With few exceptions, I have found that those who think we have a great medical system know very little about medicine, billing, and how the whole process works.  It’s not that I finished a residency in neurosurgery, but in the past 5 years, I have been around enough surgeons, internists, radiologists, residents and even medical plan owners, to have a fairly good idea on how it all works, economically speaking.

For the money, I think we have the worst medical system in the world.  When you balance how much things costs, versus what you get in return, it’s not hard to see this.  Sure, if I suffer from a rare disease with experimental treatment in the US requiring expensive equipment, then by all means, this is the place to get treated.  But routine procedures not involving rocket science?  Please…

A recent example.

My mom convinced Yanory to get an endoscopy to make sure her frequent indigestions and heartburn, weren’t something more serious.  Since we’ve already paid our yearly deductible earlier this year with Yano’s “minor” head-on collision with a bike (don’t ask), I said– screw the plan, let them pick up the entire tab.  Get every surgical procedure on the book!

For those of you in the dark, an endoscopy is a simple procedure.  They put you to sleep.  They stick a, ahem, stick with a camera down your throat, take pictures, and analyze.  Again, not rocket science, but not something for the untrained to perform.

Today I looked at the explanation of benefits from our insurance.

The gastroenterologist who did the work billed $792, however the plan decided they should only get paid $165.  This is the man who spent 4 years in medical school, 3 years in an internal medicine residency, and 2 years for a fellowship in gastro.  This is the poor schmuck with $250,000 of debt at 6% (because not all school debt is finance at 3% by the Federal government).  This is the man with a god complex paying a yearly $15,000 in debt interest alone, and possibly $20,000 in malpractice insurance, all while trying to keep up with his friend the radiologist who billed $184 for a tangentially related ultrasound, and got paid $147.

Let’s review.  MD who did all the work and stands to get sued, $165.  Radiologist who was in the office for a few minutes and pays hardly any malpractice insurance, $147.  Note to Braulio– you got suckered going into surgery.  Radiology was the residency to get into!

Now, there are still the hospital charges.  The hospital bills $6,615.  The plan, who is sometimes partially owned by the hospital, gets paid a whopping $5,300.  But wait you say, the hospital must have provided all sorts of other services.  A bed? Nope, out-patient procedure.  A meal?  Nope, that’s what the vending machines are for.  An anesthesiologist doctor?  Nope.  A nurse anesthesist making a comfortable 6 figure income instead?  Nope.  The hospital had regular nurses trained to give anesthesia.  Oh wait, that was my mom, and I know her entire wing did not make that much that day.

I have a friend who’s making a surgery clinic so he can take a bigger piece of the pie.  But while he will take in more, the insurance will estimate down his charges because he’s not an actual hospital, but a clinic– so he can’t take the $5,300 for a brief procedure.  Meanwhile, the clinic may cost millions of dollars.

You may think I’m exaggerating, that medical plans don’t make that much, but I have a (street) smarter friend, who along with other doctors, pooled in a few million dollars and bought a failing medical plan.  The result?  He said in a year, he made more money than he had in his whole career as a doctor.  And doctors don’t exactly make minimum wage.

Another example.

The gastroenterologist thought it would be a good idea to do an ultrasound of all the poop in Yano’s belly, just in case.  As we know, the radiologist made $147 for this analysis.  However, the hospital who owns the ultrasound machine made $1,200.  Wanna know how much an ultrasound machine costs?  Anywhere from 15-50 grand.  So even if it costs $50,000, the investment pays for itself in just 40 uses.  And you don’t need to go to med school to own one!  Great investment!

The reason we pay doctors so well is not because they’re so much better than in other countries (a lot of US doctors studied abroad), but because they have such high med school loans, and because we’re a lawsuit happy country.  That, and they think they should live a half a million dollar lifestyle to keep up with the dermatologists and radiologists with their high pay, low work residencies :).  Of course, it doesn’t turn out that way, because they have the high overhead of an office downtown, 2 nurses on staff, a secretary, 4 cars, two boats, a summer home, and a wife who’s a professional shopper.

I have another friend who, after he finished his residency, went to work for a hospital making a pretty penny.  No malpractice, no office overhead, no nurses’ salary out of his bottom line, virtually no overhead.  However, he was forced to work 12-14 hour days, seeing so many patients, he was only able to provide a cursory exam.  He felt bad that he couldn’t give the level of analysis and medical care he was trained for, but the hospital has strict quotas for their doctors (read, paid slaves).  Who owns the hospital in question?  You got it… an investment group who also owns a medical plan.

