Should patients pay to see the GP?
BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.h6800 (Published 06 January 2016) Cite this as: BMJ 2016;352:h6800
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There are many who have concerns about equity and access to healthcare among those who are not able to pay. In China, government has provided equality in terms of health access to every patient, whether they are rich or poor. For instance, in government hospitals if you need to visit a medical doctor, there are minimum charges which everyone has to pay as the opd fees, and they could have consultation to their respective physicians. However, sound socioeconomic patients fell they need the private consultations as they believe personal consultation could provide them better care. In most of the public hospitals, there is an expert consultation system where they could pay a bit higher consultation charges and have the consultation. As a matter of fact, the treatment and care are almost same to every patient. People thoughts vary, and some believe higher consultation charges could provide them better care.
In China, all public hospitals are monitored by the health officials, and they care the services to all no matter. You are rich and the poor. Difference is that whether one wishes to have luxury ward and personal assistance, you need to pay a bit more to the hospitals.
For instance, in Italy, the sufferer obtains free of charge assistance of the GP, and GPs are paid for based on the number of patients [1]. The same process is in China, and the hospital pays to certain charges to their consultants. Within this process, the sufferer may need a lot more appointments from the General practitioner and seems to obtain the optimum guidance to get the ideal financial advantage. This brings, undoubtedly, to some organizing avoidance appointments and several check-ups, which take much less time than needed [1].
Contrary to a system of co-payment, it could be helpful to bring in a method that benefits excellent healthcare practice. As an example, a GP that extends to the target of cardiovascular risks or comprehensive control over the continual agony within a patient will end up being effectively utilized the options, however, with a great deal of arranging and significant patient total satisfaction [1].
In China, numerous patients grumble with the very little time dedicated from the General practitioner on their overall health. This might be because of, in reality, somewhere of repayment with the General practitioner[1].On the other hand some prefer to see their physicians frequently. As we know for some disease, there is a need of frequent follow up and the patient has to pay consultation charges to hospitals. Few believe their physicians dint gave time to them, and chances of agreement ensue. Awareness is important to deal with this issue.
As Massimo described, the co-payment could minimize the number of appointments for avoidance, exacerbate overall health expenses of patients with chronic disease, decrease health care assessments needed of those that are not able to pay out, increase targeted traffic of (unneeded) needs by affluent people. Additionally, a system of participation in direct investing could start a contest in between various governmental ambitions of health programs [1]. There are numerous who may have worries about equity and having access to medical care between people who aren't able to pay. The underclass also will often have difficulties with having access to inexpensive food items, outfits and homes; shall we be likely to utilize much more taxes on their own earnings or jobless advantages on food's stamp, clothes coupon and local rental support to make certain they have got fairness to those as well ?[2] Those who have never ever been poor is not going to know how dreadful this concept appears to be. Those who have certainly not been just through the means-tested limit but fought with cash is not going to comprehend it. It's very easy to become condescending and discuss about how “it would just be £5” and “it would reduce overlooked appointments” but through your ivory tower, it’s difficult to observe how a lot £6 could be truly worth to anyone, or how had missed consultations really don't usually occur because sufferers cannot be troubled to show up[3].
Its seems too difficult to address whether the physicians should be paid or not. Insurance policy differs from country wise. Patient's satisfactions should be considered how they like their treatment. For instance private of public hospitals. Finally, as medicos we should try to provide our best to every patient, whether they are affluent or not.
References:
1.Massimo Mammucari; http://www.bmj.com/content/352/bmj.h6800/rr-8
2.Shyan Goh; http://www.bmj.com/content/352/bmj.h6800/rr-7
3.Elena Smith; http://www.bmj.com/content/352/bmj.h6800/rr
Competing interests: No competing interests
Dear Editors
I regret to report that there is an error in my rapid response and I wish to correct it as follows:
"Also keep in mind that there are some UK residents who paid even more for their health care (£18.2 billion) to access services privately. If they have the same mentality to only access NHS for these services they will account for an increase of 14% of NHS expenditure."
Thank you
Competing interests: No competing interests
Dear Editors
It is with some irony that the loudest voices in the stance that "I have the right to free health care services because I paid my taxes" are more likely those belonging to the middle class than the socioeconomically disadvantaged underclass (who also paid their taxes)
It is important to remember that the genesis of NHS is principally part of "cradle to grave" welfare-state reforms in 1948. For 2011/12, total Health Care expenditure accounts for 10% (£151.7 billion) of UK's GDP, and publicly funded health care ("NHS") accounts for 88% of total health care costs. Furthermore 81% of total NHS expenditure of £133.5 billion is directly funded by the UK government, 21% from National Insurance while patients contributed the remaining 1% out of their pocket.(1)
Total National Insurance contribution for 2011/12 is £101 billion (2): UK residents pays at 0.00% on the lower band of earnings and then at 12.00% up to the upper limit and 2% on earnings over the upper limit to the National Insurance. Thus 22.7% of NI is used to fund NHS.
