Health Care Is Not a Consumer Good

[lydy]

I have a known history of PVCs.  PVCs are "premature ventricular contractions" which basically means that the ventricles of my heart get a little over-excited and jump the gun.  Hence the "premature."  It is usually a benign heart arrhythmia.  They were noted on my sleep study, which was done three to five years ago.  Known history.

For Reasons, I got rather drunk Saturday night at Fourth Street.  While I was trying to fall asleep, I felt just plain weird, and I thought to feel my pulse.  I was missing every eighth beat.  That's...a lot of PVCs.  Since then, I've been noticing occasional tightness in my chest, a very slight something that one might call shortness of breath, and a lot of missed beats.  Now, at least some of the weird feeling in my chest is almost certainly muscular.  I don't wear a bra, I am old, and the muscles attaching to my rib cage are a bit stressed.  And some of the shortness of breath may or may not be related to asthma.

One night at work, with entirely too much time on my hands, as my patient was coming in late, I hooked myself up to the amplifier, just running the EKG.  (This cost my work exactly two disposable snap electrodes, one alcohol wipe, and one sani-wipe.)  Yep, my heart was throwing PVCs.  One morning, I was throwing between six and twelve a minute. 

Possible triggers:  alcohol, caffeine, and Allegra.  So, I've stopped taking Allegra, stopped having a nightcap after work, and reduced the caffeine.  I tried eliminating the caffeine, but that caused me to become depressed, and there's literally no future in that.  I switched to Claritin, which doesn't work as well, but man I need to not claw my eyes out.

I repeat: PVCs are almost always a benign arrhythmia.  There are tests.  I should probably have them done.  Possibly a Holter monitor, probably a (shudder) stress test.  Ick.  Probably expensive.  Sigh.  After a month of monitoring my pulse for missed beats, messing about with my chemical profile, and whinging and moaning about not liking doctors, I sent an email to my doctor through the automated system, describing my symptoms, providing the above information, and asking for an appointment.

And now we get to how health care is really not a consumer good.

I get back an email stating that they cannot schedule me an appointment based on my reported symptoms, and I need to talk to a nurse, first.  I roll my eyes.  I call the clinic's Nurseline, and go through all the above information.  I assume she can also see my email to my doc, but who knows.  She asks me a series of questions, the answer to most of them is "no."  Am I in pain?  Does the pain radiate? Am I dizzy?  Do I feel nauseous?  No, no, no, no.  She then says, "You should go to the Emergency Room."  I explain that I will not do so.  I point out that PVCs are almost always benign.  (When they aren't benign, they still aren't a terminal rhythm.  They're a symptom of cardiomyopathy or some other serious damn thing, but not instantly fatal.)  I am still paying off my last visit to the ER, eight months ago.  The nurse tries to insist.  I tell her that I will, under no circumstances, do any such thing.  We get rather cross with each other.  She states that their guidelines do not permit them to schedule an appointment for these symptoms, the guidelines require that I be seen on an emergent basis.  I point out that this is health care, and I can refuse any damn thing I want. 

Eventually, she says that she will have to talk to my provider, and will call me back.  I point out that I evidently have a condition so dire that I must be seen on an emergent basis, but if I refuse, they will not permit me to see my own damn doctor, and how does that even make sense.  We became even crosser with one another. 

I wake up to a voice mail stating that I can call my clinic and schedule an appointment.  By this time, of course, the clinic is closed, and after hours people cannot schedule. 

So, this morning, I call the clinic.  And am offered an appointment at 9:40 a.m.  I explain that this simply doesn't work, as I have to go to work tonight, which means I need to be in bed by 11:00 a.m.  The nurse asks why that doesn't work.  I point out that even if I get in and out in an hour, I'm still not home before 11:00 a.m., and that means probably not in bed until 11:30 or noon, and that assumes that they don't decide to do a bunch of stuff, and what's the chance of that?   She allows as to the justice of my remarks, and offers me...Urgent Care.  Yeah, no.  While not as expensive as the ER, it a) doesn't solve my problem with needing to be in bed, and b) IT'S NOT AN EMERGENCY, FFS.  She says that the guidelines are that I be seen same day.

Quick note:  You know how I know that this isn't an emergency?  Because every time the nurse attempts to make me go to the emergency room, they say, "guidelines."  If it really were an emergency, they'd be talking about, you know, death.  (I did have a nurse say that to me once, in reference to a possible case of tetanus.)  The fact that the nurses sound vaguely unhappy about the guidelines is also a tell.

