The Greatest Healthcare System in the Western World. . .

Ok, it’s my turn to write this one, cause I don’t know if Kristin will have the stomach to do so. I have a co-worker who often sagely remarks that I am serving in the only truly socialist healthcare system in the western world – in the sense that people come to get care, without paying anything, and I am paid a salary regardless of the number of patients I see or the procedures which I perform. It’s kind of an interesting perspective to keep when thinking about ARMY healthcare, which many state is the best healthcare system in the country right now. And no, I don’t understand why exactly people say that – let me explain some of the source of my confusion on the matter.

Kristin and I began “ARMY life” on June 17th, when I officially took my oath of office. Kristin was excited to have Tricare coverage, which everyone had said was great, especially since we’d floated without any insurance for the last few months of Optometry school with no insurance. So we were a little disappointed when we found out that Kristin and the girls by default were put onto the lower-tiered “Tricare Standard”, which is basically a preferred provider network where you have about a 20% cost share in all doctor fees, rather than “Tricare Prime” which is the free system where you just go into the ARMY hospital and get a doctor visit at no charge whatsoever, regardless of what they do. So we were a little disappointed, especially when we asked how to get them swapped over and we were told that because it was after the 20th of June they could no longer be enrolled in that month, and the soonest that they could be enrolled was the 20th of July, wherein coverage would begin August 1st – a whole month and a half after I start working for the ARMY before she can even CALL to schedule an appointment. Bad news when Kristin was already 14 weeks pregnant, and really hoping to get to know the doctors that would deliver our third child. 14 weeks is already kind of late to start prenatal care, but finding out that we couldn’t even schedule an appointment until 20 weeks was a big let-down.

So Kristin called OBGyn to see if they could work something out so she could at least have an appointment scheduled right when she came onto “Prime” coverage, and not have to wait several weeks afterwards before she got an appointment. She was told by a receptionist that they absolutely did NOT accept Tricare “Standard” and that she would have to go and find a civilian doctor. After two more failed attempts to elicit pity, she finally got an appointment and had her first prenatal visit at 18 weeks. Everybody she saw at that visit asked her why on earth she had waited so long to start her care.

Since starting healthcare in the ARMY we have learned that like everything else in the ARMY, bigger installations mean bigger bureaucracy. As BAMC is one of the main medical hubs of the entire armed forces, we can’t be too surprised by 2-hour-long waiting room sessions before being called back into see the doctor for 15 minutes, or by having long lists of lab tests ordered with little or no explanation as to what they are for, or why it is “standard practice” to order them when Kristin never had so much labwork run in both of her other previous pregnancies COMBINED. It’s of course discouraging when the chief of the OB department requires that all patients receive a mandatory 3 hour genetics counseling seminar (which he teaches personally), regardless if a patient has a degree in genetics and could probably teach the course. And of course it’s more disappointing, when the clinic chief is an hour late for that lecture because he “forgot” about it, or when during the entire seminar he doesn’t mention any of the screening tests that it was so important that they learn about. I do tell Kristin to be understanding, and to try not to be too critical of ARMY healthcare in general. All of my co-workers say that at smaller installations the care is a million times better, which I wouldn’t surprise me, but all in all it is a disappointment to receive poor care from the “mothership”.

Unfortunately, things changed a little when Kristin failed the 1 hour glucose diabetes screening test by a few points. The 3-hour glucose test was then ordered, which Kristin failed as well by a few points, and then her folder was labeled “Gestational Diabetes”, which changed a lot of things. First off, she could no longer see the nurse midwife, since she was now a “high risk” pregnancy. Second of all, she could only be seen on the “Complicated OB” days (scheduled only two mornings out of the week). At the time, this clinic was run only at their alternate hospital at the Air Force Base 45 minutes away. Getting childcare for two-hour appointments is bad enough, but add on an hour of travel time there and back and Kristin had little choice but to put the kids in the carseats and hope for the best. Luckily the OB clinic moved everything over here to BAMC about a month later. Unfortunately that was about the extent of our good fortune.

Kristin has now spent the last month and a half in the “specialty” clinic, which basically means that she usually only sees residents, who do little listening, and even less explaining. I should give some credit – there was one visit where Kristin actually had with the Doctor, which was a “group session” with two other gestational diabetic patients where the doctor read and discussed the details of each case with everyone, including her personal concerns for each patient. The lack of privacy was quite disturbing, and neither Kristin nor I have ever heard of a similar practice in any other medical setting.

The diabetes diagnosis was a bit of a wake-up call at first, and we really considered what we could do to minimize any risks to Kristin or to the baby. We hit the ground running with self-monitoring of blood sugars and attempts to eliminate bad stuff from our diets and exercise more. However our concern slowly started to decrease when her self-monitoring showed that her blood sugar was almost never outside of normal limits, even when she ate things that we ALL know aren’t good for us. When she had appointments the residents barely glanced at her food log and her blood sugar records, which also didn’t help to make us feel the importance of the test. After a month of self-monitoring with only 3 or 4 measurements outside of normal range, Kristin no longer worries about what she eats, since her blood sugars are normal. We are of course still trying to exercise better, but if the doctors don’t even look at the logs and her blood sugar isn’t suffering, then what’s the point in it?