You may think these are hospital and doctors in Argentina, where my brother-in-law is finishing his surgical residency?  Nope.  You may even think they’re in Puerto Rico, where even though the doctors are all US certified, they’re nothing but a glorified third world country, right?  Nope.  This is all right here in the mainland, where we bitch at any attempt to throttle the medical system.

If someone comes up with an alternate health plan for the US, we poop on it, accusing it of socialism, communism, or some other ism.  But no one ever bothers to see how much the pharmaceutical and medical plans pay for lobbiers in congress, or how much they fund the different candidates’ campaigns.  I have not a clue if this Obamacare is any good, because I tuned out of the debate a long time ago, but I can tell you this much– anything is better than the alternative.  It doesn’t take nobel prize winning economists to design ANYTHING that’s better than the raping we call a medical system.

As an aside, wanna know how much an endoscopy costs in Panama, where I *know* the private medical system is not that bad?  $670.  Compare to the $6,000 bill here.  How about in Peru where $400 can pay for an endoscopy in a private hospital with a private room, and your own private nurse?  Of course, nothing can beat a friend who’s a gastroenterologist, but unfortunately my friends decided surgery and internal medicine were better residencies, so unless Yano needs her stomach taken out, I’m much better paying out of pocket for a vacation in Machu Pichu.

Sorry for the somber post.  I don’t even have any solutions.  But this system definitely sucks for anything but the most advanced, expensive procedures– and maybe not even that…

In the past 10 years, I calculate that between my employer and myself, we have paid at least $60,000 in insurance premiums.  How much have they actually paid back?  You got it… the inflated $6,000 for this endoscopy, and only because we had already paid the deductible this year.  So that’s it, I’m done with insurance.  Next year I’m signing up for Red Hat’s high deductible plan with a health savings account.  I don’t want coverage for anything more than a catastrophe (car accident or cancer).  It’ll cost me $1800 less a year, and the IRS allows me to deduct travel for health care tax free from the health savings account.  For $1800, I’m sure we can visit Braulio in Argentina for an appendicitis, or wait until my friend finishes his clinic.

I have this turret like response in stressful situations: it’s called traveling.  So when my boss asked me to take on more work in the coming weeks, I panicked.  Had I not done a bad enough job at Wall Street to preclude further customer interactions?  Apparently falling asleep on top of the keyboard mid afternoon wasn’t enough.  I would not be spared the pain of more customer visits.  So, I did what I do best, panic and ask for a vacation.

Vacations here are not as easy as they were back in Puerto Rico, where we could leave the dogs in the backyard and ask the neighbor to throw some scraps over the fence every other day.  Since planning around dogs is a lot more involved here, the only quick getaway involves lots of driving– so here we are, roadtripping to California and taking it slooooow.

We’ve got to see Roy in the middle of nowhere Oklahoma, and are now in Durango, Colorado staying with Troy.  Since Troy races mountain bikes for a living, it is only natural for Yano and I to go ride the trails with him.  You’d think I’d be intimidated by riding with national champions, but I’m used to getting dropped by the worst riders– this would be no different.

Troy and Cricket took us up some beautiful mountains, and after the first 15 minutes I started to wonder if my brake was rubbing, I had flatted, or if someone was actually physically pulling me back.  I slowly started drifting back with this searing pain in the back of my throat.  Little by little it was getting harder and harder to breathe and I was starting to wonder if I would pass out and fall down any one of the dozens of precipices.  “Uhhh, can we wait for Yano?  She’s falling behind”.  Truth of the matter is, Yano was gaining on me and there was that whole macho thing.

When we get to the top of the climb Troy says, “how’s the altitude?”.  I panted, “how high are we?”.  Troy smiles and says “9000 something feet; can you feel it?”.  I was getting real dizzy by then and could only nod right before partially passing out on a nearby log.  By the time Yano came up I was lying on the side of the road wondering why the heavy breathing wasn’t helping me feel better at all.

Somehow I limped back home, huffing and puffing the whole way, meanwhile Yano seemed unphased by the lack of oxygen.  To help things along, Troy was pinning it all the way back home– in his cross bike by the way, because apparently, riding up trails in a mountain bike with us was too unchallenging.  I’m sure he could’ve done it in a road bike and still dropped me going up and down.

We got back and had a scrumptious taco night and I passed out on the couch while everyone took pictures and laughed.  My only companion was Frida who Yano had taken for a 6 mile run earlier, and had spent the rest of the day between being passed out and lying miserably under the couch.  I am definitely scratching “climb mount Everest” out of my list of things to do before I die.

Next stop, Moab Utah– at least it’s not at altitude.

