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A Question of Kneed (Part I)
by Mike Jennett
2012-01-18 08:08:37
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For reasons that bear no weight at all, there are a great number of people in America who believe that the American health care system needs little or no attention and that it is the best in the world. These people are generally the same ones who believe God has blessed their nation with rights of world dominance, that global warming is a socialist lie, that the entire surface of the planet should be drilled for oil and that every American deserves the right of unrestricted ‘concealed carry’ – the right to carry a loaded handgun.

I’m hiking in California and my right knee is giving problems so I need a doctor. In most countries, this would be a straightforward matter, but I am not in ‘most countries’. I actually need an orthopedic specialist, but my insurance company’s rules require that I get a referral from a GP - but how do I find one of those?

Despite doctors numbering zillions, finding one here is a nightmare. Leaving aside the absurdities of the unknown and immensely varying cost, even doing that much takes an effort of will. First, I have to use my insurance company website and that takes years of my life. Despite General Practice being the category of need, they’re not sorted by that, so first I have to work out the correct category and display that. It’s under ‘general clinics and family medicine’, which has 19 pages of listings for my current area, most of which are nothing to do with general practice (why would psychiatry or chiropractic be listed with general medicine?) By a sequence of accidents and multiple phone calls, I finally get a recommendation from a receptionist at one clinic to call her friend at another. By this rather tenuous method, I get to Eisenhower Internal Medicine. Why ‘internal medicine?’ What’s internal about a knee?

I arrive early for my appointment and fill in 9 pages of paperwork, most of which want the same information over and over. One page, quite obviously female only, cannot be ignored and requires to be completed with dashes or n/a in every option that can’t be answered by checking Yes/No boxes. Now, which reason do I check to explain why I haven’t had a pab smear in over ten years?

I see Doctor Lopez. He’s about as useful as a broken light bulb. For almost a whole minute he looks, feels and prods my knee, then talks about hiking and England and finally announces, 'something serious going on in there'. Then he scribbles an authorization for x-rays and gives me a card for his colleague who is an orthopedic specialist a couple of miles away, suggesting that, I 'might like to give him a call'. Thank you, $250 please.

So I go to the x-ray place which is actually in the same complex, but immensely hard to find since Lopez did not supply the building unit number and his receptionist can give no information besides 'it's a cubby hole near the corner of the building'. After wandering aimlessly for 15 minutes and then spotting a man in scrubs, I find that it was right next door but without a sign and is nothing like a cubby hole at all.
Closed for lunch.

I return at 1:00 and spend an hour doing the usual x-ray stuff. This will probably cost another $200, but no one knows until the insurance company decides how much they'll pay and how much is down to me. This is a minefield and the hardest part of the American health 'system' for anyone to grasp - including Americans.

The x-ray place gives me my x-rays on a CD – but only because I request them. What if I didn’t ask for them? How would they get to the next stage of treatment? They wouldn’t. This is another peculiarity of the system - there's no sense of linked treatments. Everything is a separate instance and if you happen to not know what to do or where to go, you're stumped. Now it’s down to me to find an orthopedic specialist and take it from there. So – how does the ‘GP referral’ work for the insurance company if it’s me that’s doing the driving here and none of these visits are linked? Who knows…
I call the number on the card Lopez gave me. They can’t see me for over a week which won’t do, as I’m leaving in 10 days to drive north, so they suggest their alternate office and I try that. After 3 transfers between different phone answerers, none of whom announce the business name on the card, I hear that they also cannot see me for the foreseeable future. They recommend the first number.

I go back to the original office but Lopez is with another patient. After some time searching around, his assistant provides the numbers of two more specialists. I try both, each time speaking to the same receptionist and each time being told that the doctor has no openings for weeks.

I must mention here, that although these various doctors work in clinics or centers comprising many physicians who share the reception desk, there’s no general number available to call to see who might be free. Everything is a private business; every doctor has his own number. Even the receptionist can’t or won’t look through various appointment books - it’s up to the patient to get a specific name and ask for that doctor. This is probably where the word ‘patient’ originated.

By sweet-talking and use of fake charm – because all this really is somewhat tiring - I manage to get one receptionist who suggests Eisenhower Orthopedics, so I call them and got an appointment for Friday – three days away. The ironic thing is that Eisenhower is the clinic that first saw me, where Doctor Lopez works. You’d expect that he would know his own place of work had specialists too….

So – Friday is the day. I will be prodded by an orthopedic specialist who will announce that I need an MRI. This is a given, however we cannot schedule one until the insurance company gives their blessing. That takes up to two days and they may not agree. Should they agree, the cost to me will be $1200, which bears no relation to the actual cost of the procedure, it is simply the deductible on my insurance. The procedure cost is an unknown and varies according to whim but anticipated to vary between $1000 and $3000 for a leg. It will then cost an additional $300 - $500 which they may or may not elect to pay, to have someone tell me the results. The two things are not linked. I wonder how many people are satisfied by simply having an MRI and then walking away, never to hear what’s wrong with them. Duh!

If the insurance company refuses to pay and I decide to go ahead and pay them myself, then the cost to me will be whatever figure had been previously negotiated between the insurance company and the clinic for that procedure in the event that they had agreed to pay. This is secret and will vary immensely between companies, so the same procedure paid for privately by two identical patients with differing declining insurances, will differ. The only way to get a vaguely realistic price is to deny that I have insurance at all, however that would then impact whatever treatment is required as a result, since that treatment would require the result of an MRI and the insurance company could disavow an MRI that they had not sanctioned.

Then we have whatever procedure is required to cure me. This will cost multiple thousands, depending on what has to be done. I don’t want to project the price because it will make me cry, but I know that the best case scenario is that the insurance company might pay ‘up to 80%’ of the ‘covered’ amount and I will be responsible for the rest. Note the phrase, ‘up to 80%’ and, of course, the covered amount is a matter of national secrecy..

To say it’s hell would be an understatement. And there are still people here who are terrified of what they call
‘European socialized medicine’ and think there’s nothing wrong with the current setup.

Of course, they also want to carry guns…

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