A Tale of Two Systems

It’s been a while since I have written a post — though I have been spending a great deal of time on my book — but have been repeatedly urged by family to finish telling the story I began in “Rise of the Leftnots” back in January regarding my experience in the very contrasting health systems of the US and UK. Not feeling I could really do it justice until the process was almost complete, I write today from a lovely hotel 5* in London having had a similarly 5* healthcare experience vis a vis the surgery I had here yesterday, but thanks to the insurance-dominated healthcare system in the US could not have had there for at least two more months, if at all. That is an important distinction to bear in mind and one I wish would reach the level of public discourse: the problem is not the healthcare system in America, but the health insurance system, industry and its powerful lobby. Unless and until we have an honest dialog about those two systems and their unhealthy relationship and unholy marriage, quality healthcare in our country will never be truly accessible and affordable to all.

Anyway, my story is very much that and I am by no means going to claim that this is typical anymore than I would suggest that everyone can give their American doctor the middle finger, hop on a plane to London and have one of the best orthopedic surgeons in the world operate on them. I am blessed both to know the right people and to be able to afford to do so, though I suspect the actual cost of it — which I am going to share — will surprise you. For those of you used to my writing, do not expect the snarkiness or attempts at humor or poignancy of my usual tone as to me, the importance of this story lies in the facts and details thereof; there is nothing entertaining about the state in which we find the current healthcare system in the US. So, without further ado…

I broke my foot on December 3rd, a notoriously difficult to heal Jones Fracture. The real deal; not what some doctors erroneously call a Jones Fracture that really isn’t the true, bitch of a break that this is. The first doctor I saw at the ironically named walk-in department of our local and somewhat (allegedly) prestigious bone clinic was closer to honest with me about what that meant than was the over-hyped foot surgeon I would see four times thereafter. The initial doctor had told me I would be in a non weight-bearing cast for 8 weeks followed by probably 4 more in a boot and that these breaks are amongst the most difficult to heal in the body with an overall non-union rate near 28%, this group eventually requiring a surgical solution. That doctor was semi-retired and worked at the walk-in to keep himself engaged, but I much preferred his style. He was old-school, blunt and seemed to not have been trained in, or impeded by the insurance speak which has so rabidly infected the rest of our system. Frustrated with the news, but thankful for the blunt talk, I got the cast and corresponding instructions and upon leaving, a follow-up appointment for 2 weeks later with “our best” (certainly their words and by no means mine) foot surgeon.

One week later, though, the severe swelling had reduced to the extent that my cast was too loose, not doing its job and causing pain. I returned to the cast room of the clinic — which is what I had been told to do — only to have the woman there tell me that the fact that I could fit my entire hand down the inside of it was “normal” and that I did not require a new one. I should have argued, yes, and should have likewise let my Southern bias of “why the hell is this woman with the most awful Boston accent I’ve ever heard in my life relegated to a cast room in the deep South” dominate my reason. But I did not, instead allowing my otherworldly, son-is-home-from-school holiday happiness dominating my otherwise notorious short patience and temperament. Yet another week later I returned to meet this surgeon of whom I had only heard praise and who for the sake of this tome will refer to only as “Dr. M.” The clinic at which Dr. M practices is large and the only one of its type in our region; it caters to every part of the socioeconomic spectrum and every bone in the body. It is also very similar to another Memphis-based production of which I am actually proud, FedEx, in so far as how it is run. Though process-oriented, non-emotive, generic healthcare determined by the bar code on your pink form is not how anyone, I think, would prefer to be treated by their physicians, that is very much how it is here. You sign in for you appointment, wait anywhere from 30 minutes to 3 days to be called, then are taken rapidly through a process which at first seems comforting in its organization and forethought, being taken to X-ray then exam room or cast room to exam room or some combination of all three.

On this day, I went from waiting room to Xr-ay room to exam room to be greeted by a very pleasant and affable Dr. M. Any interest I had in Dr. M’s opinion, though, quickly dissipated as he quickly contradicted what I had been told by the doctor who had seen me the day after the break. 6 weeks in a cast, then a boot and done. That’s what he said. No ambiguity, no managing of expectations with any sort of realistic view of “but it could go longer,” or even more honestly, “often goes to 12 or 16 weeks.” Indeed despite the fact that I told him that I travel 3 to 4 times each week for work and that being on the phone rather than in person for my job often removes an entire zero from my day rate, he seemed completely non-plussed and said something along the lines of, “Yes well, everyone has a job and a life.” Fuck you, I thought. He was in the room with me for 6 minutes and 47 seconds total. That was it. No mention of the difficulty in healing this particular fracture or alternative measures or even a hint that surgery may someday become inevitable. I got a new cast — one covered in snowmen for Christmas – was given another follow appointment for 4 weeks later and headed back home, again uncharacteristically not taking to Dr. Google to see what others might say about the lovely fracture named Jones who was impeding my life.