Personal income tax generates about £158 billion to UK revenues in 2011/12.If all of the NHS expenditure directly funded by UK government (£107 billion) is paid for by personal income tax, it would account for on average 68% of everyone's annual income tax contribution. If the idea that "I paid for my health care through tax" is true, it obviously means that there isn't much left to contribute to security, education, public works, industry spending! Since personal income revenue accounts for 26% of all revenues of UK government (£589 billion) and NHS account for 17.8% of 2011/12 UK budget (£711 billion) (2), thus the real personal income tax contribution to NHS is probably closer to 4% of all UK spending.
Since the maximum rate of personal income tax in UK is no more than 45%, then it is expected than most UK residents are not likely to pay anywhere close to 45% X 17.8% = 8% of their gross annual income
Also keep in mind that there are some UK residents who paid even more to their health care £9.6 billion to access services privately. If they have the same mentality to access NHS for these services they will account for an increase of 7% of NHS expenditure.
Similarly in Australia, many residents have the mindset that they paid their taxes and thus similarly entitled to free healthcare services. The fact is that Medicare accounts for only 30% (AUD 19 billion) of the Australian Commonwealth expenditure on health services overall (AUD 62 billion) for 2013/14 (3,4). The often quoted 1.5% Medicare Levy accounts for only $10.3 billion (ie 54%) of the Medicare budget, the rest will have to be funded by the Australian Commonwealth government. Personal income tax accounts for AUD 137 billion or 39% of total revenue of Australian Commonwealth government AUD 351 billion (2013/14). Of the AUD 414 billion expenditure in 2013/14, health care accounts for 15% spending (and thus Medicare 4.5% total Commonwealth expenditure), so therefore Australian personal income tax funding to health care accounts only for 6% (or 2% if considering Medicare only) of all Australian government spending.
The maximum rate of personal income tax is no more than 49%, then it is expected than very few Australians to pay anywhere close to 49% X 15% = 7.35% (or 2.45%) of their gross annual income on health care (or specifically Medicare).
Compare this to Germany where of the 81 million Germans, 85% are in the national health insurance scheme of which 80% of working adults contribute 7.3% (employers contribute another 8.2%, total 15.5%) of their gross income and all pensioners must contribute 50% of their pension to this national insurance scheme (6). Note this is before any personal income tax of 14 - 45%. Dr Nancy Loader should take note of this when trying to use Germany as a example of not using copayment.
Furthermore when we contribute to the health care funding via income tax, it is important to consider the scheme as a insurance plan rather than a saving account: Insurance subscribers do not normally try to put in a claim because they know they will end up paying more premium or even be denied future cover (therefore people do not usually submit a claim for minor dents or scratches on cars, for example). Insurance schemes are generally utilised by people who have to claim due to disproportionate costs of damage needing to be addressed. As such, the majority of premium payers are supporting the misfortunate of a few at the current moment. Like insurance, paying for cover now does not entitle subscribers to future cover when they become pensioners (when they become 'higher-risk' by virtual of age and yet not paying much premium if not 'free'). Unlike certain countries, individual paying taxes or levies in UK, Germany and Australia does not accumulate personal cash 'nest' or deposit accounts set aside for future use in healthcare.
Therefore the amount of tax contribution by individuals bears no relation to the cost of the healthcare, their entitlement to free access to services with no out of pocket expense, or future cover of healthcare services.
Occasionally I hear of people demanding that they should have their hip replacement simply because they "paid their Medicare Levy", rather than fulfilling the clinical criteria. Even with a generous AUD 100,000 annual income (average over 30 years of Medicare), I worked out that their entire Levy contribution barely covers the real world (as opposed to public hospital cost) costs of a total hip replacement and supporting perioperative services. It leaves nothing for any other Medicare services over the course of 30 years.
The age of entitlement and basic human rights (of universal "free" access to healthcare) is only really possible when we are willing to pay for it.
References
1. https://www.ohe.org/system/files/private/publications/389%20-%202013_OHE...
2. https://en.wikipedia.org/wiki/2011_United_Kingdom_budget
3. http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliam...
4. http://www.abs.gov.au/ausstats/abs@.nsf/mf/5506.0
5. http://www.budget.gov.au/2013-14/content/fbo/download/Consolidated.pdf
6. http://www.goinginternational.eu/newsletter/2013/nl_03/SpecialDE_EN_Unde...
Competing interests: No competing interests
The answer is obviously ” no”. We are already paying through general taxation. Would it not be better if we paid a special NHS tax and then people would know for what they were paying and when the tax needed to go up (or down)? People would pay according to their ability and the service would be free at the point of use as now. Alternatively a form of insurance could be used but this would spoil the freedom at the time of use conception.
