Medical Questions

Another Hand of Cards

I have mentioned how odd I found it that I had to carry four or five health insurance cards when I was an employee of the State of Illinois, considering that all the money comes out of the same pot. I spent a couple years with another kind of coverage, but now I am back with the State, and they have dealt me a new hard. There are four this time, instead of five, but that is only because retirees are not eligible for the Employee Assistance program, which provides things like “Anger Management” classes and drug rehab. Since I am no longer likely to snap on campus, the evidently don’t care if their medical insurance provider drives me to go postal or start asking my friends visiting Thailand to mail me some Valium.

It, of course, makes no sense for me to have so many different cards and card numbers. I won’t go into what they are all for again, but yesterday I had an experience that reminded me how kludgy our system is—and how the innovations that make American business (and American medicine, until we start paying for it) don’t seem to reach our system of charging and paying for medical care.

This fall I am not worried about Ebola, which I have essentially zero chance of encountering. I am worried about the flu. A quick look at the Centers for Disease control web site tells me that about 200,000 people are hospitalized as a result of the flu every year, and as many as 49,000 die of it. I also know that when I have had it, I have been very unhappy—and that every year I age I am more likely to move from the “very unhappy column” to the “in the hospital” column. So I get an annual flu shot. This year, since I had serious surgery not long ago and have had some respiratory problems, I decided to get a pneumonia shot, too.

So there I am, the model patient. I am not putting in an already over-burdened Emergency Room under still more strain after I have been inflected. I am not taking up time in a busy doctor’s office. I am getting my vaccinations for influenza and pneumonia in the simplest and most cost-effective way possible. In other words, I am at the counter in the back of a suburban Walgreens talking to a pharmacist.

Things go smoothly until she asks for my insurance card. First, we try my health insurance card. Then we try my prescription card. If they were treating my flu shot like other prescriptions, that would tell the pharmacist how much Express Scripts would pay, and thus how much she should charge me. But the flu shot, which may prevent my needing much more expensive medical care and prescriptions, is not covered so simply. After some research, she discovers that I have to pay myself, and then file for reimbursement.

Let’s fast forward to the present, when I have downloaded the Express Scripts claim form. I now have two pages of text, lines, and boxes, which I am to fill out with a pen. I will enter the information encoded on my various cards—the form, in fact, tells me “See your prescription drug ID card.” I also find that I have to go back to Walgreens to get the signature of a pharmacist and the numbers to fill the boxes under “NCPDP/NPI Required.” I trust that either I or the pharmacist will make a mistake somewhere, which will allow Express Scripts to send everything back to me and delay sending me the payment I am now owed. (Why don’t I call Express Scripts for help? Because I know form experience that they will lie to me until I become so nasty that they break down and look in my records—while keeping me on hold—and that even after they can not longer argue the facts, they will invoke policies I have no way of researching until I give up.) Paper, signatures, envelopes, stamps, bureaucrats: the way the State of Illinois and Express Script like to do things.

But back to the pharmacy counter. Our adventure dealing with the people obligated to pay for my health care now being at their normal dead end, I need to pay. No problem. Walgreens takes ApplePay, so all I have to you is wave my iPhone and touch my finger to its “home” button. Done. Walgreens have a rewards program, and I am part of it. No card now either: I just get my virtual card up on the iPhone screen, wave it over the scanner, and my points are in the system. All that’s left is the shots. The pharmacist gets the doses ready with lightning speed, meets me behind a screen already wearing rubber gloves and ready with alcohol swabs and Band-Aids, and in less than I minute I am immunized, wearing two Band-Aids I don’t really need, and on my way.

But I am still left wondering: we me make our commerce ever more efficient and the actual delivery of medical care wonderfully smooth, so why do we still choose to apply none of that knowledge and skill to paying for health care? And once again, I see that neither the proponents of “Obamacare” nor its impassioned opponents are talking about the real problems a patient encounters. (You can, however, find them described quite well in Kafka and Dickens.)

