Mar 05 2012

Herr Doctor will see you now

I've been in Germany about six months now and I thought I would take a moment or two to write about my experiences with the German Medical system.

In my previous employments I was either under American insurance and being seen by American doctors or I was under military care and being seen and having my medical information used against me-against my will. In only selected cases was I  personally seen and treated by foreign doctors-in Japan, Singapore,  and Australia.  I was able to witness the S.O.'s dealings with the Japanese system as well as the frustrations of her transition to American doctors and their different standards of courtesy towards patients ( something I heard about from her repeatedly-and not in a good way).

However, here-my ability to see American doctors is quite limited. Its not impossible-just not practical. As a military retiree I have some access to American military clinics. However it is such a low priority ( and it probably should be IMHO-given the budget cuts the services are taking), it is simply not practical. I do use them to fill my prescriptions though. As a result, I see German doctors. So far the experience has been exceedingly positive and it only serves to reinforce my belief that the American health care system is really fucked up-and needs massive changes.

Actually I should correct that a bit. America medical care itself is quite fine. Our system of paying for it though is completely and totally fucked up. The malfeasance of insurance companies is simply criminal.

As an "Auslander" I am not a full participant in the German Health Care system.  A system, by the way,  that is not " socialized medicine"-but does make kliniks and insurance companies adhere to a standardized set of rules and fee structure.

I have a German primary care physician. He is superb-and has done diagnostics for a particular issue relating to cholesterol-that I never got in the states. Its helped-and its actually cost a lot less than I thought it was going to. Same is true for the S.O. and her back issues. An MRI cost half what it cost state side-and the same is true of the ten sessions of physical therapy that were prescribed. The procedure where I had a sonogram of my neck and other locations was fairly reasonable given the amount of time the doctor took to perform it and explain what he was doing and the results he saw as he went.

In all cases the doctors were patient-spoke English well-and  the technicians were patient with my less than perfect German. So far I have never had to wait longer than 10 minutes to get seen after my arrival at the doctor's office. In Shopping Mall the wait was usually about 25 minutes or more.

The primary difference between Germany and the US-as far as I can concerned- is that in the US, I could rely on the doctors office to do all the billing of my insurance company. Here I have to serve as my own billing agent-meaning that I had to establish a "war chest" of money to pay doctor's bills and then replenish it through my payments from the two different health insurance plans I belong to. (TRICARE and my employer provided program).  If I had German "Versicherung" they would bill for me-but I don't and can't join because I am not a German citizen. So I am learning more than I ever cared to about filing and following up on insurance claims.

And I'm not liking it very much. With my employer provided insurance-I actually can upload claims fairly quickly, and thanks to the type of plan it is -one aimed at American Expatriates- I don't have to do medical translations of German bills. They are able to do it for me. TRICARE on the other hand is much more time consuming proposition. Not because it has to be-but because they have not taken advantage of several time saving things.

(I, like most veterans,  am completely opposed to the upcoming TRICARE fee increases, but that is a topic for another time).

So because of the requirement to deal with claims stateside I average 3-4 weeks, " in the hole" money wise. The German system of payment requires electronic bank drafts-checks are not used very often. ( For anything-I pay my rent and electricity via bank drafts too). So I have to have the cash on hand. Fortunately thanks to the advice of the S.O. and a savings effort that started the day I got rid of a substantial amount of American female baggage-it is not so big a deal. And certain Kliniks are getting up on line and direct billing my insurance company in the future. ( E.G., in Garmisch the ER was able to bill TRICARE directly).

So what are my conclusions after admittedly-a short amount of observation?  Well I have several, actually:

1) I think Doctors are pretty much the same. They got in the profession because they wanted to help people. What they morph into after being their a while though-varies from country to country. The US has probably the biggest transformation-because in the US doctors make HUGE amounts of money. ( Some of them). In Germany and Japan, doctors are still well compensated-and in Japan doctors enjoy a status in society-but not nearly as well as their American counterparts. Being human,  there is some resentment of that.

