Health Insurance is dangerous!

Health Insurance. Your most dangerous possession?

The best thing you could do for your health (physical and financial) would be to bin your health insurance. In an Irish context health insurance is not only unnecessary but is dangerous. If you have health insurance you are far more likely to have an operation, and as is the case for many who are left incontinent and impotent following prostate surgery, many of those operations are of no benefit to the patient.

During a recession,most if not all private enterprises feel a degree of pressure to improve or at least maintain their profits. Within the private sector these pressures exist even in the absence of recession. Only a fool would assume that hospitals and private health practitioners are entirely immune to these pressures. In fact, given that much private medicine is conducted in supposedly public hospitals, the public system also experiences these pressures, albeit in more subtle and perhaps more sinister ways. Take for example the new consultant contract on offer to newly appointed consultants at public hospitals. These contracts forbid newly appointed consultants from working at private hospitals outside the public hospital. As such, the only private income a new consultant can enjoy is when he or she treats a private patient within the public hospital. There exists therefore, a certain financial pressure or incentive to treat or operate on as many private patients as possible or as permitted within the public hospital.

In short if you sit on the other side of the desk from a newly appointed hospital consultant with your health insurance, you represent a significantly greater income to the consultant and the public hospital, should you be inclined to agree with the doctors recommendation for the particular procedure that is in your best interests.

We would be fooling ourselves if we were to assume that these pressures do not ultimately translate into unnecessary surgeries and interventions for those with health insurance. Add to this pressure the reality that 'older' consultants with older contracts, who are free to work in private hospitals and clinics, undoubtedly enjoy significantly higher incomes than the newer consultants. The dice are even further weighted against the impartial consideration of the patient with private health insurance.

On a deeper analysis all serious medical or surgical cases are given priority within the public system, and in this respect Health Insurance is little more than a manifestation of our health anxiety’. An entire industry has been constructed upon this anxiety, an industry that is finding it difficult in the face of a recession, where many of its patrons are being forced to recognise insurance as “luxury” that can be done without. Rarely if ever do we consider whether the possession of insurance might have an influence upon the type of treatment we might be recommended. It is often naively assumed that the more money spent on our health the more more healthy we will become or the better the outcome if we are unwell. This is not entirely true, and in many cases the best health outcome results from being left alone. The extreme version of this little truth is echoed in the old adage that medicine is 'how to occupy the patient whilst nature effects a cure'

Unfortunately our health system has not evolved beyond the Victorian model and our consultants retain what the bishops have lost. Most of us are familiar with the traditional model of the suited consultant on ward round with a train of juniors and other inferiors waddling behind like a gaggle of goslings. Rarely are we even capable of asking could things, indeed should things be different? As the priesthood of yesteryear enjoyed an absolute power that corrupted absolutely, so too do many consultants enjoy an autonomy, that is as devoid of governance and will undoubtedly form the next entirely predictable health scandal.

Whilst other countries apply strict criteria and protocols to the decision for surgical interventions, in Ireland similar criteria rarely exist and for better or for worse the ultimate decision is left with the doctor and the patient. Within the NHS Cardiologists must adhere to strict criteria before inserting stents into the arteries that supply the heart. No comparable criteria exist here in Ireland, yet insurance companies pay significantly more to both the hospital and cardiologist alike for inserting such stents. Criteria apply for stenting, for angiograms and for many invasive procedures. In a similar respect strict criteria apply to the the removal of prostates (radical prostatectomies). In the united states, insurance companies will not pay for the removal of a cancerous prostate unless it is at a more advanced stage. Here in Ireland Prostate surgery is a lucrative business for both the surgeon and the hospital alike. So much so that a private Dublin Hospital offers the surgery 'robotically' , the cost is near 20,000 to the insurance companies.

Despite the fact that radical prostatectomy has been proven to be of no benefit for localised prostate cancer, the rate of prostate removal in Ireland has increased in recent years rather than decrease.

Recently the New England Journal of Medicine, published a study that was unequivocal in its findings:

“In conclusion, our study showed that, as compared with observation, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality through at least 12 years among men with clinically localised prostate cancer that had been diagnosed in the era of PSA testing.”(N Engl J Med 2012; 367:203-213July 19, 2012DOI: 10.1056/NEJMoa1113162 )

Regardless of this well published research some 20-30 of these largely unnecessary procedures are carried out in Ireland every week. In my opinion it is highly likely that the majority of these patients have health insurance. The real tragedy here is that a significant portion (20% in some cases) of those undergoing prostactectomy are left, either incontinent of urine, impotent, or both.

As a consequence of both the lack of investigative journalism in Ireland and our collective fear of established medicine, no one is asking the pertinent question of; how the need to turn a profit, and the need for financial survival have intensified the 'pressure' on doctors and private hospitals alike, to consciously and perhaps subconsciously encourage patients towards more expensive, more invasive and more dangerous procedures?

Undoubtedly the present situation is set to worsen with this government's plans for 'money follows the patient', after which hospitals will be paid per procedure, and all presenting at their public hospital night be deemed in need of some form of an intervention.

In my own experience as a General Practitioner I have come to the conclusion that the possession of Health insurance is a significant risk factor for; prostate surgery, Cesarean Sections, Invasive Cardiology and more. It is for this reason that when I advise my patients to give up smoking I also advise giving up their health insurance. At present I am unsure as to which of the two is the lesser evil?  Personally if given the choice between smoking and Health Insurance,  I would take my chances with Marlborough man any day of the week!