An insured day in the American health care system

Being the parent of a newborn means never straying too far from the medical system. Today was our son’s first pediatric appointment outside the hospital. Alexander Daniel is on a gold-plated Blue Cross policy so cost is not a concern and we have our choice of physicians to see.

After a short wait and some paperwork, we bounce between the doctor’s office for discussion and an adjacent exam room. Every time we go back and forth or need to adjust an item of the baby’s clothing, the doctor runs out to see a patient whose visit is running in parallel. I’m not sure if this is standard procedure, but given the paltry amounts that insurers pay for office visits (see this 2010 posting about my doctor billing $510 and collecting $83), I can’t think of any alternative for the doctor.

The pedi does apologize that things are a little slow/chaotic on this particular today. How come? “We’re just installing a new electronic medical record system. And to make it work we had to get new computers because the system didn’t support Windows XP.” Was he going to run Practice Fusion, the free Web-based system? “No. We have to run eClinicalWorks. It is required by Mt. Auburn Hospital, with which we are affiliated.” Was he then upgrading to Windows 8? I could see how that would throw the office into disarray for a few months (or years). “No. eClinicalWorks doesn’t support Windows 8 so we installed Windows 7. But on the other hand they are talking about switching everyone over to Epic so we might start over in a year.”

The doctor suggested that we get flu and Tdap vaccines, but since we are not technically his patients he cannot give it to us. So we’ll need another encounter with the health care system to get these.

Then I went to the neighborhood (old-school family-run) pharmacy to get a prescription filled. They had to do some compounding. “We can’t bill your insurance company,” the pharmacist noted, “because even though we start with an FDA-approved drug, if we’ve compounded it then it is no longer FDA-approved. You can submit the receipt to them and try to get them to pay it. Usually the deductible is so high that it isn’t worth it.” I handed over $45 and didn’t ask for a receipt.

I’m wondering why Americans are so confident that they need health insurance and that, indeed, health insurance is such a good idea that people who don’t want it should be forced to buy it. Food is more important than medical care since without food a person will surely die. Yet we don’t force people to carry “food insurance” and then have the food insurance company authorize particular food providers to serve meals at times and places of the provider’s choice. If people are poor we give them a debit card (SNAP or “food stamps”) that they can use at the supermarket of their choice, with roughly the same shopping experience as a customer using cash. Poor people are lifted up to enjoy a middle-class shopping experience. In health care, it is the opposite. Middle class people are dragged down to endure the same customer service experience as a poor person dependent on Medicaid. If we hadn’t been forced by convention and now law to hand over $20,000 per year to insurers for our family’s medical care we would have been delighted to pay $160 for an appointment with a doctor who could spend a calm 30 minutes with us, rather than $83 for a rushed 15-minute appointment. And the $45 bill for the prescription wouldn’t have bothered me at all if I hadn’t already paid for prescription drug insurance that, I thought, paid for prescriptions.

The pharmacist put it in terms of dollars and cents: “People think that they can save money by buying insurance. They never wonder how it is that all of the people who own insurance companies got to be billionaires.”

30 thoughts on “An insured day in the American health care system

  1. Either your compound is covered or it isn’t. Whether you submit the claim or your pharmacist does doesn’t matter. He probably either didn’t want to bother with it, doesn’t know how to do it, or has software that went submit the claim properly.

    Source: I am a pharmacist who sometimes manages to successfully bill for compounds.

  2. Regarding the $160 and $45 — get a high deductible plan. And we why aren’t you arguing for the more efficient single-payer model. Cut out the insurance companies.

  3. Health insurance in this country is such a complicated business because so many try to game the system (your pediatrician could add some “test” to his billing and inflate the insurance payment, for example). The opera buffa that Americans call “health care system” is designed to require all participants to play the game. The scale of fraud is high (the government estimates it at $80 billion, more than the GDP of many countries ( The US has a fundamental problem: too few physicians (and perhaps too many hospitals).
    There is no relationship between being insured and health (at least as measured by longevity, not a perfect measure but very dependable). Hispanics as a group have the lowest rates of insurance coverage and the highest expectancy of life in the US.

  4. Gary: Why don’t I get a high-deductible plan? The simplest answer is that the current plan has been obtained through an employer and the employer does not offer any high deductible plans. The second answer is that I am not sure what happens with a high deductible plan… consider the situation of . Would that have chewed up $83 of my deductible (what the doctors charges insured patients) or $510 of my deductible?

