A friend from graduate school visited this weekend with his three kids. Before they departed, I began to feel my throat getting sore. Yesterday the parents called to say that one of the children had tested positive for strep throat. I called my primary care physician to find out what I should do. His assistant returned my call three hours later, referring me to a lab affiliated with a local hospital. I visited the lab, handing over a health insurance ID card (required by law now in Massachusetts). I would have expected the hospital’s IT system to be able to grab my address and phone number from the insurance company’s IT system, but instead I was asked to hand-write a one-page form with this information. Meanwhile the clerk searched among a stack of 30 or so FAXes that had come in that day, trying to find one from my doctor with my name on it. After she’d found the test order, she started entering my contact and insurance information into the hospital’s IT system. She made multiple transcription errors, necessitating two reviews by me. I was presented with a full page of fine print in which I signed away various legal rights to privacy. The clerk said that without this they would not be able to disclose the test results to my doctor. Nor do they ever disclose test results to a patient. So a patient who refused to sign the form would end up getting tested and the results would never be useful to anyone. The paperwork took about 30 minutes to complete.
The strep test itself was done fairly quickly after the paperwork was done and I walked out, having been told to call my doctor’s office the next day for the results.
I called the doctor today and the phone menu said “Press 1 if you are having a medical emergency or need to talk to your doctor’s office”. I pressed 1 and got a busy signal, then was disconnected. I called again and repeated the process. I was disconnected again. I called a third time and pressed 0 for the operator and explained the situation. She said that my doctor was out today and I should call again the next day. I explained that I had been told to expect this and that anyone else in the office should be able to retrieve the test results and read them. She said that someone would call me back. About 20 minutes later, a different physician’s assistant called me back to say that the “quick strep” test was negative but that they were still waiting on the throat culture test, which had been started in parallel. I asked how long the quick strep test actually took. She said that she had no idea. I looked it up on the Web and the answer turns out to be less than 15 minutes. So it took 21 clock hours to get the results of a test that takes 15 minutes. Two FAXes were sent and at least three additional pieces of paper were consumed; six voice phone calls were placed.; roughly 60 minutes of patient time was consumed, not including driving to/from the lab.
I would say that this incident demonstrates one point from my health care reform plan: “As the health care industry has never been competitive, nor had any incentive to control costs, we have no idea how much American health care could or should cost.”
Alright. What can we practically do though?
Dominik: What can we practically do with an industry that hasn’t figured out how to use encrypted email instead of fax? That can’t attach a .vcf address record with an email so that address/phone numbers aren’t laboriously re-keyed by every provider? Well, if you were the Obama Administration and Congress you’d say “Let’s give these good folks an extra $1 trillion per year and hope that the money shower induces them to become more efficient.” I guess that is one thing that we can practically do and are about to do.
Apparently, alas.
Let me give you another version: last week I had a sore throat, and it looked kind of scary to me. My employer has an on-site doctor, so I walked into the doctor’s office and asked for advice. They gave me an appointment that afternoon. In my appointment I walked in, they took a look, and ordered a quick strep test. An assistant came in and did the test on the spot (it was negative). Total appointment, from in the door to result and out-the-door: less than 10 minutes.
So perhaps this supports your assertion — my employer has a financial incentive to reduce its health insurance costs. By having a doctor on site, they do this _and_ increase employee productivity. Everybody wins.
I don’t understand how doctors- presumably smart people can exist in a world where the system around them is so broken, inefficient, and frustrating. Think of how emotional IT people get over the efficiencies of vi over emacs…or vice versa.
I hope to be an ER doc, but I don’t understand how waiting overnight for lab tests that should take an hour is acceptable. It seems that my best prospects are to become educated in the US and move to some other country to actually practice. I want to see first hand how other places do things. My sister, as an American in Japan apparently couldn’t get things like contraceptives because the clinics were out of them. A friend living in London had similar experiences to Phil’s above when she became sick with flu-like symptoms. I’m not sure that anywhere is definitively more efficient (Hong Kong, maybe?) but if there is such a place I wanna find it and apply for a job.
I know there are lots of problems with things like physically being able to find a patient chart and hours a day is wasted doing this. Sometimes I feel as radical and off putting as Richard Stallman pitching GNU to right wing capitalists when I suggest, gee get a flippin laptop/tablet/whatever and a basic oracle database. The technology required to accomplish basic organizational improvements is absolutely no more difficult or complicated than an SAP implementation or the back end of a bank.
