Medical Students / JMOsNews / Opinion

Public patients scared into paying for ‘superior’ treatment

When a patient ‘goes private’ in the public hospital system they get to choose which physician or surgeon looks after them. Recently in a newsletter for the MJA, Dr. Henry Woo, a urologist and Professor of Surgery, noted that conflict of interests exists when discussing the risks and benefits of staying a public patient versus ‘going private’. A private patient in a public hospital makes the hospital and the surgeon more money but the extra money is coming from the patient’s hip pocket:

http://www.theaustralian.com.au/news/health-science/public-patients-scared-into-paying-for-superior-treatment/story-e6frg8y6-1226025690655

And followed it in the MJA to find:
http://www.mjainsight.com.au/view?post=Henry+Woo%3A+Abuse+of+self-pay+patient+system+widespread&post_id=3784&cat=comment&utm_medium=ET_email&utm_content=sandipnsympatico.ca&utm_campaign=March-20-2011_b2c_20110321_newsletter&utm_source=b2c_20110321_newsletter&utm_term=

(Don’t know how to hyperlink :huh:)

I’ve got little to add to what’s been said, except to pose these questions – faced with the opportunity where a patient has health insurance and was thinking about going into the private health care system would you encourage them? If they hadn’t considered private? What if you were to financially benefit from it?

Have a read of the 4 comments on the MJA link, they’re quite good. I particularly like this comment as it brings to light a whole new issue:

The article deals exclusively with surgical patients. What about medical patients: Can anyone explain to me (an experienced physician) what benefit there is to a medical patient going private in a public hospital, unless there is a surgical episode? They essentially get the same treatment and access to me as the public patients, yet they may get a wad of bills and paperwork to deal with after discharge. Fee-for-service? At one NSW hospital, I was paid FFS – this resulted in a perverse incentive to spend as little time as possible with the patients and more time in rooms (with even a little push from administration to “keep out of the way” of hospital staff!). With administrators refusing to pay the junior staff unrostered overtime, the result was an busy hospital where “from top-down” there was no incentive to spend any time with patients. And with the pressure to discharge early, administratively, all looked fine from the point of view of finances, bed days and benchmarks, but no-one was monitoring any real parameters of quality and safety …

Anyway, off to class!

Edit: Also don’t think this is posted in the right place.. it’s meant for discussion, but I’m rushed and can’t find the right forum! Someone move it for me? 🙂