    You ask why don’t I argue for single-payer in for example? One reason is that we Americans have proven ourselves incapable of running a single-payer system without ruining ourselves financially. Medicare covers only those Americans who are over 65 and yet it costs about twice as large a percentage of GDP as what the U.S. spent on health care for all Americans prior to the inception of Medicare.

    It doesn’t make sense to argue that some future system will be more efficient than Medicare because the future system will be run under the same conditions (Congress being lobbied, American bureaucrats administering it, etc.).

    I still think the more relevant question is why we think health care needs to be centrally planned. It is 16 degrees Fahrenheit outside right now here in Cambridge. Plainly shelter is more critical to health than a visit to the doctor. But there is no bureaucracy in Washington, D.C. that forces every American to buy shelter in government-determined quantities at a government-determined price and/or supplies shelter at a government-subsidized price.

    Trevis: Why can’t the pedi give an adult who is actually in his office the flu shot? For one thing I’m not sure how he would be able to charge for it. If I am not his patient and he doesn’t have my health insurance info, then how can he charge my insurer for the shot?

  5. Philip,

    You need health insurance for the same reason you need car insurance, or life insurance. You don’t need food insurance or shelter insurance because those expenses do not vary, drastically. Maybe inflation goes crazy and food costs 50% more next year. For most people, even if this causes some hardship, is not likely to be devastating.

    However, for health, all it takes is one catastrophic event, one exotic infection, for your health expenses to soar 5000x more than your expected several hundreds of dollars a year cost. That would bankrupt most people.

    As for insurance paying for routine care, that is economically worthless. However, by having insurance, you get to pay that $83 instead of the sticker price of $510. In a high-deductible plan, even if paying out of pocket, you still get the group-negotiated rates rather than the retail rate.

  6. Its not all gloom, doom, and dysfunction. I go to Kaiser in Southern California. They have been running an HMO for about forty years. They do everything, with no paperwork. I seem to have more choices of Doctors and hospitals than I did with conventional insurance which all had preferred “networks” that I had to go to or pay a hefty penalty. Nobody has ever been less than prompt and courteous to me.

  7. Philip,

    Yes, your example addresses an inefficiency, but I don’t think your conclusion works well. Let’s do the thought experiment: assume none of us had health insurance.
    What would the real cost be for Olga to have the baby. Let’s say it was half of the current billed price (which runs in the neighborhood of 20K if I remember correctly). Then, in such a situation you/she would have had to cough up 10K. Is that affordable for most of us? I think not.

    Similarly, what about all those people who have serious conditions which require expensive treatments?

  8. cogent analysis of our FUBAR system. Salary & compensation of Blue Cross Blue Shield of National Capital Area was reported to be in excess of $800,000 about a year ago, which seems high compared to the providers under BCBS who spent 4 yrs in medical school plus additional yrs of training (CEO was not an MD at time of this WTOP new radio report).
    My pediatrician has joked with me that he isn’t allowed to look in my throat due to malpractice issues, even though that’s a reasonable query if your child is undergoing a strep test, the reason for your visit. We lived in Switzerland for a short while, the only other time I worried about strep. I recall the pediatrician actually suggested she look at my throat for possible irritation after examining my 5 & 7 yos. I have been lucky that we’ve had minimal health care issues, but I shudder to think whether I would have survived major medical intervention for myself, my husband and my four kids, without going mad.

  9. Joshua and John: the idea that health insurance is like life insurance doesn’t make practical or historical sense. Life insurance is a product that dates back to Renaisance Italy (Wikipedia says Ancient Rome and then 17th Century England) because death of adults aged 20-50, for example, was a relatively rare and unpredictable event. Similarly with car insurance. says the expected number of fatal (i.e., expensive) car accidents is about 1.5 per 100 million miles driven. If an individual is going to drive 100,000 miles in a lifetime, therefore, the chance that he or she will ever be at fault in a fatal accident is about 1 in 1000. That’s a perfect candidate for an insurance product. The probability that you will need to see doctors periodically throughout your life is 100%. And the probability of a moderately expensive illness is pretty high as well (though this is complicated by Medicare stepping in to pay for such illnesses when they occur among those older than 65). Health insurance became popular in World War II as a way around government-imposed wage controls and as a tax minimization strategy (see ). The rationale for it was not previously obvious to most people.

