I work primarily in an all ages ED in the US in a resort area. We have many international patients and they love that they can walk in the day of their injury and get an MRI on the spot, no pre-authorization, no specialty referral. The US patients get this also and their insurance is billed. I'm told they are not getting refused. Some do show ligament and menisceal tears but some show only very minor injuries.  There is no trial of physical therapy, specialist re-evaluation or time to evaluate for non-improvement. There is a big effort by the hospital to immediately capture surgical ortho cases and their associated revenue.
We also see many patients for 2 am convenience care of longer-duration problems because this was a good time to fit medical care into their busy schedules with no wait. They often can't get into any outpatient office, especially not at an affordable price, so we see way too much neglected primary care that should not be presenting to an emergency department.
When I worked in an urban ED, the waits were usually 4-12 hours for anything not immediately life threatening. Triage often made life threats wait that long and clinical deterioration was ongoing. Almost all ortho was sent out to clinic follow up due to limited resources. In many areas, there is only limited access to mid-level staffed clinics with almost no specialist care or prescription coverage. We did not see many patients over 70 years old because they rarely lived that long. There was no real effort to reduce the wait times. And many rural hospitals are not staffed by appropriately trained physicians, judging by their recruiting ads and the referrals we receive.
Patients in poor areas of the US do not receive the same high quality of care that is offered in our best hospitals. The world may travel to the Mayo Clinic, Cleveland Clinic, Sloan Kettering and the like but the quality of care is not consistently high. I often feel like advising my uninsured patients to only work for large organizations that give benefits - the school districts, hospitals and occasional private employers, but even this care is often unaffordable due to copays, shared costs and limited coverage. Having spoken with many who live in national health care countries such as Australia and Germany, I find it hard to believe our system is better for all. Like fire, police and public education, there are some regional differences but they are not great in a functioning system (public education being the exception in our socioeconomically segregated schools). We ration by ability to pay, often without regard for lasting benefit, such as with the
 full code 90+ patients who present every few weeks for the same terminal problems and receive extensive evaluations each time.
I don't know enough about the Canadian system but I do know that ours pre-Obamacare was not the answer. I am appreciative that one of its early provisions was the removal of benefit limits as my husband is recovering from a $450k bacterial endocarditis misadventure that began with a pimple on his chin and no other risk factors. I look forward to hearing more from others about delivery models that work well, with good integration of primary and emergency care.
liz muckerman, california

 From: "Joe Nemeth, Mr" <[log in to unmask]>
To: [log in to unmask] 
Sent: Sunday, April 7, 2013 12:08 PM
Subject: Bentley-Hyundai...
One anecdote than a bit of ranting...

My sister drives to Plattsburgh NY (a sleepy little town) for some cross-border shopping for the w/e....she develops a horrible sore throat and pops into the local town hospital.

She is LITERALLY in and out in 15 minutes...triaged/seen/Rx given/follow-up arranged. Cost...$800...a true Bentley (or RR for Doc). Her insurance covered it which she says she gladly pays into for the Bentley.

Now here is the Hyundai  version:

Just finished an o/n shift at a reputed adult tertiary care ED. Folks waited 6-8 hours to be seen for:
-new h/a in a 60 y.o.
-new "red eye" in a 20 y.o.
-other significant CTAS 3's
-20 y/o with a Weber C # who was told by ortho after splinting to go home and wait for a call for OR...days-?weeks later
-Oncology pts waiting for be seen by oncology
(Of note I also work in a reputed peds center and the waits are similar.)

More of our tax goes into health-care than any other province or for that matter country in the western hemisphere. So we pay Bentley prices for Hyundai service...don't even have a choice to buy a Bentley-illegal...for now. Seen as "jumping the line".

I read all of the recent posts re: the major issues with the current US health care system and I agree that as is, it is not working. But let me once again assure you that you are closer to a realistic construct than we are.

Very simply said...give the people Hyundai dealerships across the board-through Uncle Sam- but have Bentley dealerships available for folks who want them.


