Gaming Our Health-Care System

I turned 80 last month. I’ve been on Medicare, with an “AARP” United Health Care Medicare Supplement, for fourteen years. In my working years, I was a physicist and business lawyer, so I’m not unacquainted with science or business. As a world-class hypochondriac from before puberty, I’ve probably learned more about medicine than most people who never went to medical or nursing school.

During the last twenty years, I’ve given a lot of thought to navigating our rapidly changing, often dysfunctional and sometimes miraculous health-care system. So I thought I’d put my advice, impressions and experiences in writing to help people trying to figure it out. Our system is likely going to continue to offer “miracle” treatments like my two total shoulder replacements, which let me swim and do things most previous generations could not do at my age. But it’s not likely going to get any simpler, cheaper or easier to use. (Everything in this essay is a report of my opinion and experiences and my personal point of view.)

1. When you have something that you think might be serious and/or life threatening, go to the ER, not “Urgent Care.”

A good Emergency Room at a big, properly funded hospital is a microcosm of modern medicine and medical technology. It has much, if not all, of the advanced technology that can peer inside your living body without harming it. Nearly every ER can do ultrasound scans, X-rays, and Computer-Assisted Tomography (CAT) [X-ray] scans. Many also have portable X-ray machines that can be brought to your bedside. Some can also do MRI (Magnetic Resonance Imaging) and PET (Positron Emission Tomography) scans, which can see “soft tissue” inside your body better than X-rays, CAT scans, and ultrasound.

In addition, a good ER has Emergency-Medicine specialists with years of training in precisely the stuff you need when you require rapid help. Some also have other specialists, in such fields as internal medicine, geriatrics or infectious diseases, on call or on tap online. All have on-tap or online radiologists, who can interpret your medical images in hours, rather than days.

In contrast, “Urgent Care” facilities are often under-resourced and under-staffed. IMHO, they are facilities for people with little or no access to any professional medical care. They typically consist of a cadre of nurses or nurse practitioners supervised by one or two general practitioners, who are not generally trained in emergency medicine. And urgent-care facilities may have little or no imaging equipment besides portable ultrasound machines.

A good ER is to an urgent-care facility as the UCLA Medical Center is to a country doctor’s wooden shack in rural Alaska. So if you think you might have something serious, go to the ER. You might be as lucky as I was when I had an inflamed appendix, and the urgent-care center sent me to the ER just in time to have it taken out as it was bursting.

One less pleasant thing you should know about ERs: they reflect modern medicine’s total destruction of human relationships with your providers. If you haven’t noticed your provider staring into a computer screen and typing on a keyboard during most of his/her interaction with you, then surely you have noticed how MyCharts, byzantine telephone queues, and other means of computerized communication have made personal relationships with your providers difficult, if not impossible.

There is not much to be done about this. It’s the price we pay for the vast complexity and extraordinary capability and success of modern health care. The days of my youth, when the family doc came to your bedside at home with the proverbial “little black bag” and kept your and your family’s medical history in his or her head are long gone. In exchange, you have machines that can peer inside your body in multiple ways, antibiotics, antivirals, genomic medicine, a wide range of drug therapies, plus robotic surgery and AI diagnosis. It may not be entirely comfortable for people my age, but I would say that’s a fair tradeoff.

Anyway, the MBAs who control modern medicine have made it impossible to keep your General Practitioner (GP) or family doctor “on tap” in any reasonable way. My GP at a major medical group told me that, for financial and administrative reasons, his bosses make him keep a full daily schedule six weeks in advance. You may think there are a lot of medical issues that fall between going to the ER and waiting six weeks for medical advice. But many business systems in health care simply don’t let you see your family doctor in that gap.

The solution is obvious and inescapable. When something medical that might be serious comes up, go to the ER. It’s where the system pushes you, and it’s where all those advanced technologies come together in one place. Take advantage of it, and don’t be shy. Good modern hospitals are designed to feature it.

2. The second thing to know about ERs is that when you go makes a big difference. There’s a big difference between going in the wee hours of a weekday and coming in on Monday morning or Friday afternoon. Over the last decade or so, I’ve been to ERs, for myself or family members, at least a dozen times. My time to see an ER doctor has varied between less than one-half hour and 3.5 hours. The time to discharge has varied between 1.5 and 5.5 hours. The most important determinant of delay was when I or we arrived at the ER. Sometimes I even called ahead to see how crowded the ER was and delayed my arrival accordingly.

