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Year : 2014  |  Volume : 2  |  Issue : 1  |  Page : 19-22

Parental perspectives on surgical fees of pediatric squint surgeries

Department of Pediatric Ophthalmology and Adult Strabismus, Aditya Jyot Eye Hospital, Mumbai, Maharashtra, India

Date of Submission18-Feb-2013
Date of Acceptance10-Jul-2013
Date of Web Publication3-Dec-2013

Correspondence Address:
Mihir Kothari
Jyotirmay Eye Clinic, 205 Ganatra Estate, Khopat, Thane West - 400 601, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2320-3897.122633

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Aim: To report the parental feedback on the 'squint surgery fees' of their ward in an urban private practice. Design: Prospective cohort study. Subjects and Methods: Three months after the surgery, a 10 item questionnaire was administered on the parents of the children who underwent a squint surgery. Multivariate analysis was performed. Results: The parents of 46 children were included. Thirty-three respondents were fathers. The educational status ranged from 6 th grade to postgraduates including doctors. Four respondents refused to disclose the income. The mean total and per capita monthly income of the families were 59,590/- INR (Indian Rupees) and 14,670/- INR, respectively. Thirteen parents found the surgical charges inappropriate. Concession was demanded when the total cost of surgery (28,417/- INR) exceeded the per capita income of the family (10,149/- INR) by three times. The most appropriate cost of the surgery adjudged by the parents was two times the per capita income. The "appropriateness of the fees" had no correlation with the outcome (P = 0.4). All the parents recommended heavy concession in the fees for the reoperations. The quality of the medical expertise was considered the most important determinant of the surgical fees. Of 18 children with mediclaim, 12 had rejection due to 'congenital' nature of the disease. Two were considered "cosmetic". Conclusions: In a private practice, the parental feedback on fees is desirable to make surgical services demand sensitive. Clinician should avoid the term "congenital" in the medical records and loudly express, "restoration of binocular vision" as the indication of squint surgery in children.

Keywords: Medical reimbursement, private practice, squint surgery, surgical fees

How to cite this article:
Kothari M, Baldua S. Parental perspectives on surgical fees of pediatric squint surgeries. J Clin Ophthalmol Res 2014;2:19-22

How to cite this URL:
Kothari M, Baldua S. Parental perspectives on surgical fees of pediatric squint surgeries. J Clin Ophthalmol Res [serial online] 2014 [cited 2022 Jun 26];2:19-22. Available from: https://www.jcor.in/text.asp?2014/2/1/19/122633

A wide variability in the cost of surgical and medical services exists in India as well as many other countries. These variations are primarily dependent on the location of the healthcare facilities, quality of eye care, and nonmedical services offered and the socioeconomic status of the patients. However, usually the pricing practice remains largely imitative, intuitive, and routine. No scientific guidelines are available to help healthcare administrators to reasonably fix the cost of their services.

Over past decade, increasing number of patients has "mediclaim" facilities. However, various hurdles are encountered in availing the reimbursement, especially when a squint surgery is performed.

In this study we aim to report the feedback of the parents whose children underwent a squint surgery in a standalone pediatric ophthalmology private practice in an Indian metropolitan city.

The healthcare managers need to give consideration to the parental perspectives before fixing the cost of the eye surgeries in children.

  Subjects and Methods Top

Parents of 46 consecutive children who underwent a squint surgery between 11 th June 2011 and 10 th November 2011 in our clinic were recruited in this study. We included the parents whose children were aged ≤16 years, who underwent a squint surgery for the first time and who were willing to provide a complete feedback, barring the disclosure of the total income of the family.

The operation theater records revealed that total 54 children were operated for squint during the study period that satisfied the above mentioned inclusion criteria. Out of 54, four parents were not willing to provide the feedback and four were not contactable during the study period.

