• We don’t have the best health care system in the world. But we could.

    Every once in a while, I’m forced to engage the health care system in a more personal way. Yesterday was one of those days. First, one of my children (who shall remain nameless), decided to take a stroll in the mulch on Monday without any shoes. He managed to lodge an enormous splinter in his foot which I couldn’t get out. By the time I saw it that night, it was already starting to look like it might be a problem. On the same night, another child (who shall remain nameless) reported that he was having some pain and swelling in an area of his body (which shall also remain nameless).

    Yesterday morning, my wife called the pediatrician, who scheduled a visit for the latter problem. For the former, we made an appointment with the dermatologist for the foot. Before lunch, they had cut out the offending piece of wood and placed a stitch. The nameless part of the body was examined at 3:45, and there was some concern that it might be serious. He was sent to the emergency department, and I was pinged to join them. We all arrived around 5:05 PM. At 5:15, a doctor was in the room apologizing about the wait. They did an ultrasound, and the urologist drove up from another hospital to see us in the ED and go over the issue with us. He even drew us a picture. We were out before dinner, dropped off the prescription, and gave the first dose of meds before bed.

    What I’m describing could easily be taken as the finest health care system in the world.

    People think that you get care because you have insurance. But I can swear to you that no one in this process cared one whit who our carrier was. People think you get care like this because you have more money. Believe me when I tell you that we are far from the richest people in this community. We get care like this because of who we are and what we do. We’re in the system.

    The first doctor I mentioned had no sick visits available. But they squeezed in one of our children because they know I’m a pediatrician and they know my wife’s a nurse practitioner. They also know us personally. You have to remember that about a fifth of Americans can’t get an appointment when they’re sick within a week, let alone that day. The dermatologist appointment (for a splinter!!!) was arranged with a close friend at the practice. When our child was referred to the ED, I’m sure a call was placed to the urologist telling him who my son’s dad was and that I worked in the health care system, precipitating a level of service that few will see.

    I’m so grateful for what everyone did. Please understand that I’m not saying one bit of this was fake. Every doctor we saw was unbelievable fantastic and ridiculously skilled. I’m not saying that these providers aren’t just as kind and caring with every other patient. I’m sure they are. We received no scans, no procedures, and no medications that someone else wouldn’t get. We just got them served to us in an ideal fashion.

    That’s access. It has nothing to do with insurance or wealth.

    We have such potential. For all my complaints here, we have the best trained health care workforce in the world. Our facilities are top notch. Our technology is amazing, as are our medications. The problem is that the way it’s organized and distributed doesn’t work well at all. It’s like we took the world’s best and most complicated Lego set and let a small child put it together without the instructions.

    The Affordable Care Act will likely make things better for millions of people. Insurance will give them access to the health care system in ways they didn’t have before. But it won’t give them what I described above. Insurance is necessary, but not sufficient. Tons of Americans are attracted to concierge care (and I can’t blame them) because they bought the insurance, and still don’t get the access they want. Unfortunately, concierge care still won’t give you the level of care that I try very hard not to take for granted.

    We don’t have the best health care system in the world. But we could. I long for the day when we can start talking about getting that instead of whether we should give Medicaid to people making less than the poverty line.


    • Every time I visit a health provider, I end up with a stress-inducing mess of bills, most of which are payable by my insurance, but getting the provider to bill properly and Aetna to pay is a pain. I currently have two send to the bill collectors because I didn’t spend enough time trying to get the provider and Aetna to play nice together.

    • Great post. I’ll refrain from my hobby horse (chronic illness), but only indirectly. My brother, who lives with me, has leukemia. And no immunities. Over the weekend he developed a very bad and painful ear infection. His oncologist (who is located at the academic medical center 4 hours away) instructed him to see an ENT ASAP. We reside in the low country, and it’s dominated by a large not for profit health care system (which employs most of the physicians too). It turns out there is one, one, ENT in the area, and, notwithstanding my brother’s very precarious health condition (an infection can kill him if not promptly treated), the ENT couldn’t see my brother before mid-October. Even the oncologist couldn’t get the local ENT to make an exception. So my brother is off to the academic medical center to see his oncologist and an ENT. Our area has a very (very!) affluent (mostly part-time) population, and the health care system is regional and provides care for a large area. Yet, there is only one ENT! An aside, my brother lost his health insurance after losing his job (his declining health made it impossible for him to work). But he is a veteran and signed up for care at the VA, the closest VA center about 4 hours away. The VA sent him to the academic health center because they have outstanding oncologists. It’s a tricky arrangement because the VA doesn’t usually pay for care outside the VA system. But the oncologist’s dedication got my brother into a trial that has kept him alive, and the oncologist convinced the pharmaceutical supplier to donate the chemicals (which costs tens of thousands per treatment). My brother is receiving fantastic care, but only because of the charity and the dedication of the physicians at the academic medical center. This is nuts! [The oncologist recently got a coveted appointment at Ohio State and will be moving this fall. Those folks are the richer for getting such a great oncologist and human being.]

