The doctors are striking this week in Panama. Amongst other things on their agenda is the threat that hospitals would be “privatized” in Panama, i.e. run by big corporations as many are in the US instead of by the government, and whether foreign-trained non-Panamanian physicians should be allowed to practice in Panama.
Health care is in flux in many nations. Everyone needs it and few are satisfied. One of the most common questions I get is, “What’s the heath care like in Panama?” Over the ten years we’ve lived in Panama things have changed. For better or worse Panama has become more “developed” and in some ways more like the US. So I’ve been rethinking how we as expats relate to heath care in Panama.
Each year the World Health Organization [WHO] looks at an aspect of health care in 187 member countries around the world. The 2000 report provided a conceptual framework and measurement approach to help to understand the complex factors that explain how health systems perform. The report provided an assessment of the performance of national health systems for all countries. That report assessed the overall level and distribution of health care and looked at the financing of health care. Of course not everyone agreed with the methodology or conclusions of the report, but it is never-the-less interesting to compare the US and Panama. It gave two rankings, first was the overall level and distribuition of health care (that’s the number on the left below), and the second was the cost of heath care (the number to the right). “1” in distribution would be the “best” and in cost would be the “most expensive.”
Although not the “best” in the world, clearly the US was light years ahead of Panama, and equally clearly the US, even 13 years ago, had the most expensive health care in the world. Although rankings may have changed, I suspect the relationship is pretty much the same. There is no question in my mind that health care in the US is still better . . . and a whole lot more expensive.
“Better than anyone else!”
There is amongst US Americans I think a universal assumption, well, at least until the past few years, that everything in the US must be the best in the world: after all, the thinking goes, “We are the brightest, most powerful, most knowledgeable, most generous, most blessed, most prosperous, most wealthy, most envied, most lucky, most free people in the world!”, aren’t we. To suggest anything else, was to risk being called “Anti-American!” That in itself reflects the common US assumption that, “Weare the Americans, and everyone else [Latin Americans, South Americans, Canadians] are, well . . . chopped liver.”
Lately we’re discovering that we, like everyone else, are a flawed and struggling people.
And certainly that is true when it comes to health care.
So, before we talk about medical care in Panama, we need to think about medical care in the US.
Some quick comparisons, courtesy of the CIA [CIA Worldbook]:
USA 8.38 deaths/1,000 population
PANAMA 4.66 deaths/1,000 population
Life Expectancy at Birth:
USA 78.11 years
PANAMA 77.25 years
Life Expectancy at Birth Country Comparison to The World:
My wife worked for the County of Ventura. Every year the County, looking to save a few taxpayer dollars, would shift to a new HMO. One of their choices actually went under taking with them, and destroying, all of the medical records of the county employees. Before we moved to Panama, my wife paid one last visit to her HMO to collect her records, have a final check up, and get prescriptions renewed. Meeting with the doctor, the doctor asked, “So how are you doing with your diabetes?”
My wife said, “You must be looking at the wrong chart. I don’t have diabetes?”
Doctor, “Oh yes you do. We diagnosed you with diabetes a year ago. Didn’t anybody tell you?”
No, in fact they didn’t! How is that for “quality” health care?
According to the Council on Foreign Relations, talking about the impact of the cost of health care on US competitiveness in the world,
“Factoring in costs borne by the government, the private sector, and individuals, the United States spends over $1.9 trillion annually on health care expenses, more than any other industrialized country. Researchers at Johns Hopkins Medical School estimate the United States spends 44 percent more per capita than Switzerland, the country with the second highest expenditures, and 134 percent more than the median for member states of the Organization for Economic Cooperation and Development (OECD).”
We all know the US health care system is broken and may . . . or may not . . . be fixable. So let’s just drop the assumption that we have the “best” . . .
Three systems . . .
- National Heath Care – “Salud” – you see these white, yellow and green buildings in almost every Panamanian community. It is a basically “free” or “low cost” – 50 cents to see a doctor, $1 to see a specialist – system designed mainly to treat the enormous and poor Indigenous population and those without Social Security health care. It is underfunded, understaffed, and plagued by inefficiency and bureaucracy. But it is available to everyone, even expats.
- Social Security – Everyone who works in Panama must by law pay into the Panamanian Social Security system. Basically the employer pays half and the employee pays half. For our Indian worker I think we pay about $4 a week. Long lines, understaffed, and plagued by inefficiency and bureaucracy. Often doctors prescribe drugs that are supposed to be “free” but the Social Security system doesn’t have them, so users must buy them at pharmacies. Pharmacies sell drugs here by the pill. So if your doctor prescribes something, you buy only as many as you can afford, when you can afford them!
