Dr. Richey has two waiting rooms. The medical patients’ waiting room is comfortable, but the lounge for cosmetic clients is luxurious, with soft music and flowers.
And he has two kinds of treatment rooms: clinical-looking for skin disease patients, soothing for cosmetic laser patients.
“Cosmetic patients have a much more private environment than general medical patients because they expect that,” said Dr. Richey, who estimated that he spent about 40 percent of his time treating cosmetic patients. “We are a little bit more sensitive to their needs.”
Like airlines that offer first-class and coach sections, dermatology is fast becoming a two-tier business in which higher-paying customers often receive greater pampering. In some dermatologists’ offices, freer-spending cosmetic patients are given appointments more quickly than medical patients for whom health insurance pays fixed reimbursement fees.
In other offices, cosmetic patients spend more time with a doctor. And in still others, doctors employ a special receptionist, called a cosmetic concierge, for their beauty patients.
[snip]
A study published last year in The Journal of the American Academy of Dermatology found that dermatologists in 11 American cities and one county offered faster appointments to a person calling about Botox than for someone calling about a changing mole, a possible sign of skin cancer.
And dermatologists nationwide are increasingly hiring nurse practitioners and physicians’ assistants, called physician extenders, who primarily see medical patients, according to a study published earlier this year in the same journal.
“What are the physician extenders doing? Medical dermatology,” Dr. Allan C. Halpern, chief of dermatology at Memorial Sloan-Kettering Cancer Center in Manhattan, said in a melanoma lecture at a dermatology conference this year. “What are the dermatologists doing? Cosmetic dermatology."
In other words, the care you get is dependent on how much you pay.
This is fine on an airline, where no matter what class you fly, you in theory get to the same destination. But when patients who need medical care are given a back seat to those who have the resources to fight the ultimately vain battle against the clock, then some dictors' priorities are seriously askew -- and I would say, unethical.
The net result is the kind of "medicine-by-profit-margin" that HMOs were designed to address. However, HMOs and insurance companies have turned doctors, who are often incentivized to NOT refer patients to specialists, into Gandalf the Gray, standing his ground against patients and insisting "YOU. SHALL. NOT. PASS."
And all the while, dermatologists have been able to move off of the practice of actual medicine, and even from the kind of reconstructive surgery that accident victims and cancer patients often need, into a glorified spa practice -- at the same time as skin cancer rates are increasing and there is a shortage of dermatologists.
The debate about health care in this country has focused almost entirely on insurance -- how it is to be delivered, whether a single-payer model or a tweaking of the existing system is in order. What is not being discussed is quality of care. It may be easy for Rudy Giuliani or John McCain, both of whom have excellent health coverage and access to the best and most expensive doctors in the country, to say we have the best health care system in the world. But ask the young mother with the 1/2" mole that has an irregular edge, is crusty, and is red around the edges, whether she should have to wait two hours so that her doctor can shoot botulinum toxin into the brows of someone who wants to look good at her spa.
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