Feeling The Price Chasm

Even Anita and my routine medical expenses this past month show how our leadership from the top down miss the key flaw with our U.S. healthcare system.

It's like in the satirical novel Catch-22 where the (anti) hero Yossarian tends to airman Snowden aboard their WW2 bomber which has been hit by anti-aircraft fire. Yossarian painstakingly treats a serious but non-life threatening leg wound while unaware that beneath his flak jacket the dying Snowden's abdomen has been blown apart.

In similar fashion, President Obama touts a new system to tie more payments to the quality - not quantity - of health care services rendered. He echoes health secretary Sylvia Burwell's similar recipe offered up on Jan. 26, '15.  This implicitly implies that our main issue is one of over-treatment, "wrong" treatment or even waste, and data shows this to be false as I repeatedly highlight, including in my previous post. Americans already see doctors 40% less and are hospitalized 20% less often than in other developed countries so how is excessive "quantity" a big problem? Yet our bills run over twice as high.

Neither Mr. Obama nor Ms. Burwell nor any legislative leader has said anything about our core problem - grotesquely high prices of medical services and goods compared to anywhere else in the world.

So about our own March medical purchases, these involved office visits to a dermatologist, an orthopedic surgeon and an ophthalmologist for routine eye exams. All providers are highly rated and attended to us well. We paid them out of pocket as it counted towards our deductible in our health savings account.  Our rates were negotiated by our insurer Aetna, which were below "usual and customary charges" or what they would take up front from a cash paying customer without insurance.

Most Americans would consider what we paid to be very reasonable. That's part of the problem as they have no idea about the rates for medical services and goods abroad. Though reports like the 2013 IFHP comparative price study are available, listing our own payments as below and what they'd have been in Germany, France and India puts it all in a personal context:

1) Eye exam: We paid $235 for an eye exam and glasses / contact lens prescription by an ophthalmologist. The cheapest option would have been a $95 eye exam by a Costco optometrist purely to get glasses or contacts - no detailed exam for any other potential trouble.

According to an Oct. 2011 IBES study in France an eye exam costs between 25 and 40 euros (p. 35, or $35 - $55) and in Germany it is free if you buy glasses or contacts from that specialist. If you don't charges vary, averaging around 40 euros. In India an eye test by an optician is free if you buy glasses or contacts from them. Now get this: I paid only $66 for a pair of glasses with progressive lenses and free eye exam in India last year, though charges would have been $150 - $200 had I opted for top line glasses.  For my father-in-law a couple of years ago I had a detailed eye exam for macular degeneration by Pune's top eye specialist for $50.  Routine screening was for $15 - $25. In sum eye exams in France and Germany cost about a fourth, and in India about a tenth of what we paid in U.S.A.

2) Dermatologist: First, most dermatologists were booked solid for two months or had closed their practice to new patients as they were so busy. But one was available within a week. The standard office visit which included some cortisone shots lasted 15 minutes with the doctor and another 15 minutes with a nurse and for paperwork with the office staff. The charge was $262 but our payment was $181 at Aetna's negotiated rate. The doctor also prescribed a generic steroid ointment clobetasol propionate that cost us $40 at our CVS pharmacy.

In France the dermatologist fee would be 25 euros and coupled with the cortisone shots the total bill would be under $50. In Germany it may have been $70.  In Pune, India a reputed dermatologist charges $7 for office visits (and $20 for house calls) and along with cortisone shots we'd have paid $12 - $14. And that ointment that cost us $40 at "negotiated rates?" I discovered I had that exact same one, only a branded product called Tenovate made in India by the reputed GlaxoSmithKline that cost - get this - $2 for the same quantity. In addition as per Indian law the packaging had this price printed on it to prevent overcharging.

3) Orthopedist: The complaint was leg pain. The diagnosis after physical examination and taking three X rays was osteoarthritis worsened by some undesirable exercises. The treatment was avoiding those exercises, wearing a knee brace and taking ibuprofen tablets for a few days. The list charges for this 45 minute visit (15 minutes with the doctor, and the rest with X rays technicians, assistant and billing clerk) were $380 though we paid $220 at Aetna's negotiated rates.

In France an orthopedist will charge 25 euros and an uninsured visitor will pay about 45 euros for X rays (locals pay less) bringing the total to about $90.  In Germany the doctor may cost about $20 more, so overall cost is $110. In Pune, India a top orthopedic surgeon Dr. Dudani charges $6 - $12 per visit depending on where you see him, and X rays cost $5 - $15 in private facilities bringing the total to $11 - $27.

So there you have it. Our March personal medical expenses in U.S.A. for routine treatment were 2 - 3 times what we'd have paid in West Europe even without any state subsidies, and ten or more times those in India.  And it would be all traditional fee for service in those other places as well, with none of those quality versus quantity approaches that seem to be distracting Mr. Obama and his health administration.

Medical Billing Tricks From Up Close

I had of course read accounts like the $75 to $129 hospital charges for a box of tissues. But even somewhat less eggregious billing tricks make you sit up when they affect immediate family. Yesterday I heard of two such instances from my father and brother who live in the (California) Bay Area.

Story 1: My father has been getting hormone suppressing injections of Lupron at Stanford Hospital to treat prostate cancer. A dose of about 22.5mg given every three months was being billed to Medicare for about $1,800. This price is somewhat on the high side considering that it is freely available online in the US for about $1,250. And in India a generic version made by the reputed Wockhardt company has been sold since 2002 for about $140 for the monthly 7.5mg dose, or $420 for three months. So we were surprised to learn that the price of this injection has been almost tripled to $4,800 for the three month dose.

