Medicine For People!
Health Care Reform – A Letter comes back to Medicine for People!
In September, 2009, I published an open letter to President Obama during the time his administration was struggling to put together a national health care plan.
In my letter I urged that we restore primary care to its appropriate place instead of putting all our faith and treasure into specialists and expensive technologies. As part of this focus, we need to expect high standards from all family docs and also give him or her more responsibility and authority for patient care. Primary care physicians know from experience that simple, low-cost solutions often solve your problems. They can help you develop and improve health habits that prevent disease. These simple measures cut costs enormously. That means you can afford to get the care you need.
Institutions Are Not the Answer
So far what we've seen in this century is the growth of institutionalized care and the diminishing of independent family docs. For example, a medical school colleague, Vernon “Bud” Rowe in Kansas City, tells me that except for his clinic, his regional hospital has bought up most of the neurology practices in that area. These docs must then refer their patients to the hospital for MRIs, which cost the patient two and three times what they would cost in Bud's clinic. What's happening in Kansas City is being replicated all over the country. Independent doctors are finding more and more difficult to comply with increasingly complex regulations and handle the mountain of insurance paperwork. One by one they allow hospitals to take over this aspect of their profession. Once they take this step, they must operate according to the rules of the network.
Unfortunately economics of scale don't seem to apply to hospitals. The more care is funneled through that institution, the more expensive it seems to become. While hospitals have raised their prices for some good reasons, including provision of free care, compliance with regulations, high overtime rates for non-physician weekend workers, and many other reasons, we need to face the fact that things have gone too far. It doesn't have to be that way.
A Letter From Mexico
While I haven't heard back from President Obama yet, I did receive an engaging letter from a reader in Mexico. From his letter, it sounds as if our neighbors to the south are benefiting from the skills and low overhead of independent health care providers. He writes
I was very pleased to read your take on Dr Kugel. I remember him fondly. A few years back, following my second inguinal hernia operation at a clinic in Seattle, I suffered some severe pain in the region from scar tissue or a trapped nerve. I was unable to walk without shooting pain and it wouldn't resolve itself on its own. My physician, a young doctor who was just starting his practice, tried injecting a form of steroid into the area. I could tell he had no experience with this and the results were disappointing. I asked around and learned about Dr. Kugel. I had my doubts, but he knew exactly where to inject and the relief was instant. I had to go back only once for a follow-up. Since then I have had only the most fleeting of sensations in that area. I have always thought back that if it weren't for him I might not be walking at all.
I'm retired, living in Mexico now. We don't have Medicare down here (although we are actively lobbying for it, http://www.medicareinmexico.org/). Since medical care costs are so much lower here, you can on occasion receive equivalent treatment for the same out-of-pocket cost that you would pay (after insurance) in the U.S. when you weigh in the deductible for each year. There are many doctors here like yourself who give personalized as opposed to institutional treatment. Some doctors, associated with "Similares" (generic brand pharmacies) charge as little as 25 pesos (about $2.25 US dollars) a visit if you can speak enough Spanish to get by. The usual rate in tourist areas (if you need English) is about $20 to $35 USD.
An example: I was treated a couple of years back in Port Townsend (I won't mention the doctor's name) for a slightly hard spot on my leg which I was concerned might be thrombosis. The doctor was quite concerned and sent me over to Jefferson Hospital on the spot for a sono study. There they found nothing conclusive and talked around the issue. The price for the doctor visit was around $180. The one hour study was about $700. It didn't go away on its own so about six months later I visited a similares doctor in Bucerias where I live. He said it was nothing more than a fat deposit and offered to remove it on the spot if I cared. I declined and paid my bill, a whopping 25 pesos. This is an extreme and perhaps rare case of overcharge and unnecessary treatment, my cost in the U.S. for the ambiguous diagnosis being 391 times more expensive.
One final comment. I enjoy your newsletters very much and save them all. They are full of practical advice and well-reasoned conclusions. I wonder if you ever thought about putting them into a book format. This health care debate is not going to end this year or the next. Voices like yours address the general and pertinent issues of health care in real terms. Keep up the good work.
What they do in Mexico is to push most decision-making down to those on the front lines. Individual doctors can see what is in front of them and usually come up with better solutions. And individual patients can usually figure out which doctors are competent and cost-effective much better than can their insurance company, also far away and not as well informed.
As far as our health care system goes, I don't know how all this will turn out. So I stay active and eat well, work as hard as I can, save up some acorns to give away, stay informed, and enjoy the ride.
Hope you can, too!
For more of Dr Rienstra's commentary on health care issues, please check out these newsletters:
Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.