When it comes to cataract surgery, is there more to Ontario’s private clinics than meets the eye?

Will that be on your OHIP card or your credit card?

Premier Doug Ford's controversial plan to move more surgeries out of hospitals and into independent clinics to clear a pandemic backlog has fuelled concerns about the upselling" of medical services not covered by the Ontario Health Insurance Plan.

The issue has been on the radar since auditor general Bonnie Lysyk's 2021 annual report said cataract patients - who suffer blurred vision from the aging lenses Mother Nature provides - are the most prone to misleading sales practices" in some circumstances.

While Ford repeatedly insists patients will pay with their OHIP card, never their credit card," the credit card option legitimately comes into play if you want artificial lenses that do more than the type covered by provincial health insurance.

The question is simple: if you require eyeglasses or contact lenses now, do you want to keep wearing them?

Or not?

If you're tired of specs on your nose and contacts in your eyes, that's where legitimate extra costs arise. Seeing properly without them requires - get ready for some technical jargon - multifocal or toric aspheric lenses and more precise tests to determine how they must be tailored to your vision needs.

Those hard-to-pronounce replacement lenses are not provided by OHIP, which pays only for an ultrasound lens measurement test and the implant of a medically necessary" monofocal spherical lens.

As I always tell my patients, there is a standard lens that is covered. You don't have to pay anything," said Dr. Sherif El-Defrawy, ophthalmologist-in-chief at the not-for-profit Kensington Eye Institute, which is affiliated with the University of Toronto.

It gives excellent vision," added the surgeon, a professor and the chair of U of T's department of ophthalmology and vision sciences.

Thanks to advances in science, replacement lenses can be crafted to fix a number of vision problems such as astigmatism, nearsightedness, far-sightedness and difficulty reading - which lessens or eliminates the need to wear glasses.

The maximum cost at Kensington is typically $1,700 per eye for a trifocal toric aspheric lens. The lens costs $1,400 and associated extra tests add $300. The value of the standard OHIP lens is deducted, because the province still pays, in a sense, to get rid of that cloudy cataract.

For those unsure of which route to take, El-Defrawy offers this:

If a patient thinks, If I pay more for a lens, I'm getting a better lens,' that's not true. What you're paying for is the convenience of not wearing glasses as often."

He estimates 10 to 20 per cent of patients at Kensington go for lenses beyond the OHIP coverage.

With glasses no longer required in most cases, the surgery kind of pays for itself," said Dr. Barry Emara, an ophthalmologist and co-owner of the Windsor Surgical Centre, which provides similar services in the border city.

The plan to move more surgeries and diagnostic procedures like MRIs and CT scans out of hospitals and into private clinics - known at the Health Ministry as independent health facilities" - builds on what has been happening in the province for years.

There are 900 such facilities already doing work covered by OHIP, the vast majority performing tasks like blood tests, lab work and X-rays, with a fraction doing surgeries, like Kensington. Others do colonoscopies, for example.

Critics including New Democratic Party Leader Marit Stiles and health-care unions charge the Ford plan, which will also see more hip and knee replacements done outside of hospitals starting in 2024, erodes medicare by moving procedures to outside clinics and could worsen staff shortages in hospitals.

I think the solution is absolutely going in the wrong direction," Stiles said, citing the possibility of corporate, for-profit clinics as the biggest danger.

El-Defrawy says his concern on that front is that surgeons in a corporate setting could be given quotas for non-OHIP lenses.

I've really stood against the whole idea of private centres because of the worry of private equity," he said, but right now we need solutions ... and this is going to require real oversight."

The auditor general's review of complaints to the Health Ministry and patient ombudsman found they were filed by patients being charged after receiving a publicly funded cataract surgery because they were misinformed of their right to receive standard surgery, free of charge through OHIP, without any add-ons."

She concluded that the ministry has no oversight mechanism to prevent patients from being misinformed."

Health Minister Sylvia Jones, who maintains the status quo is not an option" to fix long waits in a health-care system whose weaknesses were further exposed in the COVID-19 pandemic, will issue a call for proposals for more independent health facilities this summer.

The Windsor Surgical Centre, which was approached during the pandemic by Windsor Regional Hospital to take over its cataract surgeries, will likely apply, says Emara, who has privileges at the hospital and sees patients and performs surgeries at both facilities.

That's really the long-term plan," he added, noting one of the surgical centre's four operating rooms has been built with leaded walls that would be needed to protect X-rays from leaking out during hip and knee replacements.

Cataract patients in Windsor are given a questionnaire during a consultation with their ophthalmologists to determine their vision needs, which includes offering lenses beyond what OHIP covers and explaining the difference in price, then are sent home to sleep on it.

It would be a disservice not to let them know. There is so much innovation happening," Emara said of the options than can eliminate the need for eyeglasses.

It's not our goal when we have patients coming in to upsell' them. I don't like that term. We're simply giving them the information they need," he added, noting the majority of his patients opt for the standard OHIP lens and don't pay a cent out of pocket.

There is good reason hospitals have been getting out of the cataract business, except for the most complicated cases, says Dr. Kevin Smith, chief executive officer of the University Health Network, which includes Toronto General, Toronto Western and Princess Margaret hospitals.

Cataract surgery used to be more invasive and involved, unlike the less expensive and faster in-and-out day surgery of today.

A few decades ago, it was a five-day procedure. You would lay in a hospital bed with sandbags on either side of your head," said Smith.

Now it's a 15-minute procedure with no sutures and a foldable lens. Technology has come a long, long way."

Moving most cataract surgeries to the Kensington clinic on College Street frees operating rooms at the three UHN hospitals for more serious operations. There are 80 surgical suites and 104 operations were performed on Thursday, Smith added.

He said he understands the need to protect medicare and agrees the new surgical plan must unfold with guardrails" in place to protect universal access paid for by OHIP, but says the province must evolve with the times, as cataract surgery itself has done.

It's about change, right? Change is hard," Smith said, acknowledging his preference for a not-for-profit model. I'm happy to work with private sector partners to experiment and see, can you actually do it better, faster, cheaper and create a dividend?"

He is calling on the province to create an expert panel" to monitor the process, such as ensuring hospitals don't lose staff.

In the meantime, on the consumer protection front, there is a push for regulations requiring more easily accessible information on pricing for the various options to fix cataracts.

There is limited and often technical information online from most eye clinics to guide cataract patients who are wondering how far to go in getting their eyes fixed and how much it will cost them. Pricing is typically provided only in an in-person consultation, which makes it hard to comparison shop.

A provincial requirement for online price lists would provide more clarity.

No harm in that," said El-Defrawy at the Kensington clinic on College Street.

The more information, the better," Emara in Windsor said. We have no problem with that."

Despite her opposition to the Ford plan, Stiles nevertheless acknowledges more transparent pricing is crucial.

Ontarians deserve to know what this is going to cost them because there's nothing worse - and this is one of our major critiques about upselling - is you're in a vulnerable position and somebody tries to sell you something additional," she said, and you may not feel like you really have a choice."

A statement from Jones's office says details on a robust framework for the oversight of community surgical and diagnostic centres" will come when legislation is introduced soon.

These centres are already required to ensure all prices related to uninsured services are obviously posted in the clinic, that patients have access to OHIP covered procedures at no cost and that access to these services is not conditional on their choice to pay or not pay on additional, uninsured service."

Rob Ferguson is a Toronto-based reporter covering Ontario politics for the Star. Follow him on Twitter: @robferguson1