If you have a bleeding gash, a high fever or a broken bone, you obviously have to go to the ER right away. That was the original purpose of ERs, now vastly expanded. But there can be reasons for delay. If you go when the waiting room is crowded, you might be exposed to viruses, bacteria or just some obnoxious and maybe dangerous people. Then you might wonder how important speed is.

If your own lack of medical knowledge leaves you guessing how urgent you problem is, a resort to AI might be in order. According to this review of AIs in the Washington Post, Anthropic’s “Claude” AI was the best at summarizing health research of the AIs tested. I’m appending the prompt I input and Claude’s response, which helped “diagnose” what appeared to be an upper-respiratory infection.

Claude’s response struck me as what a good GP might say. It led me to skip the ER and take a Covid test instead. Of course, an AI is only as good as the data you give it, so you should carefully note all symptoms and any deviation from your normal body temperature, resting heart rate, respiration rate and feelings of well-being.

A big advantage of going to an ER in the wee hours is having good docs and all that marvelous technology at your fingertips. You shouldn’t be shy about using it, even for things other than what you came in for. If no one else is waiting, you are making the hospital’s huge investment in the ER and its staff worthwhile.

Once I got lucky in that regard. I went to the ER at about 4 am with persistent abdominal pain that I thought might be an intestinal obstruction. The imaging showed it to be a false alarm. In retrospect, I should have known that intestinal obstructions produce nausea and vomiting, which I didn’t have.

But my mistake put me in the hands of a brand new, highly qualified, Emergency Medicine resident. He was one of the smartest, most articulate and most helpful docs I’ve ever seen. By the time I left the hospital, I had resolved a short list of put-off medical issues. I had even gotten a follow-up ultrasound scan of a longstanding lump in a testis, which confirmed and updated a years-ago conclusion that it had been benign.

Did I feel guilty about “gaming the system” in this way? Not a whit. The waiting room was empty both when I arrived and when I left. So I didn’t deny or delay anyone else’s care. Anyway, highly qualified professionals like that great doc hate to spin their wheels. By making sure he was not idle, I also lessened the chances that an eager MBA would “downsize” that unit, to the disadvantage of other patients that the same ER serves.

3. Don’t neglect prescribed care if you don’t have insurance or fear it may not cover your care. Instead, price shop and bargain.

With MAGA folk “downsizing” everything about medicine that involves government money, you may fail to seek care that you think might not be covered by insurance. In some cases, perhaps many, that would be a mistake. I’ll give two examples.

With the Covid pandemic declared officially “over,” federal Medicare and my Medicare Supplement have stopped covering Covid tests. But when I got a cough-rich upper respiratory infection recently, I wanted to know. My wife went to the local CVS and picked up a four-pack of tests for about $35.

That’s less than $9 apiece—a price easily affordable by any middle-class family. Why was the price so low, when I expected something closer to $100? I don’t know for sure. When we got the tests home, we noticed that they had just over a year to expire. Maybe there’s some regulation that drugstores can’t sell tests with less than a year before expiration, so those tests were rapidly decreasing in value as they sat on the shelf.

Whatever the reason, we never knew the price until we shopped. Not everything in medicine is priced outrageously. It’s best to find out before foregoing care or testing. And I suspect that, whether for our speculated reason or another, drugstores’ prices for Covid tests and many other things vary widely. Drugstores and chains do, after all, have different suppliers, and they are, after all, in competition for customers.

My second example is something I’ve not done personally but believe is possible. I’m one of those rare Medicare beneficiaries who reads every one of my Medicare Summary Notices. Of course I don’t read all the endless boilerplate, privacy notices and translations into multiple languages. I focus on the little numerical table, usually on the third to fifth page, that reveals the price the provider asked, what Medicare actually paid, and the balance (if any) that my secondary insurer or I would have to pay.

What I’ve learned in my fourteen years of doing this is that the prices for medical services and products are much like the prices of women’s shoes. There is no apparent rhyme or reason to them, and the opening price is just a charade. On average, it seemed to me, the price the provider ended up actually accepting from my insurers was somewhere between one-fifth and one-tenth of the asking or “quoted” price.