But enough of this. I have forms to fill out. Where’s my pen? I hope I still have some White Out, in case I made a mistake!

[Update: After having had me fill out the the forms and get the pharmacist's signature, ExpressScripts declined to pay for my flu shot. Since they knew what drug I wanted reimbursement for before asking for the form and the signature, I would ask, “Why not just say ‘No!’” But I know that is not how the game is played: They don't want meet notice how often they say “No!” They want me to give up and say “The the hell with it.” If I just give up, perhaps I won't notice how many claims they deny.]

Follow Your Doctor's Orders—But Don't Expect Us to Pay Attention to Him

If you your prescription provider only allows you a third of the pills the doctor has told you to take, should you take one pill every third day? Or should you take one pill a day for a month and then do without them for the next two months? Or should you cut them up in such a way that you can take a third of the full dose everyday?

About a half hour into a conversation with a fellow who serves as a mouthpiece for ExpressScripts, I found myself asking those questions. He replied that I should take them exactly as my physician had prescribed them. He tried to sound as if taking pills he wouldn’t let me have was an obvious and simple course of action.

During this extensive conversation, the representative of my “health care provider” also told me:

•That the prescription for which I had received a denial notice had never been received by ExpressScripts.

•That, yes, the prescription had been pre-approved, but that didn’t mean the prescription had been received.

•That if I wanted him to look for the prescription, I would have to wait on hold a listen to the same saccharine tune over and over, because he could only address my case while I was on hold. He could not do work that didn’t require my input and then call me back, because . . . well, the why was a bit cloudy.

•That, yes, the drug had been prescribed and pre-approved but that my doctor wanted me to have too much of it.

•That it didn’t matter that I had been told other things at other times.

•That I should not think his story world change, even though he had just changed his story about the prescription not having be prescribed or pre-approved. Or because his colleagues had given me other stories. ExpressScripts was committed to my health and didn’t treat its customers’ health lightly.

•That I shouldn’t doubt either the accuracy of his statements or the goodwill of his company just because they had wasted a great deal of my time and denied me a drug my doctor says I should have.

•That, yes, I should have my doctor waste more of his time pleading for the drug if I wanted to take the drug he had prescribed.

•That I shouldn’t should so hostile.

After that, I called my doctor a couple times, and he and his staff did, indeed, waste more of their time begging ExpressScripts to let me have the drug. We reached a point where I did receive the full dose, but only as two separate prescriptions at different dosages, and I had to produce paper coupons to get one of them. Then another month went by, and, whatever they had done in the past, now they would not let me refill the prescription until two week after I had run out of it again. Then we reached an accommodation whereby I got a month’s supply of the drug at the price I am to pay for drugs according the stated rules of my plan every third month. During each of the two off months I would have to pay more than a thousand dollars for the drug. Things went on like that until a test showed I should not take the particular drug anymore.

Only that last decision was about my health. Everything else was about money. The guy who fronted for ExpressScripts on the phone told me that his company does not care about money—or that, if they do, they make money by fulfilling prescriptions, not by denying them. I tried to reconcile that story with the newspaper reports that came out a couple days later about the company’s deciding to reject a whole class of prescriptions—one’s involving compounding pharmacies—because they cost too much, but I didn’t manage to square that circle. I know that I was promised healthcare in retirement in return for years of labor, but how much healthcare I get seems to be in the hands of people whose motivations do not include looking after my welfare.

I mention this colloquy the ExpressScripts flak as more evidence that our health care system is in a shambles and that neither the defenders nor the opponents of the Affordable Care Act are paying any attention to the real problems. The insurance companies—and I include ExpressScripts in that group—have no interest in the welfare of the patient. They make money by
not paying claims. My former employer, the State of Illinois, decides which of these companies to employ not on the basis of how well they further my health and welfare but—let's just say on the same basis it made the decisions that left its pension funds depleted and its former governors in jail.