- Private System – Is the system used by many middle and upper class Panamanians, by expats, and by the increasing number of people who are coming to Panama to have procedures done, a growing industry called “medical tourism.”
This duplication of systems is reflected in duplication of hospital facilities and services. In Boquete the National Health Care “Salud” has an emergency room as does the Social Security Clinic across the street. Both are open 8am to 5pm, so schedule your emergencies accordingly.
Riding Mr. Ed . . .
When we first came to Panama we used to enjoy riding horses with our friends Brad and Jackie. We found a local guy who rented out his horses for $5 an hour. It was great fun! My kids were visiting so we all went horseback riding, all five of us. I guess the guy only had four horses of his own, so he borrowed one from a friend, which turned out to be a problem horse not used to amateur riders. My wife rode horses as a kid on her Grandpa’s ranch in Montana, and although that was a long time ago, she was comfortable on horses, but all this horse wanted to do was run. The equipment was, well Panamanian, meaning, at times improvised and cobbled together. As it happened the bit was cobbled together and came apart just as the horse was acting up. The horse took off, the bit was broken so my wife had no way to control the animal . . . she ended up being thrown off and landing on the pavement on her head.
Fortunately my daughter Rebecca is a “wilderness outdoor first responder” or something like that, somewhat equivalent to an EMT except she can’t deliver babies but can pronounce people dead if they are a certain distance from a hospital. Rebecca immediately went into EMT-mode. We were a long way from town, and my older daughter said, “Dad, you have to get a doctor since we don’t know where to go!”
So I rode off for town, not knowing at that point whether my wife was dead or alive.
I rode quite away until a car came along. The driver had seen the riderless horse so knew there must be a problem. We tied up my horse and he took me into town to the doctor’s office. We got in his brand new Toyota with gray seat covers and rode back to the scene of the accident. By this time my wife was somewhat responsive. My daughter gave the doctor a quick summary. With a head wound there was blood everywhere, but the doctor put my wife into his brand new car and we went back to his office. It took 3 hours and 70 stitches for him to sew Nikki’s head together, and he saw her three times a week for 10 weeks. The total cost was $850 . . . probably the cost of an ambulance ride in Southern California.
The really interesting thing was on one of the follow up visits the doctor greeted us with, “Nikki! I’m so glad to see you! I had a dream last night that you didn’t come in, and then I couldn’t get back to sleep worrying if something was wrong.” How many HMO doctors in the States even know your name, if they aren’t looking at your chart, let alone wake up at night worrying about you?
And this guy made house calls!
I told that story on the ship and a guy sitting in the front row said, “I’m a doctor, and I still make house calls and wake up nights worrying about patients!” So there are still a few guys and gals out there . . . but, in general, it’s not the face of managed health care in the US.
So what happened? Nikki is fine! After spending a lifetime wasting 25 minutes every morning doing her hair, she discovered a new no-fuss, no-muss hair do that better suits our life in Panama. We ended up buying helmets in the States, which we haven’t gotten around to using. The guy is still renting horses, and still sometimes using the same horse, and sometimes we see obviously totally inexperienced riders on that same horse . . . If we found a reliable place to rent horses, we’d probably ride again. [One of the things about a non-litigious society like Panama is folks don’t worry about being sued.]
Unfortunately the fine doctor in this story moved to Panama City.
Every man’s favorite day at the doctor . . .
I went in for my “every five year” physical . . . new doctor, internist, $20 plus my insurance coupon, and another $40 for tests . . . and of course he told me “it’s time” for that guy-favorite, a day with Mr. Sigmoidoscopy. So I called to make an appointment, expecting to enjoy weeks of eager anticipation . . . only to discover I had an appointment in three days . . . only three days because I needed to “prepare.” I forget the exact cost, but most was covered by our local insurance (more on that tomorrow), but it was quick, easy and relatively “painless” . . . unless you enjoy that type of thing.
Roto Rooter . . .
My wife has heart disease and has had several angioplasties. Her last angioplasty had been 12 years earlier, but the familiar symptoms were returning. We did not have a cardiologist in Panama so we began asking around and talking with gringo friends to find out who was the best cardiologist in Western Panama. There was universal agreement on one doctor. So we called and asked for an appointment . . . expecting to wait weeks . . . and he gave us an appointment the next evening. We sat down with him and he spent an hour with us, going over Nikki’s records, reviewing her medication, examining her, and explaining the situation. Although his English was somewhat limited, we received the most understandable explanation of Nikki’s condition we have received from any doctor. There was no rush. He took Nikki’s records and said he wanted “to take them home to study” and set up an appointment for stress tests. A week later we returned for a series of stress tests at his office, and began a two-month series of exams, tests, adjusting medication and diet, etc.
