Two Tiers

By Jim McVeagh 28/01/2010


Dr Tim Parke, the clinical director of the adult emergency department at Auckland City Hospital, puts his concerns into an article in the Herald today. He writes that, in his opinion, the proposed use of public facilities for extra private procedures will produce a two tier system where, eventually, richer patients will have better medical outcomes than poorer ones. He says:

Over time, the difference in survival would add up and eventually, more wealthy patients would survive heart attacks than less well off patients. The cumulative effect of a range of survival differentials in many diseases and injuries would eventually exaggerate the already marked differences in mortality rates between races and social classes.

Unfortunately for Tim’s argument it falls down at one very important point. The two-tier system, he is worried will develop, is already here and has been for many years. Insured and wealthy patients can already access a much greater choice of health care than uninsured ones. To use Tim’s example:

The scenario is thereby foreseeable where two young patients arrive in the emergency department with heart attacks in side-by-side cubicles. One gets the “budget” clot buster treatment option which is probably okay, but the guy next to him opens his wallet and gets the “elite” option of emergency angioplasty with direct opening of the blocked coronaries. Both of these treatments have been shown to work, but angioplasty is slightly better and is very much more expensive.

Currently most hospitals have limited budgets for angioplasties. In the above case the uninsured patient will have to meet a number of criteria (rather like the “points” you have to make for your specialist outpatient appointment). The insured patient can simply get his GP to call an interventional cardiologist in private practice and get his angioplasty – even if he doesn’t meet the “criteria”. As Tim points out, angioplasty does have slightly better results. The only reason that we don’t do it on everyone is because we can’t afford to.

The only difference in the proposal to allow private procedures to be done in public facilities is convenience. The insured person will still get his angioplasty, but he might have to travel a few hours to get it. This may reduce the outcome of his angioplasty – so the only result of disallowing the use of public facilities is to reduce the wealthier person’s chances of a good outcome. Truly equality of outcome – both bad.

Tim’s other point is superficially more worrying:

Furthermore, those patients paying in public hospitals simply to get the best treatment option will become more and more resistant to funding anything other than pure “safety net” bargain basement treatment for the non-paying patients out of their taxes.

This also has been occurring for a long time already. What do you think the phrase “value for our tax dollars” really means? Does anyone really think that the current public health system funds anything more than “bargain basement” treatment? (Unless by the phrase “bargain basement” you really mean “inadequate”; because that is a whole different ball of wax). There is and will always be a limited amount of money in state-provided health care. We will always be making decisions about rationing health resources. Allowing private patients into public facilities is not going to change this in any way. It is even possible that the extra funds may provide better health care for state patients.

The Two-Tier system is a present day reality. Instead of having angst about it, we should be trying to make it work for us.

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