We go a couple more rounds.  My normal provider doesn't work on Thursdays, is full on Wednesday, and is also completely booked on Friday.  It is suggested that perhaps I call back on Wednesday morning and see if anything has opened up.  I point out that the system is completely broken.  The nurse agrees.  Eventually, she asks, "Do you have to see your usual provider?"  No, I don't.  I mean, I like my doctor, but I'm willing to go to someone else.  So she schedules me for 7:40 (oh god) a.m. on Thursday with some guy I've never seen.

I am a price sensitive and informed consumer of health care.  And at every turn, the system is trying, desperately, to shunt me into a high cost alternative, for no good reason.  Additionally, I already know that there is no point in asking what any of this will cost.  The provider has no idea what my insurance will cover.  The insurance company typically will not answer these questions.  Moreover, once I surrender myself to the professionals, they will run whatever tests they think wise, and I will have almost no say over them.  I will certainly not be given enough information about the test, the cost, the possible results, and the potential treatment to make an informed decision about whether or not the test is a cost-effective choice.  I have less control over my own health care, and less information, than I have about my cat's health, where they will cheerfully lay out exactly what the tests cost, what they might reveal, what the treatment path would be based on various scenarios, etc.  The other thing I have very little control over is my insurance.  I get insurance through work, and it is both expensive and not very good.  I have a $3500 deductible, and the things it covers at only 80% (after deductible) is long and irritating.  Nor can I, as an individual, shop around for a better deal. 

Health Care is not a consumer good.  A consumer good responds to market forces if the consumer is informed, if there is information available, if there are alternatives, and if the primary driving force behind the consumption is rational rather than emotional.  Most importantly, the consumer needs to have some control.  None of this is true about health care. 


 

Comments

[haertstitch]

drat the guidelines.
she was doing the Male heart attack triage.

has it improved since you made your chemical changes?
just to have a base line immediate record would be good.
do you have a copy of your trace It was done by a professional ;). I'd trust it.

but if you have improvement I would not bother
to run the medical gambit. just keep on with your montoring.

if you do get a real heavy rock on your chest, feel severely nauseous and extreme change in pulse push for a dr>stat.
do you have an oxy pulse meter? that seems the best tool.

[lydy]

Yep, she's doing the heart attack triage. Which, you know, I'm not having. If I were, I'd be answering yes to a bunch of those questions. Which I'm not. So why is she trying to insist that I be treated as if I'm having a heart attack. I have a _known history_ of PVCs.

The only chemical change that seems to matter is not drinking alcohol. And even that doesn't seem to matter that much. I'm not sure about the Allegra vs. Claritin. Will ask the nice man on Thursday.

I don't have a home oximeter. At work, my SpO2 was in the mid-90s, which is about right for someone of my age and sex.

I kind of would like to know if I have cardiomyopathy. And so, the tests.

[haertstitch]

its much easier to push people
into a disorder they"could" treat easy if guessed right

they are not comfortable with people
being educated in what is going on with them selves.

when mom had her stroke
"it might be a stroke" they said

It is a blooming stroke I said
I should have insisted they send her straight to regions
I'm sorry we cannot treat this
and make her wait while they do the test to prove it
past the 4 hours where no damage will happen if we undo the blockage.

I hate the health professional habits up here
it kills people.

[bibliofile]

> Mom having a stroke
Gah! I'm sorry.

> Male heart attack triage

Don't get me started! My mom didn't notice her heart attack at the time because, yanno, girl symptoms. (Fortunately, she didn't have the notable symptom of DEATH.)

> [lydy] health care is really not a consumer good.

You are not wrong. Alas.

I'd suggest trying to price out tests, as that may be more possible than it used to be? But that doesn't take into account your insurance "coverage".

[naomikritzer]

Yeah. Wow.

Ed was having chest pains on and off a couple of months ago. Given that it was just pain, none of the other usual symptoms of a heart attack (no pressure, no shortness of breath, no sweating, pain didn't radiate, nothing), Ed really didn't think it was a heart attack. But he knew he could not just make an appointment at his clinic: you say "chest pains" and they tell you to go to the ER. And in fact, after pondering what they might do to assess this, he concluded that he probably did need to go to the ER just to have the workup, which was annoying because he wanted to make an appointment, not go in, get triaged in IMMEDIATELY because CHEST PAINS but then left to cool his heels for six hours as soon as they established (which they can do really quickly) that it wasn't a heart attack.