At the end of the two months, and shortly before I was scheduled to leave on a cruise contract for five months, it was decided that yes, indeed, Nikki did need an angioplasty and probably one or two stents. The doctor made an appointment with the best guy in Panama City who works out of Hospital Patilla which is affiliated with Johns Hopkins. We had the appointment right away, but it took about a week to shuffle papers between our insurance provider (more about this tomorrow) and the cardiologist to get approval for the procedure in Panama City.
So my wife flew to Panama for three days and had an angioplasty and two stents implanted, and then flew back to Chiriqui. The total cost for an angioplasty and two stents (including hospital and surgeon) was $14,000.We have a friend who had the same procedure performed in Boston, and his hospital bill alone was $60,000! Because we had a hospital insurance scheme with Hospital Chiriqui in David, and because they do not do invasive cardio procedures, our local insurance picked up half of the cost, so our out-of-pocket cost was $7,000.
Hospitals . . .
In David, the third largest city in Panama, 45 minute drive from Boquete, there are four large hospitals. The Maternal & Child Hospital is a National Hospital focusing primarily on material and pediatric care. It is only two years old and was a gift from the people of Taiwan, with whom Panama has diplomatic relations. Almost next door is the Social Security Hospital which serves people who are working in Panama and paying into the Social Security system. Just down the Pan American Highway is Hospital Mae Lewis, a private hospital that is used by locals and gringos. And a few blocks off the Pan American Highway is Hospital Chiriqui, a private hospital that is generally preferred by expats because of their “insurance” program (more on that later). Hospital Chiriqui. Additionally, scattered around David, there are almost a half dozen tiny private hospitals owned and run by a consortium of doctors. In some ways it isn’t very efficient, yet the hospital costs are low. A private room runs about $60 a day! Of the private hospitals, Hospital Chiriqui has the most “bells and whistles” including a state-of-the-art MRI machine, one of two in Panama.
Unlike in the US, in Chiriqui any doctor can practice in any hospital and you are not limited to only certain hospitals where your doctor happens to be on staff.
Emergency Care . . .
Here is where things can get a little dicey.
If you happen to be one of the very few people to get bitten by one of our famously poison snakes, like the fer de lance which is fairly common in Chiriqui . . . and let me quickly add that your chances of getting bitten by a poisonous snake are about the same as your chances of getting struck by lightning or winning the lottery! . . . if you are bitten by a snake anywhere in Panama you are generally about 45 minutes from a Social Security hospital which is where the anti-venom is kept. So you have plenty of time to get to the hospital where you will find that rather than immediately giving you anti-venom there is a long waiting/observation period while they test your blood and wait to figure out what kind of snake bit you and what type of anti-venom you need. Almost everyone, except for Indians living in very remote areas, recovers. So although the fer de lance and bushmaster can be “deadly”, your chances of dying if you get assistance are very slim.
And, if you get bitten between 8am and 5pm the Social Security emergency room in Boquete usually has anti-venim available.
OK, we got that out of the way!
When we first came to Panama my wife asked our Boquete doctor, “So if I’m having a heart attack, what do I do?”
His response: “First you call me. I’ll come to your house and call an ambulance. We’ll stabilize you in David, and if necessary, once you are stabilized, we will fly you to the Panama City where the hospitals and doctors who specialize in invasive procedures are located.”
Good enough . . . but when we say “ambulance” do NOT think of ambulance service in the US! There have been times in Boquete when we had four different ambulances . . . and none were working! And an ambulance here is primarily a means of transportation. Don’t think a team of trained “EMTs” on call . . . or an ambulance with any sort of equipment on board. Over the years we’ve been in Boquete the expat community has worked hard and raised money to improve ambulance service, but it still is nothing like what we were used to in the States.
Our experience . . .
One afternoon my wife started having some kind of episode. She was dizzy, had no feeling in her arms, was weak, and couldn’t stand up. It looked like some kind of allergic reaction and I feared she was going into anaphylactic shock. [We have experience with this: I am highly allergic to shellfish of any kind in any amount, and my daughter is highly allergic to chocolate.] Without 911 or any similar kind of emergency help, I called our friend Brad, and together we carried Nikki to my car, and I went to the doctor’s office (the same guy who treated her when she was thrown off the horse . . . the story I told yesterday). It turned out the good doctor was on vacation and the gal who was filling in not only didn’t speak any English, but wasn’t that familiar with his office. Eventually she found the oxygen mask, started an intravenous drip, got Nikki stabilized and agreed we needed to get to the hospital in David. She called the ambulance . . . and the “fun” began.
