Friday, December 10, 2010

Health Care in the US

My crash on Tuesday once again brought me in contact with the US Health Care System, a system that is often lauded as the "best in the world," but in reality leaves much to be desired.  A lot of that resides in what computer experts call "the user experience."

Let me first illustrate what would have happened in Belgium (and likely other parts of Europe) after my crash. Given that it happened around noon I probably would have stopped by the local doctor's office on my way home to receive acute care. If the doctor were out, I would have asked whomever was there to have the doctor come over and see me at home. Or I would have gone home and called the office to arrange a house call that same afternoon. If the doctor were very busy I could call another doctor.

The doctor likely would have taken care of my skin wounds, given me a prescription for a strong pain killer (codein is available without prescription) and he or she would have made arrangements for an X ray at a local hospital or sent me to an orthopedic surgeon.

In the US things work a bit differently. Much depends on one's health plan and health care provider of course, but in the span of twenty five years I have been fortunate enough -if one can call that fortunate- to experience nearly every flavor of health care that is available to US residents. Not one of these compares favorably to the European system and all are a whole lot more expensive. My current plan is an HMO.

The first thing that matters in the US is where the accident occurred with respect to one's "area of coverage." Areas of coverage are often remarkably small and it is not unusual for people in the San Francisco Bay Area not to have coverage in Tahoe-where many go skiing in winter- for example. I.e. if you are into sports, it is quite likely that you get injured out of area.

In Belgium or France that is totally irrelevant and one would use the same mechanisms, have access to the same care, pay a similar amount, and receive the same reimbursement regardless of where the crash and treatment happened. Here it does matter. "Out of network coverage" is much more limited, more expensive, and often difficult to get reimbursed for. One has to receive approval beforehand for out of network care. For a borderline injury like mine -where the seriousness may not immediately be apparent- that can be very problematic.

If you go see a doctor and claim an emergency, they may refuse to reimburse you later saying this was not serious enough and you should have received approval before going there. Since you often do not know beforehand how serious something is, that may leave you in a quandary. The insurance bureaucrats have no such issues. They have the benefit of hindsight. If it turned out to be minor, they will promptly refuse to pay you back. But even within the network things are far more difficult and cumbersome than they should be.

My current US procedure starts with a call to my HMO. I automatically get put on hold and have to listen to advice such as "If this is a real emergency call 911" followed by a lengthy explanation of what constitutes a real emergency; next comes a friendly referral to "our website" and all the issues I can solve there; and then a very long-winded message about seasonal flu shots and where to get those. It takes almost 3 minutes before I am connected and before I can start entering relevant information. And by far the most relevant information in the US is your insurance number, because without insurance you are out of luck. Not only will it cost you an arm and leg, but most places won't even want to treat you.

In Belgium, trained medical personnel have to provide care to anyone in need. In the US there is no such provision and it is not uncommon for emergency rooms to refuse patients (arriving in an ambulance with real emergencies!!) and send them on to another hospital. People have died being shuttled from one hospital to the next and nobody thinks twice about that.

After many more messages, muzak, holds, transfers, etc. I finally get to talk to a nurse, who asks a few questions and then tells me I have to come into the emergency room. "Can they prescribe a pain killer because I am really in pain?" Of course not, not until the doctor sees you. And when will that happen? Well that depends on how busy the emergency room is at this time. 

There is also no other option available. Making an appointment would take 2 or 3 weeks. I don't even bother making appointments for other issues because most are over with by the time I get to see someone.

Acute care of any sort means emergency room care. In Belgium nobody would dare to show up in the emergency room with flu symptoms, but in the US that is how things are done. If you have flu symptoms and want help at night of after hours, you go to the emergency room. Going to the emergency room with a relatively minor injury (read, not a gunshot wound) means waiting for hours before someone will see you. Once again, people have died sitting in the waiting area of emergency rooms.

Going to the emergency room also means paying a hefty price, because emergency care is expensive and nobody cares that no other options are available. A few non-emergency, acute care facilities do exist in select hospitals but by and large, all acute care is done in emergency rooms.

Getting a few Vicodin tablets, something every Belgian household has lying around in their medicine cabinet (Codis is an equivalent product available in Belgium) cost me several hours of waiting. I had to drag myself to a local hospital and pay $100 for the privilege. I also received many sheets of paperwork warning me of the dangers of this rather pedestrian medication.

In Belgium I could have just gone to the pharmacy and bought some.

After I spent a night in pain with a cracked rib and an AC joint separation, I called in again and waited for another 10 minutes on hold to ask for another option. I was told I would have to come in again and would then get a higher dose formulation -but essentially the same drug.

It appeared everyone was more worried about me becoming an addict than actually treating me. The orthopedist said, "Well there is nothing we can do for that [the rib] but kill the pain. " But apparently giving a pain killer was not part of that equation.

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