There is another way of looking at this. I’m more than 40 years old, I have never had a test for ‘strep throat’ and I appear to still be alive. Perhaps part of the problem with health care all over the developed world is simply that people think they need so much of it ?
It reminded me of this item I read comparing the reactions of French and British doctors to a woman with the same symptoms
http://news.bbc.co.uk/2/hi/programmes/from_our_own_correspondent/7779126.stm .
Hope you feel better soon.
Nothing prevents you from exerting more control over this process. Most states allow you to order your own tests online, have the results sent to your doctor and yourself, and choose the time and location. This takes data entry entirely out of the hands of lab technicians.
For example, privatemdlabs.com charges $45 for an Antistreptolysin O (ASO) Antibody test and $120 for a Beta Strep (Group B) Antigen test, collected at any Labcorp location. You pay upfront and then file for reimbursement.
Nonsense, you have a very fine example of how much health care should cost. It’s called veterinary medicine. Had you been a dog, you would have received an actual exam, by an actual doctor, with test results in your possession, the same afternoon you called the office (if I were your vet). Furthermore, you would have walked out the door with the necessary medication, all for about 1/10 the cost – or less – than what you paid. Perhaps far less, if you account for the insurance you wouldn’t have to buy because the system is already affordable. Why? It’s in large part due to the lack of involvement of malpractice attorneys and insurance companies – it’s just us and our clients calling all the shots.
Heather: My Samoyed George died at Angell Memorial around the same time as my Great Uncle Archie died at the age of 93 at Brigham and Women’s Hospital. As it turns out, both had similar problems of metastatic cancer. The care at Angell was coordinated by one vet who brought in specialists as she deemed necessary. George’s prognosis was determined after a couple of days in the ICU and he was euthanized about one day before he would have died, despite all of the high tech equipment in the ICU. The cost was $2,000. Uncle Archie, who had been in poor health for years, was worked on by at least 7 specialists, none of whom were communicating with each other except through the chart. He died after several weeks in the ICU at a cost to Medicare of about $200,000. His condition was not diagnosed until after an autopsy (i.e., the 7 specialists at one of America’s greatest hospitals, with all of the best equipment of the 1990s, never figured out what was wrong with him).
I totally agree with laggards in healthcare regarding IT implementation.
I think the only way it will happen is someone starts from scratch becomes the McDonalds of medicine. It may not be the best care, but its done the same way at every office. It uses the latest IT practices from the start and they only work with outside medical facilities that adopt their method or pay a laggard premium. Also I think they their should be cost incentives for patients who get a simple physical every year.
JP — what you are describing is pretty much the recruiting pitch which Canadian hospitals use to lure US-trained doctors up north. (Both my father and sister are MDs in the Canadian system, so I’ve heard the pitch before…)
Richard — it is possible that folks test for strep too early and often (since often viral illnesses are mistaken for strep). But I have had actual strep before — and I didn’t go into the clinic until I reached the point where I was unable to eat or drink for a day due to pain. Without diagnosis and treatment strep can get pretty darn bad — but with antibiotics it clears up pretty quickly.
Oh! but it gets better! Someone was probably billed between $10 and $40 for that test, but I can tell you for a fact that the lab paid less than $2 for the cassette and it’s accompanying doodads.
I used to work for a company that manufactured and sold pregnancy tests (and the rapid strep kits too…). We sold the little cassettes that our local hospital used. When I had to go to the ER they used one of those cassettes on me, then billed me $40 for it. I still can’t get over it.
Speaking from personal experience, the key difference between the broken American system and one that works is that the patient isn’t the customer in the American system (which is more or less what you’ve been saying).
In Puerto Rico, which is in the US but not of it, the patient is, in fact, the customer. You go to a doctor, they recommend a lab test. You take the prescription for the lab test, go to a lab of your choice, and they give *you* the results to interpret yourself or to take to the doctor for further interpretation. If you don’t have a lab prescription, then your insurance won’t pay for it, but you can still get lab work done; you’ll just pay the full cost. Your strep test would have been done on the spot and they would have told you the answer, right then and there. And given that test strips cost roughly 50 cents a unit, it would have cost you a dollar or two.
Since you deal with the lab, they serve you. Since they offer prices for less formal care, they’re motivated to price things reasonably. Lab tests that cost $80 in Indiana cost $20 there, and no, the people doing the tests are not paid less; they just have a motive to compete, that’s all, and they pay their CEOs a lot less.