Ben is currently working as a junior registrar in Intensive Care.
I've made some adjustments to this thread, title and location.<br />
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To be honest, I'm not entirely sure how to interpret this opinion because I really don't know the ins and outs of private vs. public patients despite spending time in hospitals and on surgery terms. The issue seems to be that money is available to hospitals through the private system and, in response to that availability, the system will evolve to maximise the amount of money it can garner. What Dr. Woo is suggesting is certainly unethical but is the sort of thing you're not terribly suprised to hear about.<br />
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The point about the medical patients is an interesting. I'd similarly make the point about checks and balances in the private system. In the public there is the intern, registrar and consultant seeing and taking responsibility for the patient whereas the same is not always true in the private system. I understand you're seen daily by the consultant as an in-patient which is probably ok for surgical patients but might not be for medical patients. Undoubtedly this depends on the private hospital and their scope of practice but large-scale private hospitals are becoming bigger and bigger and taking care of more and more patients. <br />
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Basically, I don't know enough to know.
    The entry at Henry Woo's blog provides an explanation that makes a helluva lot more sense to me and is worth reading if you're interested: <a href=http://surgicalopinion.blogspot.com/>http://surgicalopinion.blogspot.com/</a><br />
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    I also discussed this briefly with a gen surg registrar and a senior resident and it seems to boil down to how much faith you put in the supervision of registrars in hospitals. Dr. Woo argues that with meticulous supervision the outcomes are no different but my experience in surgical theatres would suggest that supervision of registrars by consultants is variable. In some cases it is undoubtedly very good but I get the impression that this is not the case across the board. Similarly the issue of registrar training, by making a patient 'private' for a day or two you deny registrars valuable learning experience and what if this tends to happen regularly for the 'complicated' operations? In these operations the consultant will need to come in and perform the parts too difficult for the registrar anyway so is there any point in 'going private'. Interestingly, there are sometimes cases where the registrar will have more experience with a complicated 'new' operation than a senior consultant does because they haven't had the opportunity learn the new technique. <br />
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    There are some anecdotes in Dr. Woo's blog entry that are quite interesting to read.
    To encourage a patient to go private, particulary when the doctor remains the same is unethical. I actually encounter this a bit in obs, where mothers say to the obstetrician, will you deliver the baby? I'll pay you. For the obstetrician to say yes, is unfair. Despite the fact that this obstetrician does have a number of private patients under his care. They can and will recieve excellent care under the public system.<br />
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    I have noticed that obstetricians were more likely to intervene in private patients to avoid something going wrong and potentially getting sued. For example a lot of patients who hit the 40 week mark get induced. When really the evidence behind inducing is 40 +10-14. <br />
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    some doctors spend more time with their private patients, and be nicer about introducing scary items then they will with their public patients. Not all of them are like this though.
      My experience is that patients certainly do get more attentive treatment from surgeons (including obstetricians) if they are 'private patients'. These patients are more often 'private' from the beginning, though.
      <blockquote>To encourage a patient to go private, particulary when the doctor remains the same is unethical. I actually encounter this a bit in obs, where mothers say to the obstetrician, will you deliver the baby? I'll pay you. For the obstetrician to say yes, is unfair. Despite the fact that this obstetrician does have a number of private patients under his care. They can and will recieve excellent care under the public system.</blockquote><br />
      <br />
      Hmmm... why is this unethical? If you pay for private obstetrician, you are engaging in their specific services (i.e., delivery of the baby and postnatal care) along with additional services from the hospital. If you go with the public system, then you <span style="font-style:italic;">may</span> be delivered by the obstetrician, but it may quite possibly be by a registrar or one of their associates. You can can receive excellent care under the public system but it is <span style="font-weight:bold;">different</span> care. I don't see why the offer of choice is unethical in this instance.<br />
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      Edit:<br />
      With regards to the original article, the issue arises that the surgeon has a financial conflict of interest in suggesting that the patient goes private. Given that the surgeon in the specific scenario holds substantial influence and power over the patient, it may be unethical. In that example, if the financial conflict of interest is removed (e.g., the surgeon takes the patient privately but does not charge above the Medicare rebated fee), then no one would suggest that practice was unethical from the perspective of the surgeon.<br />
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      Regards.
        <blockquote>Hmmm... why is this unethical? If you pay for private obstetrician, you are engaging in their specific services (i.e., delivery of the baby and postnatal care) along with additional services from the hospital. If you go with the public system, then you <span style="font-style:italic;">may</span> be delivered by the obstetrician, but it may quite possibly be by a registrar or one of their associates. You can can receive excellent care under the public system but it is <span style="font-weight:bold;">different</span> care. I don't see why the offer of choice is unethical in this instance.<br />
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        Regards.</blockquote><br />
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        Yes, good point. The argument made by Henry Woo is that choice should be offered but that choice should not be coercion. Which goes back to the very basics of the doctor-patient relationship except in this case the consultant has a conflict of interest.