2)T.R. Reid is right: " No other country would dream of doing things the way we do. So it’s clear that we can’t fix the basic problems by tinkering at the margins of our existing system. Any proposal for “reform” that continues to rely on our fragmented structure of overlapping and often conflicting payment systems for different subsets of the population will not reduce the cost or complexity of American health care. Any proposal that sticks with our current dependence on for-profit private insurers – corporations that pick and choose the people they want to cover and the claims they want to pay – will not be sustainable."

In particular I am now more convinced than ever that insurance companies should be not for profit vehicles-and no employer or employee should be able to "opt out" of paying for health insurance. The mandate is essential-unless you wish to follow a model of Medicare for all Americans. Which would be also fine with me-but I think the private insurance model, provided employers were held down and forced to fulfill their moral obligations as employers would probably be more suitable for American society.

3) The process of paying a claim should be a lot easier and a lot more automated. If I can pay my credit card on line-insurance companies should be able to pay me electronically with 10 days from claim submission.

4) The people screaming about Obamacare "socializing medicine" and how it is making government run peoples lives-don't have a fucking clue what they are talking about. Private, for profit,  insurance companies are doing that now-and with no consistency. Free markets do not solve everything. In particular, with respect to health care, the blatantly encourage a criminal and immoral mindset among insurance companies.

5) Cost controls don't seem to be stifling patient care or innovation here in Germany.

6) American exceptionalism sucks! It is stopping us from capitalizing on the best experiences of other nations and as T.R. Reid pointed out is mostly founded on collective ignorance of how other nations really are. 

Another reason Americans tend to ignore the valuable lessons we could take from the rest of the world is that we have been in thrall to conventional wisdom about health care overseas. Thus we conclude that the foreign approaches would never work here. In fact, as I found on my global quest, much of this conventional wisdom is wrong. A lot of what we “know” about other nations’ approach to health care is simply myth.

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10 responses so far

10 Responses to “Herr Doctor will see you now”

  1. Mauriceon 05 Mar 2012 at 9:12 am

    Skippy,
    I take it that you use Foreign Service Benefit Plan as I do here along with Tricare.  I have had to go to a Japanese hosptial and had no issues with uploading the bill.  The only downside, it did not meet the deductible so I got nothing back.
    One point to your post, you are denied full coverage because you are not a German citizen, you are not a full participant in their system.  Not the same in the USA.  Every illegal person is able to get quality health care at someone's expense.  Not trying to be a GOP talking head, but I read of a story in CA about an illegal alien from Mexico who spent a year at a public hosptial (in patient) without paying a dime.  He had no job and was free to leave when they discharged him.  The hospital even went so far to state that they have this problemand spent over $500 million providing health services for illegals and the poor.
    The poor I can see helping (provided that they are US citizens) but the illegal alien costs should not be borne by the US govt.  If we had a Govt that had any "hutzpah"  I would take the TRICARE hikes, provided that we start reducing foreign aid to all those countries who have citizens in the US that we provide services for (eductaion, prisons, health care, etc).  That in my simple mind would be a fair enough trade.

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  2. Skippy-sanon 05 Mar 2012 at 1:59 pm

    I use FSBP-and I am getting better about their claims process. 

    I think its important to make a distinction-German doctors will see just about anyone-but the bill will come home and it will get collected.  Since Germany is much tougher on border controls with people it does not like (e.g., watch a Turk go through immigration sometime-it is like watching a Filipino try to get through Narita). I am also told their emergency rooms cannot turn down patients just like ours can't. However-the Polezei have pretty broad powers, probably more so than ours do in many ways. But the folks who are here-even as Permanent residents can buy health insurance. Since I am under SOFA-its a different ballgame. ( Germany and Japan are very different in how they regard SOFA status).

    But the bottom line remains the same-I can get seen-just not insured.