Medicare paid almost the entire amount billed, so my father was hardly affected. But like him enough of my father's urologist's patients noticed these dramatically increased charges to Medicare to enquire about them. This doctor is excellent, and he called the hospital administrative point person to find out what was going on. He was advised "not to worry about it" as this "was a management decision." In other words, the hospital simply jacked up the rates and hit pay dirt, including with Medicare and the taxpayer's money.

Story 2: My brother told me his wife Deanne's car was rear-ended at high speed by a teen-age driver. Her Audi S4's rear as well front scrunched like an accordian (since the impact caused her car to hit the one in front of her) but did its job in protecting her. She heeded the advice of the paramedics called to the scene and was taken to El Camino Hospital to ensure there weren't internal or whiplash injuries. A doctor examined her and ordered a blood test to ensure she wasn't pregnant since X-Rays can harm a fetus. (I thought a simple pregnancy kit can do the job but never mind.) Deanne then had a couple of X-rays taken which didn't show anything abnormal, and was out within an hour of having first entered the emergency room.

The hospital bill for this was $5,000 though they received "only" $1,500 at the discounted insurance rates. The surprising part was the cost of the blood test. The same hospital has in the past ordered these at the adjoining Quest Diagnostics lab which bills $220 and receives a payment of $110 for these services. But this time the attending doctor ordered the test to be done in the hospital's own diagnostic lab. They billed over $1,000 - the amount a hapless uninsured or self-paying patient would have had to pay for this simple test, though Deanne's insurer paid at the "in-network" rate of $110.

Why should the hospital lab charge such exorbitant amounts, that ambushed uninsured or "out of network" payers would be fully on the hook for? Even the negotiated rate of $110 is quite high. In contrast, my in-laws in Pune, India pay only $30 for a far more extensive blood and urine routine. This even includes two home visits by the technician (since my in-laws are largely bed-ridden) to collect samples while fasting and then eating something.

Both of these stories show how providers can and do game the system. Patients and payers have a very limited set of hospitals in the vicinity, and these keep pricing opaque while raising rates at will. Reforms and regulations should put an end to such price gouging, and Medicare as a major payer should be allowed to directly negotiate drug prices. Yet the opponents of reform mislabel the present system as a "free market" and the recent medical overhaul will do little to check such practices. The budgetary crisis and pressures from the crushing health care burden will hopefully allow follow on measures that change the situation.

The first case of Lupron over-pricing also points to administrative lapses by Medicare. I'd have expected their payment systems to automatically flag claims where prices were so high relative to drug costs, rose suddenly or were out of whack with those from other institutions. That's even if Stanford Hospital had tried to disguise its moves through some clever upcoding to beat detection software. Donald Berwick has now been appointed Director of CMS and Obama has been in office for almost a year and a half. So such weaknesses should be fixed quickly - you can't keep blaming these on your preceding Bush's team forever.

Northern Myth Busting

We shouldn't generalize about the state of health care from individual anecdotal accounts. But these blog posts in part 1 and part 2 back from February of 2008 by Sara Robinson are good testimony from someone who has seen both the Canadian and US systems from up close. Moreover, in debunking and occasionally confirming claims about the Canadian system she cites facts and statistics that corroborate her first hand experiences. In a word she says Canadian care is at least B grade for every Canadian, while for much higher cost US care is A grade for some Americans, and C or D grade for many.

More recently on September 10, 2009 she described her efficient and worry-free hospitalization and treatment in Canada on the very day of President Obama's health care speech to Congress.

But if you've time and appetite to look up just one item I'd recommend this entertaining link sent to me by single payer advocate Jonathan Starr. It features Canadian Steven Lewis exposing US health care myths and deficiencies with music, sarcasm, facts and humor.

At the bottom of this clip is a link to a longer and more serious expose titled "Universal Health Care Message to Americans From Canadian Doctors & Health Care Experts." Canadian health care is overall better and more cost effective than that in the US, though I prefer private insurers to be allowed to offer competing choices as in many European countries. That private competition is what all serious US reform proposals envisage anyway, though private insurers rightly fear most people will opt for the the public option if they're allowed to do so.

What about opponents of changes in US health care? Here is a clip of town hall protests on 8/29/09 against health reform in Spring Valley, CA. As I commented to some friends it's scary if these are "ordinary Americans". They remind me of the 2006 movie "Idiocracy" where future generations become retarded.

Too bad that Democratic leaders like Senate Finance Committee Chairman Max Baucus seem to have heeded such sentiments. After wasting months seeking a bipartisan solution he came up with an ineffectual Senate bill without a public option that's a sellout to the insurance industry. Surprisingly he still didn't get any of the Republican members of the "Gang of Six" to sign on.

The only way I'd view Mr. Baucus' efforts positively (or even Mr. Obama's to date) is if this bill has been conceived just get something past the Senate including their own Blue Dogs. And then the plan is to introduce effective changes like a strong public option through the reconciliation process solely with Democratic support.

CDC Can Do More on Swine Flu

Looking up the CDC website on swine flu guidance reminded me of an old joke about a balloonist who was swept away by the winds and got lost.