He solved the problem by going in early on a Sunday morning. He thought that would probably be a very quiet time in an ER (and he was correct.) They immediately determined it wasn't a heart attack; they think it might be something gastric. They gave him acid reducers and scheduled him with a GI and some other stuff.

At least in Ed's case, chest pains are actually a heart attack symptom and "you should go to the ER" is a legit response and not merely ass-covering bullshit like it is in your case.

[thewayne]

There's lots of things that can happen elsewhere in the body that can become 'referred pain' and manifest as chest pain. Currently I'm having a lot of pain in my right collar bone that my wife thinks is referred. Myself, I have direct chest pain in the form of costochondritis: I damaged the muscles on both sides of my chest shoveling snow. Absolutely nothing you can do about it, and it takes forever to heal. When I occasionally get a shooting pain from it and my wife asks what's wrong, I reply "Oh, nothing. Just searing chest pain, probably just imminent death."

[med_cat]

Yikes :(

Hope it gets sorted out.

(I'm here via supergee's LJ, in case you wondered)

Oh my!

[lsanderson]

Have you tried Xyzal? It's the newest antihistamine on the block. It's a lev isomer of Zertec which often lessens, err, complications. Of course, please remember that I ain't a doctor nor do I play one on tv, and I bailed as a chemistry major after first quarter organic.

Re: Oh my!

[lydy]

Thanks for the recommendation. I bought some this morning, and will try it. I might also look into desensitization shots, since I'm pretty sure what's going on is my cat allergies are resurgent.

[mrissa]

I have noticed this about vet med also. "Here is what it will cost and what we hope to learn": oh! Good, thanks! Human med: I quite often know what the tests are and what we hope to learn from them, but what they will cost on the price tag, what my insurance will end up deciding is my share: literally no human alive knows that at the time of me getting those tests. It is a great mystery. Whereas at the vet's they would recoil and say, "The hell you say, it costs $125.97."

[lydy]

When Lilith was dying, the veterinary was wonderful. She laid out the various diagnostic tests, the costs, the strengths and weaknesses of the tests, and the decision tree based on the possible results. As it turned out, it wasn't what she thought, and we ended up doing three scans, instead of two, for an additional $500, but that was not her fault. Also, I decided on $2000 worth of diagnostic tests because I needed to know what was going on, even though most of the outcomes were not treatable, or the treatment was beyond my means. Even so, every step of the way, through all the really hard decisions, I knew what I was doing, I knew what my goals were, and I knew what the costs were. I have none of those luxuries for myself, and I am incoherent with annoyance.

[mrissa]

And one of the things this means is that you don't have it laid out for you with primate medicine: "Okay, this course is about 98% effective and it costs $600. This one is 60% effective and costs $80 [or $8, or $800, or $8000], but it's recommended for people with your other condition because reasons. etc."

It is not a decision tree. You sometimes get all the choice paralysis of standing in front of the rows of strawberry jam, but you cannot find out how many ounces of jam you get, nor what the jam costs, nor whether actual strawberries are the first ingredient. It's literally all the drawbacks and none of the benefits.

[lydy]

And I don't even like strawberry jam. :-)

[naomikritzer]

Oh my god YES.

The reactions I get from doctor's offices when I ask what something costs are ... unhelpful.

[naomikritzer]

Here's another difference between veterinary and human medicine.

Some years back I had an old cat who had gotten sick. I took her in to the vet, who did a very gentle exam and then said, "There's a lot I can do to her but not a lot I can do for her." We agreed to try a fluid injection to see if that perked her up a bit and otherwise I'd just take her home and see how she did.

Old, sick humans tend to get Done To without anyone really asking what the purpose of the tests and treatments are.

Although, I manage my grandmother's care and when she landed in the hospital last winter with seizures, a hospitalist came to talk to me about our family's "philosophy of care." He wanted to get a sense of how aggressively to treat my grandmother's physical problems. Grammie is in her mid-90s, is in the advanced stages of Parkinson's and has dementia. I told the cat story and then said that if there were things they could do FOR my grandmother, that we wanted them, but if they'd just be doing things TO my grandmother, we would decline.

Every doctor I've talked to has seen a very clear guideline from that. It's a bright line. They may not all draw the line in the same place, but they ABSOLUTELY see that line.

But they'd never bring that up, unless the family did.

[thewayne]

I'm glad you could get in to see another provider at the same facility, at least they have all your notes. When pneumonia #4 of 5 hit when my immune system went on permanent holiday, I was at my lung doctor's office on a Monday performing a PFT, feeling like hell. I asked if I could see the doctor, told no, he's on vacation. Nice of him to tell me that when I saw him the previous Friday. Next pneumonia arrives a few weeks later (not having immuneglobin does wonders to your ability to resist infection) and I call the office. Can't see him, he's on hospital rotation for the week. Can I see one of the two other doctors? That would be a new patient intake and would be 30 days out.