With the present situation where the NHS is just not able to cope through shortage of staff for everyone to pay per consultation would just be an unnecessary complication as well as putting some people off. Compared with pre NHS days patients are not able to choose their own GP. That is the one they get on best with and the one who best understood their case. To-day patients must register with the practice dealing with their area and with the GP they are allocated, usually the newest member of the team. Occasionally they may be able to see another member of the practice if their own is away or if they specially request this but it is not possible in all practices. In any case no real understanding is achieved where the time is limited on every occasion. In this respect it should be remembered that the doctor needs to get to know his patient which may take a considerable time but once he does five minutes may be (more than) adequate.
The only real answer to this and the other problems in the NHS is of course more doctors and more other staff but how this is to be achieved I do not know.
Competing interests: No competing interests
Dear editor,
The previous responses set out the potential pitfalls of a fee based system. However it would be foolish to reject the thought out of hand.
The UK is uniquely placed in that there is a single monopoly provider (NHS) that has a capitation pay system for GP’s.
The problems in the UK healthcare system arise though a non-alignment of incentives: The provider receives a flat fee, so the incentive is to make the system as unpleasant and difficult as possible, this discourages attendances by patients, frees up capacity and leads to a higher list and more income and more pension. The patient however has no incentive to reduce attendances or make the encounters more efficient, once the appointment is booked the payment has been made (in the UK the patients pay with their time, not with money).
The capitation system reduces provider induced demand or pandering to unnecessary or superfluous patient demands, but there is no real competition for patients, as the most frequent attending patients are the least economically desirable in the current system. Only an excess capacity would encourage providers to offer improved services to hang onto patients that could move to other practices. We need to align the incentives for provider and patient to be as efficient as possible.
Currently I cannot advice patients appropriately, I can offer alternatives, but as seeing an orthopaedic surgeon costs the same as waiting for a problem to settle for a few months, the patient has only the option to opt for the MRI and specialist assessment. There is no discrete choice due to the lack of fees, only the pain of waiting and an unpleasant encounter is limiting patient's choices.
Patients may not object to co-pays if it means a better service.
Inevitable gaming (it is only human nature) means that there should be no exceptions for payment, otherwise patients will go to alternative providers (A&E) or hijack free diabetes appointments for other health problems, or use the appointments of members of family to bring up health issues. Everything should carry a charge, including GP services.
It is an odd concept that food and heating are not provided socially in the UK like healthcare, I can do much longer without a GP than I can do without food.
Eligibility for NHS could simply be determined by an NHS credit card with biometrics. The NHS is government run so payments could be taken by the Inland Revenue, or deducted from benefits and be proportional to income. Inserting your NHS credit card (or biometrics) will unlock the GP or hospital computer to access records and care and the meter starts running, incentivising the patient to be efficient, or take more time and not be rushed out the consulting room if they wish to.
The NHS card will also stop health tourism in its tracks, currently government already charges certain temporary residents an NHS fee there would be nothing new here except for using modern technology.
Competing interests: No competing interests
Dear Editors
With respect to direct payment of GPs, there may be different points of view in favor or opposed to a system of cost-sharing by the patient.
In my opinion, the co-payment could reduce the number of visits for prevention, aggravate health costs of patients with chronic disease, reduce medical examinations required of those who cannot pay, increase traffic of (unnecessary) requests by wealthy patients. In addition, a system of participation in direct spending could open a dispute between different political visions of health systems.
For example, in Italy, the patient receives free assistance of the GP and GPs are paid according to the number of patients they care for. In this system, the patient may require more visits in the GP week and tends to acquire the maximum assistance to achieve the greatest economic benefit. This leads, inevitably, to a few planning prevention visits and a series of check-ups which take less time than required. Rather than a system of co-payment it would be useful to introduce a system that rewards good clinical practice. For example, a GP who reaches the target of cardiovascular risk factors or complete control of chronic pain in a patient will prove to be properly using the resources, but with a good deal of planning and significant patient satisfaction.
Many patients complain of the little time devoted by the GP to their health. This could be due, in fact, to the system of payment of the GP.
It would be interesting to try remunerating the role of GP not according to the number of patients but according to other indicators (qualitative).
The principle of remuneration according to quality indicators should be taken into account by health authorities for testing organization more aligned with the needs of the citizen. It would also be useful to know the opinion of the patient about a health care system both, territorial and hospital, focused on results.
What would a patient with chronic pain prefer? A health care system available to receive a patient several times a week or a health care system that aims to full pain control in the shortest possible time and with the most appropriate therapy?
Competing interests: No competing interests
Dear Editors
I note that many readers who have posted rapid responses regarding this issue have used a similar line of logic to answer the question.