He lowered himself next to a tall office building. He wrote "Where Am I?" on a placard and held it up for the people inside the building windows to see. Those people responded with their own placard that said "You Are in a Balloon 100 Feet Up in the Air." That answer was however enough for the balloonist to know that he was at the Microsoft headquarters in the Seattle suburb of Redmond. For going by its help feature in its products only Microsoft could provide an answer that was completely correct and yet so irrelevant and useless.

How's this related to swine flu? About two weeks ago I briefly came down with the sniffles and a mild fever that lasted less than a day. Then over this Labor Day weekend we drove to Pittsburgh where Anita's nephew had similar symptoms. We isolated the affected person (me and our nephew) and considered the obvious question of whether to seek testing, and if yes, where.

Testing would help the authorities to compile statistics and monitor the spread of the disease. Patients testing positive would know what to watch out for and be extra careful about exposing others. Recovered patients presumably acquire immunity, and needn't worry about subsequent exposure, or getting inoculated when the swine flu vaccine becomes available.

On the other hand, patients arriving in large numbers in medical facilities could put providers and other patients at risk, and strain scarce resources. Also, uninfected patients can acquire the H1N1 virus from others in the very clinic that they visit.

Weighing these pros and cons we looked at the CDC and other official websites for guidance. Despite all the other information crammed in there, we found nothing addressing these obvious questions. Countless other patients and American families may be similarly confused and frustrated.

The closest answer I got after clicking through links and menus was an indirect one, under "Home Care Guidance: Physician Directions to Patient / Parent." It said that you should see a doctor or seek medical help if you develop certain serious symptoms, presumably meaning that you shouldn't if these don't occur. It needs to be a lot more explicit and easy to find.

The new health care and CDC leadership under the Obama administration has been in place for quite some time, with Director Thomas Friedan confirmed in May 2009. They should have personally scrutinized their agency's website and confirmed there are no glaring omissions. They don't seem to have adequately done so, but this is fixable. Having worked in government these are the obvious added steps I would take in regard to swine flu were I directing CDC or the HHS in regard to the flu:

1) Prominently feature in the Frequently Questions (FAQs) and other parts of their website, as well as in briefs to the media

• Advice to persons with typical symptoms and parents on whether and when to get tested for swine flu, and when not to
• Similar advice on when to seek medical help or visit a doctor, and when to hold off out of concerns of spreading or contracting infection
• Some information about the cost of testing, the best places to go to (doctor's office, clinic or hospital emergency room?) and the reliability of the tests. Add more "layman" information about the benefits - and the downside or risks - of anti-viral treatments like Tamiflu and Relenza.

2) Have an interactive feature on the website where users can enter their address or zip code. They then get a listing with addresses and contact information of nearby medical facilities that have special swine flu treatment arrangements and / or accept patient samples for testing. To keep pricing transparent and competitive, such facilities should disclose their prices for standard testing and treatment, and this information should also be displayed. If an interactive feature is beyond CDC's scope they can at least provide links to state and local government resources that provide this information. It will specially help the uninsured, and many insured patients as well.

3) Engage and coordinate efforts with large providers and test labs to expand capabilities to handle swine flu patients. The CDC can also issue standard guidelines and practices (e.g., separate windows and rapid turnover waiting areas for flu patients in emergency rooms with proper signage, to limit cross-infections) that help providers and patients alike. The CDC can even use its power to disseminate information to have "suggested prices" for testing and treatment. Coupled with inviting providers to include their prices in the links on the CDC website as at (2) above, this will encourage lower prices.

4) Orchestrate a system to enable healthy family members to get sterile vials or containers from labs, collect patients' samples like nasal swabs, and submit these for testing. This way patients being tested get to stay at home and again limits inconvenience and the spread of infection.

5) Encourage or help set up a system of home visits to patients by health workers. Such workers should have either already contracted and recovered from H1N1 infections, or have been vaccinated after this treatment becomes available, so that they are immune.

Similar steps can be taken to disseminate detailed information about the swine flu vaccine which is expected to be widely available very soon. The CDC and the HHS are large organization with multiple responsibilities. So ideas like these may not have been considered. I hope they are responsive once they see them. Since H1N1 flu has now spread worldwide, other countries can also adopt similar practices.

Easily Conned?

Last Friday I traded in our ancient minivan to buy a new SUV under the highly popular "Cash for Clunkers" program.

As I was signing the final papers, the manager at the GM dealership lamented the bureaucratic wringer and technical glitches that have plagued the program. The government website (for uploading claims) would remain unavailable or keep crashing. Paperwork was tedious and claims were rejected for trivial reasons. Four weeks after filing the first claims the dealership had yet to receive any money.

"The government messes up everything, and now it's trying to take over our health care," said the auto manager. I asked him what he thought of the public option, and he said he is dead set against it.

That stopped me short. Here was someone who was (a) not a health provider or insurer, (b) not a $250K+ earner who would see taxes hiked up, and (c) not a lawmaker (Republican or Blue Dog Democrat) bribed by the industry to safeguard its interests. Moreover, he is in the business of selling new and used cars. That's someone who should be savvy enough to tell facts from fiction.

Yet even he swallowed the industry claims and counter-arguments against reform. He objected to the public option because his employer may then drop his private insurance (why should it matter if the public plan is better, or he can still see the same doctors?) When asked about the popular Medicare for seniors, and why not offer it to all Americans, he said Medicare will be out of funds (if it's cheaper, the funding is just a matter of allocating enough to it.)

This underscores just how easy it can be for reform opponents to confuse (or sucker) the average Joe about changes to the system. The Obama administration certainly hasn't helped with its mixed and conflicting messages on its commitment to the public option.