By the way, we’re taking PICTURES along the way.

For those of you wondering if I survived a week-long stint of 9-5 punishment, I did!   Now if you’re curious if I’m up for repeating the feat any time in the next decade, think again!

What the hell?  Work is hard!  I’m sure 9-5 is what the framers of the Constitution had in mind when they penned the phrase “cruel and unusual punishment”.  Forget the debate over whether capital punishment is cruel and unusal, I say having to iron every morning, wear shirts with collars, long pants, and no naps in the middle of the day– that’s cruel!

The first day started with giddy expectations, kinda like what you feel on the first day of school after a summer long vacation.  I was actually excited to try on the new slacks and shirt which Red Hat was forced to pay for because, yes sir, I threw out all my dress clothes a LONG time ago (to my mother-in-law’s dismay, I got married in sandals).  Unfortunately I quickly found out that non-tshirts don’t look good fresh out of a backpack, so you have to factor in some ironing time along with your morning ritual.

After almost burning down the hotel room with the iron, I quickly found out there was barely any time to do any running, let alone cycling.  I figured I’d go for a run after work, because now I was in danger of missing my water-taxi to the Jersey side.

Work went surprisingly well, because when you don’t train for 2-3 hours before work, you’re remarkably awake, unfortunately this only takes you so far, because by 2pm you’re wondering why you’re the only one having a hard time keeping your neck in an upright locked position.

Somehow I made it to 6 pm without passing out, having survived an entire day of meetings and questions I would’ve rather responded to by email.  By the time I got back to the hotel, all plans of an afternoon workout quickly dissipated, as I entertained take-out and falling asleep in front of the TV.  How do people with regular jobs train?  I have definitely found a deep respect for masters athletes, most of which can still kick my ass, but that I blame on bad genetics, because it’s surely not for lack of rest (on my part).

I won’t bore you with the details from the rest of the week, but suffice to say that mid week I realized it was easier to wear the same shirt and pants (wrinkled or not), than have to wake up earlier to iron things.  By Wednesday I had discovered coffee and was downing espresso as if it were tequila during a spring break.  By Thursday I had rationalized that my 12 year old Clarks sandals were close enough to a shoe that I could forgo shoes and socks for the rest of the week if I hid my feet under desks at all time.  By Friday, the open bar at the hotel was looking quite tempting, and it finally dawned on me why they call it happy hour, and why weekends are such a revered period for the regular masses.

Luckily, I was honorably discharged on Friday afternoon, and was able to catch an 8pm flight back to my cave, where Yanory was waiting for me with a big grin and a sly comment: “so now do you agree that what you do doesn’t really count as work?”.  Absolutely, I now realize that I retired 10 years ago, but never stopped receiving a pay check.  If I ever get laid off from Red Hat, my only remaining skill inside of an office may be sleeping with my eyes open.

A few months ago my boss called and said, “how would you like an all expense paid vacation to Manhattan”?  He obviously knows my weakness for traveling, and you can’t beat free when being frugal.  I decided to bite: “Ok, what’s the catch?  Who do I have to go kill?”

It turns out what he really meant by vacation was, “why don’t you spend a couple weeks in the financial district while you tackle hard engineering problems for one of our Wall Street clients.”  Yano’s been busy with accreditations, tests, and the like, so I couldn’t bring her along, but I decided to give it a whirl, since the boss asked nicely, and there’s a standing bet amongst my friends of how long I’ll last working 9-5 with no naps in between like the rest of the working population.  So I’ve decided to prove them wrong!

It’s hard for me to surpass my backpacking frugal habits, so $300/night posh hotels downtown still don’t sound as exciting as a bunk bed in a hostel.  So I was sure to pack a budget guide to New York City before I embarked this morning (borrowed from the Palm Beach County Library of course).

This probably being the only day I’ll have to walk around (that whole 9-5 thing again), I decided to follow the guidebook’s walking tour of Lower Manhattan.  I’d never taken the time to properly tourist around the historical sites, so this proved an incredible experience– that is, until I started collapsing with hunger 4 hours later.

I had been starving since 4pm, but I had decided to push through it, in an effort to see the sites before sunset.  I wanted some authentic cuisine, and despite the fact that I had an ample allowance for a family of eight in just about anywhere else in the world, I decided to eat at a (guidebook) recommended hole in the wall in Chinatown.  Apparently even chefs from Nobu (one of the city’s most celebrated Japanese restaurants), still in their chef’s whites, come to dine here after their shifts are over.  I decided to try my luck, and pushed my way through a crowd of dining Asians.  This was definitely the real thing!

