IN?THIS?WEEK’S Big Interview, Dr Carlos Chase – president of the Barbados Association of Medical Practitioners (BAMP) and a Queen Elizabeth Hospital consultant – responds to concerns such as suggestions of unreasonable fees charged by doctors, raised at the recent NATION Talkback town hall meeting.
Q: First up, Dr Chase, how do you respond to charges that current doctors’ fees are simply unreasonable?
Dr Chase: What is an unreasonable fee? There are several fees when one sees a doctor and these may be a consultation fee, fee for procedure, fee for an investigation, or fee for an operation.
What are the expenses of a doctor? Registration $2 500 annually; medical malpractice [insurance] up to $60 000 annually; commercial rates for electricity, water, telephone, secretarial services, cleaning services, nurse, travel, drugs, supplies, equipment, maintenance, property and accident insurance.
Equipment is not duty-free nor VAT-free and despite asking for years to have medical equipment duty-free and VAT-free, successive Governments have denied this request. The doctor then has to recoup the cost of the equipment and repay the loans to the banks.
All of these items, services, supplies and equipment cost money and are not provided free to the doctor.
Q: So you are saying the current fee structure is justified?
Dr Chase: The doctor is faced with a dramatic increase in all of his expenses, and fees in the private sector have nothing to do with the overall cost of health care.
Doctors’ fees vary depending on speciality, procedure being performed, and complexity of the procedure, and not the value of your estate as occurs with some other professions.
In other professions there are no choices but to pay the professional fee. Lawyers, dentists, engineers, architects readily come to mind. There are very limited dental services in the polyclinics and legal aid is limited to specific issues involving court matters.
Doctors and teachers are the only two professions that have an excellent public service which competes with them.
Ultimately the patient has a choice: pay for service or have free service at the polyclinic, Queen Elizabeth Hospital (QEH), outpatients’ clinics or Psychiatric Hospital.
Q: That being said, don’t you think doctors need to exercise more of a collective conscience, given the fact that many doctors in Barbados would have benefited from the provision of free education?
Dr Chase: Doctors who receive scholarships and exhibitions are bonded to work for the Government
up to five years to repay the services. Others have student loans that have to be paid back with interest immediately on completion of their training.
We note that all professionals in Barbados receive their education free. Is the submission that lawyers, dentists, engineers, computer technicians, hairdressers and so on all give their services free in the private sector?
Q: No, but what about the issue of doctors owning pharmacies – isn’t this a direct conflict of interest?
Dr Chase: No problems have been reported, and we note that the director of the Barbados Drug Service said that she was not aware of any issues occurring because of this. It seems that someone’s perception is being made into an agenda. Are we to say that teachers should not own schools or bookshops?
A calypsonian should not own a tent? We do not see an issue here. The two work closely together. It seems to us that someone is trying to fix a problem that does not exist.
Q: What about doctors who work at the QEH and also operate private practices – isn’t that a direct conflict of interest?
Dr Chase: If the administration wishes to discontinue the privileges of private practice at the QEH and elsewhere in the public sector, then they must be prepared to pay the true market value of the consultants. Current rates for consultants in [Britain] for consultants with over eight years’ experience is a minimum £100 000 (BDS$314 194) per year.
Most of our consultants at the QEH and other public institutions have over eight years’ experience. Is the administration willing to spend $360 000 per year and up rather than the approximately $100 000 per year now being paid?
Q: But, Dr Chase, you are not operating in Britain. This is little Barbados and the argument being made is that you need to be cognisant of the market you are operating in and the privileges that consultants currently enjoy at the QEH; for example, education paid for by the state.
Dr Chase: [The Barbados Association of Medical Practitioners] has made extensive proposals on this issue since 2007 and to date we cannot get the administration to sit down with us. Proposals have been with the QEH for the past six months and they have made no effort to conclude negotiations. This has been brought to the minister’s attention and still there has been no meeting.
Q: Let’s move away from the issue of doctors for a bit and deal with the general service at the QEH. Patients are still being made to endure long waits, particularly in the A&E department, and this just doesn’t seem fair or acceptable.
Dr Chase: This issue is multifactorial. There is the question of space – physical space to examine patients – and adequacy of medical, nursing and support staff. Then the question of equipment – speed of obtaining lab results in order to make definitive diagnosis, availability and speed of radiological investigations – which influences clinical management.
Then there is the issue of bed management – getting patients out of A&E so they do no block beds and go on to the wards in a timely manner.
Next there is the continued closure of the medical ICU, resulting in patients who are critically ill being managed and ventilated in the Stat room of the A&E department simply because there is nowhere to put them. These are all issues to be addressed and of which administration is aware, and it is not simply a doctor problem.
Q: So the long wait in A&E has nothing to do with the fact that some consultants are off site dealing with their own private practices, leaving inexperienced junior doctors/trainees to run their shift?
Dr Chase: Indeed it does not.
Firstly, consultants are well within their terms and conditions of service to attend private practice.
Secondly, the staffing situation will dictate the number of doctors per shift. If the administration wants a consultant or senior registrar on each shift, then the number of consultant staff and junior doctor staff would have to be increased.
There is a cost factor to this which must be borne out of the public purse.
We must determine what standards we want and the resources that would be allocated to obtain those standards.
Q: Speaking of standards, some patients complain that they are told if they paid $5 000 for an operation, they would be able to get it the following week. However, if they decided to wait on public treatment, in some instances they end up waiting one year to get it done.
Dr Chase: Waiting lists at the QEH – let us examine the matter. We note that for a non-urgent case, there is no harm in waiting. That is why it is an elective surgery. If the patient does not want to wait and wants to jump ahead on the list, they call the minister and complain; that is not fair to the others who do not have access to the minister and who were first in line.
If a patient is waiting for elective surgery and his or her case becomes urgent, then they are done either as an emergency or earlier on the elective list but at the expense of someone else.
The current system allows that person to choose to have their case done privately and they go on a separate private list which is naturally shorter than the public waiting list. That patient then pays the $5 000, which is the figure that was quoted, to the doctor and $3 000 to the QEH.
The patient then pays for everything: use of the operating theatre, bed, laboratory investigations, medication, food, anaesthesia drugs and gases, sutures are all paid for by the patient, if they choose to go private. The public will have to determine what they consider to be a reasonable time to wait for non-urgent surgery and then the clinicians will determine what resources are necessary to achieve this goal. It may be more anaesthetists, doctors, surgeons, junior staff, nurses, equipment, aides, better bed management, better laboratory turnaround times, move toward ambulatory care, bigger blood collecting unit, operating theatres or operating theatre usage time.
The administration will then determine whether they have the resources to achieve this goal and whether they are realistic and truly attainable targets.
Q: Would you support a fee scale for doctors in Barbados?
Dr Chase: BAMP does not understand what the intent is here. When doctors attempted to set fees, they were threatened by the Fair Trading Commission saying that was illegal. Now we hear the public asking for fees to be set.
This is fine once we set fees for all professionals; doctors, lawyers, architects, engineers, pharmacists, nurses, physiotherapists, dentists, carpenters, masons, tilers, painters, seamstresses, snow-cone vendors. Newspapers, light, telephone, water rates, all entities where fees are charged should be regulated. We have no objection if this is done for everyone.
We would like to hear the Fair Trading Commission’s views on BAMP’s setting or recommending tariffs or fee structures for doctors.
We would also like to know how this would be blended with the new Medical Profession Act 2011 for enforcement. (KJ)