That was the second set of doctors that I fired in that town. Found a fantastic lung doctor in El Paso who has never disappointed, except in his insistence that I have a sleep study done which discovered nothing worse than mild apnea and that using a machine would offer little improvement.

[lydy]

Wow. That's both horrible and insane. New patient intake? How, what, why?

[thewayne]

Yeah, it was really weird.  I got sick in December '08, and in retrospect, it was probably my first pneumonia, but we don't have any evidence.  Let me put it this way: I was so sick that I don't remember being sick. February '09 I had my first documented pneumonia.  Well, it happens, you don't think much of it, you get over it.  Then a little over a month later I had it again.  My GP told me to see the lung doctor.  Turns out there was only one practice in Las Cruces that did not only do sleep studies.  And they had a 30 day wait for new patients, which makes zero sense to me.  So I wait and finally see the doctor, who was any number of rude words that I shouldn't use on someone else's blog.  My wife and I go in with four sets of x-rays: during and after for the two illnesses, radiologist reports, and bloodwork.  Radiologist says pneumonia.  Bloodwork says massive infection.  You can see the shadows on the x-rays.  Twit doctor holds up the x-rays TO THE OVERHEAD FLUORESCENT LIGHT!  Flips back and forth between them so fast that there's no way he can be doing a valid comparison.  And there's a proper light box in the hallway.  There's also a sign in the exam room threatening defenestration if you use your cell phone in the exam room: the doctor took at least two calls while in the room with us. He then proclaims "I don't see pneumonia.  I think it was severe bronchitis."  With a 103f fever?!  He orders a PFT for Monday, this was a Friday.

So pneumonia #3 hits three days after I see him.  My wife is an astronomer and worked that weekend: after working from before sundown to after sunrise for two days, exhausted, she had to drive 100 miles back to 'Cruces to take care of me.  I survive it (obviously), and fire the lung doctor.  By this time my wife has been doing research and found that I probably have CVID, Common Variable Immunodeficiency, or hypogammaglobulenimea (her father was a pathologist).  But my GP won't order an immuneglobin workup.  I don't expect him to treat me, but he could at least order the blasted test which might speed things up down the line.  He says I should see a immunologist.  THIRTY DAY WAIT. And while waiting for to see the immunologist, I had pneumonia a fourth time.  Including the previous December, probably five times.  I'm recovering from the 4th, and we get word that my wife's mother is diagnosed with terminal lung cancer and not given much time, so wife flies out to Maine to see her for the last time.  I can fend for myself, we play Warcraft together online and talk via speakerphone when she gets back to her hotel at night.  GP says I should find another lung doctor and get a bronchoscopy to make sure that I don't have any permanent lung scarring. (the name eludes me for the moment: bronchiectasis?) There's nothing to be found in Las Cruces, so I look to El Paso.  Half an hour or so away, big city.  I find a practice on the west side, so I don't have to drive all the way through town.  I choose a doctor with a foreign name: foreign doctors have to pass the boards in their native country, then again here.  I've found that serves me well.  So I call them up, give them the whole litany of what I've been through, and ask for an appointment with Dr. A, expecting to be told 30 day wait.  They can set me up with him within like 2 days.  Mind goes poof I meet Dr. A.  Present him with three sets of x-rays and labs, explain everything, tell him my GP thinks I need a bronchoscopy, and Dr. A. agrees.  Ask him how long to schedule it (I've never had one previously), expecting 30 days: "How about Friday?"  Mind goes poof again.  Unfortunately spousal unit is still in Maine, but we schedule it as soon as she returns. End result of lung study was no damage, and biopsies found bacteria that was getting ready to burst forth into another pneumonia infection that was resistant to the fourth series of antibiotics but not the third, and since it was cultured, we knew exactly what it was vulnerable to, so another course of antibiotics put paid to that.  And now I have a a set of lungs that would be the envy of most 80 year olds, which would be great if I weren't in my 50s. When I finally got to see the immunologist, he wanted to blame the illnesses on allergies!  My wife proverbially beat him about the head and shoulders until he ordered an immuneglobin panel, which showed my type-G to be 150, whereas the normal range is 700-1400. I now do weekly infusions of immuneglobin: four needles in my abdomen for about 90 minutes, and I'll be doing it for the rest of my life.  I've now done it over 500 times.  The condition is genetic, and it has probably affected me for all my life: it just happened to kick in to high gear eight years ago.  Uncommon, but not unheard of.  No one else in my family or immediate relations has it.  With treatment, I'm now actually healthier than I was before the illnesses, but my lungs are kinda trashed, and we have to be pretty careful.  I'm prone to sinus infections and we're very careful to keep on top of flu and pneumonia vaccinations, even though the evidence as to how effective they are is mixed. And that is the joy of my life.  At least since '09. Best of luck with your joy!  Fortunately I did a full cardio workup a few years ago and the doctor said my heart was in great shape, so at least I'm fortunate in that regard, at least for now.

