Saturday, May 2, 2009

The Rabies Tour 2009 (Health Care Around the World)

My previous experience with health care outside the US was in 1990, when I had younger son in the Netherlands. The quickie comparison, younger son in 1990 in the Netherlands versus older son in 1987 in the US, was comparable pre-natal care (caveat to come), comparable delivery experience, better post-natal care in Europe. The caveat on the pre-natal care was that my doctor for the older son experience in the US was a family medicine resident while my doctor for the younger son experience in the Netherlands was an obstetrician. If I'd been a Dutch woman, I would have used a midwife, but my US health insurance only covered midwife deliveries under special circumstances, so I had to use an obstetrician. The cost comparison? About a thousand dollars less in the Netherlands. I had worried about whether there would be problems with insurance covering everything or at a minimum asking all sorts of questions and making me justify every little thing. A friend who was working for a health insurance company in Ohio at the time assured me that her company typically paid routine foreign medical claims without questions because they knew the cost would be less than a comparable claim in the US.

Getting treatment in so many locations for my possible exposure to rabies has been similarly fascinating. My first stop after getting bitten was the Royal Angkor International Hospital in Siem Reap. The "International" means that they're the first stop for foreigners needing treatment which means that their prices are out of the reach of most Cambodians. When I checked in at the Emergency Room desk, I was told there was a $100 cost just to be seen. Fortunately, that wasn't a problem. The total cost for treatment there was about three times the initial $100, but included a physician's fee as well as the cost of the rabies vaccine, pain medicines (two different kinds, Tylenol and something stronger), and antibiotics (again, two kinds, pills to ingest plus salve for the wound itself).

Since Royal Agnkor was out of the immunoglobulin I also needed (I was the fifth dog bite of the day), they told me to get that in Ho Chi Minh City the next day. I finally found it at the SOS Clinic, which somewhat caters to the health care needs of expatriates. I had to see a physician in order to get the shot, so my bill from SOS lists a physician charge about equal to that on the Royal Angkor bill, and a rather sizable (about five times the charge for the doc) charge for the immunoglobulin. This bill plus the first one put the total cost to almost four digits; fortunately, we had that much cash on hand as well as a good credit card. Fortunately again, we know that insurance should reimburse us for everything when we get home and file the claims.

I got the second and third shots of the rabies vaccine in the Netherlands. To get them, I went to the local hospital in Apeldoorn (yes, that's the place where someone tried to drive a car into the royal family), explained the situation, and asked if they could help me. They did not have the vaccine on hand but were able to get two doses of it the same day. I paid for the two vials of vaccine at the pharmacy then carried them down to the emergency room where a nurse used one of the vials for the dose I needed that day. Can you imagine a hospital in the States handing you vials of drugs and telling you to carry them down the hall? I can't. After the shot, I was told to take the second vial back to the hotel and keep it in the refrigerator for the four days until I needed the next shot, something else that would probably never happen in the States. And when I asked the emergency room nurse what I owed for the shot itself as opposed to the vaccine, I was told there was no charge. For the second shot in the Netherlands, I returned to the hospital, vaccine in hand, went to the ER, and got the shot. Again, there was no charge.

For the next shot, in Trondheim, Norway, I had the advantage of a local contact. The husband e-mailed his cousin and asked him to see what he could arrange in advance so that I didn't have to appear, unannounced, at the local hospital as I had done in the Netherlands. I ended up with an appointment at the local health department. I arrived at the designated time, filled out a medical history, spoke with a nurse, and received the shot. I asked her what I owed, and she replied that I owed nothing. Surprised, I asked whether I needed to pay for the vaccine itself as I had done in the Netherlands. No, she said, assuring me that this had been approved by the director. She said that they would be reimbursed by the national health department for the cost of the vaccine so there was nothing I needed to pay for. If a foreigner needs emergency medical care in Norway (as for an accident), care is provided free of charge. My dog bite may have happened two weeks earlier and in Cambodia, but the fact that I needed the vaccine injections on very specific days, one of which happened to be while I was in Norway, made it fall under the heading of "emergency" care following an accident. Needless to say, I was quite happy about this, though I fully expect to have to explain to my insurance company why I am asking for reimbursement for charges in Cambodia, Vietnam, and the Netherlands, but not Norway.

Why do we make it so difficult and, by extension, expensive in the US? I think a good deal of the problem is not with health care in general as much as it is with the legal system and the possibility of a malpractice claim any time health care is delivered. I could take the rabies vaccine home and put it in the freezer instead of the refrigerator, bring it back for the second injection, have some adverse reaction, and sue the hospital. Or I could lose or tamper with the vial as I carry it down the hall to the ER. It's safer for the hospital to do it all themselves. And to the hospital, time is money so if a nurse spends time giving me the injection, they want to be paid for that time. As you might imagine, I prefer the Dutch model of paying for the vaccine and the shot comes for free or even the Norwegian model that distinguishes between non-elective or emergency care and elective care. I know the issue is much more complex than that, but that's sort of what I've been thinking of in mindless moments on the train, based on the Rabies Tour 2009 (we've actually played around with a t-shirt design).

Final thought at least for now: A friend asked whether I get to wear a rabies tag after I finish the course of vaccines. I think that's an absolutely wonderful idea. Since I have all sorts of rabies tags that have been given to the cats over the years (my cats don't wear collars), I plan to come up with some rabies tag jewelry after we get home. As with many things, laughter may not be the best medicine, but it certainly doesn't hurt.

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