From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of John Lee [[log in to unmask]]
Sent: Sunday, April 07, 2013 10:51 AM
To: [log in to unmask]
Subject: Re: Our Future

My concern is that the populism of this issue will push US into inexorably
favoring the politics of a Bentley for everyone: everyone deserves to have
access to all the care that anyone could conceivably ask for.  Granted,
this is hyperbole, but I don't think it is that far from the truth.  At
what point would a bureaucrat have the courage to withhold some very
expensive treatment that helps only small population but has political
influence.  The current healthcare legislation appoints about 2 dozen
people to mandate what insurances must cover.  That's an awfully small
number of people to have to influence.

For instance, what if the evidence shows that a "standard" HIV treatment is
able to get excellent results on 95% of the HIV population but highly
tailored HIV treatment is able to get 20% better results on up to 99% of
patients but would cost 10x as much?  Anyone want to bet that the more
expensive option will be mandated as part of insurance coverage?

John Lee

On Sun, Apr 7, 2013 at 6:29 AM, trzim29 <[log in to unmask]> wrote:

> Throughout my career I have worked in Florida and Illinois.
> I likely have seen about 5-10 Canadian patients per year, a few from
> Dubai, a few from the Netherlands, a few from other parts in the world.
> This is in no way scientific obviously by any means but every and I mean
> every foreign patient notes there healthcare in there country is no where
> near as good as the healthcare we provide.
> These are typically well to do patients as well.
> The Canadian patients are in shock universally how quickly they are seen
> and how "thorough" we are. Thorough is not just ordering tests.
> This is just a 15 year observation with a decent but still not huge of an
> "n".
> Rick your points were all excellent.
> TZ
> Sent from my Verizon Wireless 4G LTE Smartphone
> -------- Original message --------
> From: Doc Holiday <[log in to unmask]>
> Date: 04/07/2013  12:37 AM  (GMT-06:00)
> To: [log in to unmask]
> Subject: Our Future
> From: [log in to unmask]
> > And the US is an incredibly individual-focused nation. So each
> individual wants "everything done". Again, Bentley care.
> --> I must say that I find it unusual for "Bentley" to be used in such a
> context - I am more used to RR being the metaphor...
> ;-)
> > I wade into this debate with some trepidation.
> --> If we can't debate...
> I have been "debating" and doing lectures on this healthcare system
> comparison for quite a number of years, with associated reading this
> entails and my own exposure to the UK system as well as a few other systems
> and visits to the USA and many EDs there. A common representation I come
> across, which I find a teensy bit misleading, is the one which states that,
> while in the USA one can get up to any level of care for enough money (say
> "Bentley"), in the UK/NZ/etc. one can only get to whatever level the system
> rations. While this "ceiling" might apply in some countries, it is NOT at
> all a necessary part of the "nationalised" systems. In the UK, for example,
> where the NHS "ceiling" is set at what most experts seem to rate as at
> least 99% of Bentley, one can still buy a Bentley! That the NHS won't give
> you a free Bentley does not deprive you of your car-purchase rights, which
> are just as free as in the USA!
> Of course, it is sometimes pointed out to me,when I say this, that this is
> not as simple as buying a Bentley, as one has already been paying taxes
> into the NHS for years and then finds oneself having to pay for a Bentley
> if one requires something which is not in the 99.x%...
> This is true.
> But it is countered by another point - a medical Bentley often does not
> cost as much in the UK. For example, the NHS may offer a procedure but with
> too long a delay to satisfy, so, despite having paid taxes for years, the
> patient decides to "go Bentley" and pay out of pocket to have the procedure
> tomorrow. But the fact that the procedure DOES exist on the NHS has the
> effect of competing down the price of the Bentley in the market...
> In summary, simply because 99.x% of what a wealthy American can buy is
> available through a socialised NHS does NOT mean one cannot also buy the
> other <1% just like in the USA.
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:

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