World’s Greatest Healthcare, ctd.

Addendum to my earlier post on US health care. Impressions from a friend’s trip, thankfully not an emergency in the end, to the emergency room of Children’s Hospital in Oakland:

1. It’s not just the general practitioners in the US who are not very competent. So, a child being examined to exclude appendicitis is given a popsicle — presumably for hydration and glucose — by the intern. A bit later, he wants to give her IV fluids. Why can’t she just drink water? In case it is appendicitis, she shouldn’t take anything orally. Oh yes, I probably shouldn’t have given her that popsicle… I’m sure the microneurosurgeons in the US are first-rate, though.
2. Confirmed my impression that hospitals — or, at least, the employees in contact with the public — are either unable or unwilling to tell the customers what their services will cost. When asked, they said they had no idea what the billed price for administering IV fluids would be. The magic of the marketplace can only have a chance to work if people are going to reject services that they can’t or don’t want to pay for. Somehow the eminently private-sector doctors don’t see their concern with the business end of medicine as extending beyond negotiating maximum salaries for themselves. You’d almost thing they find it convenient to be dealing with customers who generally aren’t capable of walking away to find a competitor who will actually say what their prices are.
3. Disorganisation: Compared with health services in the UK, it is striking how disorganised everything is in a US hospital. After several hours of waiting the child needs to give a urine sample. Probably $100 or so of extra billable costs for an IV, and not inconsequential danger of infection and nerve damage, because it’s not worth their while to figure out that they should be regularly giving out urine collection bottles while people are waiting. (I should mention that this was not a busy time in the ER…) The only thing they don’t leave to chance is the billing.
4. Unless I’m seriously misreading the bills I’ve gotten to see from a few different people’s hospital stays, US health insurers are defrauding their patients on a massive scale. How? By negotiating reduced prices on their own portion of the bill. When patients do that, it is clearly considered to be fraud. The effect is that, while you’ve negotiated with the insurer that they will pay 80% and you pay 20%, if they use their market power to bargain down their payment (but not yours) by, say, half, then they are actually only paying 67% of the true cost of the treatment.
5. Atul Gawande has written brilliantly on the huge health benefits to be obtained from dull innovations in standardisation, and how physicians resist these innovations because it challenges their heroic self-image. It looks to me as though US hospitals are going in the opposite direction: instead of an integrated public institution, we have a corporation with changing casts of private contractors, none of whom has any obligation to the others, or commitment to the success of the institution as a whole.