After Hours

The Herald reported on Tuesday on a Ministry of Health survey that says there is a problem of high after-hours fees After hours patients charged up to $250. I would have posted on this earlier, but apparently my site had to “propagate its DNS” before it would work – sounds nasty Doctor’s fees are always a favorite of the media. I suspect that there may be a underlying feeling of envy involved, because doctor’s salaries are considerably higher than the norm. After all. I have a plumber’s bill on my desk for $95.00 for fixing a tap – fifteen minutes work (alas, it was more than just a washer!). I’m betting you are either feeling superior right now (because you have the skills to fix it yourself) or you are ruefully agreeing with me. But I also bet it won’t make the Herald. Why would a plumber’s bill of $95 be less interesting than a doctor’s bill of $95 for a house call? Or $65 for an after hours visit (you try calling your plumber at 10pm and see what kind of a bill you get!).

So off to the article:

“Patients are being charged up to $250 to see a doctor after hours, a Ministry of Health survey has found.”

Ok, lets deal with the outlier, first. This is obviously one of those absurdly inflated tourist fees. The sort of thing you get charged for a doctor’s visit to your hotel room, or a suturing at a private clinic. You’d have to be insane to pay that kind of fee, normally. Good opening line, though.

“The survey found that around 50 clinics were charging “high” fees of more than $15 for casual consultations for children under 6. Nineteen were charging these rates even for young children enrolled with a primary health organisation (PHO).

“More than 40 were charging “high” fees of more than $45 for children aged 6 to 17, although clinics may appear in multiple categories of the survey.”

I note that the Ministry has set their “high” fee mark at an arbitrary level. $15.00 for an after-hours consultation is high? Interesting planet they live on.

What the Ministry don’t seem to get is that the cost of running an after-hours facility (as opposed to a doctor extending his hours – see later) is massively expensive. The throughput of an after-hours clinic is substantially lower than the throughput of a general practice. In addition, the patients tend to be sicker, and take longer to see. The clinic’s fixed charges are the same but they have to pay their staff more to compensate for unsociable hours. More expenses, less patients. Each patient therefore pays more. Simple economics.

So what sets the price?

They are in direct competition with Emergency Departments. Patients will only go to the A&M clinic if the extra cost is less than the perceived cost of waiting in the ED. This is exactly why centers like Taupo do not have an effective A&M clinic – their waiting times at the hospital are low (on average) so the A&M service is uneconomical. The clinics can’t charge ridiculous fees because there is reasonable competition.

“National’s health spokesman, Tony Ryall, said last night: “You’d think that having a huge ministry and 21 district health boards working on this for over two years, more progress would have been made.””

Mr. Ryall is being a little disingenuous here. The government has not actually addressed this at all. Funding A&M clinics would be the equivalent of funding a second set of Emergency departments (already notoriously underfunded), so it has generally been an issue that is dumped in the “too hard” basket. National are also not likely to see this issue as a problem, for the economic reasons I have outlined.

“Going to an after-hours clinic can be the only option for some families where both parents work during the day or which have one car which is used by a working parent.”

Not exactly true. Most of the larger GP practices have an extended hours regime where one partner works until six (or later) each day. There is usually no extra after-hours fee involved. Smaller practices and rural ones tend to club together to do the same thing.

““The biggest issue is that children get sick 24 hours a day and places are open 10 to 12 hours a day,” said GP and Child Poverty Action Group spokeswoman Dr Nikki Turner.

““We think it’s unacceptable there’s any barrier to primary health care for a child. It’s a very short-sighted policy.””

More disingenuousness. If your child is sick after the GP is closed, you go to the emergency department, not a GP. There is no barrier at all (except sometimes a long wait). There is no longer any need for a GP to be available 24/7 except in some very remote rural situations.

The report goes on to say:

““arguably PHOs have received surplus first contact funding that could be contributed to after-hours services”.”

I love government. They are so predictable. They give you funding to perform a task and then, slowly but surely, add tasks to your list without increasing funding. Let’s be clear here, PHOs are given a capitation fee (fee per head). This is supposed to fund the primary health care needs of the people registered to your PHO. Is the government really saying that after-hours care is part of primary care? Then what are hospital emergency departments?

In reality, emergency health care is already taken care of by Emergency departments. Therefore the health care need that is left should be non-urgent (or, at most, semi-urgent). So it appears the Government is suggesting that some primary health services must be reduced (as they are not increasing funding) because some parents want the convenience of coming to the doctor at 8pm. This does not seem to me to be a good use of scarce resources. Fund your Emergency Departments properly and allow the A&M clinics to charge whatever they need to keep running. They are a luxury, not a necessity.

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