healthcare (14); The New York Times does a colonoscopy

In my last healthcare post (# 13) I praised Jane Brody and the Times for their regular reporting on problems in the healthcare industry. Industry is the right term as can be concluded from a front page article on Sunday, June 2, 2013 (with 2 follow up pages and graphs) which compares the cost of frequent medical intervention in the USA with that of many other advanced countries. American readers may take issue with the inclusion of Spain and others as advanced countries, whose per capita income is significant lower than that of the USA or even other European nations. Or they can point out that a procedure done in a physician's office, regardless of the actually good result, cannot be of the same high quality, and thus obviously cheaper, than the same procedure in an American hospital with its hordes of personnel and high technological equipment.

I have some experience with procedures done in a physician's office. When I was about ten years old and still suffering from terrible ear aches our family doctor sent me to a nose ear and throat specialist. This was during WW II and transportation was strictly limited. My mother and I walked to the specialist's home (where he had his consultation room), a distance of 4 km.  It was winter. After an examination he ordered a tonsillectomy which he would perform in his consulting room. A month later we made the same trip. He put me out, operated and after I came to, sent us home. As we walked I held an old towel in front of my mouth that had to be changed every so often as it became sodden with blood. Eventually we had to borrow some from people along the road who obviously observed out progress. Anyway after some time I was pronounced healed by the family doctor and have not had an ear ache since. There were other benefits. Once the weather was less inclement, my mother sent me to return the borrowed towels which became a sort of congratulatory walk with lots of concern, chocolate (although it was rationed) and cookies. Two years later I took the same road to my high school and each time it rained or snowed I was invited in to dry and warm myself. Other times, other mores, but the point of the story vindicates that what looks like "primitive" medicine under warlike circumstances, had no negative effects on my subsequent health. Yet, it's not a an experience that I can recommend.  Colette, my partner, recounted a similar unpleasant (even without the 4km walks) experience of having an endoscopy done in a doctor's office when she was a teenager in France, also without ill effects.

Fast forward to my sixties when I shipped on a hilly golf course and developed a painful condition in my right knee. I went to the College's orthopedic specialist. He had eight consulting rooms in an annex to the hospital and I could observe him flitting from one room to the other. When he had more than two minutes he handed me several brochures on what operations were available and ended up by ordering x-rays which was done in the hospital. He hung them up during the next visit and said he could not see anything mechanically wrong other than what he called a lack of cushioning material and some unwanted deposits but nothing to require surgical intervention. He prescribed painkillers and icepacks in case of swelling. At a later visit he suggested an MRI to be done at a brand new clinic not connected with the hospital. The clinic charged my insurance, at that time one without any co-pay, 3200 dollars. It revealed nothing new. Later I found out that the doctor was a co-investor in the MRI clinic.  Still later our women's hockey coach developed also a knee problem. She went to another doctor at another hospital and was operated on with great results. Eventually I also consulted a different doctor; he too prescribed pain killers. As his practice did not take my insurance, I consulted yet another doctor and eventually, after more x-rays and another MRI, I had my knee replaced. That was after 4 years of frequent painful periods. Now, after 13 years with my "bionic" knee, I'm not very agile (perhaps also because I am 82) but do not use painkillers. Meanwhile my eye doctor, who removed cataracts from each eye, suggested that a regimen of some of the painkillers had encouraged their growth.

A major point of the NYT article is that the too frequent, often automatic ordering of x-ray, MRI exams and scans, that may not be necessary, may lead to unnecessary and risky interventions and often done by clinics in which the ordering physician has a financial interest, are a major cause for the rise in the cost of healthcare. This point has been made in previous NYT articles, specifically with colonoscopies as example. The present article can be seen as a similar examination into the illness of the healthcare system in the USA. In a follow up Editorial (June 9) the paper suggests a way out by pointing out how the Affordable Care Act ("Obama-care") already began to work towards fixed costs. Fixed cost systems are not something new and are in place in dealer operated car maintenance programs (more expensive than the - alas rapidly disappearing - "corner store" mechanic) and obviously are designed for a reasonable profit.

As a patient I do, of course, not know whether tests or scans are necessary. Three years ago I had repeated and painful infections in my right ear and problems in my right sinus. After doses of prednisone did not work, I was prescribed a scan which "indicated possible problems." When the pain returned a year later and new doses of prednisone did not work, I had another scan, with the same result. By then I lost my hearing in that ear. The local nose and ear man suggested I see one of several specialists in Philadelphia, who would most likely perform the necessary operation. After consulting with my primary physician, I went to the Un. of Penna, where the specialist examined my ear with a fancy microscope that projected a large picture on a television screen. He did not read the cd of the last scan.  He took out a polyp, removed the tube that the local doctor had inserted to help drainage, prescribed two types of eardrops, made me come back for four check ups and the infections have not returned (the hearing in the right ear did, however, not return. The insurance paid for the two scans that apparently were of no use other than suggesting an operation would solve the problem, a conclusion rejected by the specialist's specialist. The sinus problems still exist but are no longer painful, and most likely were not painful before the ear infections. But subsequently, after more pain that I described in healthcare post #12, MRI' s and spinal injections+ phys. therapy the treating physicians concluded that my head problems were most likely caused by a seriously pinched nerve in my neck. So while modern technology eventually solved the problem, it was mostly a process of "if this doesn't work, let's try something else."

