Essentially the article points out that research published in the American Journal of Dermatology indicates that patients calling for a new appointment for Botox wait on average 8 days whilst the wait to look at a suspect mole is on average 26 days.
One possible explanation? one is a cash payment the other insurance based. (as an aside can you get Botox on insurance?)
Anyway we have similar issues on occasions where clinicians will prioritise the “interesting” cases but we are not faced within this issue in the public sector.
I suspect that this takes place in a number of specialties other than dermatology.
People don’t want to wait 60,90+ days for their money. My wife works with the county health department here and has a very hard time trying to sign doctors and dentists up to deal with their ss/medicaire/medicaide patients. Not only do those programs demand a lower price, but then take 120+ days to pay the bill.
I go to a chiro that actually gives me a 30% discount because I pay cash.
Another way to look at it is that the Botox model involves the consumer in a power position because that consumer is paying directly out of his own pocket. The more the consumer has power and spends his own money, the more efficient the system will be. As soon as you introduce a third party picking up the bill, be it the government or an insurance company, the incentives to use services wisely go out the window.
In this country we would be well served by trying to get closer to the Botox model rather than the mole model. I understand the opportunities to do that are limited. Health Savings Accounts are an obvious attempt to do this.
I suspect that this takes place in a number of specialties other than dermatology.
Here is another example. In the course of my life, I have had problems with ingrown toenails. I have found that the best course is to have them removed. Unfortunately, this has occurred enough times that I have tried various options. It also was over a long enough period that I have even had a couple of different mediacal coverage.
The first time I had one removed I had insurance (HMO) that covered podiatry. So I went to my Primary Care Physician who gave me a refferal to a podiatrist. I scheduled an appointment for 2 weeks. I went in and he looked at it and scheduled another appointment for 10 days later. By then it was infected and I could barely walk on it. But he got it out, gave me some antibiotics and then scheduled 3 follow-up appointments to follow its healing progress. To this day I have had no problems with this toenail. I was extremely pleased with the outcome although it seemed to take a long time to get there. Total cost out of my pocket was about $20.
The second time (other foot) I had different insurance (HMO) that did not have podiatry coverage. I went to my Primary Care and he said that I could schedule an appointment for him to remove the toenail and that I could get in about 2 weeks later. So I went in, and had it removed, but the PCP did not really know what he was doing (honest to God, he had a step by step manual that he was consulting) and it ended up coming back 6 months later worse than ever. I was extremely dissatisfied, I never went back to this doctor for anything. Total cost was $5 out of pocket.
The next time (6 months after the last) I have an ingrown toe nail I go to a different doctor who refers me to some kind of specialist (not a podiatrist). The total length of time was about 2 weeks to get an appointment with the specialist. I talk him into taking the nail off right then and there rather than making another appointment. He seems to do a pretty decent job. I reasonably satisfied, again the total cost out of my pocket is about $10.
Finally, 3 years after that, the same toenail becomes ingrown and close to being infected. This time I have another Dr. that is impossible to get an appointment with. I have new insurance (a PPO) with a flexibile medical savings account. I decide on a whim to call that podiatrist I saw about 6 years prior for the toenail that I have not had any problems with. I explain to the office assistant my predicament and tell her that I no longer have any podiatry coverage. She asks, “So you will be paying cash?” I respond that it would seem that I am. She asks, “Can you be here this afternoon around 2?” I say, “Sure.” I go in expecting for the quick looksie, and to my surprise the guy is standing there with gloves on waiting for me so that he can remove my toenail. 30 minutes later I’m paying his $75 fee and he is telling me that I don’t have to come back unless I see some signs of infection, but if I keep it clean there should be no problems. Again, I am extremely satisfied. Sure, I paid a little more, but the speed that it was accomplished was great. There were no redundant appointments so my time wasn’t wasted. I’ll wager that my insurance company paid out a lot more than $75 for all of the extra appointments I had to make.
I just read an article about some local doctors, very in demand, that now have a $1500 annual fee to be in their care. This fee, which isn’t covered by insurance, guarantees you a same day or next day appointment with the doctor as well as some other perks. It’s referred to as MDVIP and is billed as “executive-style” care. It will reduce the doctors’ caseloads, allow them to spend more time with each patient and, of course, ensure no impact to the the doctors’ income.
My GP doctor has just changed his practice to exactly that format. 600 patients, $1,500/year apiece. $900K guaranteed before you even see a patient. Not bad work if you can get it. He is a pretty good doctor, but not that good.
My GP doctor has just changed his practice to exactly that format. 600 patients, $1,500/year apiece. $900K guaranteed before you even see a patient.
