THERE IS A story going back to my days as a trainee surgeon of a consultant who, on discovering that the next patient on his operating list had decided not to use his health insurance, called over his assistant saying to the patient: “I want to introduce you to your surgeon. Tell me young man, have you done many of these operations before?”

The young doctor allegedly responded: “No, not really, but I have seen you do it”. The patient response was fairly predictable stating that he would sign whatever the doctor wanted as long as he did the surgery himself.

Why pay extra for same bed?

Although this is probably more urban legend than truth, it is still as indefensible as it is comical. It does, however, illustrate that the topic of insured patients choosing not to use their health insurance when in a public hospital is not new.

It has received a lot of press lately due to a concerted effort from the medical insurance companies, backed up by the representative bodies from their industry. They have been at pains to point out that the treatment a patient gets when they enter a public hospital is identical irrespective of whether their customer signs the private insurance forms or not.

Although the cost to each individual patient is no different, if they sign up to be private the insurer has to pay the hospital 10 times the cost of a public bed. Ultimately, if this continues, they say it will lead to increases in premiums. The argument is if the bed is the same bed, why would you pay extra for it, when the care is otherwise identical?

Given the current bed crisis, access to the few single rooms on a public hospital ward is difficult. It is likely that the bed really is the same bed. On this basis it’s a no-brainer. Care is absolutely identical. There is no point in signing, right? Well, it’s probably not quite that simple.

Doctors delegating

When a private patient is discharged from any hospital, the claim form has to be completed and signed by the consultant in charge. The lion share of the revenue goes to the hospital rather than any of the doctors, however no one gets paid until the consultant in charge fills out and signs the form.

At the end of the form, there is a condition that the undersigned must have provided the care themselves personally and not have delegated it to another. This means that the doctor must have seen the patient and prescribed their care.

It also means that if the patient has had a procedure or operation that the doctor billing for this must have performed it themselves.

Laya has recently stepped up its number of requests for patient chart information on the pretext that it is performing an audit. It would appear that part of this “audit” is to check whose name appears on the operation note. Is it the consultant in charge or is it someone else? Clearly they are looking to see if doctors are billing for procedures they may have delegated to others.

A challenging time to practice

As a surgeon there has never been a more challenging time to practice. Operating theatre space is reduced and is at a real premium. Surgeons are under pressure to make sure that whatever theatre time they have is used efficiently.

One of the issues which complicates this is the need to train the junior doctors – Ireland’s next generation of consultants. The vast majority of Irish hospitals have doctors-in-training on their staff. They provide much of the first line contact for patients and work long hours in doing so. The quid pro quo is that they get trained. This means access to teaching, mentoring and formal hands-on instruction.

Most surgeons enjoy this, but it does take time, showing someone where and how to place an instrument or suture takes a lot longer than doing it oneself. Taking a trainee through a case rather than doing it oneself and maintaining a certain standard can double the time for the procedure depending on the complexity of the case and the relative experience of the trainee.

The consultant can’t let the trainee do every case on the list. Not only would it take too long but the surgeon themselves needs to do some operating in order to maintain their own skills.

As a result on any given operating list some cases are performed by the doctor-in-training supervised by the consultant and some are done by the consultant themselves. These are all performed to a given, predetermined standard.

Why would you leave the prospect of a procedure fee go a begging?

If a consultant gets paid a procedure fee when they do a case but not if they supervise it, it is fairly clear how the caseload is going to be divided up. If you have to do some of the work yourself, you might as well get paid for it as not.

Why would you leave the prospect of a procedure fee go a begging? This is simply human nature.

This is complicated further by the effect this decision has on others. If a consultant decides not to be the primary operator on a given case and the patient is private, the anaesthetist does not get paid either irrespective as to whether they are supervising their own trainee or doing the case themselves.

Clearly if the anaesthetist is running the operating list that day from start to finish, it does nothing for surgeon-anaesthetist relations if the actions of one mean the other has to forfeit income.

The standard of doctors-in-training and the teaching they get in Ireland is excellent. It is reflected in the great outcomes from surgery in Irish hospitals and the popularity of Irish graduates throughout the English-speaking world. All Irish patients irrespective of their insurance status benefit from this.

Having said that, is the care as the health insurers say exactly the same for everyone? Probably not. When doctors and their loved ones are patients in hospital, the form tends to get signed.

The author of this piece has requested to remain anonymous.

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