With a h/t to my spouse, this piece from a couple of days ago offers a beautiful (not really the mot juste) window onto the multiple levels of fail of US medical business and (or rather, hence) practice. The action gets going as a young physicians assistant named Andrew T. Gray describes waking up an upset stomach, which over the course of the day blossoms into really nasty pain. Then comes the twist:
Crawling into bed, however, I realized that my pain had coalesced in the right lower quadrant of my abdomen. Could it be appendicitis?
Panic flooded me. After six weeks at my new job, I now qualified for health insurance, but I’d neglected to fill out the necessary paperwork.
Only an hour after leaving the clinic, I returned. Almost hysterically, I completed and faxed in the insurance forms.
“Go to the emergency room right now,” urged one of my supervising physicians.
Instead, Gray waited overnight so as to reduce the odds of insurance company shenanigans. The next morning, though he can’t wait anymore:
Waiting for the ER doctor, I recalled that, at some point in my schooling, I’d read a Swedish study about treating appendicitis with antibiotics. Googling the study on my smartphone, I found it.
By the time the ER resident approached, I was ready.
“I don’t have health insurance,” I said calmly. “Can I be treated with antibiotics instead of surgery?”
“I doubt they’re going to let you do that here,” he said. “But keep expressing interest.”
When the ER attending physician came in, I repeated the question.
“Absolutely not,” he replied flatly. “This is America, not Sweden. If you have appendicitis, we operate.”
The story gets better — which is to say from a policy and medical care point of view, worse. Go read the whole thing.
As to its relevance beyond itself. Well, Gray’s telling an anecdote, of course, a single encounter in a system that touches millions every day. Even so, there are at least two key points I can draw: (a) there are structural problems with the culture of medical practice in the US that both drive up costs and affect (not for the better) patient outcomes. “This is America…we operate.”
And (b): there are lots of reasons medical costs in the US seem both arbitrary and excessive. But (a) they are and (b) it actually matters to know what happens elsewhere, because from such knowledge it finally becomes much easier to see that US health care is exceptional alright — but not how the foaming hordes raving against tyranny in the form of Obamacare would have it. We sure do lead the world in what we pay. Just not in getting what (we think) we’re paying for.*
*This is not to say that for particular conditions in particular cities there is no better place in the world to receive care than, say, my current dwelling place, Boston. But brilliant tertiary care available to those clued in and covered in just the right ways doth not a system make.
Image: Hans Holbein, Henry VIII and the Barber Surgeons, 1543.
Not Adding Much To The Community
Submit to rewrite, too many parentheticals.
Frankensteinbeck
What you just wrote is the reason the insurance companies are primarily to blame for our skyrocketing medical costs. They have been rigging the system so they can’t lose money (rather than to maximize profit) and that results in a labyrinth of loopholes, restrictions, and requirements that prevent anything from being done efficiently OR wisely.
Comrade Jake
I’m sure some of you have seen this, but John Green has put up a short video on what he views drives health care costs in the US to be roughly double what anyone else in the world pays. The answer is probably not what you think. Worth a watch.
joes527
Not quite sure what this story illustrates.
As commenters point out at the link, the failure rate for the cheaper course was 23% + 11% requiring surgery within a year. (and no numbers available for 5 year outcomes)
Compared to immediate surgery, this seems like a dangerous (and potentially more expensive) choice. Certainly not a no-brainer in any case.
Also, overriding prescribed treatment in an urgent situation because the patient has some link on the internet seems like a bad idea.
But did they really need a CAT scan for the diagnosis?
Chris
Imagine the inefficient government bureaucracies that’ll happen if the government takes over the health care industry! We’ll have patients standing in line needing to fill out red tape before they can be treated for emergencies!
Amir Khalid
The link at the top of your post leads to a 503 error message. The link after the blockquote is fine.
So what happened with that $30,000 hospital bill? Is Andrew Grey or his insurer on the hook for it? And why is it thirty freaking grand in the first place?
joes527
@Amir Khalid:
Because they charged him for the whole box of kleenex that was put in his room.
(I actually suspect the CAT scan was a big chunk)
Walker
Neither link works now.
Stella B.
It looks like the first large scale study of antibiotics for appendicitis was published one year ago. I suspect that there are trials taking place in the US right now and if they pan out, there will be a change in the hundred year old treatment for appendicitis. However, as far as I can tell, this is not the first line treatment in Sweden much less the rest of Europe. I’m certain that once the Swedish trial has been replicated succesfully, it will become standard of care, but not before that.
My great-great-grandmother developed appendicitis on Christmas Day. On the 27th she died. In 1905.
Tom Levenson
@Walker: Both work for me in both Safari and Firefox. Not sure what the issue could be.