    John: Could an average American afford $10,000 for child birth expenses? If that American and his or her employer are together paying more than $10,000 per year for health insurance then by definition the American could afford to pay $10,000 for child birth every year during which he or she was employed. In any case, without the widespread existence of insurance it seems very unlikely that the cost would remain $10,000. We weren’t given any prices by the hospitals that we checked out. It is quite possible that a 45-minute drive up to New Hampshire would have cut the cost in half (real estate is cheaper there, hospital employees don’t pay income tax, and the state government runs on a substantially smaller slice of the state GDP) but, if so, we would have had no incentive to make the drive. So why would hospitals bother to compete on price? shows that $4000 suffices to get a baby out in one of the world’s most deluxe economies (Switzerland) and less than $3000 in more typical first-world countries.

    The right question is not “Can you afford $10,000 every time you have a new child?” but “What would it look like if you got paid between $10,000 and $20,000 per year extra and then used that extra money to buy health care as you saw fit?” and also “How would doctors and hospitals behave if they had to compete on price and had to convince consumers to spend money that could otherwise be spent on shelter, food, vacations, transportation, etc.?”

    Could you afford a joint replacement in the U.S. for $100,000 in that situation? Perhaps, but why would anyone other than an investment banker do that when the same surgery can be had for $13,660, including round-trip airfare, in Brussels? (see ). Either the U.S. price would come down or having joint replacements domestically would be rare.

    A friend of mine got cancer and required expensive treatment in some high-end hospitals in California over a period of years. Fortunately he recovered. As a resident of Berkeley he is a passionate advocate of a centrally planned economy, more government regulations, and health insurance for everyone. He cites his own cancer as evidence that everyone should have insurance because he was in his 30s when it happened and therefore it was a truly unexpected event and expense. But then I asked him to add up the cost that he and his employer had paid over his working life for health insurance and it turned out to be roughly 3X the cost of the retail rate for the cancer treatment.

    Anyway, my point is not that health insurance drives up costs (since apparently Americans don’t mind paying 2-10X what people in other countries pay for equivalent care). My point is that being insured and being in a system where the insurance company is the customer degrades the patient/parent-of-patient experience.

  10. John Klein,
    You would easily have 10k by not paying premiums during the preceeding 9 months, or making payments on the balance. Your argument presumes people too stupid to make plans for a purchase half as expensive as their car.

  11. We had twin boys born almost 7 years ago. Unfortunately they were premature and had to spend a few weeks in the NICU.

    Total cost at the end of the day (to my insurer)… Almost a million dollars.

    Luckily my employer has *really* good health insurance.

    Without health insurance in the US, you are just one serious health issue away from bankruptcy. Plus then you wouldn’t be able to get insurance any longer for your now pre-existing condition.

  12. Peter Reed: No– my yearly premium is about $3,000 since my employer foots most of the tab.

    Philg: I’ve spoken with several doctors about why they think health care in the U.S. is so expensive. They often tell me that the model “fee-for-service” is one reason for it. Hospitals and physicians stand to make a lot more money by running all sorts of possibly unnecessary procedures.

    Concerning single payer: I’ve been in places where it works just fine, e.g., Denmark. I’ve also been in places where it seems to work poorly, e.g., Quebec. At the risk of sounding cliche: When it comes to health care, the devil is in the details.

  13. Peter Reed: with respect to pregnancy, you can plan.

    But what about the unexpected?

    For example, my wife got severely injured in an auto accident two years ago (the other party was at 100% fault). The cost of the emergency room visit, subsequent care, as well as the additional 18 months of physical therapy is not something I could have forseen. I don’t think that I, or the party who hit her could have afforded to pay the costs of the injury and recuperation.

  14. I think it is safe to say that most educated people in the US know that the way health care is paid in this country is simply crazy. International comparisons with other advanced societies show that about 10% of our GDP is going to waste. Since all citizens (insured or not) participate in the delivery of health care, you could argue that poor people are the most affected by this problem, either because the pay significantly more as a proportion of their income or because when they get “free” care (Medicaid etc.) they are missing out on other services that could benefit them far more. It perplexes me that there is not a solid majority in favor of radical change. Why it is so difficult to solve this problem?