I have heard of these practices and I think they are a pretty cool idea. It seems to be sort of a hybrid of Consierge style practices. Of course, I think with a consierge-style 600 patients would be a lot to offer that level of personalized care.
For $1500, what do you get? Is it mainly the convenience of same day appointments? Or do you like the idea that your doctor might actually know who you are when he sees that you have an appointment that day? Does your Dr. make housecalls?
A problem with care being provided on a “margin” based decision rather than a “need” based decision is that outcomes may not necessarily improve. People may however look better (just being a little facetious)
I think there are some downsides to the Botox example and I am not saying that it could not be good but what if all care were provided on this basis and for example one did not have enough in a health saving account to cover the cost of treatment? can you borrow against future savings? if not, and you become seriously ill at a young age you are potentially in trouble.
GP’s in the UK make a great deal of money when compared to most of their peers working in medicine or surgery in the acute sector. If you want to make real money in health care become a GP.
One amusing side to this for me is that access to primary care is by and large not an issue and I admit that the current government may have used a sledge hammer to crack the proverbial nut but GP’s are meant to offer an appointment within 48 hours I believe and in the 20+ years I have lived in the UK I have never had to wait longer than the next day to see my own or another Doctor in the practice with which I am registered. That does not mean that others dont wait but access to primary care IMO is not one of the biggest issues facing health care in the UK.
The thing that I would like to know is what do you get for the $1500 other than the ability to call and see the MD that feels that they are worth this membership fee? do you get an annual medical, screenings, bloods, daignostics or are they all on top of the 1500 and the 1500 simply buys the ability to access the service?
This is quite an interesting study from Dec 06 on access to care and by this measure, as opposed to the Cancer study, we dont do quite as badly:
Some highlights from the study:
Findings
The Commonwealth Fund collaborated with five other developed nations—Australia, Canada, Germany, New Zealand, and the United Kingdom—to survey patients who had a high incidence of chronic illness and made recent intensive use of health care.
The U.S. ranked last among these six nations on four measures of access and continuity of care. Specifically: U.S. patients were less likely than patients in the other five countries to have a regular doctor (84% v. 92%–97%). Among those with a regular doctor, U.S. patients were less likely to have continuity with the same doctor for five years or more (50% v. 61%–78%). U.S. patients were more likely than patients in the other five countries to report not filling a prescription, not visiting a doctor when sick, and/or not getting a test or follow-up care recommended by a doctor because of cost in the past two years (51% v. 13%–38%). U.S. patients were more likely than patients in four other countries (except Australia) to report that it was very difficult to get care on nights, weekends, or holidays without going to the emergency department (39% v. 11%–29%) (Schoen et al. 2005)
U.S. patients reported relatively longer waiting times for doctor appointments when they were sick, but relatively shorter waiting times to be seen at the ER, see a specialist, and have elective surgery. Specifically: The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country. Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations. U.S. patients were less likely than patients in Canada (12% v. 24%) but more likely than patients in Germany (4%) to wait four hours or more to be seen in the emergency department. U.S. patients were less likely than patients in four countries (except Germany) to wait four weeks or longer to see a specialist (23% v. 40%–60%) or to wait four months or longer for elective surgery (8% v. 19%–41%) (Schoen et al. 2005).
Well, the Botox example has a lot going for it. Have you ever heard of a shortage of Botox? The idea is laughable. It will never happen. On the other hand, you hear about shortages of flu or other vaccines all the time. One hundred percent of the reason for that is the government controls that market and ensures no one can make a dime.
That fact would be a major health crisis but for the fact that the vaccine sucks every year since the 50 year old technology can’t adapt to the latest strains of the disease in time to mass produce the vaccine. Again, 100% of the reason is that the government controls the process so no one makes a dime. Gee, I wonder why we don’t have an AIDS vaccine. Could it be that everyone knows no one will be allowed to make a nickel?
I am not saying the entire industry needs to function like the Botox industry. It can’t, but it does point the direction for improvement. You need to get consumers in healthcare to the extent possible, not patients or clients.
I can’t answer your questions about the boutique practice my doctor moved too. Sorry, I am just not informed. I am informed about the state of being a GP in this country though, and it is pretty poor. It seems to get worse every year from what I can observe personally.
I do get a kick out of your list though. Why is this a slap at the US system:
“Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.”
To me, that sounds like too many sick people are still seeing doctors in the US and that other countries are totally out of control presumably since medical care is “free” so they can waste it without consequence.
Why would someone go to the doctor most of the time when sick? You have a cold or the flu or whatever, suck it up and deal. The doctor can’t help you. I don’t go to the doctor unless I have a specific problem that I think he can help me resolve or at least diagnose. In a good year that means I never go to the doctor, and I have lots of good years.
(just being a little facetious)