“I” before “E” in medicine and VIP patient access

We live in a world where immediacy reigns. From accessing a world of information in the palm of our hands within seconds to getting items delivered to our doorstep within hours, we are conditioned to expect minimal wait times for what we want — when we have the right tools within reach. However, what about equity in healthcare access? Do our expectations change when our ability to access what we need circumvents many others who are patiently waiting for the same medical answer?

This question is perhaps most controversial when a VIP (very important patient) enters the clinic. The VIP and the broader concept of improved access for those with the right connections or resources has long thrived in private payer systems. In a recent response to a challenging case in the Journal of Developmental and Behavioral Pediatrics, I argue that dialogue around healthcare equity is incomplete without addressing the ethical issues raised when VIPs ‘cut the queue’ and enjoy special-access privileges for subspecialty appointments.

Those familiar with working in healthcare settings are aware of the perks of leveraging one’s network to gain access to care when wait times are lengthy. For developmental and behavioral pediatrics (DBP) for example — a pediatric sub-specialty focused on working with children and teens with a wide range of neurodevelopmental differences including autism spectrum disorders — parents may wait 12-18 months or more for an appointment.

However, DBP wait times can be shorter if families are able to pay for evaluations from providers in private practice who bill on a fee-for-service basis. This option is infeasible for many patients who are unable to pay out of pocket for medically indicated evaluations or care. An initial developmental and behavioral evaluation with a board-certified developmental pediatrician ranges on average from 90 to 120 minutes. In that time, clinicians provide a detailed clinical history, direct developmental testing, diagnostic feedback and treatment recommendations to ensure parents have a complete picture of their child’s unique needs.

The ‘challenging case’ presented within the Journal of Developmental and Behavioral Pediatrics involves a donor of the hospital who requested an expedited appointment time for a developmental evaluation of a family member. At a time when teaching about diversity, equity and inclusion is threatened in many states, should the healthcare community even care about VIPs who cut the line? Is it problematic for donors to expect access perks if they provide substantial funding to healthcare institutions?

Medicine can no longer afford to ignore the many ways we improve access for some and limit access for others. As medicine continues to focus on and prioritize DEI efforts to help achieve equity, we must address structural and systematic barriers at all levels in our healthcare system for real, lasting change to occur.

By Dr. Anson Koshy, Associate Professor of Pediatrics, Baylor College of Medicine