@Chris: This is a profoundly stupid comment. Congratulations.
Amir Khalid
@joes527:
I have trouble believing that the marginal cost of a CT scan plus the depreciation plus, say, a 30% markup comes anywhere near one thousand US dollars, let alone thirty freaking thousand.
WereBear
True.
I had a semi-emergency procedue; I was in severe pain and if the thing had ruptured I would be in a world of hurt.
I spent the two days prior weeping on the phone to make sure my insurance company would pay for it; they had lots of hoops, and if I missed one (BTW, the pain pills weren’t touching this thing) I would have been on the hook for whatever happened next.
And I would not have wound up in the place I was in if the insurance company hadn’t dictated treatment to suit them in the first place.
OzarkHillbilly
Amen to that. For my latest (minor) surgery, I am having to pay $50 for a plastic tray (according to the itemized bill) that I most certainly did not “get.”
You would think my insurance could negotiate a better price for plastic trays. Maybe next time I should just bring my own?
Villago Delenda Est
@Tom Levenson:
Tom, please see your snark detector maintenance specialist as soon as possible…but by all means…wait until you’re sure your insurance will cover the visit!
ThalarctosMaritimus
@Tom Levenson:
Not sure, but I think your sarcasm meter needs an adjustment.
Stella B.
@OzarkHillbilly: bring your own tray. Pay somebody to sterilize it. Pay somebody to maintain it and use it in sterile conditions. Pay somebody to pay the fee to have it incinerated as “medical waste”. Pay for the surgical instruments that are used to fill it (a “tray” is filled with sterile items). I doubt you’d save much money.
Roger Moore
@Amir Khalid:
Because the numbers on medical bills in America are entirely fictitious. $30K is basically the hospital’s starting point in negotiations, and nobody is actually expected to pay that much. Indigent patients will run up huge bills and declare bankruptcy. Well off patients who somehow don’t have insurance will negotiate a lower price after the fact, and insurance companies have already negotiated rates that are drastically lower than the list price. The insurance company probably settled for 20% or less, and that was still profitable for the hospital. The complete disconnection between what hospitals claim to charge for services, what they actually charge, and how much the services actually cost is a huge part of the inefficiency of the American medical system.
joes527
@Stella B.: Assuming further trials have similar results (23% failure + 11% requiring surgery within a year + ??? requiring surgery within 5 years) Do you really think that this will replace immediate surgery as the standard treatment?
ruemara
@Amir Khalid: I spent nearly 3 consecutive Saturday a.m.s in the the emergency room. I think the most they did was stuff nitrate silver up my nose and shove a nose tampon or two up there for the bleeding, then remove it a week later. Plus some pills, a pee test, 2 blood tests. Post insurance, I was on the hook for nearly $6k. The total bills were nearly $15k. The bill is probably equipment, the doctors, the blood tests, hell, any tests plus if they gave him any magic pills. Fucking coated in gold and platinum, American medical care is.
Chris
@joes527:
I agree with this, actually. Notwithstanding the swipe at Sweden, it sounded like the doctor was mainly concerned with prescribing the method he was most sure would work. What’s godawful is that the procedures cost so much that the patient found herself begging for a more dangerous one, but that’s not the doc’s fault.
@ThalarctosMaritimus:
Yes, you are correct. And thanks :D
Stella B.
When I had my appendix removed in 2010, it cost me $250 because I had been careful to make sure the insurance papwork was filled out. The surgeon who did the job at midnight probably got paid hundreds of dollars to finance his disgraceful lifestyle of working all night long. The 24 people (4 doctors, 20 hospital employees, I counted) that were involved in the job got paid decent wages too. Disgusting. I could have been given antibiotics and spent the next week or so in pain, off work.
Roger Moore
@Tom Levenson:
You need to get your sarcasmometer calibrated. Mine says that was snark about the dumb complaints that government involvement in healthcare will lead to massive bureaucracy.
Tom Levenson
@Villago Delenda Est: Errr. Can I say that I am fail, apologize to @Chris: and slink home in shame? Saving the taxpayer money all that?
Tom Levenson
@ThalarctosMaritimus: @Chris: @Roger Moore: See above. (Slinks lower.)
Jibeaux
Just to throw the doc a bone, if there were a malpractice suit, his conduct would be judged in part on whether it was consistent with standards of treatment in his community. Europe also uses a lot more ultrasounds before resorting to MRIs, but if that’s not the local standard of care you aren’t going to find many doctors willing to do it. It just adds a sticky wicket to physician decision-making and of course, drives up costs.
joes527
I made the mistake of having a medical condition while on a business trip once. I called my insurance and made sure I went to the “right” urgent care. They looked at me and gave me a prescription for a fairly standard anti-inflammatory.
