It's been clear for a long time that the two-tiered American healthcare system rations care. People who have insurance get medical care…often very good medical care. People who are uninsured…don't.
Now it's time to add a third tier…vanity patients with cash in hand. These pampered prima donnas may be the canaries in the coal mine of the American healthcare system. The New York Times had an excellent article this week which focused on the practice of Dermatology. Many modern day Dermatology practices are divided into two groups: Cosmetic Dermatology (Botox, tattoo removal, hair transplants, etc) vs. Medical Dermatology (skin cancers, psoriasis, skin manifestations of systemic disease, etc).
Vanity patients often get preferential treatment at the expense of insured medical dermatology patients. This takes many forms, but usually means quicker appointment times (even if the medical dermatology patient has a possible skin cancer). As the article outlines, insurance typically reimburses $60-90 for a 10 minute full-body skin cancer check. A cosmetic dermatology patient might pay $500 for 10 minutes of Botox injections to the forehead. As a cosmetic Dermatologist, Dr. Richey, is quoted saying:
Cosmetic patients have a much more private environment than general medical patients because they expect that. We are a little bit more sensitive to their needs.
I dunno, doc. If I were a medical dermatology patient waiting for my skin biopsy result, I think I might appreciate a "more private environment" than the cattle call that is the waiting room in most doctor's offices (including mine). To be sure, I want to be sensitive to people with crow's feet who have a high school reunion next week. They have needs, too…and cash, lots of cash.
This is one of many problems I see with the consumer-driven healthcare model. What happens when the people with the most money get preferential medical treatment: quicker appointment times, better doctors, better hospitals, better medications, better defibrillators and artificial joints, preferred access to experimental protocols…the list goes on and on.
My favorite doomsday scenario is a bird-flu pandemic similar to the 1918 Spanish Flu which killed 50-100 million people worldwide (>500,000 in the U.S.). Extrapolate the data and you get millions dead in the US and hundreds of millions dead worldwide. Currently, the US has about 105,000 mechanical ventilators of which 80,000 are in common use daily. We would need 200,000 or more during a pandemic. Who gets on a ventilator to wait out the storm would literally be a life or death decision. Who gets to decide? Will the mother-of-all-rationing decisions be decided by who has the most money? Where does the law of supply-and-demand end? Where do medical ethics begin in a consumer-is-king world?
Now, I wouldn't blame John McCain, the Republicans, local right-wing think tanks, or other advocates of consumer-driven healthcare for the death of hundreds of millions of people in a bird-flu pandemic any more than I would blame Barack Obama for high gas prices…oops. Damn those murderous bastards.
Seriously, though, there are some ominous trends here. There are perverse financial incentives in place in the American healthcare system which do not promote improved public health. Read this article (again from New York Times) which shows how the best and brightest medical school graduates are going into Dermatology, Plastic Surgery, and Ophthalmology (LASIK eye surgery pays pretty well, don't you know). This is not to condemn those specialties…I know plenty of Plastic Surgeons who reconstruct cancer survivors; Ophthalmologists who prevent blindness; and Dermatologists who save lives. But should all the financial incentives align themselves in helping patients look good rather than treating disease? Often, the medical patients seen in these practices are seen by nurse practitioners and physician assistants…while the special needs patients (ie. cash paying patients with vanity needs) are tended to by the Board Certified specialists. You see it in my own specialty, Internal Medicine, where doc's have cash only concierge or "boutique" practices and make twice the money for half the work. (It's a good solution for the doctor and the privileged patients who can afford it…not so good for those left behind).
It's ironic that LASIK eye surgery is the example most frequently used by consumer-driven healthcare advocates to show how "competition in the marketplace" promotes "cost efficiency." OK. Fine. I guess it's great that the gentlemen making their way around the back nine at the Carolina Country Club have 20/10 vision like Tiger Woods…and it only cost them $1,000 per eye for a vanity procedure that used to be $2,000 per eye. Milton Friedman must be pleased.
Clearly, there is a huge demand for vanity care… and in a free society patients and doctors have every right to engage in this commerce. Sadly, we have become a nation obsessed with consumerism. The fortunate among us, in the top 1% of earners, are afflicted with affluenza and their purchasing power is bleeding into a world of finite medical resources. With income inequality and wealth consolidation at levels not seen in the US since 1928, the healthcare purchasing power of the super-rich is only going to increase.
What we need most are more primary care doctors. I'm afraid that this new class of cash paying healthcare diva's is pushing medical care in the wrong direction.
PS. I presume most of the readers of this blog have health insurance. Don't worry if you're not a healthcare diva and you are feeling like a second class citizen. In the New American Healthcare Caste System there is a group worse off than you..and it has 47 million members!