The Tooth Fragment of Great Price

[pktechgirlbackup]

My dental surgery was originally scheduled 5 weeks in advance. The pain got worse, they gave me antibiotics. The pain still got worse. It felt like biting tinfoil, which meant whatever it was was interacting directly with the nerve. This would make me nervous if I didn't already have a broken oral nerve. The periodontist agreed to work outside her usual hours to fit me in in a week (three weeks earlier than scheduled). The pain did get better, but it came in waves and I decided I didn't want to reschedule again, so I didn't tell them. The surgery was today.

In many ways, it was the best possible outcome. 30 seconds after cutting (just long enough to clear out the pus), she found aberrations big enough to cause the problem, but no bigger. There was a sliver of broken tooth, presumably left over from my wisdom teeth removal (which was over four years ago), and a lesion that is assumed to be a bacterial cyst unless the biopsy says otherwise.* The lesion was within a few millimeters of the nerve, but not touching it. This is good, because if it was on the nerve my choices would have been nerve damage or never clear the infection.

I don't have good data on this and the doctor was patently uninterested in playing what-if with me, but it certainly seems plausible that the three weeks between the new date and the old would have been enough to grow the cyst all the way to the nerve. I already have nerve damage on one side and it's awful, I don't know what I'd do about both. it's entirely possible the reason this got so bad was that I'm so good at not hearing pain from my mouth that I didn't notice it. I know I didn't report it to the dentist at first because I was too fucking stressed out to deal with it, I just wanted to do the right thing and get my teeth cleaned and I'd deal with the chronic stuff later. If I hadn't gone in for the intensive cleanings, who knows when this would have been caught? So there's two paths that lead to nerve damage.

I think this got treated faster in America than it would have in any other country. As I understand it (and good data is woefully hard to find), countries with national health care operate on a pretty strict queue system, and doctors have no incentive to work extra hours. I assume you can jump the queue if you can prove you have a more serious problem, but because the cyst was soft tissue it didn't show up on an x-ray; the only metric we had was my pain. While my periodontist believed me enough to reschedule the surgery, it was clear that seeing the size of the cyst** caused her to retroactively give my complaints a lot more credence. A queue that can be jumped by claiming more pain won't do it's job, so in an NHS world I probably would have been stuck with my original number, which undoubtedly would have been longer than the 8 weeks between my dentist popping the first (smaller, exterior) cyst and now. Socialized medicine could easily have caused me permanent nerve damage.***

On the other hand, I only got seen and operated on that quickly because I have money. Lots of money. Enough money to see my dentist 16 times a year, to take the first available periodontist appointment without worrying about paying for it, to take the first available surgery slot without worrying about paying for it. More subtly, having and growing up with money makes it easier to have the entitled attitude that led me to tell the periodontist this couldn't wait. When I told (not asked) my boss I needed to move the surgery earlier, but this was better timing for the company anyway, he said "well, it really doesn't matter how the timing affects us, if you need it now you need it now." This exactly the sort of care you can make yourself believe doesn't need to be treated right away, giving the infection time to spread. People die of this.

I prefer a market-based health care system not because our system is working particularly well, but because I believe it has to capability to improve in a way the NHS does not. This ability to change comes at a terrible price, and no matter how much money I donate to dental charities, I'm not the one paying it.



*Me: so is there anything the biopsy could reveal I should be worried about?
doctor: no.
Me: Then why are we doing it?
Doctor: something something best practice

I assume that there is a small but present chance this is something awful, like cancer, and she doesn't want to have to talk to me about it until we have actual data. Which I'm sympathetic to, but I'm also pissed that I was being asked to decide whether this was worth my money and the cost of a false positive while I was under a quarter milligram of a benzoate, massive amounts of whatever local anesthetic they gave me (which does make me feel mentally weird), and the stress of surgery. This was a predictable outcome of the procedure and they should have asked me ahead of time.

**Biggest she'd ever removed. She had to leave behind a plug so the gum tissue wouldn't collapse in on itself, any bigger and it would have required a graft.

***Possible relevant and even more frightening: antibiotics would not have fixed this. My cyst was that huge despite me finishing a course of amoxicillan a week prior.

Comments

[dukhat.livejournal.com]

When you say a market based healthcare system, does that include a system like Canada's where the government pays for a minimal level of essential health insurance for everyone? Doctors are still participating in markets and patients are able to buy additional supplementary health insurance. It isn't clear to me what benefit to society a profit-motivated health insurance company provides. An insurance company cuts costs by charging patients more for less care and paying doctors less for more care, the latter insurance paid for by the government can also do. But since giving people healthcare for free doesn't remove incentives to avoid illness and injury and because the demand for treatment is so strongly inelastic (I will pay whatever money I have to avoid death or debilitating medical problems), it seems like health care is a prime candidate for government expendenture. To me the best health insurance company would be one owned collectively by the people being insured so they can pool risk among themselves and pass on savings obtained by collective bargaining back to themselves.

