Urgent Care - Social Services as Businesses

A Parable about Business and Social Services

An older woman I know has a set of problems that may be familiar. She needs to take medication for her thyroid and blood pressure, and she also takes something to keep her cholesterol down. Her old doctor retired and she found a new one in Park Slope at Methodist Hospital through a friend. He seemed competent, reviewed her history, told her to lose some weight and renewed her prescriptions. It took a long time to make an appointment with him, and it had to be done through his practice, but the woman had no pressing problems, so she made an appointment over a month in advance and waited to see him. All seemed well.

However, a problem did arise. The doctor's billing service, over which he had no control, billed this woman as though the doctor were a specialist and not, what in fact he was, her primary care physician. The amount of difference was $35/visit, but it seemed a simple matter to correct. It was not. Over the course of a year, the woman called the billing department repeatedly, and they failed to correct the problem. Eventually one of the people she spoke to told her the problem was with the insurance company. Calling the insurance company revealed that this was not the case. They did not want to pay extra. At the end of a year, the woman threatened to report insurance fraud against the doctor's practice. This produced some result. The billing department stopped charging the extra amount after each visit. However, they did not reimburse the woman for the past excess payments, nor did they reimburse her insurance company. They said to do that she would have to produce paper work for all her claims and start the whole process over again. The woman was worn out.

The next problem that came up was that the woman needed a pair of MRI's. This was outsourced to a nearby company in Park Slope. She needed two and her doctor supposedly sent in the prescriptions. When she arrived for the appointment, only one prescription had arrived. It was early in the morning, so she had the procedure and then had to go back to her doctor, who went back to his appointment staff who made another prescription for an MRI. This took another month. This was irritating, but this was not an emergency; however, it did mean delay and some frustration.

Next, the woman did get a cold that turned into a bad cough and then she got a fever. She called the doctor's emergency number, but there was no reply. When she called his office, they said he was on vacation. She asked for his backup. The office said that there was no backup doctor. After some back and forth, the woman was advised to go to the Emergency Room or an Urgent Care facility. Knowing the ER at Methodist was packed with people, many of them seriously ill, the woman decided to go to an Urgent Care place on Eastern Parkway near Franklin Avenue. There a doctor advised her to get an x-ray, which she did. At yet another appointment with a different doctor, he read the x-ray and prescribed an antibiotic, which after a few days cured the woman of bronchitis. Over a week after she had called her doctor's emergency number, he sent her a text asking if she had recovered. She told him she would no longer be seeing him and began to look for a new doctor.

What went wrong here? I think the answer is that medicine has more and more become a for-profit business. It has the imperative to make money as well as treat patients. So, why does it take so long to make an appointment? It is because the business people want fees, so they see to it that every hour available is scheduled. Doctors used to stop taking patients when they got too many, but now there is no such thing as too many. So making an appointment means waiting for a long time for an opening. Why could the billing department not correct a seemingly simple error. One can bet that there is nothing in writing saying don't correct errors but there are ways of implementing policy without anything in writing. I would guess that if one sent in investigators, the operators would say one thing and the managers another. The is just what happened at Wells Fargo. The lower level people were committing crimes, but they were fired if they refused to do this, but no one in management put in writing that their subordinates had to commit crimes. So everything was hearsay, but it was possible to prove there was a criminal conspiracy. Why did a prescription go astray? Because with all the layers of bureaucracy over which the doctor has no control it is inevitable that there will be mistakes. Who had to pay for these slip-ups? The patient of course. No bureaucrat was rebuked. Why did the doctor not have a back up? Quite simply because having a back up is not economical. It would mean paying a doctor whose time is reserved for the unexpected. So it would be better to send the patient in the greatest need to get the worst treatment in the bad conditions prevailing in the ER or to go to yet another business where she became an anonymous customer. And Urgent Care makes money that way.

The sad thing is that this pattern of turning social services over to business is repeated throughout the economy – charter schools suck resources from the public system to enrich corporations; package delivery companies take the most lucrative business away from the Post Office, and the local Post Office is left a shambles; private prisons have no interest in reforming criminals; private haulers compete with the Sanitation Department to serve merchants, a train system like Amtrak that has sky high prices still breaks down all the time; National Parks are opened to oil companies and timber companies so they can make money in places that should be national treasures; a Veteran's system is starved for funds and then must send patients to private doctors and hospitals; social security might be turned into private investment accounts. The country has moved in this direction for a long time. Now it seems an opposition has appeared. Suddenly it is all right for people to be “Socialists,” people who believe medical care, education, mail delivery, garbage pick up, national parks, criminal justice, and retirement should be government run not with the idea of making money but delivering good service. Will “Socialists” do any better? Only if they can avoid the perils that lie in enormous bureaucratic systems. Transparency and accountability are essential. If before one got fired for not committing a crime, now one must be fired for falling asleep at one's desk or writing a memo instead of taking action. Some other countries have done well. The U.S., China, Russia, India, Brazil and even the countries in the next tier have much to accomplish. There are other countries that do better – Japan, Canada, the Scandanavian countries, and some other small ones.

Epilogue: the woman got a new doctor and when she got bronchitis again, she called him and he picked up the phone at eight in the morning. He prescribed an antibiotic over the phone. The woman was better in days. This doctor does his own billing and insurance; he is not part of a practice run by a business corporation. This could be what everyone gets, and maybe this is true for all social services.

UpdatesJonathan Judge