I am not for having the government—certainly not the state government—take over the health care system. They do a rotten job running some parts of it, though an excellent job managing others. I am for a single, governmental payer. Private providers would complete on the basis of health results and patient satisfaction, not on widening the spread between what they pay for drugs and actual cost of the drugs they deliver. Patients would be better off, and people like the man I talked to on the phone would be able to do respectable work instead of shooting people who are being cheated through the grease.

Surgery, Robots, Bills

This summer I had part of a kidney removed, and I have now joined the ranks of the Cancer Survivors. I will not be wearing the ribbon that seems mandatory for those who have, to use John Wayne’s expression, “whipped the Big C,” because I don’t see renal cancer as an achievement that merits a decoration, because I doubt the fruit-salad of pink and teal and white on people’s lapels has done anything except enrich the ribbon manufacturers, and because my malady is championed by two competing foundations, so I would have to choose between green and orange. Either color would be problematic: green also stands for support of the family farm, a fine cause but not what’s closest to the heart of this city boy, and, as a graduate of Princeton University, I wear too much orange as it is. My doctoral gown makes me look like the Great Pumpkin, and it was probably a mercy that my Irish father had gone to his reward before I first donned the livery colors of the oppressors of our people. And if tried for a more thoroughly Irish look by adding a white ribbon between the Green and Orange, it would not suggest peace between the warring kidney factions, but someone half as interested in breast cancer as in kidney disease.

The surgery showed everything that is best in American medicine. An operation that in my mother’s time—kidney cancer seems to be one of the Abel family curses—would have involved a large incision in the back and a lengthy hospital stay, kept me in the hospital for only two nights—and I might have gone home after one. The laparoscopic technique and robot-assisted procedure left me with only a few small “bullet holes” in the belly and no stitches that needed to be removed. The gas that expanded my abdomen into a working surgical theater did cause some pain and made me look like the Michelin Man when I returned home, but once it dissipated, I was fine. In less than a month I was traveling overseas.

So all praise to the doctors, nurses, techs, and other healers and carers. But while I am sure that those who treated me used the best practices to be found anywhere and applied them both rationally and humanely, I can’t say that about the rest of the system.

I am lucky enough to be able to afford health insurance. Since I had a “previous condition” when I left my last place of employment, I had to obtain it through the State of Missouri’s “Risk Pool.” (That is a system that forces insurance companies to cover their share of the bad risks: the term is best known from automobile insurance, where the worst drivers end up in the Risk Pool.) For the option with a reasonably low deductible, I have been paying around $700 a month—or $8000 a year. Thankfully, I can afford that.

With this coverage, my two days in the hospital has cost me about $5000, so far. I can afford to pay that amount, too—and much, much more was spent on my care. What someone in my medical and insurance situation with the median American
household income of $51,000 a year would do when faced with medical expenses that reached $13,000 just for basic insurance and one brief stay in the hospital is a question that leaves me both thankful and appalled.

But it is not just a question of the money to be paid. It is how the money is collected. The hospital whose staff cared for me so well has already had a functionary threaten to sic the collection agencies on me if I don’t pay up pronto. As I pride myself on paying my bills as I receive them, that is the sort of threat I rarely have to hear. But it is hard to keep track of all the different bills that are presented—hard not just for me, but for the hospital itself. I spent part of this morning on the phone trying to discover what payments they had received, which they hadn’t, and what they would do to make sure my credit card wasn’t charged twice if the payment I had submitted previously turned up after I had allowed them to charge my card again. That was a more difficult task than I thought. They could not simply check my account to see what payments had been posted. That was impossible, because they create a new account for each patient for each day he is in the hospital, each with a different number. I cannot think of any other business that works that way. It seems to be a system designed to create confusion.

And that is only the
hospital billing. The billing for the physicians is separate—and not always the same for all of them. I am now on two online networks that collect my medical information and allow me to pay my bills. That there are two of them undermines the purpose of the operation, because the information from different sets of doctors is not pooled. And some of my physicians are not in either system. My primary care physician, the specialist who discovered my cancer, the surgeon who treated it, and the hospital at which he operates are “owned” by different insurance companies or health care companies. The docs work together just fine. The organizations don’t.