      • What I find interesting is the referral to an ENT.

        My GP made an interesting observation about a specialist I went to see. Paraphrased it was “it doesn’t matter how good they are if they aren’t available when you really need them”. What he didn’t realize that it was also a slam on (most) doctors because they created the problem.

        This is perhaps the most insidious problem of our health care system. Why does an ENT need to treat an ear infection? Why does a podiatrist need to treat a splinter in a foot? Why do I really need to go to a specialist for that medication change when the pharmacist knows more than all of you anyway? That’s basic doctor territory. Or at least should be.

    • I am very fortunate to have been with the same family practitioner for more than 20 years (not counting the 3 when I lived in a different state). It is not corporate, it is private — one physician, one P.A., an N.P. who handles OB cases, and a good crew of RN’s. It is likely that the good preventative care I receive keeps the number of times I have an acute problem low but on the rare occasion when I finally decide that whatever it is won’t be clearing up on its own anytime soon or that there is something similar to the pain in a place that shall not be mentioned I can almost always get one of the coveted same day appointments as long as I call early in the day and am willing to be flexible about what time slot is open. My wife is under the care of a largish “physicians group” with multiple locations. When she needs a SDA, it is almost always with one of their PA’s — to see one of the MD’s requires at least a week and a reason why she wants to see that doctor.

    • I was following your logic up to:

      “We don’t have the best health care system in the world. But we could. I long for the day when we can start talking about getting that instead of whether we should give Medicaid to people making less than the poverty line.”

      I’m not sure if you are saying hell with the poor and their health or let’s stop bitching about it fix it, and move on to the issue at hand making what we have work better for all.

      • I believe that insurance is necessary, but not sufficient; but we can’t even agree on that. We can’t stop arguing about the relatively simple stuff. So how do we move on to truly hard things like delivery system changes?

    • I have a similar example. A grandchild became dehydrated and wasn’t wetting his diapers (7 mo). His mom called the pediatrician and spoke to a ‘nurse?’ Without asking any questions the mom was told to take the child to the ER.

      That is an expensive proposition for society and the family. That also imposes risks on the child, hospital infection, multiple tests that are unneeded, etc. The mom knew the child had no other symptoms and guessed it was from getting slightly dehydrated in the backseat of a car after a day of traveling, but because of a nervous first time mom she thought of calling the pediatrician first rather than pushing a bit more fluids orally which she otherwise would have done with just a bit of confirmation. A likely untrained nurse needlessly pushed her into the system which is a major cause of costs.

      The mom is smart and has loads of physicians in the family including one of the ER docs so she called them not wanting the child abused. Water was pushed and diapers became immediately wet with a happy child at no cost to the system.

      This is what we get when we treat code numbers instead of patients. This is the fault of an overly intrusive government that with good intent has removed the patient from the decision making process causing fees to be set in an awkward fashion (the tax system causing third party payer.) In a true market physicians would be far more responsive to their patients for they would ( and should ) change physicians when this happens. It seems this is the way pediatricians act in this location. The pediatricians acted quite differently when this adult was a child.

    • Pretty much everyone in Switzerland gets the kind of attention you describe. I certainly have, and its a dramatic difference from my experience in the US.

      I don’t have any data that explains why. It’s easy to say it’s “cultural.” People here expect fantastic service in all areas, not just health care. Doctors certainly don’t expect to be the richest family on the block. This is a place that’s been a democracy since 1291.

      But I wonder if that’s too glib. Certainly, the alignment of incentives still matters a lot.