The doctor called the ambulance, then said to me, “They don’t have any gas. They want to know if you can pay for the gas?” Yes!!!
So the ambulance and attendants arrived . . .
First problem: the doctor’s makeshift treatment room and the gurney that wouldn’t fit in.
Second problem: the ambulance crew hadn’t the slightest idea how to move a patient from a bed onto a gurney. Somehow we managed.
Third problem: Nikki was too big for the ambulance. Panamanians are shorter. So they couldn’t close the back doors of the ambulance all the way. She wouldn’t fit! So the creative solution was for the ambulance attendant riding in the back to wedge himself between the side of the ambulance and press his feet against the gurney to keep Nikki from sliding out the back doors, which were flapping in the wind.
Fourth problem: Nikki had an IV drip going and there was no place to hang the drip in the ambulance. The attendant in back was busy trying to keep the gurney from flying out the back, so Nikki had to hold her own IV bag.
OK, we stopped and got $20 worth of gas. Then we began racing down the mountain to David with lights and sirens going.,
Fifth problem: Nobody in Panama is going to move for an ambulance! Only the expats will pull over out of force of habit. So I’m in front, the driver is laying on the horn so people eventually will move out of the way.
Sixth problem: We start to get one of our famous, afternoon “rainy season” cloudbursts when the water is coming down in torrents. In front the windshield wipers are barely working and in back the doors are flapping in the wind and the water is coming in soaking Nikki and the attendant who is bravely still holding the gurney in place with his feet.
The reality: Supposedly “laughter is the best medicine” and Nikki, although the center of the drama, couldn’t help but find the humor in the situation.
Fortunately we arrived at Chiriqui Hospital and into the tiny emergency ward. It took a while, but Nikki was stabilized and a team of internists eventually discovered that she had developed an allergy to aspirin. She spent two nights in the hospital, before coming home. The ambulance ride:(for those of you who remember the original Disneyland . . . definitely an “E-ticket” ride!) $20 for gas, and another $5 (in gratitude) for beer for the guys. Hospital: emergency room, two nights, and physicians $225.
Yet another story . . . my wife keeps things interesting!
Nikki was experiencing tingling in her arms, chest pain, yada yada . . . with her history . . . “Come on, Nikki, don’t be a hero! Let’s get it checked now. If it’s nothing, fine . . . if it’s not, “golden hour” and all that stuff.” So we go to Boquete to the new clinic for such emergencies that Hospital Mae Lewis has opened. The only problem is there’s only a receptionist staffing the clinic. No doctor . . . not even a nurse . . . receptionist and janitor. The receptionist informed us that the doctor was going to be coming in an hour and that we could sit and wait. OK, so this is to be an “Emergency Clinic” . . . right. And if it is a heart attack, we’re going to sit here and twiddle our thumbs for an hour and hope that the doctor actually does show up as scheduled . . . which, in itself, would be somewhat of a miracle anywhere, let alone in Panama. And I’m about to have a “Richard-goes-ballistic” attack . . .
I remembered that a friend I had met because he had read this blog, lived in an apartment upstairs. He is a retired neurosurgeon who still consults via video cam in complicated surgeries around the world. Although he wasn’t a cardiologist, I knew he had his own personal encounter with a massive heart attack and open heart surgery, so I went upstairs and asked him if he could just come down and take a look at Nikki. Gracious friend that he was he put on his slippers, found his stethoscope and came down and took a look. His verdict, “I can’t say what is going on, but I can say with 99.9% certainty that she is not having a heart attack.”
So . . . forget paramedics and 911. Panama does have a new 911 system but it is for traffic accidents only.
As a reader, “oldsalt1942″, once commented, “You get better or you die, and that’s the reality of health care in the vast majority of the world. You get better or you die. Period. And let’s face it, you can’t take life too seriously because none of us are getting out of here alive.”
We do have in Boquete an emergency contact system which is really quite remarkable. We have a phone number to call which is answered by a gentleman who is confined to home in a wheelchair. He speaks both Spanish and English fluently and will contact on your behalf the police, fire, ambulance or other emergency assistance as needed.
In my next post I will discuss what we have liked and disliked about health care, based on our mostly positive experiences, the very negative experiences of some of our neighbors, and insurance.