  15. John: Your premium is not the $3000 that you see most directly. Your cost includes what your employer pays as well because economists have found that benefits like health insurance end up being paid for almost 100% by employees in the form of lower cash salaries (i.e., competition for labor would force employers to pay higher salaries if they did not purchase health insurance for employees (personally I am not sure this is true for non-market employers such as government)).

    And the auto accident case that you cite is a good argument for accident insurance, since accidents are rare and unpredictable. It is not a good argument for insurance that attempts to cover the costs of predictable events such as pediatric visits for a child or checkups for an adult.

    As noted above, if insuring against expenses that a person was 100% guaranteed to incur were a good idea we would see a market for shelter and food insurance. When a person graduates college at age 22 he or she doesn’t have any idea what kind of income is in the future. So wouldn’t it make sense to buy an insurance policy for food and shelter so that he or she wouldn’t have to worry about a roof over his/her head and food on the table?

  16. John’s premium not only includes the employer contribution (a trivial distinction, that amount is just a form of compensation as phil points out). It also may include cross-subsidies by other payers who pay more for the same services. In the US a provider contracts with insurers and the government (or its intermediaries) and seldom those contracts contain the same pricing for identical services. When someone flies NCY to San Francisco for $300 round trip the cost of that trip may actually be $800. Price discrimination is at the core of our health care system, but it is a form of price discrimination that only favors those who know how to play the game.

  17. Anonymous:

    my employer’s contribution is indeed a form of compensation. But if my employer handed me that cash directly, I could not get a plan with the same level of coverage at that price.


    Your approach is simply pie in the sky. I challenge you to get dump your health insurance. I doubt that you would go to that extreme. Of course, you live in MA, where insurance is mandated.

    We can complain all we want, but there is no way to know exactly what the true cost of health care would actually be if no one had insurance.

    I’m no health care maven (and I take it neither is anyone else who responded), and I think ObamaCareTM was a terrible mistake.

    My preference instead would have been to build a single payer system for **catastrophic** care at a low price (only this part would be single payer). Individuals should then be free to go to the private market to purchase additional insurance, but only if they wanted it.

    Philip, I don’t think you’ve addressed the issue of catastrophe in your post. Perhaps you could respond to that?

  18. John: Actually we have a pretty good guide to what health care would look like if insurance were uncommon. Just ask any dog owner. You call the vet if your dog is sick. You get an appointment the same day. You wait for no more than 15 minutes before seeing the vet. The vet does as much as possible without referring you to a specialist. You pay a $100 to $400 bill on your credit card. If things get catastrophic, e.g., cancer requiring chemotherapy, you pay thousands of dollars. The same techniques and drugs are used as with humans. Vets get paid about a third as much as medical doctors (see and ) though they have the same training.

    Anyway, I’m not against insurance for stuff that is rare and very expensive, which would include accidents or a rare and expensive disease. The current system doesn’t work that well for parents of special needs children, even if the parents have the most comprehensive health insurance available. The kids get gold-plated care when they are in the hospital, paying for every doctor’s luxury car and McMansion. But as soon as the kids go home the parents are on their own. It would be better to buy a policy before a child was born that, in the event that the child needs 24×7 care, the insurance company would pay for help at home for the life of the child.

  19. One advantage of having most health care covered by insurance is to make people not biased to postpone diagnosis and treatment for financial reasons – thus ameliorating the impact of catastrophic illness.

  20. Philip:

    Some, but not all, veterinary expenses are comparable with human health care expenses.

    For example, the cost of a dog MRI is about the same as an MRI for a human (running between $500 and $2500).

    (Even so: I doubt that dogs and cats have MRIs nearly as often as humans.)

  21. I agree that wealthy people might only need insurance for catastrophic health problems. (We’ve had quite a few in my family, such as my micro-preemie niece who weighed less than two pounds when removed from her mother. Her care probably cost millions, at least list price. She’s fine now. I also have a nephew with a brain tumor, who will soon be having his second surgery.)

    People who are not wealthy would be likely to underspend on medical care if they had to pay everything out of pocket at the time of use (just as people currently overspend because they don’t pay the full cost). Imagine a mother struggling to make her monthly minimum credit card payment, with a child whose eyeglasses need replacing. She discovers a lump in her breast. If she knows (or fears) that it will cost hundreds of dollars to have it checked out, she’s likely to ignore the lump. It may not be rational, but it is human nature. (A close relative of mine recently discovered a lump in her breast the month after getting a clean mammogram. She got it checked out, found out it was cancerous, and got it removed before it spread.)