    • Lawyers, bankers, even preachers as well as most other professionals take extra care an attention for friends, family or members of the “fraternity” or for those who have a VIP position of power or a connection. Well functioning health care providers (there are more than you think) have institutionalized these patient focused behaviors but many have yet to find a pathway for their organization to accomplish this culture of care. It’s a focus on service excellence and an attitude of “how would I want to be cared for.” Thereally good one make it look effortless and graceful.

      Health care has become so fragmented and disconnected. This is so sad when you think about how intimate a professional service medical care is. But excellence is compensated the same as crappy service. How do patients reward providers who truly give excellent care? I try to always complement and brag on my physicians and their staffs who provide wonderful care.

    • Arron, thank you and I agree with you.

    • You describe an interesting phenomenon: in healthcare, privilege can’t be bought or stolen (say, the way access to an elite university can be bought or a status-symbol item of clothing can be stolen).

      Instead, access to ideal healthcare requires an arsenal of cultural capital on par with acceptance into the world of high fashion: years of experience, jargon fluency, feverish social networking. But life and well-being (arguably) don’t rely on access to high fashion.

      Elite access to medical care–what you experienced–relies on an architecture of privilege that was meticulously crafted by the AMA during the 20th century. Heroic medicine was becoming big business, and big business likes privilege.

      That’s not the world we live in anymore. The astronomical costs and technological complexity of even everyday healthcare places an undue burden on those already excluded from medical privilege. It’s time to start closing the gap. And that will mean less access at the top.

    • Let me introduce you to the real world of inadequate medical care in the USSA.

      First of all, when I call a doc or dentist, the first question he asks is “Do you have insurance”? This irritates the hell out of me.

      All medical and dental practitioners, not to mention hospitals, are skilled at hiding the ball when it comes to fee for services. I had to file a FOIA to get the Medicare allowances by CPT code in Texas. The poetic justice of Obamacare is that it will ultimately result in medical practitioners’ becoming gummint employees. That will ruin medicine altogether, but oh do they so deserve it!

      Furthermore, I seldom find a medical practitioner who is skilled at science. Very few can speak proper English, much less a foreign language. I had the sorry job of trying to teach pre-meds (and pre-laws) Baby Physics and Baby Math, while they were trying to learn as little as possible but still get the A needed to get into professional school.

      So, I know they’re relatively dumb, but they still have a license to practice, and I sure as hell don’t want them practicing on me! Besides the insurance question, one way I disqualify them is to pay attention to their grammar. Very few avoid the urge to commit the solecism, “…at risk for…,” for example.

      Insurance is a religion. It returns less than 80 cents on the premium dollar. Neither Medicare nor Obamacare is available overseas. I knew some cradle-to-grave insured Germans, who died anyway after a traffic accident in Chile. You won’t need your expensive insurance if you climb Everest or sail around the world. Insurance is for fearful, risk-averse, superstitious and religious persons.

      There is no ultimate assurance in life, and insurance and religion are costly and senseless attempts to find it.

    • The medical-care system in Amerika sucks big-time. It is discriminatory, inefficient, obscurantist, and, above all, extremely costly.

      Some, but not all, of its problems are directly due to its being linked, in Amerika, to insurance. Medical care and medical insurance are not fundamentally compatible, since insurance pays for cheap items like vaccinations and check-ups, but is often not available when needed for chronic, serious and expensive treatment. I high percentage of bankruptcies are due to medical costs suffered by the insured! And you have to wait forever to make an appointment!

      Just imagine what it would be like if your medical care were administered by Walmart:

      There would be someone to greet you at the door with “Good morning, welcome to Walmart” instead of “Do you have insurance”?

      Every service would be instantly available.

      All of the prices for all of the treatments would be listed by CPT code and readily accessible on the Web, along with the guarantee, “If you find a better price, we’ll give you a 5% discount.”

      Everyone would be charged the same price with no coddling of women and no exploitation of young males, who under insurance or Obamacare deeply subsidize the health care of hypochondriacs, women (who use 87% more health care than men) and their elders (who use six times the health care).

      Folks would not be charged for treatment they don’t want: perinatal care for men or prostate exams for women. Contraception and abortion for the Roman Catholics.

      Most importantly, they would not have to pay the 20%+ premium that insurance represents. Imagine if you had to subscribe to Obamafood, taking out insurance to cover bread purchases at the market!

      If you get sick while living in Brazil, though you have your insurance or Obamacare paid up or are fully entitled to Medicare or Medicaid, you will have to pay out-of-pocket for your health care. Walmart does not charge you for things you can’t get overseas.