The NYT article also delves into the great variation in the charges for the same procedures in various parts of this country and even within some cities. This too had been reported on in recent articles. It would seem to me that there cannot be any reasonable explanation for that variation other than the fact that medicine is a private enterprise and the charges a based on the maxim "what the traffic will bear," i.e. GREED, which is fed not by the need of doctors to meet the varying expenses of the actual cost of living but on competitive life style expectations. (I guess, I can't escape having written my Ph.D. Thesis on Thorstein Veblen, the author best known for his devastating crtitique of the Leisure Class" "football stands in relation to athletics as the pigskin to agriculture"). In another of their occasional in depth investigations, Sunday Aug. 4, 2013, the NYT exposes specific differences  in the cost of joint replacement, focusing on the coast of hip replacement with a 2007 US estimate of $73.000 which the patient had done in Brussels for 13,660 (incl. travel costs).

Both Colette and I grew up in countries (France and the Netherlands) that now have national health systems (which contrary to American propaganda, deliver the required healthcare readily and well). The comparative costs in European countries with high standards of living for a procedure is not only significantly less than in the United States, but the same throughout a particular country. Colette's brother is a physician and can afford a time share for the family ski vacations as well as vacations throughout the year in such exotic places as Thailand or the Caribbean. Colette sister in law is a trained geriatric social  worker employed in the national social care system. Colette and her bother own the former second home of their parents in the Provence and if she so desires he'll buy her out. His three sons, having completed the required secondary (national) education went on to specialized private education (2 of them taking a year in the United States).  It doesn't sound like his standard of living is lower by the same percentage as the cost of the medical care he delivers in comparison to an American colleague. I have 2 nephews (by non-marriage) one of which ran a blood laboratory and the other a dentist, the latter living in what we call a "gentleman's house" and drives a fancy BMW. The difference is that not only is there a national health system, but also a national education system as well as a national pensions system, all of these systems paid for out of  the general revenue based on a graduated tax code. For those who so desire and are able (and willing) to pay there are also private institutions.

Obviously, as is made abundantly clear by the opponents of "Obama-care" (a very imperfect hybrid between a national health system and private enterprise), so-called "socialized" medicine is undesirable on principle. Which is too damn bad! After all, the members of Congress, most teachers (in my case it's included in the tuition of private education) and other civil servants or unionized workers have socialized medicine paid for out of tax revenues or added to the cost of the product made by the union workers.

Somewhat less anecdotal than Colette and my experiences is an article on p. 6 of the June 16th NYT's business section about the healthcare system in Sweden, unfortunately a country that in the USA has a "socialist" reputation. It also has a very high standard of living and a thriving free enterprise economy. Yet, the GREED factor has been eliminated from the general healthcare system which is government run, efficient and about half as expensive as the American one. And, as in the Netherlands and France, for the rich and those with high-cost health plans there are "boutique" hospitals as well.
My niece, an exec. in a firm checking possible healthcare fraud in the Netherlands, wrote me that the gov't was going to economize (i.e. no longer free healthcare), but she included an American item making fun of the shortcomings of US healthcare for the elderly, saying that it would not be as bad as that. The item shows an elderly lady with a revolver who is encouraged to shoot 4 congressmen so she can get all the health care she might need for free in prison and also would no longer have to pay income tax.

If it seems that there is no end to this BlogSpot it is because there's no apparent end to the NYT's discovery of more gauging medical practices. This time, in a front page+ on Oct. 12. 2013, it deals with the exorbitant costs of medicines, for ex. for asthma patients: one steroid inhaler retails for $175 in the US while pharmacies in Britain (with that much maligned - mostly by US opponents to a national program - healthcare system!) pay $20 and dispense it free; a nasal spray sold in Oakland for $250 a month but costs only $7 in Europe where it is available over the counter. An on it goes.


Addendum: As I was rereading some Dutch mysteries I came across Blond Baboon by J. van de Wetering. It dates from the 1970s and in it there's a subplot in which a neurosurgeon with financial interests in scanning devices habitually scares patients into undergoing more than one tests, all of which were paid for by the insurance. It appears that there's nothing new on the western medical front.