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

[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.