It took over a year of calls and letters to get the billing straightened out.
Chris
@Tom Levenson:
LOL, it’s no problem. That was a condensed version of bitching about “red tape” and “inefficient bureaucracy” that I’ve been hearing for years on end before, during and after the health care debate, and sadly in most of these cases it wasn’t snark… so I can’t really blame people who mistake it for the real thing.
WereBear
It’s like a volcano where they toss the uninsured.
Basically, if you don’t have health insurance the outcome is guaranteed; and if you do have insurance but it starts getting costly, you could also be in the volcano line.
They treat you, they grind as much money out of you as they can until you declare bankruptcy, then they do some corporate magic and you are doomed to penury.
And you might not even be cured!
WereBear
That’s the point; because being on the hook for that much money is almost as much of a DEATH as letting the appendix burst and dying of perionitis. It just lasts longer.
As currently rigged, bankruptcy doesn’t work either; you are still on the hook for years, with the added bonus of lowering your chances of being unemployable and able to rent housing.
Amir Khalid
@Roger Moore:
Ooh, just imagine if other businesses could bill people like that: pluck some ridiculously high number out of the air, and invite the customer’s insurer to talk the amount down.
pseudonymous in nc
A relative was diagnosed with Graves disease not long ago. Her endocrinologist wanted to blast the thyroid with radioactive iodine and put her on medication for the rest of her life. We pointed out that outside the US, the first preference is to use antithyroid drugs. Finding an endocrinologist willing to do that was… a struggle.
“This is America, we operate.” Blast away, clean up afterwards.
This particular preference is just path dependency.
pseudonymous in nc
@Roger Moore:
Aka medical bistromaths: “The third and most mysterious piece of nonabsoluteness of all lies in the relationship between the number of items on the bill, the cost of each item, the number of people at the table and what they are each prepared to pay for.”
Villago Delenda Est
@Chris:
To me, it’s one of the most asinine arguments in the entire debate…the notion that some “government bureaucrat” is going to dictate to you and your doctor what treatment to use. This is happening RIGHT NOW, but it’s not a government bureaucrat, it’s a corporate bureaucrat. But then again, as long as it’s being done in the name of sacred profit, as opposed to concern about allocation of resources for the best outcome, it’s perfectly OK to strangle people with red tape.
pseudonymous in nc
@Stella B.:
Oh, bullshit. Surgeons in the US are not pleading poverty. They go home to their big fucking houses and big fucking cars and their financial worries extend to whether it’s okay to get Little Muffy another pony for Christmas.
Villago Delenda Est
@pseudonymous in nc:
It’s the profit center mentality.
The fact of the matter is, it is simply not possible to use traditional market techniques to obtain medical care. Because you can’t find out what the price tag is before you choose to get the care. It’s not like shopping for a car, or a wide screen TV. No one can tell you what it will cost, because they have no idea themselves.
OzarkHillbilly
@Stella B.:
$10 for the tray, $5 for the sterilization and the plastic wrapper they put on it. All that other sh!t you mention? Those were itemized separately and I had to pay for them too (Needle Counter- $8, Lactated Ringers Inj – $36.10, etc etc etc). But then, you haven’t looked at many itemized hospital bills before have you?
pseudonymous in nc
From that piece:
And yes, we’ve heard that from medical professionals in hospitals. But the snuffling account-management piggies that work alongside them don’t think that way. That’s the problem.
The medical professionals don’t really know what their shit costs. And that’s frankly a good thing: they do what they’re trained to do. But the disconnect between that and the billing side — and the way that the billing side actually gets absorbed into the training along the way — is the killer.
(I’m reminded, again, of how Scrubs was one of the few medical shows on TV that actually engaged with the issue of cost and insurance and billing.)
OzarkHillbilly
@Stella B.:
Sigh… I remember those days. I had Carpenters (union) insurance. All I ever had to pay was my copays, everything else was covered. Now I am on my wife’s insurance (copay plus 20% to a $ I have yet to reach) and I am finding out how the rest of the world lives.
It sucks.
The Moar You Know
He’s lucky. Mine never hurt, not even a little, and it had ruptured. I had been feeling a little nauseous, is all. I only went in to the doctor that Monday because I needed a note to justify missing work on a Friday, which I didn’t miss because I felt ill, but because it was a nice day. He sent me straight to the ER. I thought he was insane.
I was less than 24 hours out from full-bore septicemia, which probably would have killed my sorry ass.
Mnemosyne
@Stella B.:
I had to spend $300 to not have my appendix taken out — it resolved itself in the hospital overnight. But I almost had to pay $2,000 because my insurance company insisted that my PCP was the only one who was allowed to tell me to go to the emergency room and because I had seen a different doctor in the same office (my doctor was out of town), it was outside the network and I was going to have to pay $2,000 instead.
