price, high-quality cataract surgery program in rural areas in south China [9
]. Surgery was subsidized by HKI and priced at 66US$. A total of 80% of those surveyed stated that they were willing to pay something for surgery, but only 56% of these respondents stated a willingness to pay amount of 66US$ or more. Blind subjects were significantly more likely to pay anything for surgery, but would pay on average 32US$. The patients suffering from cataract were mostly older patients, and many of them were no longer in control of their family's income. Compared with the rural annual income per capita, the expensive cost for cataract surgery may be an important contributing factor for the low CSR in rural China.
In our survey, the number of patients from rural regions was significantly lower than that from urban regions. Jingshan County located in central China owns 640,000 people, with approximately 440,000 people living in rural areas. Our data showed that the cataract surgery rate (CSR) per million in Jingshan County was 552, about one-tenth of that in the United States[21
]. Therefore, there is apparent potential for an increase of CSR in China, especially in rural areas.
A large variation in costs of intraocular lens was found in four providers. A foldable intraocular lens (IOL) is more expensive than an equivalent rigid IOL. In ZOC, all patients were implanted with foldable intraocular lens. The variation of total costs among patients mainly came from the cost of different IOL types. Costs of multi-focal intraocular lens or adjustable intraocular lens were more than 1,100 US$, which were too expensive to be reimbursed; thereby most patients chose single focus intraocular lens. In three hospitals of Hubei province, neither multifocal nor adjustable intraocular lens was used. All four providers used imported lens. Although there are cheaper domestic lens, none of domestic lens was used in these hospitals because patients thought that the quality of imported lens was better than domestic lenses.
Under the current conditions, phacoemulsification and small incision surgery have allowed cataract surgery to be conducted on one-day-case basis, and then it is feasible to use eyedrops to prevent infection. A large part of cost was spent on the usage of antibiotics by vein injection in UH and FHJ. Therefore, using antibiotic eyedrops instead of intravenous antibiotics would decrease 20% cost of cataract intervention.
There are no qualified surgeons of cataract surgery in Jingshan County Hospital. In China, there are around 2,200 counties like Jingshan County; and the overwhelming majority of county hospitals have neither qualified surgeons nor expensive equipments for phacoemulsification. Qualified surgeons from provincial capital carried portable phacoemulsification equipments to county hospitals and then performed cataract surgeries once or twice a month, which was a common health care activity. It is obvious that the phacoemulsification procedure is more expensive than ECCE. Manual small incision cataract surgery (MSICS) is a modified form of ECCE performed through a 6.5 to 7.0 mm sclerocorneal tunnel [22
]. As compared with phacoemulsification, MSICS is almost as effective and more economical [10
]. The advantages of MSICS as a low-cost "equally effective" technique make it an alternative, especially in rural regions in China. There are severe shortages of skilled cataract surgeons in the majority of county hospitals in China; thereby it is essential to train qualified surgeons for these hospitals.
Most of Chinese elderly population is rural-dwelling and cataract is the leading cause of blindness and low vision in this group. Approximately 66% of the cataract operations were conducted in county hospitals with limited eye care services and 34% in specialized and provincial center [20
]. Because of the low benefit level and low reimbursement ratio, patients had to face a very high financial burden even after NCMS reimbursement[17
]. Moreover, the shortage of cataract care specialists in county hospitals is also a barrier for many patients who need cataract surgery. Consequently, efforts should be made to increase the financing of health care and to train qualified surgeons for county hospitals.
Finally, the data from four different graded providers were provided in the results, which were of potential use to blindness prevention programs. However, there was no a statistical point of view in our report, and the selected four places could not fully represent the status of other areas in China. Further work is needed to explore the cost-effectiveness of cataract surgery in different graded provided in China.