[lydy]

Wow. What a saga. I hate the fact that doctors won't listen to their patients. I kind of understand the reason. Patients lie. They really do, all the time. Sometimes on purpose, sometimes by omission, sometimes because they are just plain wrong about what's going on with their bodies but insist on reporting their theories rather than their symptoms. At the same time, self-report is the primary tool for diagnosis, and so the primary tool for diagnosis is notoriously unreliable. There are ways to deal with this conundrum, but it requires care, empathy, continuity of care, and time. And the way the insurance companies run things, time with the patient and continuity with the same doctor are badly deprecated.

On the other side of things, I understand why patients lie to doctors. They need a thing, and getting the doctor to give them that thing is hard, and unreliable. So they work the system as best they can. It's a genuinely toxic relationship, made so in part by the way in which medicine is distributed and paid for.

[graydon]

Insurance company incentives are for you to die as quickly as possible with as little treatment as possible after having paid as much as possible. And they set things up on that basis.

The thing about single-payer is not really so much that it's more economically efficient; it's that it has decisions being made by people whose pay and promotions can -- not will, but can; it's really hard to prevent the measure-with-money mindset -- rest on health outcomes. (Which is how flu shots went from special-request to public-clinic to every-pharmacy here over a decade; the actuarial case was compelling.)

[lydy]

There are some studies that suggest that preventative care is actually more expensive. Probably, this is because with preventative care, people live longer, and die of more expensive problems, or because chronic conditions are found and treated before they become terminally acute.

Fucking broken system.

[graydon]

Preventative care does generally cost more to a specific healthcare provider, yes. (If only because they did something they would not otherwise have done!)

The cost reduction is systemic; the total expenditure on health care goes down. It's why anybody arguing for market solutions isn't actually concerned with cost control.

[thewayne]

The big objective is to prevent people showing up at emergency rooms with horrible problems that require them being admitted, such as my pneumonias. We were able to defeat them with antibiotics and bed rest, which left my doctors at National Institutes of Health dumbfounded. We were quite happy with that, considering the horrible bugs that lurk in hospitals: hospitals are no places for sick people. It spreads costs over longer intervals in the hopes of avoiding sharper peaks by not having treatment: for example, by getting people in to healthier life-styles and monitoring problems, you might be able to avoid diabetes or heart problems and tremendously higher costs.

I have had a friend actually die from lack of health insurance, and another who would be dead if he weren't Native American enough to get enrolled insurance.

For me, my immune meds would cost approx $3,000 a month without insurance. Fortunately my situation is fairly simple and I just have the one condition, plus I'm covered under my wife's plan. My other health problems are trivial. Some people have what I have plus other immune disorders and are VERY complicated and expensive to treat! It's possible that I may degenerate to that point, crossable appendages are crossed.

[green_knight]

I don't think that healthcare *should* be a consumer good. I think that if you're ill, you should be able to trust that you get advice based on your health, not on costs or paperwork, and that the person being ill should not ALSO have to do comparison shopping and medical research and advanced accounting and reverse customer support and...

[lydy]

I do agree with you.

One of my constant peeves is the idea that medical care _should_ be treated like a consumer good, when it really can't. My current example is more about the cray cray way in which we currently administer health care. Even if I wanted to be a "good" consumer, it's virtually impossible. Your comment, though, points to the larger issue that this is a cruel and insane goal. We say we don't, as a society, value people based on their money, and yet if health care is a consumer good, we must surely do exactly that.

[guppiecat]

It might be worth sending this story to our senators in case they need an anecdote to use in upcoming debates.

[gerisullivan]

Agreed with guppiecat.

[armiphlage]

I was about to rant on my journal about my irritation with Canadian health care (I had to wait over 20 minutes for a blood test! and go to three different desks to fill out forms!), but now I just feel so grateful. Thank you for putting things in perspective.