By Daren Anderson
Standing at a hospital checkout desk, credit card in hand, can be nerve-wracking. How much will it cost? Is my credit limit sufficient? Will there be more bills later when they calculate the radiologist’s fees or blood tests? Will I need to dip into a home equity line of credit to cover the costs?
But wait — we are in Italy. Maybe healthcare is different here.
We waited in line at the cashier’s desk for about 10 seconds before being called up. A few keystrokes later, we had a bill for $177, paid for with our Visa, and we were on our way.
What, do you suppose, do you get for $177 in an Italian hospital? A glass of orange juice? A CBC?
In Italy, $177 was the total charge for an ambulance ride on a backboard, an emergency room assessment, an X-ray of the lumbar spine, a head CT, an electrocardiogram, and an orthopedic telehealth consultation from the University Hospital in the nearby city of Perugia.
All of these services were provided for Esterina after she slipped on wet pavement in Assisi and fell hard on her sacrum. The fall itself was painful, but the shock, pain, and stress of the event caused her to faint, prompting an ambulance trip to the ER.
You might wonder whether you get what you pay for. Joking aside, in the US this entire event would likely have cost thousands of dollars, some covered by insurance and some not. Would the care have been thousands of dollars better?
The entire experience lasted about four hours. The ambulance took roughly 20 minutes to reach us on streets designed for mules, not advanced life support vehicles. Upon arrival in the ER, Esterina spent about 15 minutes on a stretcher in a hallway before being wheeled into an assessment room where an ER physician sat at a desk asking questions while a nurse relayed them and performed a cursory exam. An ECG was quickly performed and found to be normal. An X-ray of the lumbar spine was ordered. Although we were all certain she had not hit her head, a CT scan was ordered nonetheless for a fall associated with loss of consciousness.
After the consultation, we were back out in the hallway. We waited about 30 minutes for the radiology room to free up, watching several more seriously injured patients appropriately move ahead of us for imaging. Finally, lumbar films were taken, followed shortly afterward by the CT, and once again we returned to the hallway.
We spent much of the next two hours there, staring at a few bad pieces of art on the walls and watching patients, some bleeding, some moaning, some stoic, come and go. Eventually we learned that the CT was normal, but the spine film showed a “cortical irregularity” in the S3-S4 region. In other words, there may have been a small sacral fracture, though the findings were equivocal.
The ER physician was not comfortable discharging her without an orthopedic consultation. The orthopedist was in the operating room, and no one knew when he or she would be available. There was even discussion of transferring her to a larger hospital.
This was a dark moment for both of us.
I try very hard not to “play doctor” when family members are involved. Judgment can be clouded by emotion, and I have not actively practiced clinical medicine in over 10 years. Still, the concern about transfer felt disproportionate to her clinical condition. She had no neurologic findings, minimal pain, and no clear fracture. Rest, movement as tolerated, and some ibuprofen seemed the likely outcome.
Fortunately, soon afterward an orderly came out and explained that the orthopedist had reviewed the films remotely, spoken with the ER physician, and cleared her for discharge. Ibuprofen as needed. Nothing further.
Ten minutes later we were at the cashier, Visa in hand, and a few minutes after that we were on our way back to our hotel.
Once the trauma, fear, and emotion of the event settled, we had ample time to reflect on our healthcare experience in Italy and to compare it with our own system back home. All in all, the right things were done. The ECG and CT scan made sense. The diagnosis was appropriate, and she was triaged correctly from the start. Getting an orthopedic consultation for a marginal finding may have been somewhat excessive, but it happened quickly enough that the reassurance was probably worthwhile.
In Italy, we got the basics, without the frills. The hospital has no shareholders and earns no profit from our visit or anyone else’s. There was no prior authorization process and no insurance intermediary standing between patient and physician. The radiologist, ER doctor, and orthopedist earn far less than their American counterparts. Yet we still received the essential components of appropriate emergency care, and the outcome was entirely appropriate.
So what might more money have bought?
Better artwork on the walls, certainly. Better bedside manner as well. The physician never actually spoke directly with us, and the nurses and orderlies, while professional, were fairly scarce and often brusque when relaying information. More money might have purchased a more thorough exam. I was somewhat surprised that Esterina was never placed in a hospital gown or given a complete physical examination. She remained in her street clothes and sneakers the entire time — admittedly making it easier to get up and leave.
More money also might have bought a blanket. Throughout the experience Esterina was cold. I covered her with both of our coats along with a thin hospital sheet that I had to request. Perhaps more money would have bought us a curtained exam room like those seen on The Pitt instead of a dingy hallway.
It also could have purchased better facilities and groundskeeping. Many of the hospitals we have seen in Italy, including this one, feel austere and physically underinvested, more functional than welcoming. Tall grass and weeds surround institutional-looking concrete buildings that appear to receive little attention beyond what is necessary to keep them operational.
The biggest thing we did not receive, however, was kindness or reassurance. Everyone was professional, but there was very little warmth. No smiles. No expressions of concern. No one paid much attention to Esterina’s non-life-threatening symptoms or comfort. She was nauseated, dizzy, cold and scared. No one asked. No one checked.
Still, it is important to remember that we were technically uninsured in Italy, even though we carry international coverage that will reimburse us for the charges. An Italian citizen likely would not have paid anything at all for the same care. In the United States, an uninsured person experiencing a similar event could easily face thousands of dollars in bills unless they were fortunate enough to qualify for charity care, Medicaid, or other assistance programs.
How much are all these “extras” worth? Are they worth having 5–20% of the population uninsured? Are they worth a system that can leave people financially devastated by illness or accident? Are they worth the inequities that still define so much of American healthcare?
Personally, I do not believe we should have to choose between humane affordability and humane care. Italian healthcare could use more warmth, comfort, and investment. American healthcare could use far less profiteering and inequity.
Most surprising of all, however, we have not received a single call or card from an injury attorney. And I have not seen a single billboard advertising one anywhere in Umbria.
Back to travel, back to Italian food, and back to health!
A dingy hospital in South Italy (not the one we were in in Assisi)