In terms of health care outcomes in practice, is seems as if most countries get better results on average than the USA does and pay less for these outcomes. Denying a rich person the ability to pay more to get treated faster seems a bit perverse, but my impression from being affluent and having lived and known people in Canada and the UK is that this doesn't happen much.

The real question for me is what should government provided insurance actually cover? This is a thorny and complicated issue. For example, in Canada the government doesn't provide dental insurance. What treatments are too expensive?

[scythe-of-time.livejournal.com]

Socialized healthcare always reminds me of the Bermuda triangle. "Who pays" and "who decides where that money goes" are, as you've said, thorny and complication questions. I believe that preventative care and education are the best medicine, so let's treat that collectively to give a public baseline (how? with what money? who decides how much? and that's not an umbrella for pre-existing conditions).

Pktechgirl, best of luck on a speedy recovery. I'm impressed that you're able to write about these things so shortly after a major surgery. I know I couldn't!

[pktechgirl.livejournal.com]

because the demand for treatment is so strongly inelastic (I will pay whatever money I have to avoid death or debilitating medical problems), it seems like health care is a prime candidate for government expendenture.

Can you expand on this? because I would have drawn the opposite conclusion.


I will readily concede that the US system is broken beyond belief. That said, I don't find the intrercountry statistical comparisons compelling. First, the US is essentially subsidizing care for the rest of the world by providing the profits that incentivize new research. Second, medical care is not the only input in health outcomes. At any given week of pregnancy, the US has a better survival rate than any other country, despite the fact that events we would classify as live births followed by a death are classified as still births or miscarriages in other countries. But the US has many more premature births. Is that due to poor prenatal care, culture, or something else?

[dukhat.livejournal.com]

I would like to recant my claim that it is inelastic. Although it might be true, it isn't necessarily true. It is true that the only constraint for people buying cancer treatments seems to be ability to pay, but since enough people are already priced out by the cost the demand might drop as costs go up.

Some arguments I see for government providing basic health insurance are:
- we can prevent many people from dying of poverty
- we encourage people to take desirable risks like quitting their job to start a company or get training for a job they would be better at
- there are beneficial public health effects from poor people not being afraid to see a doctor because it will necessarily bankrupt them
- it is a natural way to pool risk over a really really large number of people, larger than even large private insurers and it removes incentives to squeeze patients and make them pay more for less care

[pktechgirl.livejournal.com]

there are beneficial public health effects from poor people not being afraid to see a doctor because it will necessarily bankrupt them

This seems like an excellent argument for paying for care for communicable diseases, but not for chemotherapy for 80 year olds.

[crystalpyramid]

Good. Can we please have socialized that, at least?

[pktechgirl.livejournal.com]

Agreed. Were either of us in a position to actually influence this there are details I suspect we'd have to work out, but I am actively in favor of using tax money to prevent, diagnose, and treat communicable diseases. I would also cover pre-natal and childhood care without hesitation, at reimbursement rates much higher than we pay now.

[dukhat.livejournal.com]

I haven't been able to find a lot of data on where all medical research money comes from worldwide. A lot of drug research money comes from monopoly power granted to drug companies who profit from Europe and Canada as well as the USA. There is also a lot of government funding for medical research. And in some sense, when US biotech firms do drug trials in russia so they can pay people to participate in potentially dangerous trials and not have to pay them much, russians are subsidizing medical research too. Having the government pay for basic health insurance seems like an orthogonal issue to how much profit drug companies get. Sure, other countries use state monopoly power to negotiate better deals on drug prices. And we could do that too, but the drug companies still have patent protection. So if they can't profit from a deal, even with the monopoly power of the government they have their own monopoly power.

Basically, I don't know to what extent the US plays a crucial role in global medical research, but even if it did play a crucial role, I don't see how this relates to universal healthcare.

[pktechgirl.livejournal.com]

You keep talking about the government paying for insurance, I assume you mean being insurance/paying for care? When I hear "pay for insurance", I think of a voucher program.

Yes, the US government, and many other governments, pay for a lot of research. Thus far, they have not had a lot of success turning that research into usable drugs. I'm open to experiments on this, but until someone else does it, we need the drug companies to produce drugs.

Europeans and Canadians pay less for drugs and other on-patent medical care because they pay barely over the cost of production. They don't cover the cost of research to produce that particular drug, much less all the drugs that fail. They do this by mandating the prices and threatening to break the patent if the company stops providing drugs for the market- so yes, they have a patent monopoly, but they'll lose it if they use it. If the US stops paying dramatically over production cost for drugs, we've dramatically cut the profit incentive for developing new drugs.

So yes, drug company profits are orthogonal to who pays for the drugs. But then you have to factor out the increased price of drugs in America when comparing our cost and outcomes to other countries.

[dukhat.livejournal.com]

I agree we seem to need drug companies to produce drugs and since this is such an expensive and risky process in order for them to do that they need to make a lot of money when they succeed. I too am open to experiments on having governments actually try to pay for drug discovery.

Yes, when I say "pay for insurance" I think I mean being insurance/paying for care.