4 weeks went by somewhat uneventfully thanks mostly to holiday distractions and bourbon, and I returned yet again to see Dr. M, though on this occasion I was sent first to X-ray, then to the cast room where Dr. M would see me, I was told. They cut off the cast, he glanced at the X-ray and said, “It’s not really healing, but at this point we always move to a boot. That’s just what we do,” and indicated he would order me a bone-stimulating ultrasound machine that would aid the process by an FDA-approved-claim rate of 38%. He was with me a record 7 minutes, ordered me an orthotic for my boot and went on his way. By this time I was getting irritated and impatient, being able to still feel the break plain as day when I walked and sensing — being a quasi-intelligent and aware human being — that my body was not doing its part in this process. Two days later, a complete dingbat of a woman from the company who owns the (very expensive) bone-healing machine called me to take my details and then informed me that despite what my doctor had told me, I was not in fact eligible because I had fallen outside of the 30 days since being first seen or 7 days since first X-ray. I made every argument I could, but in the end it seemed fait accompli and I began to look at alternative measures in the event that in two more weeks, no positive change would be detected.

2 weeks later I returned yet again, went straight to X-ray, then to the exam room. 6 minute 50 second visit, more condescending than ever, but indignant I had not received the ultrasound bone-healer, he did — in fairness — dictate a letter to the insurance company to attempt to correct that and asked me to wait while his nurse rang the rep. This is where I really began to come apart at the seams. The rep told the nurse an entirely different story and claimed I had not wanted the device. Bullshit. The nurse — who is lovely and honest — related the entire conversation to me and then also added something I wish my doctor had both the freedom and balls to do himself: “We have to follow this process,” she said. “This is what is dictated by insurance and if we do not follow it, if it comes to surgery, they may not approve it. We have no choice. We are entirely at their mercy. They tell us what we can and cannot do.” And anyway, she continued, his surgical schedule was booked up 9 weeks in advance, so I was looking at least 2 more months for an operation even if we decided then and there to go that route, but he would not make that decision until he had exhausted everything else. Or, as it turns out, make that decision for me at all. They would see me again in 4 weeks. Buh bye.

The rep from the bone-stimulator company emailed me about 4 days later while I was away and in a meeting. What she said astonishes me still, but is merely one symptom of a disease at epidemic proportions. Well, 2 diseases, actually: one being ongoing idiotification of America and the other being the bureaucratic layers of bullshit within the American insurance monolith. In her email, she told me that my doctor’s clinic had misspelled my last name and gotten my birthday wrong and that the insurance company had therefore not initially been able to find me (yet a third version of her story, for those keeping track), but not to worry because she had corrected it for me. Ahem. My birthdate and name at the clinic were 100% correct – I wrote them down on my first visit and these are details I have known for 47 years. The insurance company had them wrong. This woman in her comfortable ignorance had changed my birthdate from the correct 5th to the incorrect 15th and had changed the Os in my last name to As with the clinic and I would now — in order for records to match — have to stick with that for the duration of this experience. Never mind reality. So I had gone by now 3 weeks without any help from this device and would wait 1 more before it was approved and received and was now also possibly an entirely different person.

I used the stimulator for exactly 2 weeks before returning for my final visit with Dr. M, during which he attempted to show me the progress in my X-rays and convince me that healing was taking place. I actually could see some whitish evidence of activity on the X-rays, but by now we were at 12.5 weeks post-break and yet the break itself was still 100% complete and visible. He again mentioned surgery, but only in the “if” context — as though deferring to me for a decision — and said that he didn’t want to decide that for 4 more weeks (which would have put me at 16.5 weeks into this epic and still likely 9 weeks away from a surgery date at that point), and that if we went that route, I would be in a non weight-bearing cast for another 6 weeks thereafter and then back to a boot. In other words, my break incurred on December 3rd of 2016 might have finally seen healing, freedom and actual shoedom by August 9th, 2017. In what third world country is this okay? I told him that day that I was leaving for London on Saturday and did not know when or if I would return, and whereas I think he believed this to be reactive hyperbole, his nurse recognized the look on my face all too well and on the way out asked if I would like a copy of my images to carry to London. Abso-fucking-lutely, I said, though trying to get them would again be the equivalent of drawing blood for a stone. Giving up after 5 calls to the “direct” line of the records office, I texted my personal GP in London, told him the story and asked for his help.