So suppose you are completely uninsured, maybe even an undocumented immigrant. What’s to prevent you from asking your family, friends, neighbors and acquaintances to reveal their Medicare Summary Notices to you (or equivalent notices, if any, from Medicaid), so that you can find out what providers in your area actually receive for the care you need? Then what’s to prevent you from contacting your preferred doctor, or even his/her business overlords, and offering to pay the much-lower-than-asking price that insured people pay? Doesn’t it stand to reason that any care center run as a business would rather take that price than leave a care team standing idle and get nothing?

I wonder whether the many nonprofit and charitable organizations that serve marginalized communities could perform this sort of price-investigation and bargaining service for patients in those communities. I can’t imagine why any rational care provider would object to this service. It would fill their schedules, increase their revenue, and give them the same revenue that government insurance provides.

4. Consider traveling for health care. Quality medical caregivers are not evenly distributed nationally. Most are located in or near big cities. This is especially true for emerging technologies such as genomic immunotherapy for cancer and tailored-drug therapies for depression, anxiety and PTSD. If you need standard and well-developed therapy, it makes sense to get it as near where you live as possible. If you need emerging, advanced or exotic technologies or therapy, it makes sense to get it where it is under development.

This approach is especially true for advanced and innovative surgery. These days, the price of travel and a hotel stay, even for a week or so, is far less than half the price of advanced, innovative surgery. And the comparison becomes even more favorable for rural people visiting a nearby prestigious city hospital, who might be able to reduce their expenses by traveling with, and even residing in, a camper or RV.

There’s one other thing that rural residents also should watch like hawks. In recent years, private-equity firms have swooped in to buy rural hospitals, for profit, from charitable, religious and local-government owners who have had trouble sustaining them. The primary goal of these new owners is to make money, not to improve care. Sometimes they find that hard and end up closing the hospitals down.

If I needed surgery and lived in such a rural community, I would avoid these private-equity owned hospitals like a hospital-acquired infection. Instead, I would travel to a hospital with a good reputation, run by a religious organization, charity, or local government. Or I would travel (further, if necessary) to a big-city hospital with a reputation for innovative and high-quality care.

5. Don’t fear scientific and medical innovation. Innovation in health care is one of the last, great triumphs in American science and technology. We Americans have lost the lead in many other fields by ceding our manufacturing base—and also the basic research, science, and advanced engineering that go with it—to China. But in medicine and health care, we have kept our edge and, in some fields, may even be increasing it.

A shining example is our recent development of mRNA vaccines for Covid. These “designer,” “programmable” vaccines are one of the greatest innovations in medical history. They are unique in two respects. First, they train our own cells to make the Covid “spike” protein that allows the Covid virus to attach itself to, and to enter, our own respiratory and other cells.  This process then provokes our immune systems to make antibodies to that “spike” protein.  Second, the vaccines’ method of operation permits “redesigning” them to generate other proteins to which our immune systems then make antibodies.  In theory, it thus can make an mRNA vaccine “programmable” for any new variant of the Covid virus, whether or not it uses the same “spike” protein, and potentially for a totally new virus as well.

A final gigantic benefit of the mRNA vaccines is important. In producing antibodies to the “spike protein, but not to any other feature of the virus, they do not introduce to our own cells any part of the virus that allows it to reproduce itself and thus cause disease. (The “spike” protein is a surface protein that has nothing to do with the virus’ reproductive processes.) Thus, unlike many conventional “inactivated-virus” vaccines, the mRNA vaccines have no risk, even in theory, of causing the disease that the vaccine targets.

Understanding these advantages, I have had nine mRNA vaccines against Covid and am eagerly awaiting my tenth. Every time, I have specifically asked for the mRNA vaccine, in order to realize these advantages. I have had Covid twice, and my wife thrice. Each of us has relied exclusively on the mRNA vaccines and the Paxlovid antiviral treatment to avoid recurrence and reduce the risk of serious consequences of infection, such as “long Covid.” Neither of us has experienced any such consequence.

We cannot understand why some people seem to fear this stunning scientific advance in “programmable” and safer vaccines. The only reason we can conjure is that some people confuse mRNA with DNA and believe there is a risk of the mRNA vaccines changing one’s hereditary machinery.