        <blockquote>Hmmm... why is this unethical? If you pay for private obstetrician, you are engaging in their specific services (i.e., delivery of the baby and postnatal care) along with additional services from the hospital. If you go with the public system, then you <span style="font-style:italic;">may</span> be delivered by the obstetrician, but it may quite possibly be by a registrar or one of their associates. You can can receive excellent care under the public system but it is <span style="font-weight:bold;">different</span> care. I don't see why the offer of choice is unethical in this instance.<br />
        </blockquote><br />
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        The obstetrician saw it as poaching patients from the public system. He felt it was unfair to the patient when they would recieve very good care under the normal system, and if he had allowed it, it may encourage him and others to encourage other patients to go private.
          Firstly, why is "poaching" patients from the public system unethical? Actually, isn't it potentially a <span style="font-style:italic;">good</span> thing since it reduces public costs? Couldn't one make the argument from a health policy perspective, that encouraging patients with the financial ability to pay privately to do so <span style="font-style:italic;">voluntarily and without coercion</span> is in fact the better ethical position as it improves access to resources for patients who rely on the public sector?<br />
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          Secondly, why would it be "unfair" if it were a freely made choice of an informed patient? Is it "unfair" for one plumber to charge $100 for a service and a second plumber to charge $200 when they are both equally good insofar as the "plumbing" outcome? Couldn't one make the argument that restriction of choice in this setting is <span style="font-style:italic;">more</span> "unfair", insofar as respecting patient autonomy? One could construe that this position is somewhat paternalistic as although outcomes may be <span style="font-style:italic;">no better</span> from a biometric perspective, it isn't going to be any worse.<br />
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          Now, I know what you are getting at but be careful differentiating the macro heath policy arguments (i.e., public vs private vs mixed funded health systems) and <span style="font-style:italic;">ethical</span> arguments at micro level.<br />
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          Regards.
          <blockquote>Firstly, why is "poaching" patients from the public system unethical? Actually, isn't it potentially a <span style="font-style:italic;">good</span> thing since it reduces public costs? Couldn't one make the argument from a health policy perspective, that encouraging patients with the financial ability to pay privately to do so <span style="font-style:italic;">voluntarily and without coercion</span> is in fact the better ethical position as it improves access to resources for patients who rely on the public sector? </blockquote><br />
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          but increases them for the patient. I don't believe this lady had private health insurance, and I think fear played a large role in her motivation to ask for the obstetrician to be present. She was 37 weeks and had so far been very happy with public care. <br />
          <br />
          <blockquote>Secondly, why would it be "unfair" if it were a freely made choice of an informed patient? Is it "unfair" for one plumber to charge $100 for a service and a second plumber to charge $200 when they are both equally good insofar as the "plumbing" outcome? Couldn't one make the argument that restriction of choice in this setting is <span style="font-style:italic;">more</span> "unfair", insofar as respecting patient autonomy? One could construe that this position is somewhat paternalistic as although outcomes may be <span style="font-style:italic;">no better</span> from a biometric perspective, it isn't going to be any worse. </blockquote><br />
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          I guess the thing he was getting at was that- to use your example the public plumber was already delivering the service, and didn't feel comfortable saying "come and see me in my private office". <br />
          <br />
          <blockquote>Now, I know what you are getting at but be careful differentiating the macro heath policy arguments (i.e., public vs private vs mixed funded health systems) and <span style="font-style:italic;">ethical</span> arguments at micro level.<br />
          </blockquote><br />
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          I wouldn't argue this in an assignment. Maybe it was also policy, or maybe he made a fuss of it because I was in the room. However I still do not think that it would have been right to simply take her money, especially as she was pretty much under his care already. <br />
          <br />
          I do understand most of this is paternalistic and violates patient's right to choose. Personally I saw precious little benefit in private obstetric care; apart from a private room and increased chance of obstetric intervention (vs.public obstetric care).
          <blockquote>but increases them for the patient. I don't believe this lady had private health insurance, and I think fear played a large role in her motivation to ask for the obstetrician to be present. She was 37 weeks and had so far been very happy with public care.</blockquote><br />
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          True, the cost increases for the individual patient. But you claimed that this cost increase was "unfair", I'm not so sure that you've justified that. As for fear playing a large role in her motivation to ask for the obstetrician to be present, is that not a reasonable motivation? The structure of the health system is that you do not get your specialist of choice under the public system in an acute situation. If it is her preference that a specific doctor be present at her delivery for whatever reason, and she is willing and capable of paying, how is it unethical? Many people choose to utilise the private health sector in Australia in the presence of an otherwise excellent public system.<br />
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          <blockquote>I guess the thing he was getting at was that- to use your example the public plumber was already delivering the service, and didn't feel comfortable saying "come and see me in my private office".</blockquote><br />
          <br />
          ... which we should acknowledge as a personal choice of the physician. It is how this doctor structured his practice and billing. An alternative arrangement in this setting is ethically neutral.<br />
          <br />
