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Thursday, December 8, 2016

Credit where credit is due

A couple of weeks ago I started taking medicine to lower my blood pressure and another to reduce my cholesterol. This was a controversial move, given my deep distrust of the practice of medicine, when it is practiced on me, and pharmaceuticals in particular.

I know that, as a woman of 55 with an very active and healthy lifestyle, no chronic diseases and most importantly as a nonsmoker, I am at very low risk for any of the conditions that high blood pressure or high cholesterol could cause to happen. I am unlikely to have a stroke or a heart attack, develop narrowing of the arteries to my legs or develop kidney failure. The blood pressure and cholesterol levels have no effect at all on how healthy I feel. But one day, while pointing an ultrasound probe at my own neck, I saw a small plaque (a thickened area) in my left carotid artery. It was very calcified, which meant that it had been there a long while, but my carotid was not pristine. It is undeniable: I have vascular disease.

Will this lead to a stroke? Does it imply that the arteries around my heart are also affected? I don't know, and I may not find out. But I do know that taking a cholesterol lowering drug helps reduce heart attacks in patients with vascular disease around their hearts and I extrapolate that it may help reduce further changes to my carotid arteries which might lead to a stroke. My blood pressure is a bit high, and bringing blood pressure down does reduce stroke risk. I don't know that it will reduce my stroke risk, however.

So it was not entirely clear that I should take either cholesterol or high blood pressure medication. A little reduction in my very low risk may not be worth taking a medication with potentially profound side effects and associated high costs.

I decided to try the medication in order to assess whether it gave me trouble of any kind. If it did not, I might have nothing to lose. The blood pressure medication, lisinopril, has been on the market for decades. It is strongly associated with reduction in the usual complications of hypertension. Its main side effects are a nasty nagging cough and dizziness. It can also cause life threatening swelling, often of the face, but this is rare. I have had no swelling, no dizziness, and though I can feel just the tiniest bit of increased tickle in my lungs, it is hardly noticeable.

Regarding the cholesterol medication, atorvastatin (formerly known as Lipitor), it, too, has been around for a long time and has been extensively tested and found to be pretty safe and effective. It can cause muscle cramps and weakness, and I have been told by some patients that it makes them less mentally acute. It can cause gastrointestinal upset and may be associated with weight gain and a risk for diabetes. I am having no trouble so far.

As for the cost, I have had to shell out nearly $5 in copays each month, with my insurance footing about $1 of the bill. This is not expensive. This is a superb deal. I get it from my local pharmacist, not even from a mail order or Walmart's $4 plan. It is cheaper than Walmart's $4 plan! In 20 years I will have spent around $1200, plus there will be the occasional blood tests to monitor my kidney function. I checked my cholesterol after being on it shy of 2 weeks, and it was dramatically lower. I, once again, am not sure that this will translate into better health, but it is not odious at all.

The moral of this blog is that not everything is terrible in the US healthcare system. I could, and will, complain about the surrounding process that leads to people like me being on medicine at all, including issues like medicalization of the healthy and blockbuster drugs being widely adopted without adequate scrutiny, but presently I will give generic atorvastatin and atorvastatin a big high five.

Friday, November 18, 2016

Presidential Election 2016 and the internet--the real winner

The last year has been difficult to watch, and the last few months even more so. News and quasi-news organizations have been bombarding my email with stories about the people vying for our presidency. It has been anywhere from difficult to completely impossible to screen this information for accuracy. Lies and information taken out of context and repeated until it seems true has been part of both party's rhetoric. The whole field of potential candidates were infected with it before the primary elections.

The emotions have been high, too. By the time the election finally happened on November 8th, we had a comic book villain straight out of the Batman movies running against Satan in female form. The outcome has left people deeply sad and frightened, even people who voted for the winner. There is hope, too, and kindness and gathering together. There is huge uncertainty.

I've been alive for 13 presidential elections, and this one was really different. This is partly because of an increasing gap between rich and poor, fallout of the financial crisis of 2008 and the changing international landscape, but the biggest change has been the growth of our use of the internet and social media.

