Notes From the Medical System

Our stupid medical system

Nearly two years ago I wrote about a monthlong series of illnesses and medical incidents our family experienced, one of which included a trip to the emergency room after our second-youngest chomped on a dog pill. Winter just isn’t our season: We’ve been dealing this January with another sort of low-key rolling series of annoying medical hiccups, nothing serious but some fevers and stomach bugs and now, as it turns out, yet another trip to the emergency room with the same child.

In this case he shoved a Lego in his ear. This is apparently somewhat common among small children. I do not know why. The human species is at times so confounding. The human brain is complex and Gordian enough that it can desire endless yearnings and proclivities, and moreover it can pretty easily realize those desires, up to and including literally colonizing other planets. That’s great. The upshot is that small humans are born far too young by mammalian standards and are given this organ of unbelievable cerebral power even as their psyches are far too underdeveloped to make proper use of it. So the endless yen of the human mind gets incomprehensibly scrambled up in a three-year-old’s brain and then—bam!—he shoves a Lego in his ear. Deep in his ear.

So initially we went to Patient First. They could not get it out, so they sent us to the emergency room. They could not get it out, so they dispatched us to the ENT. The ENT was able to pop the Lego out in about 12 seconds flat using nothing more than what looked like a $19 dental scraper. I mean it was just so easy for him to do. It seemed like something that the doctors at the general outpatient clinic should have been able to, you know, do pretty easily. But doctors are at times almost comically risk-averse; if they cannot do something in less than four minutes—diagnose an ailment, remove a foreign object, whatever—they’ll punt it up the ladder, to the emergency room or the specialist or whoever’s nearby. That’s how you go into the weekend fine and dandy and end up on Monday having dropped $1,800 all told on a Lego.

Here are some observances from our latest trip through the Great American Medical System, in no particular order:

• Nothing anybody says ever really means anything. If there is one thing that is consistent about the medical industry it’s that nothing is consistent, ever. Nothing any doctor or nurse or staffer tells you has much bearing on what happens next. In our last trip to the emergency room, we had to wait and ensure that our two-year-old’s blood pressure did not drop from the dog medicine. We were at first told we’d be going home in a few hours; after an hour we were told by another nurse it would be another few hours; fifteen minutes later we were told by yet another nurse we’d be gone by 6pm; twenty-five minutes after that a doctor said we could be out by eight; shortly thereafter we were admitted for an overnight stay; a few hours after that I asked the doctor if we could just go home since he seemed fine, and she said yes, so we left. Medical assessments don’t really mean anything in an industry where nobody seems to effectively communicate with anyone else at any one time.

  
  Similarly, this month, we were told at Patient First that the emergency room could give our boy a numbing shot and pop the Lego out; the ER neither of these things, instead they gave him a sort of nasal benzo and tried briefly to get the Lego out, after which they quickly gave up and sent us to the ENT, who was himself confused as to why Patient First didn’t just send us to him in the first place.
  
  Basically the medical industry is like an entire complex of divorced parents who don’t talk to each other and who in fact seem sort of vaguely contemptuous of each other even as they insist they want what’s best for you. It’s extremely frustrating, and of course the end result, like divorce itself, is invariably very expensive.
  

• Catastrophic insurance + mostly cash pay is better. The way we pay for medical care in this country is uniquely weird and neurotic and awful. In much of Western Europe the government pays for all of your medical care; that is sub-optimal for a large variety of reasons, but it has the really wonderful benefit of being extremely simple and predictable and easy. The U.S. healthcare system seems, on its face, like the exact opposite, insofar as it appears that we’re all paying for our own healthcare out of pocket. But it’s actually not like that: In the U.S. we’ve developed this ghoulishly bizarre system in which we submit monthly payments to an insurance company, after which we often use the insurance company to pay for everything, including routine medical visits and periodic unexpected visits that are otherwise affordable. The medical industry almost always charges insurance companies higher rates to make up for the hassle of dealing with the paperwork as well as to compensate for the inevitable long delays between service and receipt. The end result is insurance companies paying inflated prices for the same service; the higher cost may get passed on to you in the form of a negotiated bill, but even if it doesn’t you can be sure you’re paying for it in high premiums that your insurance company must inevitably charge to compensate for the inflated rate. Basically everything gets more expensive because of this dumb system.
  
  Yet cash pay—for low-level and even many mid-level medical services—is almost always going to be considerably cheaper than the rate at which they bill insurance companies. Hospitals and doctors charge less for cash pay because they love cash pay: They get the money in hand at the point that they render service, they don’t have to deal with the miserable arcana of insurance forms, they don’t have to dicker with some actuary in Omaha over the price of an otoscope. This month when the ENT found out we were cash pay he mulled it over for a bit and said the price was $200 for the Lego extraction. That’s a bargain by medical standards. It would not be beyond a doctor’s office to charge insurance $400 for the same procedure—which, again, you may ultimately pay less of out-of-pocket but for which you’re doubtlessly making up for in your monthly premiums.
  