Incidentally, Puerto Rico has universal coverage, along with a private insurance system, and somehow they manage to coexist fine. We had Blue Cross there, so even our own insurance companies manage to compete just fine in that environment. They don’t exclude for preexisting conditions, either (not allowed to). Frankly, if the United States were simply able to provide a system as good as freaking *Puerto Rico* we’d be far better off. Somehow, though, it doesn’t seem to be politically possible.
Oh, hey – RD, thanks for the link! I’d been wondering how to get routine testing for my son without flying back to Puerto Rico or mortgaging my soul to the American system.
Incidentally, for test strips for nearly any straightforward chemical testing (i.e. urine glucose and protein and the like) you can order things online as well, e.g. drugstore.com. If people had any sense, somebody would start a cheap-o clinic chain along the lines of what Michael@10 is proposing, with these quick tests available on the spot and referrals to physicians for treatment.
A lot if it has to do with medical industry’s unwillingness to disclose prices. You buy the service, you get the bill a few weeks later. Some people might say that this is because of insurance, but the system works the same way for uninsured patients.
If airlines operated the same way, we would be bankrupted by the cost of travel.
In medicine, basic consumer protections don’t apply and the contract of the form “we’ll provide you service now, and later, we’ll charge you whatever we feel like.” is enforceable. That’s the root cause, IMHO.
Oddly enough, hospitals disclose prices for overseas patients. Why? I guess because it’s hard to send bill collectors overseas, hence, a pay-as-you-go system.
The fully-socialized VA system actually has solved many of these problems: Longman cites a study published in the New England Journal of Medicine in 2003 comparing veterans’ hospitals with fee-for-service health care funded by Medicare. Both, of course, constitute socialized medicine in the sense that both are paid for by the federal government; but the hospitals treating elderly patients on Medicare are not government-run institutions. By every criterion, the New England Journal found the veterans’ hospitals to be superior. This is especially striking when one considers, as the New England Journal noted, that patients in VA hospitals:
Surveys by the National Committee for Quality Assurance and other organizations, have reached the same conclusion. The superiority of VA hospitals is so obvious that by now it ought to be common knowledge.
I live in southern California and have coverage through my employer with Kaiser Permanente..an HMO. I have the option of selecting a “private” doctor of my choice at a much higher cost to my employer.
I stay with Kaiser because I can email my doctor personally, check test results online, and see my entire medical history online. Many test results are posted within 24-48 hours.
With all of Kaiser’s records online, their doctors are able to compare treatments and results between all of their patients at the click of a mouse. All I ever show them is my Kaiser ID card.
And to think what you could have done with all of your time if you had just:
a) gone to a doc that will do the test in the office
b) gone to a doc in the box (we have those on every corner here in Texas)
c) gargled with warm salt water morning, noon and night
d) drink more hot liquids (herbal teas preferably)
e) place garlic glove in back of mouth bite down and let the oil run down the throat. (garlic kills bacteria, kills any hope for a good night kiss too!)
But seriously, every sore throat does not mean strep, even if you have been in the same room with it. We all need to be more pro active in keeping our immune systems intact and ready to wage war against the germs we all share. I am of the opinion that too many people seek medical assistance for the most minor of things. Don’t get me wrong, strep is an evil bacteria. But over time it has become immune to our over dosing of antibiotics. We have to get back to the basics. Strengthen our immune systems and fight back with good old fashion remedies available in any produce isle.
As far as the paper work goes…that’s why our health insurance costs so much and health care costs are astronomical. In this era of technology, the doc, if too busy to see you, could have emailed you the script, you should be able to enter a secure website, input your info (just like they are paying that employee to do) upload a digital copy of ins. card and attach along with script from doc. Press submit and then go to lab with your confirmation number a there ya go. No paper used. Because you know that the lab just emailed your results to the doc. And let me tell you….You can bet your sweet cheeks that the doc will bill you insurance for giving you the results over the phone. Probably coded as an office visit by proxy.
Cindi, et al: How did I get to be a hypochondriac overconsumer because of this one $2 strep test? Despite my advanced age (46), I haven’t even been to a doctor for maybe three years (I’m leaving out my FAA-required aviation medical exams). I humbly submit that the problem is not with my lack of garlic, but with the fact that the $2 strep test cannot be marked up to $10 and delivered as efficiently and quickly as a fast-food meal, with the information stored in a system as convenient as Google Docs or gmail.