Most people like to believe that the reason for our recent presidential election results can be found in the thoughts and behaviors of human beings. It feels good, in the face of a frightening and unexpected event to imagine a way that it could have been under our control, that next time we could anticipate it and make significant changes.

As human civilization has evolved, so has our ability to communicate complex ideas. Language, then writing, then printing presses, then telegraph, radio, television and now the internet, links us and allows us to learn from each other and share ideas and feelings and events. With the internet, and now our mobile phones which are ridiculously powerful computers in our pockets, we nearly share a common brain. Even the progressively smaller portion of the population that isn't directly connected via a computer is indirectly connected if they read a newspaper, watch a TV or even talk to a neighbor.

The internet of news is a small part of the entity that is the entire internet. Items that people like to look at rise to the top of any search and appear prominently on Facebook or other sites where people share information. This could be a cute baby dancing, a way to lose weight or a delicious news story, such as a powerful person behaving poorly and getting caught. We will choose to look at these things even if they are out of context, don't work or aren't true, and they will become a larger proportion of what we see. We will be less likely to look at things that are complex, nuanced, and present more than one side of an issue. What we click on is what we get.

There is actually quite a market in made to order "news". Paul Horner was featured in the Washington Post, explaining that the lies he successfully spread via Facebook and other sites around the elections were really just satire and made to be taken as such. But readers believed that people were being recruited and paid $3500 to protest at Donald Trump rallies (he invented this and even created a fake Craigslist advertisement to back it up.) He made money on stories like this, and others such as that the Amish had decided to vote for Trump. Ads on these fake news sites make a good salary for a person with a good imagination. I won't link the stories because that would, in a small way, add to the viral nature of the stories and Paul Horner's livelihood. In fact, by posting a link to the Washington Post article, which links to Paul Horner's stories and his ads, I have contributed to his success, and perhaps the success of fake news in creating misguided popular sentiment.

Humans are amazing. We have created a way to communicate instantly with a group of friends on opposite sides of the earth. But with this we have power to make fiction nearly real, with potentially disastrous consequences. On the medical side of things, I have noticed that the ability to be completely absorbed in communication that requires nothing but small movements of the hands has contributed to an epidemic of diabetes and obesity. Although entertainment that doesn't require the use of resources may be an important aspect of life in a resource stressed world, I don't think we are ready for what we have created. We are more than what we have let ourselves become. We have abilities to connect via touch and smell and eye contact. We care for each other deeply. We have let ourselves become communication nodes made of flesh in a supercomputer which does not have our best interests in mind.

Personally I am being a bit childish about all of this. The internet has let me down. It has sucked up my free time and made my patients fat and has elected people to the country's highest office based at least significantly on information which is not true. I read that we need to take to social media to unite to fight for causes I believe in, and I am questioning that. Facebook is no longer on my phone. I think several times before clicking on links. And I realize that this is a piddly and ineffective response to a problem that is huge and unacceptable. There has been tremendous good that has come out of our ever more powerful abilities to communicate, but presently I am very angry at the internet and I refuse to play.

Monday, November 7, 2016

Suicide, psychiatric care and inadequate resources

An article released today in the JAMA sites evidence that the suicide rate in America has risen by 24% in the last 15 years associated with a significant reduction in the numbers of psychiatric beds available. The US has had a lower capacity for psychiatric patients than comparable countries in Europe for years, but in between 1998 and 2013 that number dropped even further.

Waiting in the ER for days
This trend has resulted in atrocious treatment for people with mental illness. Because it is so difficult to find room in a mental hospital for patients with mental conditions that make it unsafe for them to return home, such as suicidal thoughts or intentions, we sometimes see these people spend days or even weeks in emergency rooms just waiting for something to open up. I never saw this a decade ago, but now it is not uncommon, even in our small critical access hospital, to see a patient in one of the little windowless and noisy cubicles of our ER for days at a time. They can't move upstairs to a more comfortable, if inappropriate, hospital bed because our hospital cannot offer psychiatric hospitalization because we have no psychiatrist on staff. Psychiatrists are rare in small towns.