It doesn't have to be this way. Here's a link I received from Jonathan Starr of an MSNBC "Morning Joe" discussion between Republican host Joe Scarborough and Congressman Anthony Weiner (D - NY). Weiner advocates a single payer system and his logic for it even gets Scarborough (to his credit) thinking hard and admitting he's impressed "and speechless." Why isn't Mr. Obama making this case?

Paul Krugman has criticized Obama in today's Op-Ed in The Times. He also repeats that "Reaganomics has failed to deliver what it promised, yet people still believe that government intervention is bad, and leaving the private sector to its own devices is good."

A remarkable national survey result also shows that a majority of Americans believe most of the 19 myths floated by reform opponents.

Republicans also have some (a few, I wish they had more) good ideas on health reforms that are being ignored by Democrats. Chief among these is the need for malpractice reforms. It may bring down some health care costs, or at least remove one major reason (or excuse) advanced by providers for high costs.

Then there are reforms that neither party stresses, like vastly expanding the supply of doctors and other providers, and curbing hospital market power. A reason reforms are so difficult is that each interest group has powerful leverage and lawmakers protecting them. Strong public demand can pressure the politicians to do the right thing. For this to happen President Obama needs to stop being so passive and overlearning from the Clintons' 1993 experience. He should instead imagine how Hillary would act now if she were in his place.

And Americans like my auto dealer need to better judge industry claims.

Another Pune Hospital From Up Close

In our current India trip I've come into close contact with another major hospital in Pune, India. This time it is Ruby Hall Clinic (aka Grant Medical Foundation) which is more plush than Inlaks & Budhrani Hospital that I first talked about in my Oct. 28, '08 post. It's a more likely destination for Western medical tourists, though still imperfect including from the perspective of its geographic location and distance from an international airport.

On Dec. 24th after arriving in Pune Anita and I took my in-laws (Daddy and Mummy) by ambulance to Inlaks for a thorough follow-up medical examination. The pronouncements by Dr. R and Dr. P were very encouraging. Daddy had recovered well from his two surgeries 2 - 3 months earlier, and both Daddy and Mummy needed just some minor adjustments in their medications. Our system of having four good round-the-clock attendants and daily home visits by a physical therapist seemed to have worked well. Mummy's main problem was a persistent irritation in the throat and esophagus that sometimes caused her to throw up while eating. Dr. R ascribed this irritation to a drug she was taking to control heart function and blood pressure, and switched it.

On December 25 while we were dining together, Mummy gagged on a mouthful of food. Familiar with the drill, Shabana (her attendant) brought a pan as she coughed and retched, and then quietened with her head down while (we thought) regaining her breath. But a few moments later we asked whether she was okay and there was no response. She was immobile and slumped over with her eyes open. I immediately did a Heimlich Maneuver in case something was choking her. No effect. Then suspecting a major stroke attack I dialled 101 (the Indian equivalent of 911) for an ambulance though the system worked differently from the US.

The operator advised me to directly call the ambulance service of the hospital and gave me the number of Ruby Hall that I picked among the choices. The Ruby Hall dispatcher was quick, and asked if I wanted a doctor to come with the ambulance for an extra charge and I said yes. (Otherwise they send ward boys to help evacuate the patient, but they are not trained and equipped like the paramedics in the US.)

Mummy came to four minutes after her attack, just as I put down the phone. She didn't recall losing consciousness, and wondered what the fuss was about. Fifteen minutes later at about 10pm the Ruby Hall ambulance arrived with a resident doctor from the trauma unit and other staff. The doctor asked questions, examined Mummy, and found her functions and vital signs to be near normal. Mummy was then carried down from their second story apartment to the waiting ambulance and we arrived at the Ruby Hall emergency and trauma center.

There, she was further examined by other personnel including the emergency medical officer, then sent for head MRI, X-ray and other tests. They found nothing alarming. By now it was well past midnight, and she was moved to a nice big private room in the in-patient wing. Our attendant Shabana whom I had brought with me had done a good job helping tend to Mummy and stayed the night with her in the hospital.

In the morning the senior neurologist Dr. B. came into Mummy's room, examined her as well as the test reports and told us she hadn't suffered a stroke and there was nothing to worry about. She had merely fainted ("transient loss of consciousness") because her fit of coughing and heaving had temporarily restricted blood flow to her brain, with no other ill effects. If it ever happens again, he advised, she should be made to lie down (this time she had been kept propped in her wheelchair) so that the increased blood flow to her head revives her more rapidly. By 4pm that evening Mummy was back at home. Anita had stayed back at the apartment to take care of it as well as Daddy, and there was relief and celebration when we all got back together.

The outcome was the best we could have hoped for under the circumstances, and we went ahead with our plans to fly to Delhi the following morning. Our overall experience with Ruby Hall was very good. Here are some highlights:

Ruby Hall is certainly more upscale than Inlaks. Security staff at the entrances checks bags (a fallout of the Nov. 26 '08 terror attacks in Mumbai.) The staff to patients ratio is higher and the rooms and corridors are cleaner. In the inpatient wing the attentive female staff at the nurses' station was smartly dressed in two distinct types of sarees. I learned that nurses wore one type, and the other was worn by "coordinators" who were there to help schedule appointments for patients, assign them rooms, look to their comforts, regulate visitors, etc.