Not being able to read or understand most of the menu, I opted for the book’s recommendation “sauteed pea shoots”.  After a short wait, I realized that sauteed pea shoots were mild flavored lettuce looking things with a semblance of seasoning.  I quickly scarfed down the entire 2 pounds of lettuce, and ended up hungry.  I looked around at the nearby tables and the scrumptious plates around me.  It seemed I was the only one with a less than spectacular meal.  All right, let’s try this again… this time I ordered something more recognizable: chicken fried rice with onions.  Wrong again!  This other meal was what you cook yourself when there’s nothing in the fridge but left overs.  This is what you cook when there’s no seasoning, the rice is stale, you have no soy sauce, no vegetables, and you only have one egg to spread for 8 cups of rice.  Maybe a little too authentic, or maybe the entire restaurant staff, was secretly laughing at the stupid foreigner ordering the 5 English things on their menu.  Oh well, I wasn’t about to try a third plate, so I politely smiled, paid, and left.  I could hear the laughter as I closed the door.

Now, I’m all about taking public transport, but it turned out that I was in an uncomfortable corner of Chinatown, in which I was so far from a connecting subway line, that it was a wash between taking a few subway hops and a bus, or just walking back (a taxi would have fared worse with the bumper to bumper traffic).  I started to walk, and as is customary, it started to rain, so before I knew it I was running full speed, pushing small Chinese women out of the way, out-running small children on their bikes, and screaming at tourists for walking too slow.  After a couple miles I started doing some quick mental calculations:

• 2 pounds of lettuce: 80 calories
• boiled chicken parts: 200 calories
• copious amounts of rice: 700 calories
• miniscule bits of egg: 17 calories

All for a total of 997 calories.  But then you start subtracting:

• 4 hour walk: 800 calories
• 3 mile run: 300 calories

So I was basically sporting a caloric deficit which was bound to wake me up in the middle of the night with insatiable hunger pangs that are only serviced by room service (which I’m obviously philosophically against).  So I did the next best thing– I stopped at the closest hotdog stand and ate a big New York hotdog.  Unfortunately, by the time I got home it occurred to me I had only had two meals today, and had gone for a 2 hour bike ride before I got on the plane.

So now I’m sitting in the hotel room and the $15 can of peanuts is looking mighty fine, cause I’m not about to walk to McDonald’s, let alone Chinatown.  I think the fine dining experiences in the subsequent week will be kept down to a minimum of mostly recognizable plates: I’m thinking Indian food every night, because that’s never done me wrong.

So, I may update the blog in the next week, if only to amuse myself after a long day of “real” work.  I’ve yet to prove to Mirialis that I can “nine to five” with best of them.  I can even do proper overtime, and can even donn dress slacks and button down shirts for work (ok, I had to buy some last week)…

It’s been raining non-stop for the 3rd straight day, but rain cannot stop Bob.  It can deter me, but not Bob.  He wants to continue travelling: bastard!

I cycled through the Cordillera Central (Puerto Rico’s mountain range) on the third day.  The view, which in dry conditions is spectacular, was nothing more than fog scintillated by the occasional light of an incoming car.

I guess it was better not to see the mountain tops, because I doubt I would’ve finished the day had I seen I what I was up against.  After crossing 4-5 mountain towns, I called it quits in Cayey.   I dragged my sorry looking drenched self into a quaint restaurant on the side of the road: Lechonera (pig roaster) El Cuñao.

El Cuñao (literally, brother-in-law) sells traditionally slow roasted pig, and has been doing so for over 65 years.  Three generations of the Lopez family along with a couple dozen locals serve a myraid of customers on any given day.  On a busy Sunday afternoon, there’s a staff of over 20 workers.  The restaurant serves a variety of local plates (the rice and beans are to die for), but their mainstay is roasted pork.  Over 20 pigs weighing over 100lbs each end their careers in El Cuñao every week (100 per week during the Christmas holidays).

El Cuñao is yet another of the plethora of well oiled family run restaurants along the mountainous region.  Its walls are lined with local and international sports figures, and every conceivable local political figure from the 40’s, till today.

One of the owners welcomed me, and a little after learning of my odyssey, offered me a large bathroom/cabin to camp for the night.  I spent all afternoon talking with locals, eating arroz-con-dulce (rice pudding), and quietly typing away since I have full 3G signal on my cell phone.

I am continually amazed at the local hospitality in the rural areas.  I would’ve spent quite a few cold rainy nights out on the side of the road, had it not been for the generosity of folks along la Cordillera Central.

If you’re ever in town, El Cuñao is definitely a place to stop by, not only for the food, but for the exquisite ambience.