At this point I am sure that some readers are beginning to suspect that I only came down with cancer so that I could use my own experience to denigrate the greatest healthcare system in the world. They may even suspect that I am a proponent of Obamacare and bent on bringing socialism to God’s Country. That is only half-true. I have not liked the Affordable Care Act since it was passed, and only support it at all because it is the only plan to expand medical coverage on the table just now. I would like a plan that was easy to understand, that would more completely ensure health care coverage for all, and that would remove the burden of providing healthcare from employers. (And, most of all, that would not further abortion in any way or trample on the consciences of some people—but I set the most important issue aside for now.)

Like anyone who has had an involuntary encounter with the American health care system, I cannot help seeing the disparity between our technical mastery and our organizational incompetence. Our physicians can do wonders to reduce human suffering. Our medical providers and insurance companies make our lives—and, by all reports, our physicians’ lives—a series of pointless battles fought for no good reason. When I think of a person living on the median household income, especially one in a household of more than one, I also think it is a system that is not only annoying, but genuinely cruel.

The Catechism of the Catholic Church, which I tend to take seriously, has this to say about the role of government in society:

The political community has a duty to honor the family, to assist it, and to ensure especially:
. . . . . . . . . . . . . . .
- in keeping with the country’s institutions, the right to medical care, assistance for the aged, and family benefits;
- the protection of security and health . . . (2211)
We have failed on these measures—and I hope that no one will be pharisaical enough to claim that we’ve got an “out” because our neglect of our duty is “in keeping with [our] institutions.” If ensuring that health care is available to all is socialism, the Catechism is socialist, its promulgator, The Blessed Pope John Paul, was a socialist, and I am, indeed, a socialist as well.

What the Catechism describes is the moral minimum we should set ourselves. And I don’t see how it can be achieved without universal health care.

The practical minimum we should set is that we provide universal care with as much efficiency as possible. Physicians should not spend their days arguing with insurance companies. Patients should not spend their convalescence figuring out “explanations of benefits” and dealing with dunning robo-calls from providers.

The system called Obamacare may do something to provide the minimum level of coverage for all. I do not see how it will address most of the practical problems. It has adopted the current unwieldy structure and added a new level of complexity to it. As the problems with the website show, we have just expanded a Rube Goldberg contraption with a few more shoots and pulleys instead of figuring out the simplest way of putting the ball in the bucket.

No one has ever given me a satisfactory answer to the question, “What value do insurance companies add to the health care system? “They do not make it more efficient. They do not make it easier for the physician to formulate and carry out his treatment plan. They do not make it simple for the patient to keep track of either his medical records or his medical bills. They do, however, put a lot of money that might pay for medical care and place it in the pockets of the executives and shareholders of insurance companies.

I would never want a state-run health care system, such as the British NHS was at its height. I would like a single payer system, where one entity negotiates with private health-care providers and pays the bills. They have that system in Canada, and it works quite well. We, in fact, have it here in America, and it works, too. We call it Medicare.

Medicare, however, generally only covers those of retirement age. Why can’t we simply expand it to all? I cannot help noticing that those groups who oppose “Obamacare” most vociferously are made up disproportionately of people eligible for Medicare, but they do not clamor for that “socialist” system’s abolition.

What do I want? I want a single card for all my health coverage. I want a single website for all my medical records, appointments, and communications with providers. I want the providers to be able to share information efficiently so that I don’t get the same test in three offices. I want to pay for my share of the total cost of medical care through my taxes. I am happy to be charged reasonable co-pays, especially for missed appointments, since people do not value what they do not pay for and investment in the process encourages patient compliance. And I want the people now working in the health insurance companies and medical billing offices to find new careers in fields that might actually increase the stock of human happiness.

That does not seem to me to be a radical plan. I could go on to describe how it would be better for business if they were freed from the burden of supplying health care for their employees—or the stigma of denying it to them. But I have another form to fill out in order to get the supplemental coverage that will pay more of my hospital bill because my kidney problem was cancer and not hepatitis. But if there is a reason you can insure yourself against cancer but not against infection, I have yet to figure out what it could be.

