First Do No Harm

As I’ve become balder and more grey, I have come to think about the health system as much as the delivery of acute care.  This is another advantage of FOAMed.  It allows you to broaden your horizons and still stay in touch with the latest in your chosen specialty.  I would like to share a story that has brought me out of the blogging wilderness.

Last week, I looked over the fence and noticed my neighbour had her arm in a cast.  She told me she had fallen over playing tennis and fractured her wrist.  She had been seen by her GP first, then sent up to a local private emergency department.  This would have cost her a few hundred dollars which, as a regular middle class family,  would have been affordable. She told me she was due to see an orthopaedic surgeon in a couple of days.  I knew him and passed on to her my confidence in him to sort things out.

A few days later, my distressed neighbour knocked on my door asking for help.  She had seen the orthopaedic surgeon and had been given a quote for the operation.  She would be out of pocket nearly $4000.  This didn’t include the anaesthetist’s fee.  This was despite her having full private health insurance.

For those not in Australia, we have basically two hospital health systems. The first is the public system which is fully government funded and free to everyone.

The second is the private system, which is partially funded by the government through Medicare and also funded by the private health insurers.  There is also often an out-of-pocket fee to be paid by the patient.  The fee charged by a private specialist is a combination of all three.  The hospital fees (bed fees, theatre fees, etc) are usually fully covered by the private insurers.  Private health insurance is taken up voluntarily by individuals and lets say costs about $2ooo per year for full cover.

In my neighbour’s case, Medicare and the private insurance would pay about $1200 for the proposed procedure.  The quote given was nearly $5100.  The patient was told the operation wouldn’t take more than 90 minutes.  The other information given to the patient was that she must sign an agreement to use this orthopaedic surgeon’s physiotherapist after the operation.  If she didn’t use them, the orthopaedic surgeon would not see them at all after the operation.

My intention is not for this example to be derogatory for the Australian private health system.  It is an efficient, well functioning system that provides fantastic care for many patients in Australia.  Nor do I intend for this to be an individual witch-hunt.  The very large out-of-pocket fees seem to only exist in a few specialties and for no obvious reasons other than history and politics.  In the past, I have discussed similar issues with my orthopaedic colleagues and was once told, “Yes, but you work in a care model and we work in a business model.”  Of course I understand that the service costs money, but we all know that these kinds of practices are not struggling to break even.  They are a business motivated to maximise profit.

Maybe that just highlights a different set of values, but the trouble is, you can’t have it both ways.  If you want a true business model then the service should be subject to market forces like any other business.  As is stands, patients generally can’t find out the costs until after they have seen the surgeon and paid for the consult.  This makes it pretty hard to “shop around” like a consumer in the normal market.  Also, the Australian Medical Association sets suggested fees, which again vary wildly between specialties in terms of out-of-pocket costs, and could be considered price-fixing in a true commercial market.

The other big-picture issue is that it is not a sustainable model.  More and more people will be driven out of private health insurance, placing an even greater strain on the overloaded public health system.

All those “business” issues aside, what about the real issue?  The patient. What about our ethics and non-maleficence?  I have seen first-hand that these kind of fees cause harm to the patient.  They cause emotional stress, loss of confidence in their treating doctor and delay in care while they consider financial options.  This is an issue we should be considering when we provide care to our patients and set fees for the service.  And maybe it is an issue for the government to sustain a viable private and public health system in this country.