Many factors led up to this
This situation is a slow motion car wreck, not an all of a sudden sort of thing. Care for people with mental illness has been spotty and often terrible in the US, but has generally had a trajectory that aims toward better care and understanding. Early in the 19th century an approach called "institutionalization" created mental hospitals which were intended to care for people with what was then untreatable mental illness for long periods of time. These institutions fostered dependence, usually did not cure or treat psychiatric disorders, made patients vulnerable to abuse and, to top it all off, were quite expensive. Some of the costs were defrayed by unpaid work required of inmates, but in 1973 a court ruled that they were owed at least minimum wage, making the overcrowded and expensive institutions even less viable. Starting in the 1960's a strong movement, led by mental health pioneers, pushed for deinstitutionalization. It was argued that most mental patients could have their needs met by community mental health centers and could live in sheltered living situations such as halfway houses. Many state mental hospitals were closed in the 1970's and 1980's, with good and bad results. The number of severely mentally ill people who are homeless did increase significantly, putting a higher burden on already stressed acute care hospitals. Drug therapy for depression, bipolar disorder and schizophrenia began to be more effective, though, which meant that some people with these diseases genuinely got better and were able to be successfully independent.

Medical insurance and mental health
There was less capacity for inpatient care of mental patients after deinstitutionalization, but for many of these people any care at all was prohibitively expensive because most insurance plans had little or no coverage for mental health issues. In 1996 the Mental Health Parity Act was passed which required health insurance companies to cover mental health costs up to the same dollar amount as covered for medical or surgical care. Insurance companies quickly circumvented this by restricting numbers of visits and numbers of days in the hospital. In 2008, as the real estate market, banks and stock market were going up in flames, a rider was placed on TARP (Troubled Asset Relief Program--otherwise known as the bank bailout) called the Mental Health Parity and Addiction Equity Act. This was worded in such a way that mental health care is now generally covered by insurance.

It is wonderful that people with depression, schizophrenia, bipolar disorder and other serious mental illness can get help without necessarily bankrupting their families. This can mean that people get treatment for these problems before they get serious enough to require hospitalization. It probably also increases the demand for psychiatrists and psychiatric beds, both of which are in short supply.

The American psychiatrist: an endangered species
Psychiatry is not a very popular specialty. Out of about 30,000 residency positions each year, only 211 were for psychiatry in 2014-15. That would translate to 211 new psychiatrists for the whole US the year they complete training, assuming all of those candidates finish the program and choose to practice in the field. Many psychiatrists are aging and retiring and there is already a critical shortage of psychiatrists to meet our present needs. Psychiatry is one of the lower paid medical specialties and is a difficult row to hoe. Successful treatment of patients is very dependent on variables over which a psychiatrist has no control, such as community support, housing and job programs.

Prisons: our new insane asylums
Prisons now house a tremendous number of people with mental illness. In 2007 the Department of Justice reported that 24% of jail inmates had symptoms of psychosis, about a quarter of people in jails and prisons had a history of mental illness and a higher percentage had symptoms of mania and depression. The total number of patients in state mental hospitals is about 35,000 and the number or mentally ill people in prison is over 10 times that number. It is very difficult for people dealing with mental problems to tolerate the stresses of incarceration, leading to high rates of injury in fights and attempted suicide.

But people with mental disorders who are at risk for injuring others or breaking the law are more likely to get a bed in a psychiatric facility than people who are simply miserable or increasingly psychotic and have not broken the law, who could really benefit from a stay in a psychiatric hospital to stabilize their medication and give them intensive treatment. It is those miserable, suicidal and psychotic to the point of inability to care for themselves people who end up in emergency rooms for days awaiting a bed.

What would it be like...
I can only imagine how it feels to be seriously mentally ill in some of these situations. Picture being seriously depressed or anxious and being in prison, where kind words are mostly non-existent and there is nowhere to take comfort. Or schizophrenic, hearing voices that break you down, surrounded by nobody who cares. I can hardly allow myself to conceive of depression, anxiety or psychosis while homeless, exposed to the rain and the cold and vulnerable to assault. Closer to home are the patients who wait in the emergency rooms, with nothing to do, no chance to go outside, take a walk, lying on a 30 inch wide gurney covered with rumpled sheets, contemplating suicide while having no idea what is happening and when.