60 x 3 = 180.
Except When You're Counting Pills.

In a previous post I mentioned how baffling the behavior of my health insurance provider continues to be. The saga continues.

I have been trying to get all my regular prescriptions via mail, so that I do not have to go to the pharmacy each month to pick them up. Since I am on 8 prescriptions and their delivery dates cannot be synchronized, in practice that means a couple trips to the pharmacy every week.

Getting three-months supplies of each drug by mail would be a great convenience for me and—I thought—a money-saver for the prescription provider, since the mail order provider, working in bulk, takes a smaller cut than the behind-the-counter pharmacist.

But when I submitted one of my prescriptions to be filled by mail, the mail order drug people told me my insurer had refused to approve payment for it. The drug was too expensive. Now, I have been taking this drug for over a year, and the insurance company has never balked at refilling the monthly prescription. The price of 180 pills to cover three months cannot be higher than the cost of 60 pills to cover one month. If there is any difference, the bulk purchase should be cheaper—the saving on time and packaging alone should cut off a couple bucks.

I pointed out to the nice person at the mail-order pharmacy’s customer service desk that the cost would not, in fact, be higher. I think she may have even agreed with me, but said I had to take it up with my insurer. I did. They told me to call the prescription benefits company. I did, and once again I think the nice person on the phone agreed that 60 pills over 30 days three times would cost no more than 180 pills over 90 days. All the same, she said my physician would have to contact them. I pointed out that he had written the three-month prescription in the first place, so clearly he thought that there was a good reason for it. Logic did not prevail here either.

So what it comes down to is that I wasted my time trying to do something that should be simple. The three companies that together delay my prescriptions saved not a cent and squandered at least some on the salaries of customer service representatives that they do not allow to serve customers. And my physician spent time he could have used to talk to patients or read medical journals pleading with a benefits company to provide a drug it had already approved for me in the amounts I was already receiving. To whom does this procedure make sense?

I am again led to suspect that the companies who are supposed to pay for medical benefits make things complicated simply in the hope that patients will give up, say the hell with whatever prescription or treatment it may be, and try to get along without it, no matter what effect that has on their health. If they are paid by the number of patients enrolled, that will put more money in their pockets until some frustrated client actually dies—and that, I suppose, is just a cost of doing business.

Again, I don’t see how the new Health Care System is going to address this problem.

I have just had three tests—the last two preceded by calls from the insurance company about cost-cutting—and I see a specialist on Friday. I dread the billing more than any actual procedure he may recommend.

Can I Draw a Single Card?

In all the rancor over the Affordable Care Act (Obamacare), I think we have forgotten what the problems with our health care system actually are. While we have been embroiled in discussions of important issues (the HHS contraception mandate) and hysteria over chimeras (“death panels”), we have forgotten the main problem. And that is that our system is frustrating for everyone, cruel to some, and pointlessly wasteful.

That was borne in upon me recently as I tried to order three-month refills of my various prescriptions. I now go the pharmacy every month for each my refills, and, since they cannot arrange for them all to be refilled on the same date, I get a series of robo-calls reminding me to pick up pills throughout the month and stop off at the drugstore at least once a week. So I very much want to get everything filled through the mail and delivered in three-month batches.

My health insurance will not allow me just to ask my pharmacist to set this up for me. Nor will it do it itself. I must first take my number from them and get in touch with the company they have contracted with to handle prescriptions. That company gives me a new number, and refers me to a third company, which they have hired to handle the mail-order prescriptions while they focus on paying the brick-and-mortar drugstores. The third company has me set up a new account with them, which is then linked to my account with the pharmacy manager, which is linked with the account at the health insurance company—which is linked to my checking account, but that’s another story. So, to get my pills I have to have three accounts, three account numbers, as well as various User ID’s, passcodes, and group numbers. I have spelled my name and reported my birthdate so often that I feel like a POW who gives only name, rank, and serial number. (Rank is the one bit of information that need not be offered up repeatedly, since we are all buck privates in the Army of Wellness.) I now hate the sound of my birthdate, both because it has become part of a Kafkaesque drone and because on its next anniversary my provider will change and I will have to do this all over again.