Before commencing the study, the questionnaire [Table 1] was administered by trained hospital staff on 10 subjects (that data was not included in the study). The interviewer had conducted several surveys in the past. Then, feedback of 46 parents was obtained 3 months after the surgery.
Table 1: Questionnaire for the parental feedback

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Those included in the study were first contacted on phone and an oral informed consent was obtained after explaining the study protocol and its implications. After the parents' approval, a second call was scheduled on the same day at their convenient time.

All the communications were conducted in their preferred language (English/Marathi/Hindi). The data was entered in an excel sheet. Two-tailed t-test with equal variance was used for the comparison of continuous variables and chi-square test was used for the comparison of discrete variables. Correlation (Pearson's r) was calculated for the parental income (total and per capita) and the recommended surgical charges.

The procedures followed were in accordance with the ethical standards as stated in the Declaration of Helsinki of 1975 and revised in 2000.

  Results Top

In this prospective cohort study we included 46 children with the mean aged 5.6 years (standard deviation (SD) 3.4 years, range 1-16 years). Sixteen were boys. Thirty-three respondents were fathers. The educational status of the parent ranged from 6 th grade to postgraduates including doctors [Figure 1]. The educational level of three out of four respondents who refused to disclose the income was postgraduate. Paradoxically graduate parents earned more than the postgraduate parents [Figure 2].
Figure 1: Pie chart depicting the educational levels of the respondents

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Figure 2: Pictogram showing the mean per capita income and total income of the family with respect to the educational level

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Of 46 patients, one patient received the surgery at 75% discount, five received at 50% discount, and two received at 25% discount on the total fees. All the other patients paid full charges as per the existing policies of the clinic [Table 2] and [Table 3].
Table 2: Surgical charges during the study period

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Table 3: Payment policy of the clinic

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Four parents (three postgraduates and one parent with education grade ≤12 were not willing to disclose their income). The mean total income and per capita income of the families (n = 42) were 59,590/- INR (SD 83,949/- INR, median 40,000/- INR, range 3,000-480,000/-INR) and 14,670/- INR (SD 26,190/- INR, median 9,166/- INR, range 375-160,000/- INR).

The mean number of dependents in the family was 4.9 (SD 1.9, range 3-12). Mean surgical fees paid by the parents was 25,500/- INR (SD 7,113/- INR, range 10,000-40,000/-INR). Thirty-nine percent (n = 18) had a mediclaim. However, only four received the reimbursement. All others were rejected citing congenital nature of the disease (n = 12) or the indication for the surgery was considered "cosmetic" (n = 2).

Of 46 patients, 33 found the surgical charges appropriate. Of 13, who found the charges inappropriate, two parents (both parents were doctors) felt that they were under charged by 33 and 25%. The correlation between total income and suggested charges as well as per capita income and suggested charges was poor (r = 0.1 and 0.6, respectively). The mean per capita income of those who desired concession (mean 10,110/- INR, SD 5,072/- INR) versus those who did not (16,000/- INR, SD 28,623/- INR) was low (P = 0.06). The parents typically requested for concession when the total cost of surgery (28,417/- INR, SD 3,686/- INR) exceeded the per capita income (10,149/- INR, SD 6,667/- INR) by three times. The cost of surgery suggested by those parents (21,167/- INR, SD 9,962/- INR) was two times their per capita income.

Mean improvement in the ocular alignment after surgery, as appreciated by the parents, was 73% (SD 27.6, 0-100%). There was no correlation between the parental satisfaction and the desired surgical charges (P = 0.4).

All the patients recommended significant concession in the fees for the reoperations [Figure 3]. This recommendation was independent of per capita income of the family/educational status of the parents/how much patient paid for the initial surgery/how much improvement was felt after the surgery.
Figure 3: Bar diagram showing the parental recommendation for resurgery charges

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Apparently, the quality of the medical expertise should be the most important determinant of the surgical fees followed by the socioeconomic status of the parents/patient followed by threat to vision from the disease [Table 4]. Parents felt that the surgical fees for a disease that present higher threat to the vision should be charged more since the beneficial effect of the surgical correction on vision is proportionately higher.
Table 4: Determinants of surgical charges

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  Discussion Top

There are many factors that an organization must account for when deciding the surgical fees. Healthcare administrators are frequently confronted with a situation where "higher" surgical charges could mean delay in the treatment or discouragement to the parents or an increased stress to the family. On the other hand, to keep up with an ever increasing cost of a medical establishment and maintain cutting edge technology, a clinic must maintain fixed policy of revenue generation.