It took three years of wrangling with the insurance company and ruining my credit, but I finally got a $300 bill from the hospital instead of the $2,000 one they had been sending. Imagine how much more time the hospital would have had to provide patient care if they hadn’t had to pay someone to chase me around for money I didn’t owe in the first place.
ETA: Don’t be so frickin’ judgey. Not everyone is as perfect as you are.
retr2327
The article is interesting enough, but the comments are more so. Note, in particular, the guy in finance who draws the conclusion from this article that what patients need is to have more skin in the game. Now contrast that with the debate amongst medical professionals about what, if anything, the Swedish study shows about the advisability of treating appendicitis with antibiotics instead of surgery.
So the finance guy’s opinion (which is bascially Repug dogma) is that the patient, while suffering from appendicitis, should research the available options, weigh the different (and essentially unavailable) costs, and try to determine the best course of action.
And then note that most of the doctors commenting belive that the author of the article (a trained medical professional, although not a doctor) probably made the wrong choice, and offer some pretty convincing explanations as to why . . . .
It seems to me to be a pretty good illustration of why “skin in the game” is not the answer to health care.
The Moar You Know
@Amir Khalid: It doesn’t. I’ve done two cash-only CT scans in my life. My cardiac CT was $400. My full-abdominal was about $900. They weren’t taking a loss on those scans, either.
Almost all of that $30,000 is you/your insurer paying for all the uninsured folks coming through. That’s why even incremental change – which Obamacare is and I’ve never made any secret that I feel Obamacare is an awful law, but better than what we have now, so hey, progress – is better than not changing at all.
Mnemosyne
@retr2327:
I swear, the next person who says that bullshit to me gets punched right in the throat. What are people with chronic conditions and diseases supposed to do? Choose not to have diabetes or Crohn’s Disease?
elmo
@Stella B.:
One of my uncles died as a teenager, of appendicitis. Family lore isn’t exact as to dates, but it was after my father was born, and he was born in 1931.
Ilya
Tom, great to see a writing professor lecture doctors on how the “culture of medical practice” is driving up costs in the US. As a fellow MIT affiliate (albeit lowly grad student, after my MD), I’m embarrassed by your argument. An appendectomy is an extremely simple surgery that has a 99+% success rate. In that Swedish study, antibiotics were successful 77% of the time, but 11% of those people would eventually need surgery anyway. In other words, you’re asking this surgeon to gamble with the patient’s life (yes, appendicitis can kill you, the nurse was correct), just so the patient can save money. And when the patient’s condition deteriorates, or God forbid, he dies, what do you think happens? At the end of the day, the doctor is both morally and legally responsible for the patient’s health.
Of course, there’s some conflict in two of the pillars of medical ethics here: autonomy (the patient’s ability to make decisions for themselves) vs. justice. Justice says you treat everyone equally, regardless of willingness/ability to pay. Autonomy means respecting the patient’s wishes. In this case, autonomy won out, and the patient did okay. That being said, I do not want to live in a world where doctors triage care based on knowing the patient’s financial status beforehand, which is what this patient seems to be advocating as a rule, rather than the exception here. If I had been his surgeon, I would have done the exact same thing.
Mnemosyne
@Ilya:
I agree with you that he seems to be mad at the wrong people here. It’s not the doctors and nurses who want to charge him an arm and a leg to have his appendix out — it’s the hospital and insurance company.
Also, I’m not sure that I’m as confident as he is that the antibiotics were the deciding factor. As I said above, my appendix flared up and then subsided without any further treatment. It’s entirely possible that it would have subsided on its own and the antibiotics ended up not doing much at all.
Eric U.
my plan will cover new orthotics at 90%, i.e., most of $500. Zero for rehabilitating old orthotics, probably $100.
I'mNotSureWhoIWantToBeYet
@Amir Khalid: I was getting a 503 as well. I was able to get to the article by starting at the home page and drilling down. http://www.pulsemagazine.org/
HTH.
Cheers,
Scott.
pat
I read the piece and I see two problems with what he did:
One, he neglected to fill out the insurance forms until he needed treatment. Why????
Two, he should have read the whole study, seen that there is a significant reoccurence after antibiotic treatment, and gone back for the surgery after he discovered his insurance had come through.
In other words, he might be a good writer, but he lacks something in the “taking responsibility” area.
WereBear
Like you don’t already have LITERAL skin in the game?
Besides which, it’s probably 2% of the population who have the unique combination of medical skills, access to studies, and sheer balls to buck their medical provider.
You have the option of walking out, but very few ever do that.
satby
@Ilya: You know, a 77% success rate is pretty good, and if the antibiotics weren’t working, it’s not like the pt was in Borneo and had to fly back for treatment. Telling Pts what signs to look for and when to come back if the antibiotics aren’t effective is not all that risky.