  The markedly simpler, easier, cheaper solution for many people is this: Opt out of this weird and expensive system in which health insurance has become a proxy for cash payments, get a “catastrophic” plan instead in which you pay low monthly premiums for high-deductible coverage, and put the considerable difference into savings. Average costs of catastrophic plans are probably around $2,000 per year; compare that to the average cost of health plans in general, which are just under $9,000. (For families it’s even starker: Our annual catastrophic insurance premiums cost about $3,700, compared to a national yearly average of $25,000). Put those thousands of dollars into savings and do cheap cash pay in the event you have to go to the doctor. (In the rare event that a medical event costs more than an average visit but not enough to justify insurance usage, you can usually negotiate a greatly cheaper cash-pay rate and then sign up for an interest-free payment plan, often less than $100 per month, until it’s paid off). Do this and your overall medical bills will likely ultimately be much cheaper, and what’s more you won’t be contributing to this bizarre, schizophrenic, expensive system in which we’ve conscripted third-party fiduciary mediators to pay for a routine consumer product.
  

• Keep it simple, stupids! One of the greatest things about modern life is the advanced medical care. It’s really hard to comprehend how much better it is than even a few decades ago. I mean, look: For the vast majority of our species’ history, if you got injured, the most medical care you could expect is that your buddy Grog might hit you on the head with a chunk of granite and end your suffering. For maybe the past 3,000 years, in the age of civilization, if you got really hurt, you were likely to die a slow lingering death; we grew out of the granite solution but hadn’t yet developed something effective to take its place. Maybe they stuffed some crocodile feces in your infected cut in the hopes that would cure it; maybe they literally cut your wrist and drained you of a few quarts of blood in the hopes that it would cure your pneumonia; that was about it. For most of history there just haven’t been a lot of solutions other than, “Let’s try this and see if it works, ah man, we just killed him.”
  
  In the present era we have a medical industry of almost unthinkable opulence and splendor and luxury. A few centuries’ worth of real medical knowledge; clean, well-lit, climate-controlled medical offices; clean instruments; extremely sanitary practices; ways to mitigate pain and suffering that would strike even early 20th century patients as essentially magic; machines and devices that can often pinpoint an ailment with laserlike precision; the list goes on. Honestly you get the sense that some of these doctors at times would like to haul out the ol’ chunk of granite and be done with it, but for the most part everyone seems pretty happy with this historically unprecedented bounty of medical standards.
  
  The flipside, however, is that even as the medical industry has become infinitely more technically specialized, its personnel has become considerably less adaptable and resourceful. Doctors and nurses often just can’t seem to do what they used to be able to do. Case in point, as I noted above: It should have been remarkably easy for a well-trained doctor at Patient First to pop a Lego out of our son’s ear. The ENT did it in nothing flat, with no specialized equipment, using only a metal pick and a little plastic tube. Certainly this should have been no problem at all for an emergency room! But the state of the industry is such that, confronted with even the most minor jobs requiring a bit of canny deftness—the kinds of things that it seems doctors were previously able to just do—a doctor will invariably kick it up the chain, deferring to someone else, even to the point that an emergency room can’t do in two hours what an ear doctor can do in less than a minute.
  
  Here is a great counterpoint: Years ago when our firstborn was very young, he had a little blood in his diaper. This happens with some regularity and is often of little concern—likely coming from just a small interior tear that will heal itself—though it can be a sign of more concerning conditions like intestinal bleeding. We took him to our PCP, a really very capable and fine doctor but one who had only just started practicing a few years prior. She was unable to diagnose the problem and recommended we go to the university hospital for an endoscopy. Any normal parent, of course, will do anything, anything at all, to ensure that their child is well and healthy. But most of us would like to avoid spending about $2,000 unnecessarily if we can help it. So in a last-ditch effort we took our baby to Mrs. Morris the Elder’s childhood doctor, a fellow who has been in the game for decades and who has what could legitimately be described as a country doctor’s office, up-to-date but out in the middle of nowhere. While there he performed what he said was called a “poor man’s endoscopy,” using a small plastic vial and a flashlight to see if the source of the blood was a minor tear. It was. Absolutely nothing to worry about. The visit cost us $100. This is the sort of affordable cleverness that used to define much of the medical industry. Not anymore—now you get sent to the $1,500 emergency room or the $2,000 butt doctor at a moment’s notice. No good.
  

• Having to fill out forms everywhere you go is just unbelievably stupid. I know this is the punchline of a lot of dumb standup humor from the 1990s, but really: It is of almost breathtaking stupidity that we are still expected to fill out copious paperwork at nearly every new doctor’s office we go to. This is just criminally absurd. We have had the technology in place for about three decades to render this whole superfluous tradition absolutely moot. It should be more than easy for some enterprising startup company to create an industry-wide standardized form online, held centrally and encrypted out the wazoo, for doctors to easily access in their offices. You can just picture it showing up at a new medical office: “Hi, welcome to the Hip Care Center. Can you enter your RealForm ID on the keyboard there?” You punch in your ID and it auto-fills immediately. Maybe it asks you to confirm your address or date-of-birth or something. But otherwise you’re able to sign in in about 12 seconds as opposed to the grating, grinding process of sitting down with a clipboard and scribbling in the crap you’ve already written so many times before. How is it possible that this hasn’t been done yet? Why are we still filling out our medical forms like pilgrims? This may not be the worst problem of the medical industry but it’s surely the most casually stupid, the most frustrating, and probably the most easily fixable. Let’s start reforming the medical industry but reforming this before anything else.