There were several residents and interns in the emergency and trauma center when we had arrived around 10pm who looked very young and not too experienced. They did have a "full-fledged" doctor in the emergency medical officer and a head resident, who both also looked thirtyish or less. But when I think back to emergency room visits to US hospitals during off-hours the availability of doctors is far less.

The canteen and food catering service was impressive. Poor Shabana hadn't had time to eat dinner in our rush to the hospital. When we finally settled into the private ward past 1 am, I could order in sandwiches, tea and coffee from the limited menu they offer round the clock. And during regular mealtimes they had an extensive menu and good preparations of vegetarian and non-vegetarian fare that would have done an upscale restaurant proud. The prices were low too - under $2 per entree. I half-joked that we should come here when we want to eat out.

Some folks had warned me that hospitals like Ruby Hall may try to keep patients longer and order more tests than are necessary just to increase their earnings. But I found absolutely no evidence of this. In fact, Mummy was upgraded to a "super-luxury room" at no extra charge because the deluxe room we sought was unavailable.

The senior doctors here (who are mostly "consultants") enjoy a good reputation, including the neurologist Dr. B who was competent, genial, and committed to his patients. He was very accessible and gave me all the extra time I requested to discuss Mummy's condition and prognosis.

In overall prices Ruby Hall is costlier than Inlaks, but still remarkably inexpensive by Western standards. We paid a total of Rs. 15,000 ($310) including $160 for the MRI and X-rays, $60 for a deluxe private room, and $25 for the two ambulance trips (with the doctor on board for the inbound trip). Our total also included $42 for an optional bone mineral density (BMD) test that we went for since Dr. R from Inlaks had recommended it though Inlaks didn't have the equipment and Ruby Hall happened to be offering it.

One shouldn't extrapolate from a single instance and I've heard a couple of stories to the contrary about Ruby Hall. But our own experience there was very good.

A Common Doctor Blind Spot

Patient alert: Many doctors seem to have a blindspot while treating infections. This can subject patients to needless agony or worse. I have personally observed this at least half a dozen times in India and the US, and some cases ended very badly. In all of these the patients were intensively treated with all kinds of strong antibiotics, to no avail. Here they are in chronological order:

1. Over forty years ago my father's uncle suffered a slow and agonizing death from virtual starvation after being hospitalized and then released. He refused to eat anything, and by the time they figured out why, it was too late.
2. My brother Kaku as an infant was afflicted with this infection and suffered for weeks after a hernia operation. It even transferred to my mother who was breast-feeding him. Finally, a very good and experienced doctor diagnosed the problem and it disappeared quickly.
3. Vivek from my college and subsequently my IAS batchmate in HP had a severe illness in the late 70's that landed him in one hospital in India and then another for several weeks. He had high fever, loss of appetite, yellow eyes and other symptoms of hepatitis that had doctors stumped since he did not respond to conventional treatments. Starting from a healthy body weight he lost about forty pounds in that time before doctors in India's famed AIIMS hospital correctly identified the infection. They then quickly (and easily) treated him, bringing him back from the brink.
4. In the late 80's my friend Raj was hospitalised in LA for several days with high fever and other symptoms that defied any treatment. Finally, a doctor of Indian origin happened upon his case, asked him one very relevant question, then ordered a test that confirmed that doctor's suspicions and prescribed medication that rapidly cured Raj.
5. About 10 years ago my young cousin Pavan in the US who was a medical student had a tonsillectomy. A few days later the pain in his throat was so acute despite all the medicines he received that he couldn't eat. Based on her experience (and high intelligence) my mother who has no medical background guessed at the problem and asked Pavan's family to bring it up with his doctor. The doctor after needless delay finally listened and Pavan was treated, but his prolonged suffering caused him to miss his medical board exams that year.
6. Just last month my father-in-law (Daddy) was recovering from two major surgeries at Inlaks hospital in Pune, including complications of pneumonia and hospital acquired infections. His lungs cleared and surgical wounds healed after a strong regimen of antibiotics, but he continued suffer from cough and persistent throat irritation. He couldn't sleep, asked to gargle every 15 - 30 minutes even at night. The Inlaks doctors ordered more antibiotics and tests and thought the irritation was due to residual infection in the breathing passages, as well as the feeding tube that was subsequently inserted because Daddy wouldn't eat or drink. But the problems was as bad or worse for several days after the feeding tube was removed and he was taken back home. Then I had Dr. I examine Daddy at home. Dr. I is very intelligent and sought after though he doesn't have quite the fancy qualifications of the Inlaks doctors. He had Daddy open his mouth wide, depressed his tongue and peered at the back of his throat with a flashlight. That was enough to provide the answer and clearing the condition in two days, though this was after two weeks of avoidable suffering and debilitation.

There is a common thread in all these cases. The doctors did not consider anything beyond bacteria and viruses as the cause of the infections, or simply ascribed the problem to "weakness" or irritation.

But in four of these cases at 1, 2, 5 and 6 above involving my great-uncle, brother Kaku, cousin Pavan and Daddy respectively the culprit was oral fungus, commonly known as thrush. The "good" bacteria in the oral cavity normally keeps this fungus in check, but antibiotics can kill this good bacteria. Then this very painful fungus infects the delicate lining of the oral cavity and typically shows up as white spots (though these may not be visible in the esophagus.) Once diagnosed, thrush is easily and rapidly treated. But if doctors who don't catch on and simply give more antibiotics can make the problem worse instead of better.