Edited to add: because of course, surgery has it’s own risks which also need to be factored in.
Ilya
@Mnemosyne: You’re right, some people have fairly asymptomatic appendicitis and subsequent rupture – that’s why we still have doctors, and not CT machines wearing white coats that scan people then print out “APPENDICITIS” or “NOT APPENDICITIS”. It just upsets me that uninformed people hear that someone got a bill for $30,000 (of which he will pay close to nothing if he has insurance, and substantially less than 30K if he doesn’t as long as he calls the hospital and contests the bill), and assume that’s going to the doctor and nurses. In reality, for each operation (about 20 minutes of actual surgery but one hour of my time if you include prepping and talking to the patient post-op), I get paid closer to $200 – which I’m thankful for, but that’s after 4 years of medical school (and 100K debt), and 5 years of general surgery residency (where we get paid minimum wage), and I still have to work 60 hour weeks to run a successful surgical practice. Which is why I’m leaving it for the world of research.
Ilya
@satby: the risks of a 20-minute operation are negligible, I tell my patients 2% (includes anesthesia, post-op complications, etc.). 77% is NOT good, especially when I’m defending myself in court. “Doctor, you could have gone with surgery, which is 99% successful at treating appendicitis. But for some reason, you went with antibiotics, which is USELESS for ONE OUT OF FOUR patients, all based on some obscure study from Sweden, and now your patient is dead from septic shock, leaving his wife a widow and his children fatherless. What do you have to say for yourself?”
elmo
@Ilya:
When my partner’s appy burst, her surgery took four hours. Apparently the thing went off like a balloon and then snugged up under her liver or something – the surgeon said he had a hard time finding it.
She was sent home the next day, without oral antibiotics. Of course she became septic, and a few days later she was back in the hospital, this time NPO for five solid days.
texasdem
@pseudonymous in nc:
Actually, that’s not true, at least not for general surgeons. Many of them now have a hard time making a go of it, and have become, in essence, hospital employees. I’m not saying they are poor, but it’s surgical specialists (for example, orthopedic surgeons) who make the big bucks.
Roger Moore
@retr2327:
Because having your life on the line isn’t enough skin in the game; you should also be faced with potential bankruptcy if you survive. People like that need to be strung up by their thumbs.
RSA
@Ilya: I appreciate your informed comments, Ilya, but I have to ask about this:
This tradeoff is baked into our current medical system, and patients can’t ignore it. What this means in practice, I think, is that many sick people just don’t go to a doctor because of the risk that it will cost too much, maybe even bankrupt them. Is this better than doctors taking cost and risks into account? (I honestly don’t know.)
JustRuss
Last night I attended a presentation by a woman who has several children with a very rare blood disease, treating it can burn through 100 grand in just a bad weekend. Part of her presentation covered the tremendous benefits Obamacare is now providing for families like hers, as well as some of the shenanigans the insurance companies are pulling to try to get around it.
I know a few of the attendees were free-market kool-aid drinkers, watching them squirm while she explained how the ACA is saving her family was absolutely delicious.
mai naem
I have a very good friend who practiced dentistry in the UK. I know all the jokes about British dental care or rather the lack of it, but she’s extremely smart and went to a really good dental school in the UK. One of her instructors was the queen’s dentist.
Anyhow, she moves here and she thinks American dental practice is kind of stupid and a lot of it is motivated by $$$ not for the good of the patient. She thinks orthodontics are way overdone here. She thinks often times retainers can be used but American dentists automatically go to braces. She thinks wisdom teeth extractions are done many times, unnecessarily. And she thinks the specialization is ridiculous. She says any decent dentist worth his/her salt should be able to handle most root canals instead of referring them to endodontists. And, oh yeah, one last thing – when she first moved here and was taking her boards, she went looking for a dentist for herself and went to 4 dentists, did not let them know that she was a dentist. All four told her she needed work that she knew she didn’t. She went to one more and told him she was a dentist and he just did a regular cleaning, didn’t find any problems.
Mnemosyne
@mai naem:
Here’s an interesting thing, though — after years of wearing braces, my roots ended up in some strange shapes (usually a C, but sometimes closer to an S) that actually do require an endodontist. (My husband did not wear braces, so our regular dentist was able to do his root canals with no problem.)
So it may be a problem compounded by a previous problem — the overuse of braces leads to oddities in the roots that end up requiring a specialist to fix.
retr2327
@Roger Moore:
Well, when the people making such comments are congresscritters, politicians, etc., I’m inclined to agree. if not upside down from lamp poles . . . .