Why do I need so many identities? Whoever is administering the benefits, wouldn’t one number for me be sufficient? With that and a bank account or credit card number, they should have everything they need to keep track of my records and make sure they get paid.

Instead, I have many numbers and passwords and codes to keep track of. And many of them come with cards. At one point, when I had more complete coverage, I had five different cards for my health benefits, all with different logos, account numbers, and customer service numbers. I had the medical insurance card, which I was to use for hospitals, doctor visits, and some forms of mental health care. It was a nice stiff plastic, the sort you can use to open any door that does not have a deadbolt, and a slick logo. Almost matching it was the prescription card, which was just as impressive, and could be used at drugstores. Then there were two cards for care that didn’t involve M.D.’s; to mark the lower status of the D.M.D.s and the D.O.’s, those cards were uncoated paper. The dental card was at least on card stock and came with crisp, nicely rounded corners, but the vision care card had to be torn out of a badly perforated piece of paper and so had slightly ragged edges. Humblest of all was the “Employee Assistance Program” card, which had a cheery, childish logo and looked nothing like the prescription card, perhaps because you were to present it when you checked into drug rehab, needed to talk to a therapist, or enrolled in an anger-management course.

None of the cards provided any information on my health conditions—you had to go to my driver’s license if you wanted to harvest my organs and a card with no official standing if you wondered if I was allergic to Penicillin or Sulfa or wanted to know my blood type. In fact all any of the cards said was, “This person is covered by the State of Illinois, which will pay for your services, though you’ll have to wait for your money.” A sticker on my driver’s license saying “IL Med” would have served the same purpose, left room in my wallet, and saved the money wasted creating and mailing the cards and keeping track of the various different numbers that meant the same thing. Why didn’t the state, which needed the money, insist on at least a single card instead of cooperating in all this waste and trouble?

The only answer that comes to mind is that five cards meant five corporations doing business with the state, each offering its own set of campaign contributions from both management and union. (I will not even suggest any money was passed under the table: why bother when so much slides right across the top?) The redundancy and complication is bad for the patient, who is confused by the complexity and wastes his precious time figuring it out, and for the provider, who must either add an M.B.A. to his medical degree to keep track of things or hire staff who never help patients to untangle the mess of payments. But it is gravy for the insurance companies and the politicians upon whom they shower their largesse.

When the Clintons made their attempt to improve American health care, one of their targets was this burdensome system. To solve what I think of as the “Five-Card” or “Full Poker Hand” problem, they proposed a single card and they matched it with a single form to take the place of the endless variety of forms the providers had to master use if they wanted to be paid. Perhaps the forms providers deal with have been simplified somewhat, but this drive for simplicity certainly did not animate the Affordable Care Act. It is more than a thousand pages long, and many people are unsure what is really in it. That is because the insurance companies were allowed to write the various systems from which they profit into the law. While I am glad we have made some progress toward universal coverage, I do not see how we are reducing costs in the areas where they can be cut without hurting patients or actual providers. The physicians I talk to don’t see the burden of complex forms used to delay payment being lifted from them.

To return to prescriptions, years ago I had an experience that showed most clearly what the complexity of our system is really intended to do. At that time, those in my medical plan had to fill out a form for every prescription, pay for the prescription, have the pharmacist sign the form, mail it in, and wait for either payment or requests for more information. The form was lengthy, with plenty of room for errors. I was sure, though, that I had completed one satisfactorily, with every date, price, drug name, and prescription number in place and all the appropriate receipts included with it, and was surprised when it came back unpaid. I had failed to give the address and phone number of the patient. I had filled out all that information correctly for the “insured, ” and carefully checked “self” as the relationship to “insured” under “Patient #1” before listing my prescription details. But I had not filled in Patient #1’s address and phone, which were, after all, right there on the page and obviously mine since my checking “Self” meant: “Guys, that’s me. I live with myself. I use the same phone. I take the same pills. It’s all the same.” In the eyes of the insurance company, however, my claim was incomplete until I wrote in all that information again two and a half inches below. They were clearly not confused, and if the info had to be on those lines, too, for some reason, they could have copied it into them. Their end was clearly just to delay payment, even if it meant wasting my time and stamps as well as theirs. The interest on a state’s worth of prescriptions comes to real money in the time it takes to process, reject, reprocess, and approve a form.