If we were to fix this, what steps would we need to take?

Clearly we need more psychiatrists. We also need more psychologists and they need more authority to treat, including with medications. This is a different conversation, with intrigue that I don't really understand. But we do need psychiatrists, MD trained, motivated, excellent at what they do, and we need to pay them in accordance with how vital their work is. There are already incentive programs to train as a psychiatrist and work in underserved areas, but we need more incentives.

We need more capacity to take care of patients in hospitals, for those times when things get too intense for them to survive independently.

We need systems to help take care of people with mental illness who need jobs and housing and treatment for substance abuse. We need to strengthen social networks in neighborhoods and communities. This is vitally important for keeping patients out of psychiatric hospitals and out of prison.

We need to shift people with mental illness out of the prisons, which are overcrowded, overused and dysfunctional. This will involve better and more capable staffing and better oversight along with more capacity to take care of them in psychiatric hospitals and community mental health facilities.

We need to support the families of these patients because they are often the only stable thing in their lives. Patients with mental illnesses often burn out their families which is a tragedy in so many ways. Programs to support families, including caregivers and assistants to help support patients' independence should be strengthened.

All of this will cost money, but I suspect not more money than we are presently spending on our dysfunctional systems. Shifting money towards appropriate care for people with mental health problems will not only reduce costs that go to warehousing many of them in the prison system and the cost of acute medical care for the homeless and those plagued with addiction, it might also decrease the overall national burden of misery, hopelessness and isolation.

Thursday, November 3, 2016

Recovering--a sacred time.

One day a few weeks ago, after returning from a set of seven 12 hour shifts in a hospital away from home, my husband convinced me to go to a concert. The group performing was the Deviant Septet, based out of Brooklyn, NY. They were an odd combination of instruments and they played mostly newly composed music.

The second piece in their program was by Chris Cerrone and was called "Recovering." I expected nothing, perhaps a nap even, but was completely absorbed by the music which wordlessly represented a magical period that I get to observe regularly but rarely remark upon.

Patients come in to the hospital when they are sick, and often getting sicker. They are vulnerable and place themselves in the hands of strangers. Usually they feel terrible. We do things to them to try to make them better. Often we are successful. And then something magical happens. Their faces look brighter. Their vital signs stabilize. Their eyes focus. They make jokes. It's still not over, though. There are setbacks. There is pain. They are weak and their appetites are not vigorous. But a gate has been passed through.

I don't often take the time to appreciate this transition. For me it is often filled with new concerns. What next? How can we all avoid this kind of event in the future? How much more time before this person can leave the hospital?

This piece of music took me back to the times when I was sick and finally getting better, when the world around me began to be relevant again, and sometimes beautiful. It reminded me that there is a thing that happens, this "recovering", and spending a little time noticing it will be a good practice.

Saturday, September 24, 2016

My week in ultrasound

After 5 years of doing bedside ultrasound, I'm still excited about it. Bedside, or Point-of-Care ultrasound is using an ultrasound machine during the physical examination of a patient in order to make a diagnosis. I use a pretty tiny machine that fits in my pocket. As an internist who works in the hospital and in rural clinic outpatient settings, I get to use my ultrasound all the time, and it's still lots of fun. (For more on adventures in ultrasound see this or this or this.) Those of you who have read this blog for awhile can skip the intro and go to the cool cases.

When I talk about it, most people who haven't already heard me wax eloquent say, "you mean you look at babies?" Ultrasound has been used as a bedside tool for looking at pregnant wombs for a very long time. It is extremely useful for that, since you can see if the baby is alive, about how old it is, whether their are two, what position it is in and a number of other useful things. I would never give up the chance to look at a baby if my patient were pregnant and willing, because they are so cute, but since I am not an obstetrician, I look mostly at other things. I can see whether the heart is failing, whether there is extra fluid in the lungs or belly, whether the kidneys are blocked, whether the bladder empties. I can see pneumonia and broken bones, tell whether a swelling is full of fluid and whether a lump is solid or a cyst. I can see disease in blood vessels and stones in gallbladders. Combined with talking to a patient and doing my usual physical exam, I can determine whether a patient is dehydrated or the opposite and can often be more accurate about diagnosing blood clots or sepsis. It's cool. Yes indeedy it is.