In case 3 involving my colleague Vivek, the culprit was amoebiasis where it was the amoeba that had invaded the liver. Again, while antibiotics don't work at all, anti-amoebic medications rapidly clear the condition - provided the doctors make the correct call.

Wanna guess what Raj had come down with in case 4? Well, it was malaria. The American doctors did not have this on their radar as it rarely occurs in the US. But the Indian doctor asked Raj if he had been abroad recently, and when Raj mentioned his recent trip to India, the doctor asked for his blood to be tested for the malarial parasite, and viola!

The takeaway: it seems to be a fairly common doctors' blind spot. If conventional treatment isn't working ask your doctor early on if he / she has considered and ruled out non-bacterial and non-viral infections like those caused by fungi, amoeba and parasites.

Hospital Drug Deals

My in-laws' lengthy hospitalization at Inlaks in Pune exposed me to the gamut of practices and attitudes of the doctors prescribing drugs. Most of my observations are applicable to medical practitioners elsewhere in India and the world, including in the US. An eye-opener for me is how largely unseen doctors like pathologists can steer expensive drugs to patients.

But first the main takeaway: it can help a lot to seek multiple inputs, even informally, especially when expensive drugs or treatment are involved. I managed to identify some good and caring doctors and asked them questions like, "If our patient were your own parent, then what would you do or advise?"

As elsewhere, the Inlaks doctors can be divided according to their prescribing behavior into three types.

Type 1 had close ties with the pharma reps who frequent hospital hallways and waiting areas. These doctors aggressively prescribed expensive brand name drugs (when cheaper generics or substitutes were available), and especially so if you appeared to be a patient of some means. My in-laws were regarded as such because Anita and I live in the US.

Type 2 were the bystanders or silent collaborators of the Type 1's. They didn't actively push the most (unnecessarily) expensive drugs themselves, but tended to concur with colleagues who did, when specifically pressed on the issue, or consulted for a second opinion.

Type 3 were the ones I truly liked and respected. They were strongly guided by their patients' physical as well as financial well-being. They recommended expensive drugs and treatments if they felt we could afford these, AND if these had significant advantages over cheaper options. They also laid out any trade offs fairly. More importantly, they were uncomfortable enough with the behavior of Type 1's to be willing to call them out.

My sense of the Inlaks doctors is that about 20% of them are Type 1, 70% are Type 2 and 10% are Type 3. Dr. Y, a Type 3 whom I came to like a lot wryly noted that most doctors will support their colleagues because they expect to be similarly served when their own actions are questioned. That's why there are so many Type 2's, apart from this being the path of least resistance.

I had noteworthy experiences with some Type 1 and Type 3 doctors.

I regretfully categorized Dr. R as a Type 1 because he otherwise had many positives. He was highly experienced and competent, with a great bedside manner. It was his quick conclusion that Daddy may need emergency surgery, his ordering immediate tests and alerting the surgeon Dr. P that helped saved Daddy's life. Dr. R also sized up Mummy's condition and treatment well. But he spent much more time with pharma reps than his colleagues did. He prescribed a lot of expensive drugs for Daddy that his colleagues felt were unnecessary, or where cheaper substitutes could have worked as well. It's possible that Dr. R genuinely believed in the greater efficacy of the more expensive options, but I sought other opinions to settle nagging doubts.

It was also revealing to see how the Inlaks pathologist Dr. A and his staff from behind the scenes could foist expensive drugs on to patients. Their role may or may not have been in concert with others like Dr. R. Dr. A performed culture and sensitivity tests on Daddy's sputum and other samples. In this, the harmful bacteria present in the sample is cultured for 2-3 days and tested with various antibiotics to see which ones kill it and should be given. The only thing is, Dr. A only tested some of the costliest versions of some drug categories, and omitted the cheap ones that may have worked just as well.

Such practices create broader problems that go beyond draining patients financially. You, see, a lot of these costly new drugs have been introduced to combat germs that are resistant to the cheap conventional ones. They should be sparingly used only when others don't work, or else we'll quickly end up with bacterial strains that are resistant to the new drugs as well.

Case in point: Dr. A's lab tested tigecyclin to combat Daddy's infection caused by the pseudomonas bacterium. This tigecyclin is a tetracyclin-variant drug patented by Wyeth. It was shown to work, but costed $500 - $700, and they never tested for basic tetracyclin or its off-patent versions like doxycycline that cost as little as $20.

I learned about this only because I routinely sought out the opinions of other doctors, two of whom turned out to be Type 3's. One was Daddy's surgeon, Dr. P whom I've talked about in the previous post. The other was Dr. Y in the ICU who was passionate about his patients and visibly worked up over any instances of their inadequate care by the hospital staff.

I asked Dr. A why the much cheaper alternatives to tigecyclin were not tested on Daddy's sputum sample. Dr. A's unsatisfactory response was that he stocked a limited number of drugs for testing, and that his lab "did not concern itself with the costs (of the drugs)." When I expressed my dissatisfaction he agreed to test a fresh sputum sample against drugs that other doctors suggested, like doxycyclin, so I had a fresh sample submitted. But we still had to start Daddy's treatment with the costly tigecyclin since we couldn't wait another 2 - 3 days for the new culture and sensitivity results.

Then Dr. A quietly "rejected" Daddy's new sputum sample as being insufficient in quantity and discarded it without testing. By then it was too late to test another sample since Daddy's tigecyclin treatment had already started and killed off the invading pathogens.