But what I found interesting about his comment was his (apparent) good faith: from a certain viewpoint (i.e,, pure bean-counting) and with a certain amount of (understandable but widespread) statistical ignorance, it was perfectly reasonable for him to read that article and come to the conclusion that having more patients making their own decisions based on their (limited and incomplete) understanding of the options and their own financial self-interest would be a happy and desirable outcome.
While the medical professionals looked on aghast . . .
gene108
@joes527:
Probably room and board charges. CAT scans and other things, like the IV drip, are not that expensive by themselves.
From what I’ve gathered talking to hospital people, I think the cost for a hospital room, from an administrative standpoint, has to do with hospitals managing their operating revenue partly like a hotel or other establishment where temporary guests make up a large part of the revenue base. There’s an opportunity cost associated with each room that a patient occupies or that goes unoccupied and the charges need to cover the break even point of that plus a little something extra.
I could be wrong, because IANHA (I ain’t know Hospital Administrator), but that’s my best guess.
@Frankensteinbeck:
In all honesty, insurance companies are as bogged down in our health care mess as anyone else.
Is it there fault, if a hospital decides to get new MRI machines that are just as effective for most scans as the older MRI machines, but can detect one type of abnormality in a small subset of patients and thus the hospital decides they need more money from the insurance provider?
Or is the hospital to blame because they feel they are losing patients to another hospital that bought this MRI machine and will go under without the investment to upgrade facilities?
Insurance companies are an easy scape goat for a lot of people, because they are the one step in our healthcare system people deal with that isn’t as warm and friendly as their doctor, but there’s probably a shit ton of bureaucratic crap going on behind the doctors that keep driving up costs and probably a few docs, who want the latest toys are helping this along.
WereBear
It’s NOT that the person in the article did the “right” thing… it’s that such a diabolical choice was forced on a medical professional and because of their training they lived to tell.
If this person was working at a fast food place they would have been whipped into the operating room and their life would have been saved.
But they would probably lose their job, then have trouble getting another because now their credit rating is borked, and if they get evicted because they can’t make rent, they will have trouble getting another apartment.
So what we have is a homeless person with a teeny little scar. Great work, American Medical System!
cckids
@WereBear: Just this past weekend, my sister found herself in the ER with a ruptured appendix. 5 days prior, she’d fallen on their stairs & hit her back/side; wound up with a spectacular bruise. She saw her doctor the next day, he gave her pain pills.
The pain kept getting worse, however. Saw the doc again, after 48 hours; he sent her to her GYN. She (the gyn doc) also thought it was the fall, but said “it could be your appendix”. So, 4 days after a fall which, though painful, wasn’t catastrophic (she’s 42, not 90), in so much increasing pain she can barely function, doctors are still pointing to the fall, no X rays or CT scans or MRIs have been done. Sometime on the 5th day, with a rising fever, she disregarded her doctor still telling her to wait, and got to the ER; the appendix had already ruptured.
She’s still in ICU; can barely sit up. She’ll miss at least a month of work, and FSM only knows what the bills will be. And they have TriCare; her husband has been in the Air Force for almost 30 years.
I suppose my point is, for all we hear about over-testing driving the prices up, a reluctance to look beyond the easiest answer causes problems as well. To me, common sense tells me that, days after a fall, pain should be decreasing, not increasing. Best health care in the world, my ass.
cckids
@Villago Delenda Est:
Yes. Even for something that seems more straightforward, like dental care – I have a cavity/need a root canal/need a tooth pulled, getting a true idea of costs seems almost impossible. “What tooth, how many roots, we need to do x-rays to determine how deep, etc, etc.” And then you have the fine print of extra costs. It is impossibly aggravating.
Ilya
@RSA: I don’t know either. I do know that when I practiced we never took someone’s income level into account when offering options. Insurance, for all its faults, by and large pays for most things, and most people are insured (close to 95% now). I would not be comfortable telling a patient “we have the $100,000 option, which is the gold standard, but if you can’t afford that, we also have the $10,000 option, it won’t work as well but it might work for you.” Also, like someone was saying further up the thread, the big costs are the inpatient stay and procedures, rather than different therapies, so in reality it wouldn’t be $100,000 vs $10,000, it might be more like $12,000 vs $10,000.
WereBear
@cckids: I so agree! Increasing pain is not normal… it’s a bad sign of something going downhill!
Best wishes to her; I hope she gets better care now.
Tom Levenson
@Ilya: You embarrass easily, I’d say.
More seriously: Do you think that among the factors that produce the high – cost/middle of the pack outcome statistics* that characterize American medical care, the culture of practice doesn’t rate?