      Fortunately, there are Walmarts in Brazil (http://www.walmartbrasil.com.br/) where you can get the same treatment you get in the States: fair, non-discriminatory, instantly available, no-insurance, greeting-at-the-door, transparent pricing and guarantees!

    • Finding a good doctor certainly seems to be the first step. Not just a good doctor, but a brave doctor as well who is willing to care for patients regardless of legal liability.

      That’s a tall order these days. Do you have to have insurance to find one though? Many doctors will take cash- avoiding the insurance mess and ultimately lowering the cost of the visit. It’s a whole underworld of health care removed from insurance inspired nightmares.

      • Yo Doctor in Austin,

        I live in Austin, too, and it is there that I have a hell of a time “finding a good doctor.” First of all, since the medical profession does all it can to hide the ball about quality of doctors, quality of hospitals, fees for services by CPT, costs of associated labs, and even criminal records from a doc’s past in another state.

        “Finding a good doc” is a herculean task, one I find impossible given their disqualification for lack of math, science and even English grammar.

        Yes, I always ask for a cash discount from docs and dentists, and most will offer a measly 5%, when the true value of cash is what they save on credit-card fees, insurance haggling, insurance record-keeping, insurance late payments, and insurance denial of payment. Apart from the math, science and English deficiencies, it appears that all of them suffer from a total lack of understanding of economics and the marketplace.

        We might be better off in Cuba, as far as medical care is concerned.

    • Doctor in Austin:

      You raise a good point regarding a doc’s liability. I can only respond that, as a rocket scientist, I have been involved in the design of bombers, fighters, ICBMs, doomsday communications and nuclear weapons. Should I have been worried about the (immeasurable) liability?

      No, because I was an contractor-employee working for a firm like Rockwell, Honeywell or Siemens, all of whom bore the ultimate responsibility under the doctrine of respondeat superior. What we need is to turn all docs and nurses into Walmart employees at the $7.25 per hour they deserve for their 29 hours per week max.

      • Rocket scientists are overpaid and overvalued as well…..

        Why should I pay you $80k per year when I can hire a Bangladeshi engineer overseas who studied harder than you, is smarter than you, and will do a superior job for $20k?

    • I think we have the best system in the world. I believe it is how one approaches the health care system. One needs to arms themselves with information. Go into a medical situation and ask questions. A lot of the times this will create a higher awareness about your case.
      You don’t just want to be a number with the Doctor, You want them to know who you are. Build a relationship with your GP. Follow their advice. If you don’t have a GP then you should go find one.

      If you don’t have insurance then that is an issue you have to address.

      In my industry I have seen the best qualify of care given. I have seen peoples quality of life improved 10 fold by the treatment they have received. I have also seen terminal people receive a qualify of care
      that was more than dignified. “Having or showing a composed or serious manner that is worthy of respect.”

      There are some medical facilities that I would not go to because of the high rate of complications & infections. Today we have access to that type of data, so one can make an informed decision.

      We do have the best health care system in the world because we are able to choose.

      • @Tony N
        I’ve lived all over the world and experienced many health care systems. In plenty of second rate countries, you can get excellent care. The difference is whether the system consistently delivers excellent care or not.

        That means does the US consistently deliver excellent care to the uneducated, un-connected, and uninsured? The answer is a resounding NO.

        • SAO,
          I would disagree with you. I have seen charitable clinics provide a level of care that is over and above. The clinic in mind treated a lot of undocumented workers and they did not speak english.

          I don’t think you can save one from ones oneself. Should we be a cradle to grave nation? When does individual responsibility become part of the equation?

          There are all kinds of community organization that can help people that are poor and uneducated.

          I believe you if seek medical attention in the country you can get it..

          • @ Tony N

            My point was consistency. Can you feel confident that anyone, no matter their age, education, insurance status or situation will get excellent care in the US system?

            I can’t. I’ve had trouble getting imaging transferred to another provider, despite actively trying to ensure the images were provided to the next doctor in time. The result is poorer follow-up of an existing condition.

            I’ve moved a lot and co-ordination of care is an issue in America the way it isn’t in a single-provider system like England.