I'm convinced Dr. A acted this way to avoid being exposed if the cheap doxycyclin turned out to be just as effective as tigecyclin. I voiced my concerns to the Inlaks Medical Superintendent who oversees all medical matters. She promised to thoroughly look into these practices though I wonder if anything came of it.

What I do know is the immense value of identifying and dealing with Type 3 doctors. I relied on four of them at Inlaks - apart from Dr. P and Dr. Y, there was the head of surgery Dr. L and orthopedic surgeon Dr. D. Even though we ended up using tigecyclin we were spared other unnecessary treatments.

But being a Type 3 isn't easy. I could see the pressure on Dr. P who was Daddy's attending physician. Guided by his convictions Dr. P would cut out treatments (especially costly ones) that he felt were unnecessary. This often put him at odds with more senior colleagues like Dr. R who could impact his professional career, yet he followed his conscience. I hope he and others like him are appreciated and do well.

Medical Blunder and its Aftermath

We faced this situation while in India last month: How to react when a dedicated and otherwise competent doctor makes a grave mistake that puts the life of your loved one in limbo?

Our spirits were high on October 1st. It had been almost nine days since my father-in-law (Daddy's) emergency surgery for a ruptured duodenal ulcer. Anita had joined me in Pune, and my mother-in-law (Mummy) was also doing well in an adjacent private ward in the same Inlaks Hospital. Both were to be sent home the following day.

Daddy's surgeon Dr. P had said that the first 6-7 days were the most critical in Daddy's case. This is because the sutures to repair the large perforation of the duodenum are very vulnerable to the strong acids in the stomach, and can typically give out by day 6. If they hold past that, then the prognosis is very good. Daddy was now past that critical period. He had some problems with cough, pneumonia and weakness following the surgery, but this was under control and considered normal for someone of his age who was inactive after a major surgery.

Daddy's IV lines were removed and similar preparations were made for his urinary catheter as well. Dr. P came in and removed the external staples that had held Daddy's almost 2 feet long abdominal incision together. He then urged Daddy to try and resume normal activities including walking as quickly as he could.

An hour later things went terribly wrong. Daddy was coughing hard, and as a result suffered a burst abdomen, meaning that his recently stitched abdominal wall gave out, spilling out some of his insides. Anita raised an alarm and Dr. P. was there within five minutes. He and his juniors hastily tended to the gaping wound, temporarily taped it up, assembled a surgical team and began an emergency surgery within 45 minutes to repair the damage.

The cause of the problem? Daddy is 89, and many of Dr. P's colleagues told us that they'd have not removed the staples for at least 12-14 days after the surgery (instead of the nine days as happened here) and have taken other precautions to protect the healing wound.

The trauma of this second surgery and its consequences placed Daddy's life in the balance for the next couple of weeks. Apart from blood and fluid loss his complications included pneumonia, kidney malfunction, severe hospital acquired infections and heart complications. He was in pain and delirious or semi-conscious for several days. Anita and I cancelled our flights back to the US and postponed subsequent programs in this period. Fortunately, Daddy pulled through, slowly recovered and is now recuperating at home.

Despite his blunder my relations with Dr. P and his colleagues remained warm and cordial. I have repeatedly been asked two questions. First, did I genuinely harbor no ill will towards Dr. P, or did I just mask my true feelings? Second, had this happened in the US, would we have sued and made Dr. P pay heavily for his mistake?

To the first question, I obviously very much wish that Dr. P had played it safe and none of this had happened. But after it did, I still had good feelings about him. We continued to have an easy relationship and I'd even joke about the colorful shirts worn beneath the white coat of one of his cheery-faced residents when they'd visit us in Daddy's room. Here's why:

• I believe Dr. P's prompt action and skill during the first surgery on September 22 was a big factor in enabling Daddy to pull through. So I attribute Daddy's being home and improving today to Dr. P's initial action
• Dr. P is overall an accomplished surgeon who is also very responsive. Like many of his colleagues (and not at all like in the US) he had given me his cell phone number at the time of the first surgery and was directly accessible on that when I needed him. (Of course I tried not to abuse this privilege)
• I perceive a big difference between negligence that may come from not putting in the required time or effort, and "just" a misjudgement. I knew that Dr. P never lacked for sincerity, dedication to Daddy's welfare, or hard work. His unfortunate miscalculation in removing staples prematurely stemmed from a concern about their continued insertion causing a surface infection. I'm sure the consequences will guide his future judgement and help other elderly patients
• We were fairly high profile at Inlaks (partly because it is rare for both husband and wife to be simultaneously checked into adjoining deluxe wards, and that too by a son-in-law visiting from the US.) Dr. P's mistake was widely known among his colleagues. He paid enough of a price in that sense without me raising the subject with him
• Dr. P as a person was decent, caring and straightforward. He was uncomfortable when other doctors tending to Daddy prescribed medications that he felt were unnecessary or even needlessly expensive (yes, some of that pharma - doctor linkage seemed to exist here, too.) As coordinating physician he struck off some of these medications or expressed reservations about them, even at the risk of running afoul of his colleagues. I felt I could trust his commitment and intentions
• Once the second surgery became necessary, Dr. P did everything necessary to reduce its risk. General anesthesia for a second time in a frail patient is a major risk, so he performed this surgery using spinal tap and local anesthesia. He also got his team to waive overtime charges for performing it after hours. He closely monitored Daddy's condition and incessantly advised and encouraged him

Coming to the second question, how would we have acted had the same lapse occurred in the US? We wouldn't have sued Dr. P for all the reasons above. A sued physician pays a huge price even when he is fully insured. This price is in terms of damage to his record and reputation, the distraction of defending a lawsuit, and increases in future premiums.