Illinois stopped doing such obvious things many years ago. Now it just withholds payment until long after the dentists start getting testy with the patients it covers. Our entire health care system, however, seems to be devoted to perpetuating this sort of skimming by people who don’t provide any real service.

The hours with the cards, the web sites, the customer services representatives and the three companies who are involved in getting me pills through the mail make me wonder again, what value do the insurance companies add to our health care system? For the most part we are not talking about spreading risk, which is what insurance does. We are talking about providing the care that everyone needs and that has to be paid for. Does keeping the insurance companies involved in the system further the efficient accomplishment of that end? I don’t think it does.

We have not yet had a chance to see how things will work under the Affordable Care Act. But I don’t see any reason to think there will be less of the waste, frustration, and, most importantly, skimming of resources by those who do not provide care that I have been describing. I would want not a state-run system of healthcare, like Britain’s NHS. I do think I would like a single source of coverage that would foster rational competition among service providers without skimming a lot for itself. And I definitely want to carry a single card, access a single website, and go by a single number—or even just by my name and birthdate.

My Foot Hurts. Is that Urgent?

I have a pain in my right foot. I have had it for almost two weeks. It hasn’t gotten worse, but it doesn’t go away. I don’t remember having hurt myself. I can find any growth or bump, but I am not ideally situated to view the soles of my feet. I don’t know what to do.

Why am I telling you about my foot? Because I don’t know who else to tell. On the television shows I grew up with—and on
Doc Martin today—everyone would know what to do. All you need to do is drop by your GP’s office, wait for fifteen minutes while having a cup of coffee, slipping through Look magazine, and chatting with your neighbors while wondering what’s wrong with them.

The trouble is that I don’t have a GP. I have a “primary care physician,” but he is an Internist, certified in specialties and sub-specialties, and no one drops in on him. Even getting to see the nurse practitioner in his office is a bit of a production. If I can’t wait for my scheduled appointments, I’m not likely to even try to see him or his colleagues.

So what do I do? Go to the Emergency Room? I know a lot of people do that, and I have gone only when I felt truly awful (awful enough to be hospitalized, it turned out). I just don’t want to be the sort of man who thinks it’s an emergency when his foot hurts.

If not the Emergency Room, how about an Urgent Care Center? To me URGENT sounds just as dire as EMERGENCY, and I just can’t see a pain that hasn’t even driven me to uncap the aspirin bottle as urgent. I might be less reluctant to go if they dropped the grandiloquent name and just called the place what the doctors themselves call it, the “Doc-in-a-Box.” That name fits the whole ambience of the establishment. When I last went to one, for a horrible backache, I found myself getting my Vicodin from a vending machine. I bought a Coke from another machine to wash down the first dose. Next time I expect them to ask me if I want a side of fries when they take my insurance card.

I understand that in other countries they preserve the local doctor who looks at non-urgent feet and other pre-emergent conditions. I understand that they also have physicians who make house-calls and do other archaic things American medicine has abandoned. I hear they have to wait to see specialists, but I have to wait for weeks to see any physician unless I go to the Emergency Room or the Doc-in-a-Box.

I will not offer any opinion on the Affordable Care Act (Obamacare). I know it will not do the horrible things some people claim it will. The trouble is that I don’t have any reason to think that it will provide an answer to my simple question: When it’s not urgent and definitely is not an emergency, where do I go when my foot hurts?