I’ll cop to aggressive compression of the argument, and I’ll even concede that this one anecdote (repeatedly labeled as such) is not as clear cut as some other examples. But within the phrase culture of practice is contained this idea: that there are approaches to care which vary by institution, locality, region and country that are entrenched for reasons other than analytical considerations of best practice as applied to individual cases. Those habits are often deeply held, and they produce a varying standard of care, half of which is by definition below average (outside of Lake Woebegon). Those habits can derive from all kinds of places, and not just those blinkered doctors whom I did not indict above.
Insurance companies, hospital management, litigation concerns, influence of particularly powerful teachers or leaders, all kinds of things can shape approaches to care place by place and system by system. None of this is (I think) the least bit controversial. It is, for one thing, a running theme in the excellent coverage of the US approach to health care by someone like Atul Gawande…and in lots of other writers’ work.
One of the strengths of Obamacare is that it has some measures in it that attempt to capture knowledge that can penetrate pre-existing cultures of care. It’s not perfect — there is no perfection this side of the grave — but the idea that it’s possible to address craft traditions in medicine with better and more rigorously established evidence is a good one.
And to that I’ll add that yes, I did make reference to a slightly different kind of “culture” — the “in America we operate” trope. Sometimes that’s a great thing. It may be so in appendicitis care. But a careful read of, say Siddhartha Mukherjee’s The Emperor of All Maladies will provide several counter examples in a framework that suggests that approaches to disease depend very heavily on the speciality that “owns” them — and that’s a cultural effect, not a scientific choice, and one that can indeed bite patients in the ass (or some other appropriate body part.)
So, if you’ve read through all of that, more power to you; you may return to your embarrassment at your leisure.
EthylEster
@Amir Khalid: opposite for me now.
EthylEster
@Tom Levenson: Actually you are not fail. Why can’t we all just admit that snark has run its course? And stop doing it. Snark has jumped the shark. It is just as probable that Chris meant what he said as it is that he was snarking.
I blame DougJ.
Later: I read Chris’ reply to your “fail” comment. Seems like he sort of agrees with me. Sort of. Or at least accepts the nature of my argument. ;=)
gene108
@Comrade Jake:
Epic rant you linked two. The guy really hits on the two main points that drive up health care in the U.S. versus other countries: (1) no economy of scale on the purchasing side and (2) medical services have inelastic demand.
(1) There’s only so such purchasing power a hospital chain has over GE or other medical equipment makers, versus say what the NHS can dictate for an entire nation and thus drive the costs down on what providers make.
(2) If your sick, you’ll pay what it costs to get treated (more or less), and since we lack a large purchasing agent to drive down costs, providers can charge more here than they do in other countries.
What’s ironic to me is many free-marketeers applaud Wal-Mart, because Wal-Mart uses its large puchasing power to drive down costs from its suppliers, while they cannot grok or want the government to do the same in health care.
And I don’t think the government has to actually spend money, they just need to set up rules that say you can’t charge more than ‘x’ for a certain device. I know Obamacare has some provisions about the cost of medical devices and it is meeting resistance.
EthylEster
@The Moar You Know: Cost?
pseudonymous in nc
@Ilya:
Are you a doctor in the US? Are you in something other than general practice? In that case, let me scrub the tears from your BMW’s upholstery with a sandpaper block.
Seriously, spare us. It would be better if medical students weren’t saddled with a mortgage’s worth of debt and the incentive to become specialists to pay it off, but once you’re in the black, you’re fucking loaded for life.
EthylEster
@texasdem: They are hospital employees NOW because that is how they can make the most money NOW. I have a relative in the biz.
Ilya
@pseudonymous in nc: Yes, general surgeon in the US. I don’t have a BMW. I make a decent income, but not great compared to the hours I work. I could be making far more money per hour doing dentistry, let alone something with little social value like corporate law. I chose medicine because I want to help people and I like the science behind it.
@Tom Levenson: I exaggerated a bit, I don’t get embarrassed easily. I haven’t read The Emperor of All Maladies (it’s been on my to-do list for a while), but I would agree that different fields in medicine often have different cultures and ways of doing things. Surgeons tend to be hierarchal hard-asses, while pediatricians tend to be touchy-feely. I was always taught that the best surgeon is the one who operates least – not literally, but if your approach to problems is to always operate, it’ll a) backfire on you, b) do your patients a disservice.
You have to understand, you may read that article and think that the surgeon is being unreasonable for not wanting to honor the patient’s wishes and try a trial of antibiotics. I read the article and think the patient is telling the surgeon how to do his job AND asking the surgeon to accept responsibility for what happens. This is dangerous. A hospital is not a hotel. The surgeon has likely done thousands of appendectomies in his career so far and has seen both the best-case and the worst-case scenarios. It’s bad enough having another doctor for a patient, but if we make this a thing, where anybody with access to the internet can come in and say “I think I might have X, and I read the treatment is Y, and I want you to sign off on that!” not only do we produce a retail mentality out of one of the few truly human services we have in our lives, but we also produce inferior care.