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  3. Mauriceon 05 Mar 2012 at 5:31 pm

    Skippy,
    I hope that you dropped the paid version of TRICARE and now are on TRICARE Standard.  Since you are overseas that is the only one we can get.  It's free, but you do get limited to using US medical facilities first.  I have not really had any problems using USNH Yokosuka as a retiree.  To me, they seem to be doing a lot of self-inflicted wounds to themselves.  The whole process of making you go to see a GP first at Family Practice before you get referred to see a specialist is what makes the problem so slow here.  It is fine if you are not working, and you have the time to wait for the first appointment at FP and then after they give you a few pills and see you for a follow-up then you get to see the specialist, but I don't have the time to go through the process.  If you do get to see a specialist, the smart person would make appointments at least every 3 months, even if you get better to show that you are on continuous care in order that you don't loose your referrral and have to go through the whole process again.  Every Tuesday I go to a Base Support Meeting, and the XO from USNH shows how many missed appointments and no-shows they have.  In some areas, they are running as high as 35-40% missed appointments.  LIke I said, they do it to themselves a lot of times.
    I will not even begin to talk about the Dental care.  I'm just glad that there is a dentist (pretty Japanese lady) that is US trainned and accepts Delta Dental and has an office outside Mikasa gate and gets inspected by the Dental on base.  Hopefully I will not have to use her, but for the times I did have to go to dental, I had to go at sick call (0730) and not get seen until 0900, and then told to come back the next day to do it again.

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  4. Skippy-sanon 06 Mar 2012 at 1:35 am

    I have always had Standard.  I never liked being forced to have a particular doctor-and after I came back to the US, I wanted the freedom to pick my own doctor.
    But the Army must be different than the Navy-they actively discourage you using the clinic if you are a retiree and pretty much push you out into town. I think a big part of that is the budget presssures they are under-postal service is only twice a week for now-and so anything they can do to shove burdens back on "BIG DOD' they do. Also the German system is different-GP's are not gatekeepers, but folks who treat a certain cross section of maladies. If they think you have to go to a specialist-you call and see them directly. Their hospitals are kind of the same way-specialized for different things. So if you need a mammogram you go one place. Need internal things go to another that has a specialty practice. Thanks to the train system its not too hard to get from one to the other.
    What TRICARE will do is make the appointment for you though-with their German speaking staff.

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  5. Mauriceon 06 Mar 2012 at 1:45 am

    Skippy,
    It sounds like Germany is much better run in regards to TRICARE for retirees than here in Japan.  They have a certain list of providers that you must use if you choose not to get services from USNH.  I admit they will help with getting your a referral and help with billing, but I think it still is somewhat lacking.  They only keep the Negeshi clinc open not much even for dental.  They really are not running things as well as I think that they should.
    They have been really pushing the policy CNFJ wide on house guests and insuracne.  They have had cases where people have come over to visit here and were staying onbase as visitors, and for some reason they had to go to a JN hospital.  They have had a few people skip out on the bill, so now if someone is going to be staying in your onbase housing to visit, you must show proof of Travelers medical insurance.  That's from USFJ.  One hospital in the Atsugi area has stopped taking referrals from the clinic there because some person left without paying.

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  6. Cy-Kickon 06 Mar 2012 at 7:30 am

    "But the folks who are here-even as Permanent residents can buy health insurance."
     
    "They have had a few people skip out on the bill"
     
    Now where do you guys think people got the idea to not have to buy insurance and or just not pay for services?

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  7. Skippy-sanon 06 Mar 2012 at 10:23 am

    Cy,
        I think he is refering to Americans-which does not suprise me one bit. Still percentage-wise, I'll bet its not a large number. Leave it to CNFJ to overreact though-instead of hunting down the guilty bastards they way a credit card company would.

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  8. Cy-Kickon 06 Mar 2012 at 2:38 pm

    Yes Skippy, it was Americans I was talking about. Why would they go to another country and think that they don't have to pay?

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  9. Skippy-sanon 06 Mar 2012 at 3:45 pm

    Because they think they are never coming back.

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  10. Mauriceon 06 Mar 2012 at 5:32 pm

    Skippy/Cy-Kick,
    Oddly enough, from what I remember from one of the briefings on the subject, one party was an MWR employee in Atsugi.  He was referred to an off base hospital, and for some reason just never paid.  Not sure if the person was covered under any health insurance, but basically he just left.  They have had some problems with nopayment of services at USNH, and have been trying to find ways to make sure that people don't skip out on the bills, trying to make the civilians who leave go through a check out sheet through HRO.

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