    On a more practical note, have you looked into One Medical Group? The charge a surprisingly low annual fee that enables them to spend more time with patients and offer same-day appointments. They also are very efficient with electronic records and services. They started in San Francisco but recently opened a branch in Boston. They might be a good option for your family.

  22. Ellen: Thanks for the anecdotes. As noted above, I don’t think it would be a bad idea for people to buy insurance against a premature birth or similar catastrophic problem, though even there I think it would be better if the insurance company gave the insured cash and then let the insured shop with that cash.

    As far as people who are not wealthy being likely to underspend…. well, we already have Medicaid that provides unlimited no-cost health care for the poor. Medicaid pays for eyeglasses. Medicaid was serving about 70 million Americans prior to the Obamacare expansion (see ). But I don’t know why that means that middle class people can’t purchase health care in a way that reduces us to tokens passed between the provider and the customer (i.e., the insurance company).

    Thanks for the One Medical Group link. is interesting. They actually publish prices! Amazing. And certainly those prices don’t suggest that going to the doctor should be something that requires insurance. The average checkout bill at the Fresh Pond Whole Foods is more than those guys charge for a primary care visit in their downtown Boston office. I don’t have Whole Foods insurance (though sometimes I wish I did!); why would I incur the bureaucracy, administrative cost, shareholder profit, and hassle from having insurance that covered a $100 primary care visit?

  23. For a different perspective, a few notes about how things look like with the healthcare system from the Eastern European country I was born and raised in.

    1) There is a public health care system. The hospitals that are managed by that system are pretty bad overall (crowded, not very well maintained, not having all the supplies they need, no A/C in the patients’ rooms etc), and have been so for the past 30+ years. To be fair, for the past 10-15 years the country’s economy has improved dramatically so the things have gotten a bit better in those hospitals too.

    2) The doctors and the nurses from those hospitals are making relatively little money. A doctor, for example, makes about 12-15,000 US dollars per year, while a software engineer, for example, makes about 15-20,000. Therefore both the doctors and the nurses have very little incentive to work so, to compensate for this, many of them need to be paid (or bribed, if you prefer) by the patients, or by their relatives, in order to do a decent job.

    3) Because of the above, a number of investors have decided that it might be better to simply create private clinics and hospitals where you can pay upfront and have both the patients and the healthcare employees happy. These initiatives have proven quite successful. For example, many middle-class people I know have preferred to have their children born in these private hospitals because the experience is much better and because the costs are reasonable (about 2500 dollars for the entire package, I believe). My experience has been positive as well – while visiting the country on two different occasions my 5-year old required a visit to the doctor and for about 50 dollars the doctor saw us within a couple of hours of making the appointment. There is no insurance to cover these costs, everybody pays the costs upfront.

    4) For critical health issues (e.g. liver transplant), some people I know have been successful with the public system. A couple of others, who needed cancer treatment, have come to the States and their friends and families have helped as much as they could. Finally, somebody who needed expensive treatments for a liver condition, was denied by the public system (death panels anyone?) because there was no money.

  24. Alex: A huge number of countries worldwide have the system that you describe, which isn’t too different from what I suggest in (except that since federal and state governments seemingly can’t hire anyone for less than $250,000 per year (including pension costs realistically accounted for) I suggest that the basic option be a government paid-for HMO membership). It has the advantage that the cost to the government is known in advance each year rather than limited only by the creativity and greed of those who are billing Medicaid/Medicare.

    Obviously the folks who are currently billing Medicare $15,000 per patient per year (see ) would not be thrilled to collect only $5,000 per year or whatever it is that we decide we’re going to allocate to health care. I wonder if it is really the case that they have enough lobbying power to keep Americans at their jobs 5-20 extra hours per week in order to pay for the extra cost of doing things the way that we do (i.e., differently than any other country on the planet).

  25. You have broken the code! If everyone paid cash up front for medical care, or had a very high deductible plan, you wouldn’t NEED to pay a monthly fee so that someone of only moderate competence can become a billionaire.