This week I worked as an outpatient doctor in clinic and also in the hospital, admitting and taking care of sick patients. I use the ultrasound nearly every time I examine a patient and it always helps, but there were some cases in which it was more spectacularly useful than in others.
  1. A patient in clinic had pain in her head and cheek and teeth on the right side 3 weeks after getting a cold. She had a long history of allergies and sometimes used a nose spray or an antihistamine, but this was worse than usual. On exam there were polyps in the nose and maybe a little bit of tenderness in the right side of her face. It is possible to use the ultrasound on the sinus bones behind the cheek to see if there is fluid, because fluid transmits ultrasound and you can see the back wall of the sinus only if there is fluid in it. I could see the back wall on the right, the side with symptoms and not on the left. I diagnosed a sinus infection. She will try nasal steroid spray and washes to see if things can open up and drain, and if that doesn't work, she has a "pocket prescription" for an antibiotic which she can fill and take. I also looked at the teeth on the right with the ultrasound and found no evidence of an abscess, which was reassuring.
  2. Another patient in clinic had stubbed his toe pretty hard. It had swollen and then swollen some more and he was concerned about an infection. The clinic does not have an x-ray machine and is a pretty long drive to the closest one. Beside the cost, it takes an hour of a patient's time to wait, fill out papers and then have an x-ray done, plus I will usually then wait another hour for results and the patient will then be difficult to contact. I was able to ultrasound the toe, find a non-displaced fracture at the point where he was tender and give an explanation plus an appropriate set of recommendations.
  3. At the hospital I had a patient who had been admitted with low blood pressure and likely pneumonia along with blood enzyme tests suggesting a possible heart attack. He responded well to antibiotics and fluids and, due to having lots of chronic medical problems, wanted to avoid being transferred to a larger hospital to see a cardiologist. I knew from previous visits what his heart looked like with ultrasound and could tell him that it looked no worse, which meant that an emergent visit to the cardiologist was not necessary. I was able to use the ultrasound of the heart at the time of our conversation to help guide our shared decision-making about whether to get in a helicopter and head far away from family and friends.
  4. Another patient had severe pancreatitis, an inflammation of one of the nastiest and most caustic organs in the digestive system. He was 80 years old and drank too much whiskey on a daily basis, which caused the pancreas to become angry. After a day or so he developed an acute alcohol withdrawal syndrome, trying to crawl out of bed, anxious and with an elevated heart rate. We treated him for the alcohol withdrawal, but his heart rate remained elevated. Was he dehydrated? None of the other labs gave me the information I needed, but ultrasound of the inferior vena cava showed that he had been adequately hydrated and that, as expected in severe pancreatitis, there was some fluid in the belly and at the base of the lungs, so more fluid would make things worse rather than better. I was able to repeat the ultrasound daily to determine how much intravenous fluid to give.
  5. A young man, with a history of longstanding intestinal inflammation and several operations in the past, presented with abdominal pain. X-ray was pretty normal, but can be hugely misleading. A CT scan would have been helpful, but is associated with a high radiation dose. He had undergone many CT scans in his life and the possibility of his developing cancer on the basis of his radiation exposure was already significant. I was able to look for fluid in the belly or fluid filled loops of bowel which would suggest obstruction and feel pretty confident that a non-surgical approach to his problem was safe. 
It was a good week. Nobody died. I felt competent. Patients were happy. Bedside ultrasound was terrific.

Sunday, September 18, 2016

What's wrong with socialized medicine? The Economist calls the National Health Service "a mess"

The British National Health Service (NHS) was born in 1948, based on legislation passed that year mandating free high quality healthcare for all paid by taxes. In contrast, the US started Medicare in 1966 to provide healthcare to the elderly and the State Children's Insurance Program (SCHIP) in 1993 to fund healthcare for children whose parents were unable to afford it. Healthcare in the UK is still almost entirely funded by the government (through taxes, of course), which it is not in the USA.

