Public vs private – is it good for our health?

The voice on the radio advertisement is warm and reassuring, clearly that of an older person, extolling the virtues of the emergency department of the private hospital. Given that many of us, particularly as we age, may be unsociable enough to fall ill at night time, a first warning signal to lay people that the service is not similar to public hospitals is that is only open during the day.

What the advertisement does not state is that should you be admitted and do not have appropriate insurance, you could be staring at financial ruin if your episode of care is complex and prolonged. Both of these aspects of the private system reflect a failure to openly articulate in public debate how the private and public systems should work alongside each other, given that the democratic mandate has thus far opted for a divided system.

It is likely that the universal healthcare (generally a good thing) and universal health insurance (in our culture, almost certainly a bad thing) promised by the last government will not see the light of day in any foreseeable future.

The key impetus for generating this debate is the central fact that older people, along with children, are the key user demographic of healthcare and ideally the health system should reflect their care needs. These are notable for complexity, the presence often of multiple illnesses and multiple medications and the loss of function, such as immobility, incontinence or delirium, with acute illness.

Flawed as it may be, the public system has developed formal strategies to anticipate the needs of older people, including the development of geriatric medicine and stroke units in general hospitals, the appointment of geriatricians to acute medical units and evolving systems of integrated care.

Within the private system, no such clear intent is visible, largely arising out of a system that prioritises procedures and technology over multidisciplinary care.

The insurance system will pay out readily for scans, scopes and angiograms which tend to be relatively predictable, fixed and non-recurring costs, but cavil at reimbursing the combined medical and rehabilitative approach required for the majority of acute medical emergencies among older people.

Hence, no private hospital has a department of geriatric medicine nor does one have a stroke unit. Even more troubling is the assumption noted in recent weeks in this paper that the public hospital should assume the burden of very complex patients from the private system, a medical version of the property developers’ creed of “capitalism on the way up, socialism on the way down”.

As noted previously in this column, if private hospitals negotiate a fixed price for a procedure, it is on the basis of covering both the cases which recover quickly (and generate a profit) and those which have complications which require a longer stay.

Awaiting any major change in the system, it is important to emphasise that neither private nor public systems are inherently bad: what is damaging is the failure to have an open and constructive debate on the distractors, flaws and costs of each and how to provide a health system which works in a synergistic, transparent and fair fashion.

For example, the private hospital system has had an enormous, as yet unquantified, subsidy from tax breaks for construction from the public purse. For the private system to meet the needs of older people, there needs to be a move away from procedure-based reimbursement towards a financial model which recognises the more complex and ongoing needs of older people.

In addition, there needs to be a stronger regulation to prevent health insurance companies from gaming the system to attract younger, less expensive and more profitable subscribers. Finally, older people should be assured of age-attuned care within each system.

The medical profession also needs to show leadership. It is 110 years since George Bernard Shaw described the distortions of private practice with coruscating wit in his play The Doctor's Dilemma.

Irish research has already given an indication of how private or public status impacts on optimal prescribing, antibiotic use in general practice and the rates of Caesarean sections, and not always ultimately in favour of those in the private sector.

Ideally, the next edition of the ethics guidelines from the Medical Council, due shortly, should articulate clearly how to recognise and respond appropriately to financial dynamics which may alter clinical practice.