            • Totally disagree with you. I have had clients use the medical services in England. They had a horrible experience. One had a close to death experience and need a defibrillator at his side. The Hospital only had one and they could not find it. So for about 24 hours this Man is sitting in a bed in a room with about 9 other patients, not knowing if he is going to die. He made it, and had a bill in the morning for just $800 US.

              I give more horrible experiences with the Canadian health care system.

              So I will keep our system vs anything else out there.

    • When I’m waiting 2 months to see the Dermatologist about an itchy disfiguring rash that my GP can’t figure out I’ll remember that they’re fitting in family and friends with splinters the same day.

      • For the record, the splinter had to come out. It was already getting infected.

        But to the larger point, I wrote this because I want everyone to have this kind of access.

    • Aaron Carroll,

      If you really “want everyone to have this kind of access,” why wouldn’t you favor entrusting medical care to Walmart, where everyone does getfair, cheap and 100% access, instead of to our byzantine and kafkaesque medical-insurance-drugmagnate system?

      • You obviously havent been keeping up on current events.

        Obamacare has sstrong financial incentives for doctors to re-organize into large collective organizations called ACOs, under which doctors are “employees” under a corporate model.

        As a result of this nonsense, ACOs are now consolidating forces and driving prices upwards.

        Doctors should be employees of the federal government, not Walmart. Walmart’s interests are to serve its shareholders, which would cause a massive spike in prices as the Walmart shareholders unanimously demand that Walmart use its monopsony power in the healthcare marketplace to extract ever higher revenues.

        • ACO is an Accountable Care Organization. This is where the doctors /medical facilities are paid on performance.
          If the patient is not re-admitted then the doctor may be eligible for a additional compensations. This is a step in in getting away from the fee for services system that we are currently on.

          The problem with the ACO model, is only 1/3 of the hospitals that tested it are going to stay in this model of care.

          The lack or participation shows that this lowers the cost of care.

    • Our family is not “in the system” like Aaron’s is, but we somehow manage to get the same level of care- maybe we just picked the right doctors? For example, last week my kids’ pediatric practice was happy to schedule a same-day appointment for my son just because I was worried that his eczema was looking bad. In fact, I have always been able to schedule sick appointments with them the same day.

      My own doctor is just as good- it’s always same day or next day appointments when I’m sick. They use an “open access” scheduling system. Maybe it’s really about getting more doctors to move to this system?

    • Yes, its a great and heart-warming story. But what about the opportunity cost of the care provided? Were the MDs that provided the care otherwise unoccupied, or did they have to cancel or delay other appointments?

    • Surely you woudl just go straight to ER for the foot splinter and not bother consultant doctors or even a family doctor, which strikes me as unnecessary and overuse.

      In the UK, I would just take one of my kids to one of the local minor injuries units or A&E (accident and emergency) departments, which usually have a dedicated child part where they are usually seen quickly (and with no charge of course).

      But we don’t have the choice of seeing a dematologist directly (unless you pay of course).

      • Of course, once Walmart adds Nurse Practitioners to its clinics, you will be able to take your kid to have his splinter removed for $45. If Starbucks added such clinics, you could just walk to the nearest corner.

        I’d personally like to see bars open emergency-care or urgent-care clinics; then you could have a few beers in the 5 hours of waiting.

    • My wife’s family lives in Honduras and her father wanted one of hist children to become a Doctor and so one did. This would be unreachable for a comparable family in the USA. IMHO Medical school needs to be made easier to get into, less rigorous, shorter and less arduous.

    • That the ER doctor apologized for the non-existent wait made me chuckle.

      We are all judged by our press-Ganey patient satisfaction scores these days, with financial penalties and sometimes your job on the line if you’re a low performer. So the “science” of patient satisfaction has become almost a religion in the ER, and the first thing they teach you is to apologize for the wait, no matter how long or how short it was. Looks like your doctor was paying attention!

    • Everyone deserves to be given the best healthcare system but unfortunately, let’s fface it, not everyone receives it. I guess, when you have money and insurance, you get to have the best healthcare system. You get to have the best treatments, best doctors. I guess it all boils down to having money.

      • Is there an alternative for “it all boils down to having money”?

        Historically, even when using the barter system, it all boiled down to an exchange of goods or services where both parties felt they benefited from the deal. That never stopped anyone from giving something for free, which is known as charity. How charitable a person is, is not related to how much a second party forces a third party to give. That is known as power hungry and that generally represents a non charitable person.