Britain is proud of the NHS, and rightly so. They have it figured out. Or so it would seem. Everyone can get care and nobody goes bankrupt because of huge medical bills. Brits do have to pay for prescriptions but everything costs the same, the equivalent of $11 per month.

So why would the Economist, the global news magazine based in London, call it a mess? This article says that the NHS is in trouble, and needs to learn some new tricks in order to stay effective. It turns out that Britain only spends 7.3% of its gross domestic product on healthcare which is significantly below average for its peers in the Organization for Economic Cooperation and Development (OECD) countries, and plans to cut that expenditure to 6.6% in the next year. Because their population, like ours, is aging, costs of care are actually rising so already pinched services are being further curtailed. Because of the high costs of caring for patients with complications, some local health commissions will not provide routine surgery to patients who are obese or smoke cigarettes. General practitioners are overworked and can't provide the kind of preventive services that keep patients out of the hospital and nursing homes are unable to house all of the patients who need their beds so those patients stay in the hospital, limiting the beds available for sick people or people needing surgery.

The US, in comparison, spends over 17% of its GDP on healthcare, at least 5% more than the next highest OECD country. Most of our problems are not due to stinginess of payers, but rather to distribution of healthcare dollars, with some people having no access to affordable medical services and others receiving care that is very expensive which they may not need or want. Many of us long for a fully government funded healthcare system like the NHS.

So what has gone wrong with the NHS, then? I'm not entirely sure, but I have some ideas. Since the government is the payer for services, they have the ability to limit funding. Because of the inevitable waste that goes on with the provision of medical services, it could well be that 6.6% of GDP is plenty to provide good healthcare. It is not enough right now with the system they have. Because the government pays for services regardless of whether the consumers find them to be of good quality, there is no direct incentive to please the patient. Because doctors don't know how much things cost, they are less able to be good stewards of resources. Their healthcare delivery is therefore inefficient, and reducing funding has not made it better.

We do have similar problems in the US, with both lack of knowledge about what things cost and lack of incentive to do things better or more efficiently. Because the government is not the only payer and so cannot put a cap on payment for healthcare, our system is much more expensive. Our hospitals are prettier and our technology is more snazzy and we probably do more miracle cures per capita.  But citizens of the UK have universal access to medical care and nobody goes bankrupt because of medical bills.

Since healthcare per the NHS is not what we want, but we do want universal access with good quality and lower costs, how shall we do it? Americans have enough mistrust of government, and fiscal conservatives are absolutely allergic to the federal government being the sole provider of health insurance, so we will not get "socialized medicine" anytime soon. The Affordable Care Act (ACA, also known as Obamacare) has improved our situation considerably. Expanding Medicaid to cover Americans whose income is at or below 138% of the federal poverty line has helped in the 31 states that have adopted that (my state, alas, is not one of them.) It is now easier and cheaper for the rest of us to get insurance, which helps avoid catastrophic and crushing medical bills. But even people with health insurance go bankrupt due to their share of healthcare costs, combined with inability to work. Footing part of our medical costs is supposed to help us make more frugal decisions, which is one of the reasons most healthcare proposals have included some kind of a deductible ("cost sharing.") Unfortunately most patients don't have the information they need to make frugal decisions and their doctors don't know enough about costs or other options in many cases to help them do this.

In the JAMA (Journal of the American Medical Association) an article reported that an intervention to give doctors information on costs of the various aspects of their patients' care as well as a look at their outcomes significantly reduced costs while improving hospitalized patients' health. This seems obvious. Of course knowing what things cost and how a patient fares will make us do a better job and not cost so much. The strange thing is that this is not standard practice. We don't know what the tests and procedures we order actually cost. And most of us don't get a longitudinal view of how a patients illness or surgery actually turned out.

