Monday, February 14, 2011

The Profit Motive in Medicine - the Bottomline vs. Patient Welfare

I will always rally against the profit motive in medicine after a recent encounter with private health providers in Hanoi.  Of course, I have always been a firm supporter of public medicine and friends have accused me of being driven by ideology rather than reason.  However, my recent experience has given me a practical example of the perils of neo-liberals' policy of choice  -  privatisation of health care.

‎Six months ago a well-known foreign-owned medical clinic popular with expatriates in West Lake, Hanoi, advised me that it was not possible to get a mammogram in Hanoi and that I would have to visit its sister clinic in Bangkok. I rather stupidly relied on a physical examination and didn't follow up. Six months passed and I discovered a painful lump in my breast. I consulted a rival clinic and was advised that it had been offering mammograms and ultrasounds for some time. It was apparently a policy of the other clinic not to refer clients to rival medical institutions. I have since discovered that this has happened to other peope in Hanoi.

When I posted this story on Facebook, friends were upset that I challenged the profit motive.  One friend promptly responded that it wasn't the profit motive - just plain stupidity no matter which way you look at it.  Others accused me of not being sensitive to different standards of care in the third world, the most surprising accusation of all given my repeat visits to hospitals and clinics in the developing world. 

Another friend argued:

"I've noticed in the developing countries I've lived in, not unlike the developed US in fact, there are tiers of care. For those who can afford it, the private sector will provide largely because the public sector is too under resourced to provide health care beyond a basic level. As you've discovered, buyer beware is the principle to apply with private medicine. As unethical as that behaviour might be, that clinic is still providing some service where none might exist at all if there were no private sector market for medical care. I'm assuming the rich & wealthy of Vietnam now have access to services once reserved for overseas visits as a result of Doi Moi? So long as the State is providing for average Vietnamese, let's hope...."

My argument is this. Whichever way you cut it, my experience points to unethical and dangerous  business practices by this medical provider. It was ultimately driven by the bottom line, eager to avoid losing business to rival medical providers. Stupidity is ingrained in this approach to service delivery - granted.

I do not accept these arguments as you cannot depend on the private sector when there is no profit to be made. In most developing countries, public spending on health care is on average less that 5 percent of that spent in developed countries. Obviously, this is insufficient to meet health needs in most countries. However, a modest redistribution of resources away from military and other unnecessary expenditure in some of these countries would appear to be economically as well as socially justified. I am tired of IMF and World Bank mantras about the virtues of the private financing of health care. Immunisation, control of vector-borne diseases, sanitary waste disposal, cancer screening, maternal care, family planning, health education, HIV/Aids prevention and care-  these should all be public services of the highest priority. There are no profits to be made in most of these things, but I am sure the private sector will find a way to make money out of even these essential services.

A friend in the medical profession had this to say:
"I think perhaps ideology may also be creeping in here Maria. As someone who has worked in several different aspects of healthcare and who has a purely pragmatic approach, the best solution (for everyone) is a mixed system, like most "first world" countries have. Certain things are definitely worth a society banding together and paying collectively - yes, immunisation is an excellent example. However, healthcare is an infinite "want", funded by a finite amount of money, that is valued by different individuals in different ways, so if you go down the UK ideological path, you will always fail to provide good care for everyone/everything. In fact, I would go so far as to say the NHS is sometimes more draconian about what it funds than many private providers (depending on what the service is). In a good system, the doctors/nurses etc are asked to focus on the patient in front of them, certain core services are paid for using the collective wealth of the people via taxation, and there is transparency about what you can pay extra for and get faster/better quality for. Your example above Maria is just plain stupid - bad medicine, bad business and you are demonstrating this by not going back to them".

Bad medicine indeed.  I accept that a mixed system is necessary as  health care is an infinite "want" that is valued by different individuals in different ways. But I stand by my position that cancer screening is an essential public service. As for the clinic - plain stupid is an understatement.  It is one thing to say I am taking my business elsewhere, but they also need to understand that they are playing god with patients' lives.

I wrote to the Clinic and this was the response:

"Thank you for your email to our Clinic Manager  regarding local referral for mammography.

It is (*name deletd*)  policy to only refer for mammography, or any other procedure, when this can be performed to an acceptable standard.

The current "Gold Standard" in Australia and the USA is for the mammographic films to be reviewed by two radiologists (i.e. specialist doctors) who have received further training in interpretation of mammograms. It is our understanding that this is NOT the current practice for mammography performed in Hanoi. Therefore, if we were to refer patients for mammography locally we could not ensure the validity of the results. The consequences of a missed or delayed diagnosis of breast cancer would be devastating. It is our duty of care to our patients to ensure that this does not occur, by referring to a facility which can provide investigations to an acceptable standard.
Should the local situation change we would be happy to review our policy".

If that is the case, I would have appreciated advice to this effect during my consultation. I believe it is best practice to provide patients with all the available information and allow them to decide how they wish to proceed.  It need not be an official referral. It would just be furnishing them with all the relevant information, including that the procedure does not meet international best practice at other clinics.

A medical practioner had this to say:

"As pure scientists, we are not allowed the luxury of never making a decision. We must (all of us, not just health care providers) learn to understand levels of certainty and make as informed decisions as we can. Not all of us will make the right decisions, but if you believe in individual freedom then we must take responsibility for our own choices".

The question is can individual choice and patient safety be guaranteed when profits are at stake?

PS- I have since found out that the "gold standard"of mammography is indeed offered in Hanoi. Aftering hearing about SOS Clinic's policy of non-referral, the clinic where I ended up having a mammogram and ultrasound has decided to hold a Breast Cancer Awareness Week.  I have not yet received a second response from the first Clinic.  However, I will be working to change their policy  of non-referral.

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