          <blockquote>Maybe it was also policy, or maybe he made a fuss of it because I was in the room. However I still do not think that it would have been right to simply take her money, especially as she was pretty much under his care already.</blockquote><br />
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          The usual practice with becoming someone's private obstetrician is that you personally attend to the birth, a duty that is not required otherwise, so it would hardly be "simply taking her money".<br />
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          <blockquote>Personally I saw precious little benefit in private obstetric care; apart from a private room and increased chance of obstetric intervention (vs.public obstetric care).</blockquote><br />
          <br />
          However, it isn't really your opinion here that actually matters; rather the patient's and doctor's opinion. As an aside, private antenatal and obstetric care is substantially different to public antenatal and obstetric care (insofar as timely access to appointments, educational classes, clinical services, facilities, etc.) especially in the low risk/uncomplicated setting. I suspect that you simply haven't been overly exposed to the private system outside of a public hospital (I agree, that private in a public hospital isn't really all that different but you do get your physician of choice).<br />
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          Cheers.
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<blockquote>To be honest, I'm not entirely sure how to interpret this opinion because I really don't know the ins and outs of private vs. public patients despite spending time in hospitals and on surgery terms. The issue seems to be that money is available to hospitals through the private system and, in response to that availability, the system will evolve to maximise the amount of money it can garner. What Dr. Woo is suggesting is certainly unethical but is the sort of thing you're not terribly suprised to hear about.</blockquote><br />
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It didn't suprise me, actually.. which I think was one of the strangest things about it. I'm in a similar position - not able to comment very much on what's been said because I don't know anything about it. With regards to what Vitualis has posted though, I think that clarifies things more for me, at least. I personally feel now that if the patient requested your specific services then it's definitely not unethical to oblige; the choice shouldn't be avoided. Even in the case where the patient hasn't requested it, but you feel that you specifically taking a handle on the procedure would be beneficial then I don't see it being unethical... provided there's no monetary benefit arising from it.<br />
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Interesting article and comments, anyway.
    <blockquote>It didn't suprise me, actually.. which I think was one of the strangest things about it. I'm in a similar position - not able to comment very much on what's been said because I don't know anything about it. With regards to what Vitualis has posted though, I think that clarifies things more for me, at least. I personally feel now that if the patient requested your specific services then it's definitely not unethical to oblige; the choice shouldn't be avoided. Even in the case where the patient hasn't requested it, but you feel that you specifically taking a handle on the procedure would be beneficial then I don't see it being unethical... provided there's no monetary benefit arising from it.<br />
    <br />
    Interesting article and comments, anyway.</blockquote><br />
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    The issue seems to be the conflict of interest though, because as Henry Woo explains there definitely is a monetary benefit for the doctor. So as the doctor it's you're job to educate the patients on the benefits and risks of making a decision contingent upon specialised medical knowledge but you serve to gain money by their going private and they serve to lose money.
      I think that it is important to realise that there is an intrinsic conflict of interest in a fee-for-service system. If you categorically claim that monetary benefit for service/intervention is unethical, then all health practitioners would have to work for salary or charity only. That MIGHT be possible in a purely public system but it implies dismantling the entire current health system.<br />
      <br />
      The case highlighted by Dr Woo is somewhat more complex than just financial gain. Rather, think about the "pillars" of bioethics (autonomy, beneficence, non-maleficence, and justice):<br />
      - is the patient's autonomy respected if they are given distorted information with regards to risk?<br />
      - does choosing the private option benefit the patient?<br />
      - does it harm the patient?<br />
      - what effect does this action have on the just/equitable distribution of health resources?<br />
      <br />
      As you can see, there is a bit of a tension between the various principles of bioethics in this case. You could argue that going private DOES benefit the patient as they receive more timely care. Harm is more difficult to assess; it is principally financial in this setting and would depend very much on the individual setting. The effect on distributive justice is probably neutral; after all, the private health system already exists.<br />
      <br />
      The serious problem is autonomy; if the practitioner knowingly distorts the information given to the patient, it impairs the patient's ability to make an informed choice and as such reduces their autonomy. Further, if the practitioner deliberately instils unreasonable fear, then it would be contrary to the principle of non-maleficence; the harm being a psychological harm.<br />
      <br />
      In this setting, it is particularly a "conflict of interest" because the scenario incentivises the practitioner to behave unethically. However, it would be a mistake to conclude that the scenario in itself (encouraging a patient to have a procedure done privately rather than wait on the public list, where the practitioner is a financial beneficiary) is unethical. It would depend on the actual content of the individual contexts.<br />
      <br />
      Regards.
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In my personal experience the only difference between me choosing to have a minor surgery done privately or publicly was the waiting list. With the private surgeon I could choose the day, and also book it for school holidays so I do not miss out of school.<br />
If I had of gone public (I would have saved the $3000) but it would have been an 18 month to 2 year wait, and then I would be given 1 option to have it done and if that did no suit it would be another long wait.
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Ben thanks for sharing Dr Woo's stuff with us. I find it extremely interesting and I'll definitely blog about it sometime. Cheers mate. : )
M