So if we could have any system at all, what would be best for us here in the USA? I'm not sure it actually matters, as long as we get what we need and so long as there is enough shared knowledge about what things cost, how well they work and what are the alternatives. The direction we have gone, with private and government funded insurance has lead to our present situation. But if the insurance companies paid physicians to take care of patients, and how much we actually made depended on providing the most appropriate care that caused the least unpleasant impact on patients' lives, costs would go down and care would improve. This would require that patients' voices be heard. It would require that doctors knew what was good value and the healthcare industry was encouraged to create options with better value. A single government payer could do this, but not without built in systems to feedback what patients value and what actually works and innovate actively to improve quality.

Thursday, September 8, 2016

T-mobile and medical billing nightmares--a rant

A few months ago I had a clever idea about how my husband could use my cell phone in England, because getting cell phone service across the Atlantic can be expensive and inconvenient.  

So I had this bright idea. I have an unlocked smartphone that I use in Africa or Haiti with a sim card that I can buy there cheaply and with no difficulty. T-mobile, the cellular phone provider that began as a German company and has provided competitive service in the US, advertised that their service would also work in the UK and Europe and that it would include unlimited data. Or something like that. It sounded great. I would just buy the T-mobile sim card in the drugstore here, get the service and be good to go. But not so fast. T-mobile does have the no fuss pre-paid option, but to get the international service requires a different plan, with a monthly fee. After attempting to do this online, then converting to the monthly service, nearly losing the money I had mistakenly spent on prepaid minutes, speaking to operators working out of many non-English speaking countries, whining and finally prevailing, I signed up. Unfortunately T-mobile didn't work in most of the places my husband traveled and didn't work at all in my community. No big deal, live and learn, and I never received a bill. Cool. It didn't work and I didn't have to pay. Eventually they notified me that my service had been discontinued. All good.

Then I got a notice that my account had been sent to collections. $185.00 I owed. I called, spoke to people from many countries, raised my voice, heard vile hold music, spent an hour predominantly on hold, closed my account, and assured the poor folks at the call center that I didn't intend to pay for a service that had never worked and for which I had never been billed. As I delved more deeply into what had happened, I found that they had notified me of billing, via the cell phone that had no service where I was. When I tried to log in to my account at their website to look at an itemized bill, I no longer had access due to having closed my account. I fumed and felt myself to be ill used. At last I paid the bill in order to never have to speak to them again or listen to their hideously distorted hold music. Probably worth it. I will think of it as a fine for making a poor choice. I did research other customer complaints regarding T-mobile and found that mine paled in comparison. It could have been so much worse.

But the whole experience did make me much more viscerally aware of how my industry treats people who owe money. I consider T-mobile to be a bunch of amoral and powerful extortionists. But the same kind of thing happens to thousands of unsuspecting medical consumers when they unwittingly spend huge amounts of money on medical care. Take, for instance, a person hit by a car. Insured or not, they will be billed for some portion of their medical care in emergency rooms, surgery, intensive care and for their general medical hospitalization. As they lie helpless in the hospital the bills will likely arrive at a mailbox that is being emptied and put in a shoebox by a neighbor, possibly under a utilities bill that is more important or likely lost amid catalogs, and certainly confusing as heck once they are opened. Hospitals and doctors are not shy at all about sending unpaid bills to collections. When the unfortunate car accident victim finally gets home after rehab, the collections agency will likely have reduced the information in the bill to a single heart-stopping number without any itemization or information about how to dispute it (such was my T-mobile experience.) The Consumer Financial Protection Bureau documented in a December 2014 report that just this sort of thing happens frequently due to the complexity of medical billing and insurance payments. People sent to collections for medical bills often have completely clean credit histories and didn’t pay those bills because it was never quite clear who owed what and to whom. (For more info on medical billing, read this blog.)

I can choose never to deal with T-mobile again if I want. Also my bill was only $185, which is a lot for nothing, but will not bankrupt me. Medical debt is the major cause of personal bankruptcy and a decision to never receive medical care again can have devastating consequences. Sometimes, as a person who is supported by healthcare dollars obtained in part from heinous billing practices, I wonder if I'm really one of the good guys.
(I would like to see a system in which medical care cannot destroy a person financially. This will involve reducing what we spend on it by getting rid of wasteful practices that do nobody any good, simplifying the payment system and assuring universal access to what we can agree are necessary medical services. But that is a story for another day…)