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Monday, July 28, 2008

Two-tier medical care
Posted by Jill | 6:23 AM
Following up on Melina's post from yesterday, I noted an article in today's New York Times about the practice of dermatology becoming a two-tier system -- cosmetic patients sit in luxurious, comfortable waiting rooms where they spend little time because they are served first, while patients with exczema, skin cancer, or other actual diseases wait until the society women get their Botox injections:

Dr. Richey has two waiting rooms. The medical patients’ waiting room is comfortable, but the lounge for cosmetic clients is luxurious, with soft music and flowers.

And he has two kinds of treatment rooms: clinical-looking for skin disease patients, soothing for cosmetic laser patients.

“Cosmetic patients have a much more private environment than general medical patients because they expect that,” said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. “We are a little bit more sensitive to their needs.”

Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.

In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.

[snip]

A study published last year in The Journal of the American Academy of Dermatology found that dermatologists in 11 American cities and one county offered faster appointments to a person calling about Botox than for someone calling about a changing mole, a possible sign of skin cancer.

And dermatologists nationwide are increasingly hiring nurse practitioners and physicians’ assistants, called physician extenders, who primarily see medical patients, according to a study published earlier this year in the same journal.

“What are the physician extenders doing? Medical dermatology,” Dr. Allan C. Halpern, chief of dermatology at Memorial Sloan-Kettering Cancer Center in Manhattan, said in a melanoma lecture at a dermatology conference this year. “What are the dermatologists doing? Cosmetic dermatology."


In other words, the care you get is dependent on how much you pay.

This is fine on an airline, where no matter what class you fly, you in theory get to the same destination. But when patients who need medical care are given a back seat to those who have the resources to fight the ultimately vain battle against the clock, then some dictors' priorities are seriously askew -- and I would say, unethical.

The net result is the kind of "medicine-by-profit-margin" that HMOs were designed to address. However, HMOs and insurance companies have turned doctors, who are often incentivized to NOT refer patients to specialists, into Gandalf the Gray, standing his ground against patients and insisting "YOU. SHALL. NOT. PASS."

And all the while, dermatologists have been able to move off of the practice of actual medicine, and even from the kind of reconstructive surgery that accident victims and cancer patients often need, into a glorified spa practice -- at the same time as skin cancer rates are increasing and there is a shortage of dermatologists.

The debate about health care in this country has focused almost entirely on insurance -- how it is to be delivered, whether a single-payer model or a tweaking of the existing system is in order. What is not being discussed is quality of care. It may be easy for Rudy Giuliani or John McCain, both of whom have excellent health coverage and access to the best and most expensive doctors in the country, to say we have the best health care system in the world. But ask the young mother with the 1/2" mole that has an irregular edge, is crusty, and is red around the edges, whether she should have to wait two hours so that her doctor can shoot botulinum toxin into the brows of someone who wants to look good at her spa.

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Blogger Melina said...
well, you know that I tend to do a little of the microdermobrasion and the like, and what Ive found is that in general (this also from being friends with my derm in CT and watching her try to build a practice all these years) most of them DO treat medicare patients (of course not Husky children's insurance in CT that is the jewel in Joe Lieberman's crown...no one takes that!)
and it is a different crowd with different needs. The stratification of this stuff would be fine if it were possible for these doctors to do real medical practice and stay afloat on only that. Many of them are taking weekend courses and buying lasers because Medicare doest pay enough, and regular insurance often doesnt either...and the paperwork is daunting no matter what you do.
I see alot of doctors struggling, besides the rare few...some of whom Ive seen...who cater to the very rich. Even those guys tend to go out and do some sorta charity work here and there...even my derm in CT just offered to treat Ben for free because its easier than trying to claim from Husky....and when she tried that with Will she ended up with $14 after they made her wait to treat a plantars wart until it had spread disgustingly....not worth it unless you're in the soup line.
I don't see anything wrong with Dr's having different rooms and all, but Id really like to see drs be able to treat medical cases and be paid for it so they don't have to spend a certain percentage of their time sucking fat and shooting botox into the faces of the rich.
7/28/08, 8:45 AM  
Anonymous Anonymous said...
I see the irony in a slightly different spot than you ladies.

As someone who has been the office manager in a laser and esthetic medicine practice (we never took insurance, so we never had this double-standard thing), there was a lot of backlash from the derm and plastics guys who felt that ONLY THEY should be allowed to do lasers and botox. All the rest of us, no matter how many certifications we had from the big laser makers and from the companies that make Botox and Restylane, we were all considered quacks just out for money.

The bottom line is that the cash patients -- the ones seeking Botox and microderms, etc -- pay cash, 100% of the bill, today. The people who actually need dermatological services pay a small co-pay, the insurance company will pay roughly $0.40 per dollar billed, and the doctor won't even see that for 60-120 days. The system is broken. Don't blame the guy who has to pay his staff, pay his rent, pay his student loans, and try and run a business in the broken system.
7/28/08, 4:24 PM  
Blogger Distributorcap said...
again - as long as we view and treat medical care as a luxury as opposed to a right....

this is exactly what will happen
7/28/08, 8:09 PM  
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