However, in the US the extra cost following the second surgery may have exceeded $100,000 even at negotiated rates. A substantial chunk may have been payable out of pocket and I would probably have asked the hospital to waive or substantially reduce this. At Inlaks in India the extra charges only came to about $3,500. Given how everyone pulled so hard for Daddy's recovery I didn't seek any reduction in this. In fact when it was Daddy's time to leave he asked me to give some gifts to the staff that had attended to him so well.

Long Stay in an Indian Hospital

I have been out of blog circulation for a while, having just returned from a five-plus week unscheduled trip to India. Anita joined me for three weeks in this period. We spent all our day time hours and half the nights as well in an Indian hospital in Pune where both of my parents-in-law were admitted. In the process I learned a lot about one of the many decent hospitals in India that would not make the cut as a medical tourism destination. Here's how it happened.

We heard in mid-September about how my mother-in-law's (Mummy's) health condition worsened after she was bedridden after a couple of falls in the bathroom. She also had difficulty swallowing and stopped eating. The doctor making house calls suggested that she be moved to a hospital for extensive tests and possible treatment. The only way we've moved her out of their second story apartment that lacks elevators is by stretcher and then transported her by ambulance.

My father-in-law (Daddy) simultaneously developed high fever caused by a suspected viral infection. This was followed by side effects of some nasty medication that was prescribed, but we expected this to pass relatively quickly.

Since Anita and her two brothers are all living in the US I left for Pune for what I thought would be a short trip to have Mummy and Daddy checked out and treated. My direct flight on Delta Airlines from JFK to Mumbai was surprisingly comfortable and I headed straight to Pune by road, arriving there within five hours.

While Pune doesn't have JCI accredited hospitals popular with medical tourists, it does have some decent private ones. The three we considered were Jehangir (now owned and run by the famed Apollo group), Ruby Hall (aka Grant Foundation) and Inlaks & Budhrani (run by the charitable Sadhu Vaswani Mission.)

The former two are reputedly more posh and professional, but I settled on Inlaks on the advice of two of my in-law's relatives who said (a) the doctors and staff there are more caring and less driven by profit, and (b) this hospital is run by the Sindhi community to which my in-laws belong, and they'd have more access and attention from the top operatives if this is needed.

My in-laws were admitted to Inlaks just a day apart. Contrary to expectations Daddy's case turned out to be far more serious. He had a large perforation of a duodenal ulcer that was building for years but one we were all unaware of. At age 89 he went through two emergency surgeries nine days apart, which were the first in his life. He spent 25 days in the hospital, and his situation looked grim for quite a bit of this time.

Fortunately, Daddy and Mummy are now home and recovering well. Here are some notable aspects of our experience:

• The hospital costs were very low by US standards. Daddy's 25 day stay in a deluxe single occupancy room, a score of specialist consultations and two surgeries could have easily cost $200K in the US, even at negotiated rates. At Inlaks it came to about $6K. Similarly, Mummy's 19 day stay and treatment cost about $1,600.
• In addition to these hospital costs, I also for good measure engaged round the clock help-maids (called "maussis" or "aunts" who help clean and care for the patient) privately for both Daddy and Mummy. They cost a total of about $20 per day and made things a lot easier.
• A lot of the hospital staff was very caring. The nurses and aides would call elderly patients "Uncle" or "Aunty." Those in the ward would visit Daddy in the ICU the times he was moved there just to see how he was doing. When the time came somewhat to our amusement Daddy was reluctant to leave the comforting cocoon of hospital care.
• I came to know many of the doctors and administrators, and developed distinct impressions about them. I was struck by the competence and humanity of a sizable number of them.
• The hospital adjoins the Osho ashram founded by Swami Rajneesh (first made famous by the Beatles who visited it decades ago) and is popular with many Western visitors. I found several of them coming to Inlaks for medical attention and chatted with some of them. They seemed happy with the care overall. That said, I don't consider this hospital suitable for medical tourists, who should expect a more upscale, sterile and professional environment. But if you're not too choosy, you get decent care and can't beat the price.
• A lot of the nurses had very arduous tasks and often seemed to be understaffed and under stress. I was surprised at how little they were paid - netting about $150 a month in cash or even less. There seems to be a strong case for paying them much more without hurting financial viability.
• Anita has a phenomenal extended family. I joke that when I married her I didn't realize I'd get such good relatives as dowry. Her cousin Rita insisted on coming from Mumbai to Pune with maid in tow for 5 days and was invaluable in taking charge of Mummy's care in hospital while I dealt with Daddy's situation. Another set of cousins Ashok, his sister Indru and her husband Gul (who own the Sun-n-Sand hotel chain) came from Mumbai to visit. They gave us the penthouse suite of their Sun-n-Sand Pune 5 star deluxe hotel (located less than a mile from the hospital) and full run of all facilities and an army of liveried staff through our stay there. Gul specially called and Ashok threatened to "kill me" when I protested I couldn't accept such lavish help. But it made a huge difference. Then there's Meena and her parents Hira Uncle and Dru Aunty (Mummy's sister) who were always there with help and advice. The list goes on and we're blessed.

I intend to describe some aspects in more detail in the days to come. It's good to be back in the US. My brother-in-law Prakash who lives in Pittsburgh is now with my in-laws for the past few days and doing a great job caring for and settling them down.