But that is impossible. DNA and mRNA are different molecules with different structure and functions, and mRNA plays no role in people’s or cells’ hereditary genetics. In contrast, mRNA is the means by which our hereditary DNA-controlled internal machinery in ordinary cells “directs” those cells to manufacture proteins. It has nothing to do with individual or even cellular heredity. If new pandemic viruses emerge during our lifetimes, our family will look for, and will take, mRNA vaccines against them first, because we expect them to be: (1) developed more quickly, (2) less risky overall, (3) more effective, and (4) more easily modified to control genetic variants (mutations) or even new related viruses.

Another innovation to seek and not to avoid is “robotic” surgery. This phrase does NOT mean that little robots will be running around autonomously in your body, controlled by AIs. The most important thing it does mean is what I call “reverse leverage.” When the surgeon moves his or her hand three millimeters, the electronically controlled knife may actually move only three microns, or one-thousandth the distance. This makes a surgeon’s shaking hands and random twitches much less dangerous. “Robotic” surgery also allows the surgeon to see what’s going on through powerful optical and/or electronic magnification, so his/her thinking and decisions are vastly enhanced by clearer, more detailed images of the surgical site. Finally, robotic surgery usually permits a smaller incision and less gory body-entrance procedures than manual surgery, thereby reducing the pain and time for post-operative recovery.

If memory serves, I have had at least six surgical procedures on my prostate. The most recent, nearly five years ago, was by far the most successful, with the greatest increase in flow. It was robotic surgery done in an outpatient surgical center, from which I went home as soon as the procedure was over.

6. One last bit of advice for Seniors: Get a Medicare Supplement or “Medigap” supplemental plan, NOT a Medicare “Advantage” Plan. Not only does Consumer Reports associate the latter with in-network requirements and requirements for pre-approval of spedific treatments. A friend who moonlights as an ER nurse reports that a number of his patients have had trouble and delay getting pre-operative approval for life-saving doctor-prescribed treatments under their “Advantage” plans. In contrast, my Supplement Plan (the big “AARP” Plan from United Health Care) has never denied denied me a provider or treatment prescribed by any doctor, or required special approval, in fourteen years. Apparently the “Advantage” of the plans that carry that name is to the insurer.

Endnote: “Claude” AI’s Prompt and Cough Diagnosis

My prompt:
For two to three days, I have had an intermittent, mostly unproductive, sometimes rasping cough, with some pain in the trachea or esophagus. I picked this up from family, including three young children, recently arrived in Berkeley, CA from Bali Indonesia. I have no or a low-grade fever, at most 0.5 degrees Fahrenheit above my usual body temperature. I have one Covid test left and have not used it yet. What is the most likely diagnosis? (Please do not assume any facts not stated.)

Claude’s Response:
Based on your symptoms - intermittent, mostly unproductive cough with occasional rasping, tracheal/esophageal pain, minimal fever, and recent exposure to family members including young children from international travel - the most likely diagnosis is a viral upper respiratory infection.

Here's why this fits best:

Viral respiratory infections commonly cause:
Dry, irritating coughs that can become rasping
Throat and upper airway discomfort/pain
Minimal or low-grade fever (especially in adults)
Easy transmission within families, particularly from children who are frequent vectors
The international travel context (Bali to Berkeley) increases exposure risk, and young children are notorious for picking up and spreading respiratory viruses during travel and in new environments.

Other possibilities to consider:
COVID-19 remains possible, which is why using your test would be valuable
Bacterial infection is less likely given the minimal fever and symptom pattern
Irritant exposure (air quality, allergens) could contribute but wouldn't explain the family cluster

Recommendations:
Use your COVID test, especially given the family exposure pattern
Stay hydrated and rest
Monitor for worsening symptoms (high fever, difficulty breathing, persistent pain)
Consider isolating until you know what you have, given the contagious nature

The combination of family cluster, travel history, and your specific symptoms strongly suggests a viral respiratory infection, but testing will help confirm whether it's COVID-19 or another virus.
[End AI output.]

In my view, the most important part of the AI’s analysis, which led me to skip the ER, was ruling out a bacterial infection, for which early use of a powerful antibiotic (which I might get most quickly from an ER) might have been useful.  Also, an ER could send the bacteria to a lab for a culture, in order to determine precisely which antibiotic would best work against it; nothing similar can be done with viral infections.  BTW, the Covid tests—three of them over three days—three of them over three days were all negative.

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