The real hit-home was at the last visit 2 weeks ago when, after 2 hours in the waiting room with two bored toddlers, Kristin is brought into the exam room for a 15 minute checkup, following which the resident told Kristin that because Kaela had a shoulder dystocia (baby’s shoulder gets stuck coming out and a bone sometimes has to be broken to get her out) that Kristin should “choose” to schedule an “elective” cesarean to avoid the 10-15% risk of a recurrence with a 1-2% risk of actual complication (chance of actually needing a cesarean). Regardless of the fact that Eliora came without any problems, Kristin and I both view c-section as a rather invasive procedure that is wholly acceptable when necessary (i.e. life of mother or baby is in jeopardy). But since it can be done even when the baby is in the birth canal, stuck, the idea of choosing a cesarean to avoid a remote possibility of complication which could easily be confronted if it arose didn’t make much sense to Kristin. The idea of scheduling a cesarean for patient (or doctor) convenience really doesn’t carry well with either Kristin or myself, due to the long and difficult recovery (imagine with a newborn AND two toddlers to watch!) as well as the serious limitations which it can put to future family options. Kristin was so taken back by the “suggestion” from the resident that she told her that she would actually “choose” to please not have that mentioned to her again, and to have that request put in her record.

The resident was actually a bit flustered by the response, and responded that “that goes against medical counsel”, since the risk to the baby was obviously extremely apparent at 5 1/2 months (before even entering the 3rd trimester). Of course, if the resident had actually been attentive to the history and thought over Kristin’s food log and blood sugar record, she might have re-thought the risk she’d assigned, but I doubt it. Kristin and I both feel like “GESTATIONAL DIABETIC” has been stamped onto her folder, and that the doctors only see that and only think about it when gathering data. The resident said that she would speak with the doctor, and a few minutes later she returned stating (much to our surprise) that the Doctor agreed with her assessment. She then brought an un-named uniformed “witness” into the room to listen as the resident “informed” Kristin with numerous scary statistics as to why the course of action was necessary and why “going against medical counsel” could have “severe repercussions”.

At about this point we felt things had progressed beyond bureaucratic annoyances, and I actually started discussing the situation with coworkers. Since as far as we understood the only other option was to “disenroll” Kristin back into Tricare Standard and pay 20% of the cost of all healthcare (which can quickly add up to a lot of money in a hospital), it was a surprising comfort to learn that we could ask for a referral to seek a “second opinion” to a civilian doctor for assessment of the situation, and that in some instances a referral could even be granted for care at an outside provider.

We called the “Patient Advocate” at BAMC OBGyn to request such a referral, and were told that absolutely under no conditions do they ever grant referrals, since they have enough space at BAMC to accommodate patients themselves. It was a disappointing response from the person who was apparently supposed to be in our court. We called primary care to see if they could refer us, and they told us that unfortunately since Kristin is under the care of OBGyn the referral would have to be routed through them, and they would likely veto it. We called the Tricare office itself, and were informed that our only option was probably to dis-enroll and pay out of pocket.

So, after all of this, this morning we had another appointment, and I cancelled half of my patients to be able to go with Kristin and meet some of these people myself. Overall we came away with an ok impression – Kristin said it was the first “not awful” experience she’s had there. We were taken in quickly because the appointment was early and the waiting room was empty. I got to see the ultrasound of the baby, and shortly thereafter the Doctor (not a resident) came in with a 4th year medical student who was shadowing. The doctor ran the ultrasound a bit, and despite the frequent comments about how “huge” this 5 1/2 month baby was and how easy it was to appreciate the “rolls of fat” on the grainy ultrasound screen, in the end we actually managed to keep her from leaving the room to schedule the follow-up by asking if we could talk to her. She stayed, and much to her credit, actually listened to us.

After several minutes and repeated requests, she stated that she would “allow” Kristin to re-take the 3 hour test, but that the results wouldn’t change anything since the diagnosis had already been made and the baby was clearly huge. Still, Kristin and I had been concerned, mostly because we worried that the reason she might have failed in the first place was that no-one really explained to her how to prepare for the tests, and we were concerned that she might have failed because she went in during the wrong time of day (afternoon rather than morning) and because she’d been fasting WAY too long (in which case her blood sugar might have spiked simply because she had no insulin in her system and her blood sugar was really low, not because she was insulin resistant). Regardless, it was a small victory. When we asked if we could have a referral to get a second opinion from another doctor, we were told that she could not grant it but that it would depend on the clinic chief (see above paragraph about the genetics course). She said that after the glucose test they could discuss it, but that he would likely say no, since both of them specialize in “complicated births” and he would likely state that a second opinion was not necessary.

All right, so if you’ve stuck with me this long, way-to go – get ready for the punch-line. Much discouraged, I spoke again with my colleagues about the whole situation and they advised me to try to go around OBGyn by discussing the situation with the Director of the Hospital. All in all, the idea that any serviceman would have to un-enroll his family from military healthcare and pay large out-of-pocket expenses in order to get decent care just seems wrong and sad, to me and to most of the people I’ve discussed this with. First they told me to go and speak with a counselor in the Tricare office, which happened to be in the building next-door to my clinic. Since it was lunch, and I had no patients afterwards, I walked over and learned in 5 minutes that I had been misinformed – apparently Tricare “Standard” offers 100% coverage of maternity with no cost sharing and no deductables. This is only for maternity, but essentially they pay everything except a $25 copay at the hospital at the time of delivery. They also told me that this didn’t even have to be in the network of providers – it would be covered at almost ANY facility.

So now Kristin and I are forced to ask, is there any reason at all to keep going to BAMC? Moreover, we have been humbled to reflect upon the great truth that in some instances, including in this case poor medical care, “anything” isn’t always better than “nothing at all”. And of course, we have to laugh a little when we reflect that had we known at the beginning, Kristin could have started pre-natal care at any doctor she chose right after I signed my oath in June, but instead we waited several weeks to get the “better” option.