J R in WV
@Villago Delenda Est:
Not only is it a corporate bureaucrat going to set your costs, it’s a corporate bureaucrat whose annual BONUS depends upon his disallowing every cost he can possibly disallow.
In what fantasy universe is this better than a government bureaucrat making a decision based upon the known stastics of treatments and outcomes who has no personal financial stake in manipulating the finances of medicine into his own pocket!
Rob in CT
Healthcare billing in this country is a effing joke.
We recently had a child. She was early. She spent 2 weeks in the NICU (nothing serious, really). The bills, of course, added up to a huge number. We’d been through this before, so we didn’t really sweat it. We’re insured. We knew we’d pay a small %, ultimately.
So then we got the BCBS explanation of benefits. It indicated they’d paid X and that we owed a remaining ~$3k. Which was fine.
Months pass. Finally, my wife called the hospital and inquired as to whether we’d be getting a bill. They told us we had a $0 balance.
Obviously this is nice for us. But I can’t shake the feeling that incompetant bullshit like this is hurting somebody else some other time. This is FAR from the only time where our experience with healthcare billing has been puzzling.
pseudonymous in nc
@Ilya:
I see an extreme example of a general problem, which is that when you’re at the mercy of the American Way of Healthcare, you’re either sucking it up or second-guessing, because you simply can’t trust a process where line-item billing plays such a big role.
That applies even in emergency or semi-emergency situations.
I can understand if you don’t notice it, in the way that fish don’t notice water. But it’s there. It is a cultural reality. The retail mentality already exists thanks to all the billing drones that are in your peripheral vision at work. You may think that you work at a hospital, but in fact you work in the medical wing of an organisation devoted to sending out $50,000 bills.
johnny aquitard
@Roger Moore:
What happens to that bad debt for the hospital — do they get to claim that inflated figure as deduction on their taxes?
Wouldn’t that be like taking an old sofa down to Goodwill, donating it and claiming it was worth 5 grand on my tax return?
Ruckus
@Ilya:
On one hand we have medical people saying “We are trained and we know things you don’t. Listen to us and do the following.”
On the other hand we have conservatives telling us we need to make our own medical decisions, making the ones we can afford.
On the other hand we have insurance and hospitals telling us that we have to pay whatever they want but will tell us the amounts only after we agree to pay whatever they want to charge us and after they treat us.
On the other hand we know that the insurance co doesn’t pay anything like what we get a bill for if we don’t have insurance. But that’s OK because we are all such super negotiators that we will be able to finagle bills that won’t bankrupt us while recovering from surgery which we may not need.
On the other hand….
I think I ran out of hands.
And the trust me I know what I’m doing speech? That’s right up there with I’ll pull out in time.
So to summarize, the whole system is fucked up and that it works at all is a miracle. It certainly isn’t a well planned system and it certainly isn’t working well at all. Not when people with insurance won’t use it because they still can’t afford their own health.
johnny aquitard
@Ilya:
Why this enormous gap between the bill and the real bill even exists is the key.
It’s about why you go through med school and get paid 200 bucks and a patient gets billed 30 grand.
Nerull
I know people who have almost died because they waited a couple of days to get possible appendicitis checked out. A burst appendix is not a minor inconvenience – you stand a very major chance of dying, and antibiotics won’t help you.
Waiting until you may be on the verge of bursting at any moment and them demanding your doctor treat you with an experimental treatment that takes time to work is never going to go your way, sorry. The malpractice suit your family will hit him with after you die won’t help either.
Nancy Cadet
We know that in Western European countries , most future MDs get medical training at public universities , generally with low or no tuition and grants for food, housing , etc.
My Danish -educated doctor friend said that when he did his residency in the US, he was criticized for not taking totally meaningless measurements of hospitalized patients. There’s definitely a culture of work that affects how we see what’s right and necessary. When I had an office visit with a GP in France, she spent at least 25 minutes with me, doing a hands on exam, talking and analyzing various treatment options, for a 50 euro
fee.
Anecdote: My brother in law died last month of undiagnosed, untreated heart disease. He had lost his job and savings in the recession and was destitute. That’s the American way!
pseudonymous in nc
@Nancy Cadet:
They also start their pre-clinical training at 18. Yes, there’s a difference in terms of residencies, but as Atul Gawande has said, American med students have to start thinking about the monetary side of their career the moment they pay their first tuition bill.
I was back in the motherland for a college reunion, and had a chat to a friend who’s a GP, and now has to deal with the commissioning shit that the Tories have imposed. He said that he didn’t become a doctor to stare at spreadsheets.