After the initial scolding I took from him for letting it go for this long, I replied that I would arrive on Saturday and would be staying at my usual place. On Sunday evening, he came round to see me himself and generally check in on my health and well-being, both physical and emotional. He texted a well-known orthopedic surgeon he knew and arranged for me to see him the very next day. When I arrived  Monday morning at his office in a 4 story townhouse in the private health mecca around Harley Street in London, I sat in the beautiful, hardwood floored, contemporarily decorated waiting room for less than 10 minutes before being directed to a lift which would take me to the X-ray department in the basement. I sat there for less than 2 minutes before a lovely young man came to collect me and explained exactly what images he would take and where I would go thereafter. We were done in less than 5 minutes and he again pointed me to the small lift and to the 2nd floor wherein I would wait for my actual doctor. On the lift, however, a warm and lovely man saw the name on something I had in my hand and said, “Ah, Belle! I am Mr. R.” (Doctors in the UK are “Dr.”; surgeons are “Mr.”). “Oh, come on then. No need waiting. Follow me.” Straight into his office. We talked for almost 40 minutes, he asking questions about my general health, though he had already also been briefed by my beloved GP. The difference between this interaction and those in the US was stark and startling, but perhaps the most immediately noticeable difference was this: what caused this to happen to a completely healthy 47 year old who takes near fanatical care of herself when there was no “accident,” as such. Yes, it was broken and he would further evaluate it and fix it, if need be. But he was far more interested in why it happened in the first place and in ensuring it did not happen again. One point I left out of my episodes in the US is the fact that my left foot is now suffering the same exact pain symptoms my right one had for 10 days before it unceremoniously snapped. When I had related this to my doctor in the US, he said, “That’s crazy.” Fuck you, again, Dr. M. When I told this to Mr. R, however, he said, “Then we need to do an MRI of both and I would like a CAT scan of the right to see what we’re working with,” and then went on to review my X-rays with me and said — a direct quote — “This is making almost no effort at healing. It’s been 13 weeks. I would’ve likely scheduled you for surgery 7 weeks ago at this pace.”  That visit — consultation and X-ray inclusive — cost me 270 Pounds, which at today’s rate is about $335 USD. Before I left, they had scheduled a CAT scan for later that day and an MRI for the following morning.

The CAT scan was at the same private hospital that nurses the Queen and Phillip when they are unwell and cost me 840 Pounds or about $1041 USD. The MRI was the same amount, though back at the imaging suite in my doctor’s clinic. I flew back to the US the following day – Tuesday – and on Wednesday Mr. R rang me with the results of my scan. The break had made more effort to heal itself than had been evident in the X-rays, but was still complete and it was his view that it would not be healing on its own, or at least not within the next 3 months and not without a good chance of re-fracture. Again, an exact quote: “If this were my daughter or wife, I’d make them get it fixed. It’s just the right thing to do.” I confirmed my agreement and his secretary was in touch within an hour to get it scheduled. It would take place at a state of the art private orthopedic surgery center owned by him and several other surgeons, and only a block away from his office. When she confirmed the surgery, she also confirmed the costs. Mr. R’s fee would be 1000 pounds ($1240 USD), the anesthesiologist would be 400 Pounds ($496 USD) and the surgical center, support staff, pre-op screening and testing for germs such as MRSA, and all other needs on the day would be 2,850 Pounds ($3534 USD). And they do accept American Express.

