Monday, July 5, 2010

Choice in Healthcare?

Great Z has posted again.

Now I admire his blog although it is quite clear that politically we are a little ways apart. I both agreed and disagreed with aspects of his blog.

His story about the choices in his local car wash reminded me of a movie I saw a long time ago (Lady in Red). In this movie a young woman was starting out in a brothel and was told that there were three prices for her product, $2, $5 and $10. "What is the difference?" she asked the madam. "There is no difference", replied the madam.

Health care is however more of a black and white thing. It is either done right or it is done wrong. Actually it is various shades of gray but what makes it less black or less white is more intangible. Those of us in the know all know who our first choice of surgeon or anaesthesiologist would be for any given procedure. We would never think of paying more for them, we just request them. We don't ask for a $2000, $5000 or $10000 gall bladder because we know there shouldn't be any difference.

I have always maintained that if you had three doctors each charging $20, $40 or $60 for a visit, each doctor would be equally busy and that the social strata in each office would be quite similar.

When ondansatron came out 20 or so years ago, it seemed to be clearly a better anti-nauseant than what was available (I am less sure of that now). Unfortunately because of its $20 per dose cost, our pharmacy restricted it. I remember thinking, "I would happily pay $20 in order not to puking out my guts". This is in fact what we did; if a patient came in really concerned about nausea and we saw him in sufficient time, we wrote him a prescription for oral ondansatron, he picked it up and took it pre-operatively. Likewise propofol; I would have happily paid the extra $7.50 in order to be more awake and less nauseated.

Length of stay is another issue, if a patient wants to stay an extra night in hospital and can afford to, why not charge him the extra $1000. The problem here comes, because rich people are notoriously cheap and because frequently patients do have to stay longer than normal, there would be all kinds of disputes over whether the extra night was necessary or not.

Our province and other provinces allow people to pay for MRI examinations. If you have a sore back and want to know what is wrong when your stupid doctor is just telling you to exercise and lose weight why not? This is fine except that radiologists especially when they know the patient has paid out of pocket will never report an MRI as normal. They will find something to report, and the patient will take the MRI to his doctor, and the subsequent follow-up tests, consultations etc will fall on the public sector.

Our hospitals are funded by the government through byzantine and ever changing funding formulas. To raise extra funds, hospitals in Canada depend on revenue from the cafeteria, parking and private room charges. Even then the government insists upon dipping its beak. One of our obstetric hospitals has had for many years theme rooms for post-partum moms for extra cash. Of course because obstetrics is so unpredictable, these rooms are frequently not available plus we discharge normal deliveries so early anyway. The newest of our hospitals was built with no room more than 2 beds. Therefore by definition if you are admitted to that hospital you will get a semi-private. If you keep your mouth shut you will not be charged extra for this semi-private room. If however you don't realize this and ask for a semi-private room on admission, you or your extended health will be billed for this. When I heard this I could not believe the utter sleaziness of the whole arrangement.

Now columnists in the right wing and sadly in a few of the mainstream newspapers are calling for competition in health care as a means of improving quality while decreasing costs. Even our provincial government is once again in the process of getting hospitals to compete with each other. I attended a day long strategic planning session more or less on that.

It would be nice if hospitals actually competed on things like, our infection rate is better, our preventive programs are better, our rehab is better, our costs are lower etc. We all know that that is not going to happen; where hospitals are going to compete is, our theme rooms are nicer, our foyer has better art work etc. We also no that hospitals are going to compete to see who can do the most simple procedures on the healthiest patients, leaving those sicker more complicated for some other hospital. It is already happening.

I did have my car detailed a few years ago and was offered gold, silver or bronze packages. Being Canadian I chose bronze and asked what was included. After hearing all of what was included just in the bronze package, I wondered what more could be included in the silver or gold packages. I had some ideas that were slightly obscene but we really shouldn't go there.

1 comment:

ZMD said...

Your brothel story perfectly illustrates the lack of capitalism and competition in American health care. People with means will gravitate toward the more expensive product, even if the outcome is the same. Unfortunately many Americans who can't afford it still demand the expensive treatment. With government funding and insurance companies obscuring the true cost of treatments, people want nothing but the best ie/costliest care since they are not paying the full cost. If Medicare was subsidizing brothel visits (isn't sex one of life's necessities?) every old geezer would be down at the Chicken Ranch to get his $10 worth instead of paying $2 out of pocket. And if somebody's getting their $10 worth of subsidized nookie instead of paying $2, then everybody will want it, quickly bankrupting the system which is where we are today.