    I found prices ranging for a CT scan in the area of Pennsylvania I lived in ( I was paying cash) ranged from the typical hospital charge of $2700 to $4000, to the outpatient clinic in a depressed area, (owned and operated by the head of the radiology department at a big hospital), where I paid $264 with a credit card on the day of service. So the question: what is a fair price for a CT scan? I submit that the lack of pricing transparency in American healthcare means 99% of people will never find out.

  26. Coming from France, which had mandatory public health insurance for over 70 years, your problem doesn’t seem to be mandatory insurance. It’s the network of super-complicated bureaucracy that private insurances have weaved for ages, to get as much money as they can out of you, yet keep ways to weasel out of their obligations when you need them.

    Facing a well-organised network of drugs+insurance mega-corps, with influence in the medias and DC, are scattered individual patients, with no organized leveraging. You’re being fleeced and can’t help it. Having one single mandatory insurance for serious health problems (it handles your chemotherapy, not your flu shot or your glasses) has many advantages:

    * drug companies and hospitals don’t have the last say: it a drug isn’t endorsed by universal insurance, it’s not sold. As a result, negotiations turn out differently, and drugs are sold here at a fraction of their US price (yet still profitably, don’t cry for Glaxo).

    * there’s no weaseling out of its responsibilities for the universal insurance: it’s universal, so your cancer or your pathological birth is by definition its problem, it pays and that’s it. We don’t even have a translation for “preexisting condition”.

    * it’s politically accountable. When people have strong opinions about what universal insurance does, our political representatives call the shots. It’s as imperfect as the democratic process goes, yet way better than relying on Blue Cross’ shareholders’ sense of civil duty.

    It’s no soviet union here: a doctor has the option of setting his prices freely; you can go to a private hospital and pay for the luxury/elective stuff you want and can afford (the things covered by universal insurance will still be covered even if they’re performed by a private hospital, provided they respect reasonable public prices); you can get complementary insurance for stuff that don’t threaten you with death or ruin, and most middle and upper class people get one; doctors are still among the best paid jobs. We get similar healthcare quality for half the price per capita, without the risk of falling out of the safety net due to a layoff or a technicality in our contracts.

    US private healthcare insurance bureaucracy isn’t more efficient than a public one, but is much less accountable. And forcing everyone to participate in a unified public healthcare system because it’s much more effective is no more liberticide than forcing everyone to pay and obey national police forces, or to fund the DoD.

    Obamacare isn’t universal insurance. It seems to be a shy and bureaucratic attempt to vaguely make private insurances a bit more accountable, and to prevent some of their most socially harmful habits. But you’ve had so much money wasted on so many influential fat cats through the current system that you won’t be able to make the system efficient easily. Healthcare is one of those cases where free market doesn’t work.

  27. > being in a system where the insurance company is the customer degrades the patient/parent-of-patient

    There’s an easy partial mitigation to that: let caregivers fix their prices, but force them to be public, and to be the same for everyone. This way, when Blue Cross negotiates, it negotiates for the common good, only only on behalf of its patrons.

    > what healthcare would look like if insurance were uncommon. Just ask any dog owner.

    There are a couple of key differences:

    * medical malpractice trial isn’t as serious a risk for vets;

    * putting your dog down is always an option. When it’s your life or your kid’s, it’s not, and it seriously lowers your bargaining power.

  28. Fabien,
    Merci pour votre analyse! I worked for the OECD in Paris back in the 1980s (Chateau de la Muette), and even though the insurance covered all but 7.5% of my medical, dental, etc., expenses with no deductible whatsoever at the outset, I didn’t undertake any additional care, with exception that once I found a Georgetown Dental School-trained Vietnamese dentist, I had some non-urgent work done (in those days, French dental care was vastly inferior to American — you may have a different view).

    I recently learned at my annual checkup with my gynecologist (whom I’ve been seeing since 1986) that he cannot share medical records electronically with a radiology practice, so that when I have a mammogram, it has to be sent to him if I authorize that. The only difference is that now it can be done via email between the radiologist and the gynecologist, whereas it used to be done via US Postal Service (near bankrupt thanks to the internet). Ditto, he told me, if his patients require surgery at any local hospital — he cannot access their surgical records without an email from their surgeon. He is about to retire, and laughed when I told him what I heard on the radio recently: “What do doctors hope will happen with their difficult patients? They hope they will go away.”

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