Fast-Forward 3 weeks and here I am, not in a non weight-bearing cast which would prolong this mini-hell, but in a boot, up walking around, just as I was within one hour of surgery. They do a different sort of procedure here — one we reserve for million dollar athletes who pay rather than suffer though insurance nonsense — and so the subsequent cast and immobility time is not required. The surgical center itself was like a Scandic dream of modernity and white space. The “ward” was a series of very comfortable private cubbies with flat screen TVs and fluffy, Frette-like beds. The morning of my surgery, I checked in at 7 and was immediately taken to the ward with 3 other patients, each of whom were being operated on by Mr. R that day. He only does 4 in one session — morning or afternoon — and the ward cubbies are number 1-4 in order of who is taken first. While you wait, a lovely young lady brings you a lunch menu from the 4* hotel across the street and asks you to choose a lunch meal for post-op, because they like for you to eat before they release you in order to ensure both that you are able and that it offsets  the effects of the pre-op fasting and inundation of drugs. The meal, too, is included in the flat fee. As for the surgery itself, I’ve had operations in three countries and that was the most impressive, state of the art operating room (or “theatre,” here) and team I have ever seen or met. The staff were all, 100% awesome: nice, helpful, professional, thorough. I cannot say enough good things about them or the experience as a whole. I came out of surgery and Mr. R came to see me in recovery quickly before going into his next op. I was then taken back to my ward where I rested for just over an hour before being served lunch and having a second, longer visit with Mr. R. In the meantime, they had called my “escort” — the person you must designate to collect you and accompany you home before they will allow you to have surgery, in this case my GP – and advised him what time I would be ready to go if all things continued to progress. After three checks of all vitals at intervals of 30 minutes, I was allowed to dress and all remaining tubes and stickies were removed. My GP had arrived and the wonderful male nurse who had looked after me from start to finish came to see me with a bag containing all of my prescription medications (also included in the price and their corresponding instructions, as well as a water proof cover for my incision site, things to watch out for and emergency contact numbers should I need them. Not quite 6 hours later, one flat fee paid, I left the center with everything I needed to possess and to know in order to continue healing. My GP took me back to my hotel and then visited me once again at almost midnight to check my vitals and ensure I had everything I needed, and to tell me they had developed concerns over bone density and that I need a bone scan to check it. And that he had already scheduled it for Monday. It will be 270 Pounds ($335 USD). So I will leave London not only on the road to healing, but with the knowledge of what created this situation in the first place and a corrective, diagnostic based plan developed to ensure it does not happen again.

The Differences

In the US, our health insurance industry and healthcare system are inextricably, incestuously, unhealthily linked and co-dependent. I have spoken at length with my GP here and to some extent my surgeon about what has become of the US healthcare system, and they have made some excellent points and also validated many observations I have shared with them. In the US, the onerous, cumbersome nature of the paperwork and documentation that must be carried out in order to communicate and comply with both government mandated regulations and health insurance company policy has made staffing ratios of support staff to doctors skyrocket. Overheads have increased dramatically and as a result, doctors now must churn out volume to see their clinics turn a profit whilst also not stepping one toe outside the safety zone of liability mitigation. As Mr. R put it when I told him the story of 7 minute average doctor visits, “It truly has become managed care, hasn’t it.” Yes, it has; managed by policy made by people who would not subject themselves to it if given the choice. Our doctors cannot give freely of their time because they have to move through more patients in order to make money, and as my GP aptly observed yesterday, they are also loathe to “dictate” care based on what they are trained to know is best because as long as they do not say definitively that you “must” have a procedure, they are not taking full responsibility for the outcome of the treatment. Mitigation to avoid litigation, as he put it.

The healthcare system in the UK has always been and still is dominated largely by the NHS – socialized healthcare. And whereas I would rather shave myself bald and eat my own hair as go to an NHS facility based on the one experience I had in one many years ago, it being the mainstay of the British society has negated the dominance and for many years, prevalence, of private health insurance. When I moved to the UK in 1996, private healthcare was very rare and for only the most elite sectors of society, though still very affordable compared to the US. Even now, according to the most reliable data available, only 11% of British citizens have some form of private health insurance, and only 8.7% have a policy which is considered comprehensive or non-restrictive. Everyone else is treated by the NHS. But whereas the doctors in the US  would either struggle to, or cannot conceive of how to survive without insurance companies, doctors here can freely choose to not practice on the NHS and to accept private healthcare policies or direct payment. It is an almost entirely separate industry, especially within the confines of London. Because the health insurance industry has not yet infected the UK with its need for over-documentation of every cell in a person’s body before approving a claim, the majority of staff in private UK facilities here are actual hands-on carers and not administrative compliance functionaries. The overheads are therefore mostly for quality facilities and quality staffing.

Further – and I continue to think most importantly — these talented caregivers receive a large portion of their fees. This is a service industry and they are incentivized to provide the best service possible. They are not giving away their time to filling out paperwork or having the will to live sucked out of them by bureaucracy. They can spend as much or as little time with you as they wish, and can prescribe any path to wellness or plan for diagnosis they see fit, as long as you can pay. They are gratified both in the quality of care they are allowed to provide and in the monetary rewards they receive for doing so. It is simple, commercial, transactional based healthcare.

My insurance premium is due in the US tomorrow and I will not be paying it. I have used insurance one time twelve years in the US and that was for this break, which has now cost me 17 weeks and more than $12K because of a combination of unmet, insane deductibles in the US and my choice to travel here and have private surgery. My premium of $443 can buy be any number of things, but perhaps most symbolically and appropriately at the moment, a very nice PAIR of new shoes I will be able to wear in just four more weeks.