Informed medical costs - Well intentioned actions failing in delivery

Dr Richard Zhu is reported to be on a mission to “expose” the out of pocket expenses associated with initial consultations to see specialists in Australia.  He has created a website called SeekMedi in his “battle for greater fee transparency”.

His creation of this “one-person army” is with good intent but in its current form is more misleading than helpful. If the website is about transparency, then it needs to practice what is preached. My concerns are as follows:-

1. The website should state it’s funding (even though we know from news reports that he personally funds it) and as to how the data is collected.  We also know from media reports that he personally telephones specialist practices and following discussions with their secretaries will record the cost of initial consultations into an Excel spreadsheet - this methodology should be also be recorded for transparency.

2. The website is misleading in that the standard initial consultation fee does not factor in discretionary fee discounting or bulk billing that occurs for patients who have genuine financial hardship.  The relationship between general practitioners and the specialist to whom they refer also makes a difference.  When GP’s with whom I work regularly takes the effort to call, email, fax or write to me about a patient with financial distress, I always oblige with fee reduction if not bulk billing. I know my colleagues are no different in these circumstances.

3. The website fails to time stamp the published fees.  What may be current at the time of publication on the website may not be accurate at any time in the near future. There is the potential to create unrealistic expectation from patients as to the fees and out of pocket expenses which might actually turn out to be greater.  The most accurate indication is the quote given to patients at the time of making their appointments.  The website should include a disclaimer about the fact that fees do change over time as well as to time stamp when Dr Zhu had made a phone call to a specialist office and recorded the quoted fees.

4. The data is incomplete. Many specialists are missing from the list. The website should state that this is the case and indicate if missing specialists will be included later as well as why certain specialists are included and others not. 

5. Specialist fees as recorded do not factor in the time allocated by the specialist to review the patient. Some specialists book patients in as frequently as 5 minute time slots and are able to achieve this through the use of medical and non-medical assistants. Other specialists may spend as long as an hour with their patients on an initial consultation.  Within the same specialty, the variations in time spent with a new patient can vary considerably.  The role of assistants who play a role in initial assessment is not considered in the initial consultation fees.  It is also becoming increasingly common to see advanced specialist trainees in private rooms.

6. Specialist fees do not give accurate guidance as to the likelihood of subsequent out of pocket expenses should any intervention be required.  It is not uncommon for a number of specialists to load most of their ‘income generation’ into their procedures rather than consultation fees. It is therefore not uncommon for some of the most expensive specialists with regard to procedural costs to have very average or even below average initial consultation fees. Initial consultation fees are only one aspect of out of pocket expenses.

I am not against transparency in specialist fees but if we are to embark upon this path, it needs to be done in a professional, collaborative and transparent approach.  A divisive lone wolf approach will never achieve acceptance.  I have written to Dr Zhu to seek his comments but to date have received no reply. If and when he replies, an addendum to this piece will be published. 

Abuse of "Self Pay" Surgery in Public Hospitals

This entry is more of an update rather than a new opinion piece. I have held off from posting additional blog entries on unrelated subjects to enable the current topic to headline the blog for a little longer. I do have plenty to say about many other aspects of medical practice but for another time.

It has been very interesting observing the reaction to my initial blog on the subject of abuse of "self pay" in the public hospital system. I am extremely grateful for the numerous private emails and sms messages of support. When you write such a piece, it is a very lonely moment in your professional career knowing that few if any colleagues will be prepared to stick their neck out and publicly support you. One email received earlier today makes a chilling comment in stating "It always interests me how unethical practices soon become the norm when no-one speaks out". Another email from a colleague made the following disturbing comment "I am aware of some surgeons that abuse the self pay system by accelerating the patient on the wating list. That is, if they pay, they get done sooner". I too have been made aware of this happening at my own hospital but chose not to mention this in my earlier piece.

I was pleased to be invited to have the opportunity to write a short opinion piece on the matter that was published on the Medical Journal of Australia's (MJA) discussion portal known as MJA Insight. Users must register to access this site and it is my understanding that there are over 25,000 registered users and that in the order of 17,000 become repeat visitors. Although less than a year old, this should not be surprising given that the MJA is arguably the most recognised and respected of the key opinion leading medical institutions in Australia. Registered users are invited to make comment on the opinion piece. I note that of the opinions given, not one has been from an individual who is prepared to use their real name and instead opting to use a pseudonym or be noted as an anonymous. The "Poll" asks users "Are you aware of patients being coerced into becoming self-pay patients in the public hospital system?" and it is interesting that as of the time of writing this entry, there was a 50% "Yes" response. Putting aside the non-scientific nature of these types of polls but it is disturbing to see this level of response. As previously indicated, this is mainly an issue within the public hospitals of NSW where there is poorer separation of public and private systems compared to other states. In short, the Public Outpatients in NSW hospitals has been significantly dismantled forcing specialist doctors in the private sector to effectively provide the outpatient service for uninsured patients. Furthermore, many of the readers would not necessarily be working in the public hospital system and as such would not be expected to have knowledge about the abuse of "Self Pay".

My opinion piece on MJA Insight was 'picked up' by The Australian where an article was published on 22 March 2011. I am sure that it has been passed around in many a surgeons lounge at the various hospitals and hopefully will prick the conscience of those who feel that the article is about themselves. I am expecting some surgeons will come forward arguing for the rights of patients to elect to be "Self Pay" in the public hospital system. There is no argument with this. My argument is the widespread manner in which patients who elect to be "Self Pay" are receiving inappropriate counselling on the risks of being a Medicare patient in a public hospital or in other words, they are being scared into being "Self Pay" patients.

How do we move forward on this? There is a huge temptation for the Australian Medical Association and the Royal Australasian College of Surgeons to bury their heads in the sand and hope that the whole thing goes away. A number of those who engage in this activity are significant movers and shakers in the field and have significant influence over these organisations. The NSW AMA has invited to meet with me to discuss these concerns further and the RACS has indicated that the matter will be discussed at their forthcoming Board of Professional Development and Standards meeting.

The ideal next move would be for these organisations to support an independent audit of the mix of public and "Self Pay" patients in the NSW public hospitals. There is a need for transparency and these results should be published for all to see. Surgeons who appear to be abusing this facility should be counselled. Ongoing audit and publication of results according to specialty in each hospital will allow transparency in the use of the "Self Pay" facility.

I have been away at a conference followed by annual leave and when I return on Monday 28 March 2011, I do not expect a warm welcome back to duties.

A further update will follow.