I will illustrate this sort of thinking in a common scenario (albeit an emotive one).
We should not have chemotherapy treatment for cancer drugs because of the problems related to a small number of patients. What if some of them cannot tolerate the drugs and the side effects? What if the drugs are too expensive to buy or too costly to give, involving specialised procedures and specialised nursing room and staff to carry out treatment? What if the drug doesn't work?
Similarly the logical answer to "Should patients pay to see the GP?" should first address the benefits and harm of all patients having to pay the GP. Does it interfere with treatment? Does it make patient follow up harder? Does it make patients more involved about their own health?
Only after we are satisfied with the answer to that, can we discuss how we help those who cannot pay the GP out of pocket.
There are many who have concerns about equity and access to healthcare amongst those who are not able to pay*. The underclasses also usually have issues with access to affordable foodstuff, clothing and housing; are we going to apply more tax on their income or unemployment benefits on food stamp, clothing voucher and rental assistance to make sure they have equity to these as well?
Some are worried that having 2 classes of patients (paying vs non-paying) will worsen the pride of non-paying patients. Not that having the unemployed go to job centres and local council offices and various other departments to seek benefits or exemption has done no damage to their self-esteem. Furthermore, it is common for clinicians to ask patients about their employment so as to determine whether they can return to work for the illness they present with. It is also a standard thing to advise patients an estimate of any out-of-pocket costs of any treatment (not every thing is covered by NHS) and check if they have problems with that.
*(as opposed to those who scream they can't afford to pay but actually have a very healthy middle-class income)
Competing interests: No competing interests
Whatever the rights and wrongs of this complex question, the key issue was not discussed. What happens when the patient doesn't pay?
It leads to a dark labyrinth of disasters.
Patients cannot ethically be denied access to health care until they pay.
The alternative is to set up a massively expensive process to recover the non payment, far exceeding the initial sum. Like other non payment of fines, poor people unable to pay face mounting fines, bailiffs , criminal records and presumable ultimately prison?
Is that the sort of NHS we want?
Competing interests: No competing interests
It is a great privilege to consult with patients with no money entering into the relationship. I have worked in New Zealand, where patients paid to see me in a surgery and out of hours. I felt more pressure to keep the consumer happy--for example, to prescribe antidepressants earlier--rather than see them in a week of two and re-asses. However, I think I have come to the conclusion that it is inevitable and, although less fair than what we have now, is the least unfair way of bringing more money into health care.
I do not believe healthcare spending can continue to consume a larger share of the public purse. It squeezes out social care, police, justice education, defence and transport spending. One might argue spending in theses areas contribute more towards health than healthcare does. We must find a way of drawing more private money into healthcare, while preserving almost free access to people who cannot afford to pay and prevent severe financial hardship for those who can.
In New Zealand I worked in rich and poor areas. In rich areas patients paid NZ$26 to see me for 15 minutes, while in poor areas it was $6. The money was collected by reception. Kids under a certain age were free and those with chronic illness had a certain amount of free consults a year. I perceived it did reduce some demand. I saw more complaints that I would class as legitimately medical, while in my UK practice patients come more with non-medical issues over which I have little to offer besides empathy. I am in fact the wrong person to see . . . but I am free!
One could take it further. Why not let GPs charge a convenience payment to see folks outside normal hours? I wonder how many colleagues would willingly open up late evenings for those busy working who could afford a modest convenience charge to justify the unsocial hours their GP was working? What about £5 to see an out of hours GP, but £10 to go to A+E?
Consumerism in healthcare already exists, the problem for me is that it is tax funded. If patients demand this, rather than basic evidence based care, there is a case they should pay out of their pockets for it and let the tax be spent on something that truly improves health.
Competing interests: I work as a GP, earning a good income from free at the point of use, government /tax funded care.
Re: Should patients pay to see the GP? No: GP charges drive A&E demand for richer, for poorer.
I agree with Dr Nancy Loader.
User fees and copayments in primary care are regressive, reduce accessibility and promote a doctor-patient interaction full of moral hazard.
Whilst we are in the midst of the current NHS Crisis with Emergency Medicine Departments struggling to cope with existing demand, those supporting a GP user fee system must contemplate and recognise the impact posed to free Emergency Departments.
A household survey in 2012, not far from home, in Jersey, Channel Islands, identified that GP user-fees create cost-related demand for the Emergency Department. [1]
Charging primary patients is counter productive from a wider health service perspective and fails to support the most vulnerable patients in society.
1. Arun-Castro S DO GP USER-FEES AFFECT A&E USAGE? GP CHARGES DRIVE A&E DEMAND, FOR RICHER, FOR POORER Emerg Med J 2014;31:786-787.
Competing interests: No competing interests