16 November 2006

Comparative Medicine

I will knock on a nearby birch tree while saying this, but I have enjoyed pretty decent health through most of my life, a circumstance that I attribute more to genetic endowment or fate than to anything else. Even so, I have had several opportunities to study health care in comparative perspective. Here is a brief report.

About ten years ago, I fell ill on a trip to Scotland. As soon as we arrived in St. Andrews, I staggered into a “surgery,” or clinic. It had a musty air and looked as if it had been furnished in the early 1950s, but I tried hard not to judge it on those grounds.

Except for the fact that I had none of the papers that the receptionist asked me to produce, I had no trouble getting in to see a physician, who determined that I was suffering from a fairly rare malady that had to be treated with a powerful drug that sometimes interacts badly with common medications. Thus, he had to identify the drugs I was already taking. That proved to be quite difficult, since the names of prescription medicines vary considerably from country to country. He had to look up all of my meds in a reference book with extensive cross-referencing, and then check on the side-effects. He explained his diagnosis, the prescribed treatment, and the prognosis. He was wonderfully articulate in the way that only the Brits can be.

The thing is, I had always thought of the medical profession as thoroughly international—as universal as science itself—and so was astounded to see for myself that it is in certain respects profoundly national. That discovery was reinforced by something else that impressed me, and that was that the brilliant physician who cured me of a serious disease was absolutely flummoxed by the question of how much I should be charged for services expertly rendered.

At first he insisted that it simply was not possible for him to present me with a bill. We do not bill our patients. We would not know how. It really is quite impossible. I put up a fuss. Surely your services can be reduced to some kind of hourly rate that can simply be applied to my case. In principle, yes, he conceded, but that does not solve the problem of how, exactly, we are to issue you a bill. We are wanting a form for that. There would be no way of accounting for it in the ledgers. In the end, he pulled a number of the air, and I paid it. As I recall it was around 35 pounds. It was the best 35 pounds I ever spent, and I have had a soft spot in my heart for socialized medicine ever since. A few years later, when I contracted the flu during an extended stay in London, I again had a very positive experience.

(Permit me to wander into dentistry for a moment. A year or so ago I made the acquaintance of some distant relatives from the Republic of Slovakia. The daughter of my second cousin won the green card lottery and has been in the United States with her family for some time. I met them in Atlanta. They are now living near Detroit. Her husband, who used to work in a bank in Slovakia, and is a construction worker here, told me that he had been having dental problems, and that he had gone to see an Atlanta dentist for an estimate, which came to over a thousand dollars. He determined that it would be cheaper to fly back to the Slovak Republic and have the dentist in his village do the work, which would be covered by the state health insurance plan. And that’s what he did.)

When I first started taking the bus to the University of Oulu this fall, I noticed an office called Medivire (four syllables, each ending with a vowel) that looked suspiciously like a clinic. I filed it away for future reference. As the (cue Carl Sagan here) billions and billions of regular readers of this blog know, I have been sick for over two weeks. It does not seem to be anything serious, only a sinus infection that causes runny eyes, laryngitis, and fatigue. Last Monday, 6 November, one of my colleagues said I looked like death warmed over, or words to that effect. That was fairly persuasive.

I promptly deposited myself on the Medivire doorstep. Given my appearance, I had no trouble securing an appointment for later the same day. The physician, who was very young but seemed able, gave me a prescription for antibiotics and a decongestant. The interesting thing is that although I once again had none of the papers that patients customarily produce when they are treated by physicians, Medivire had no trouble determining how much I should be charged. Two days later, I received, via snail mail, a bill for 36.15 euros. A bargain, I thought. The invoice included Medivire’s account numbers with three Finnish banks—Nordea, Aktia, and Sampo. I went on-line and arranged for the bill to be paid directly from my own Nordea account. Later, I Googled Medivire and found a story about the company’s acquisition of another healthcare company, called Engel Care Services. The article then provided a little background:
When Medivire was privatised in 2000, the state became a minimum shareholder and MB Funds the main stakeholder. Now the state has surrendered its stake in the organisation. MB Funds owns 82% of the company, Ilmarinen 10% and the company's active management 8%. "Medivire's business is now set to see good growth and the company has great potential for the development of both its health and care services. After the business expanded and capitalised, it was only natural that the state should surrender its stake in the company," says (Hannu) Puhakka (identified as a partner in MB Funds).
This would seem to go a long way toward explaining why Medivire knows how to issue a bill for services rendered.

My prescriptions also seemed to me modestly priced. I had them filled at a pharmacy—apteekki—that same day for 26.23 euros. I took the medicine faithfully, as directed, until I ran out on Monday of this week. While my condition has vastly improved, I cannot say that I have been completely cured. Since Monday I have noticed that my eyes are getting runnier and my voice scratchier. Because I am due to lecture at the University of Helsinki on Friday (I am writing this on Wednesday, 15 November), I went back to Medivire this morning, looked pitiful again, and talked things over with the receptionist. “The medicine was working,” I explained. “It’s just that it ran out before I was completely recovered. My eyes are still itchy, and they run at night. And I’m still having trouble talking. So I need a refill.”

“How long have you been ill?” She asked.

“Two weeks,” said I.

“That’s a long time. I think you should see a doctor,” she said.

“I don’t think it’s necessary,” I said. “I think I just need to stay on the same regimen for another week. The longer I’m without medication, the more ground I'll lose, and the longer it will take to knock the thing out for good.” She looked dubious. “I’m not resisting another examination,” I continued. “Whatever we have to do to get a refill, that’s what I want to do, and I want to do it before I leave for Helsinki tomorrow.”

“I think you’d better see a doctor,” she said again. And then, since the physician I had seen earlier was booked through the end of the week, she proposed that I see one of his colleagues. I said fine, and she set me up for 3:00 in the afternoon.

I took my seat in the waiting room at 2:55, and promptly at 3:00 I was summoned by physician #2 into his examining room. I explained the situation to him. “I feel great compared to the way I felt a week ago, but we didn’t quite knock it out,” I said. “I wake up in the middle of the night, and my eyes are kind of glued shut. My voice is still a little froggy, and I think all I need is a refill.”

He looked at my throat and pronounced it “not too bad.” (I was reminded that by Finnish standards Pavarotti is "not too bad" a tenor.) Then he checked my sinuses, I think with a Doppler device, and determined that while my right passages were clear, the ones on the left were clogged. He signed the original form in a new place and explained that it can be used for up to three refills. But clearly, I would have to undergo an “examination” each time.

When I checked out I was assured that Medivire would send me another bill, presumably for 36.50 euros, and I will cheerfully pay that one, too, through Nordea’s online bill payment service. Let the record show that I am perfectly satisfied with the medical attention I received, and I can’t complain about the price.

My experience with the healthcare system in the UK is a decade old, so I’m not sure where they’re at, as we used to say back in the ‘60s, with respect to privatization. As for the Finnish medical profession, I think it’s fair to say that they’ve got the hang of it.

By the way, that fellow up top is Elias Lönnrot, the physician who went round Karelia collecting folklore that eventually found its way into the Kalevala, the national folk epic beloved of the Finns.