In a consumer (read as patient) oriented market (read as hospital), novel strategies are adopted by various business models around the world to obtain optimum pricing of their product. In medical establishments pricing practice remain largely imitative, intuitive, and routine. The demand elasticity, customer price sensitivity, and the importance of price differentials, that is, charging different customers different prices for the same product or service, as a means of introducing flexibility are not approached in a systematic or strategic fashion. [1],[2],[3] In this paper we have emphasized the strategy of obtaining the patient feedback to make the pricing of the surgical services more demand sensitive.

In this study, the per capita income of those who desired concession was low. Charges recommended by the parents fell between two and three times the per capita income of the family. Nevertheless, an exact correlation between the total income and the desired surgical fees does not exist.

The patients who need a resurgery were always desirous of the concession irrespective of the complexity of the preexisting disease, socioeconomic status and appropriate counseling about the potential need of the resurgeries. Hence, the surgical fees levied during the first surgery should be adjusted to provide concessions if a reoperation is needed. A 50% concession during the reoperation was considered reasonable.

While justifying the charges of a surgery, the administration should highlight the "superior" or "optimum" quality of the medical care as the reason, since parents appreciate this factor the most.

The medical records must clearly manifest that the surgical indication for correction of the squint in pediatric age group is functional (to restore binocularity and stereoacuity) and not cosmetic. Also, the clinicians must avoid the use of the term 'congenital' viz. congenital esotropia syndrome, congenital nystagmus, etc., because it disqualifies the patient from getting the reimbursement.

There are various limitations in this study. The income related data was sought directly from the parents. There is no evidence that the parents were upright in reporting their income. However, the study was conducted after 3 months of the surgery; hence the parents were assured that the revelation of the total income of the family will not result in any extra charges to them.

The study was conducted in an urban private practice that caters only to pediatric eye diseases and adult strabismus. Variation in the geographical location and the scope of the services can result in different parental/patient perspectives. Also, the cost of the surgery is decided by many other factors like the qualifications and experience of the surgeon, cost and quality of medical and nonmedical services provided by the organization, capital investment, and running cost of the organization and the socioeconomic status of the patients.

In India, free and subsidized medical services are available in government as well as philanthropic nongovernmental hospitals. However, even in a private set up, requests or need for reduced charges are encountered frequently where patients' feedback is a must to appropriately decide the cost of the services.

Our study is first of its kind that has attempted to provide parental perspectives on the surgical fees. The results of the study may have implications on other ocular/nonocular surgeries in children and adults.

In summary, in a private practice, for appropriate pricing and to make surgical services more demand sensitive, the parental feedback is desirable. In the medical records, the clinicians should avoid the use of terminology such as "congenital" and loudly express "restoration of binocular vision" as the indication of a squint surgery in children.

Future studies are needed from various organizations across the country so as to provide guidelines for setting up the surgical fees in a more justifiable and scientific manner.

  Acknowledgements Top

We acknowledge the support provided by Ms Sneha Argade in interviewing the parents.

  References Top

1.Morris MH, Joyce ML. How marketers evaluate price sensitivity. Ind Market Manage 1988;17:169-76.  Back to cited text no. 1
2.Morris MH. Separate prices as a marketing tool. Ind Market Manage 1987;16:79-86.  Back to cited text no. 2
3.Oxenfeldt AR. A decision-making structure for price decisions. J Market 1973;37:48.  Back to cited text no. 3


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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