Market Medicine in El Salvador

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In the United
States, the current debate over healthcare reform is really no debate
at all. Both sides of the argument accept the fundamental principle
of government intervention. Today few can recall a time when healthcare
was not considered an entitlement. Americans caught up in this racket
would do well to look south, to El Salvador. It has been a half-century
since medical care in the United States could be described as a
business. In El Salvador that is exactly what it is, a business.
There, the customer (patient) meets the service providers (doctors,
labs, hospitals, pharmacies) at that voluntary, mutually beneficial
place known as the market price.1

The typical
doctor's offices I have encountered are two-room suites in buildings
that are physically attached to small private hospitals. This is
the arrangement for my pediatrician, endocrinologist, and otolaryngologist:
a reception/waiting area and another space that serves as both office
and examining room. This is low overhead at its finest. Only two
people are involved, the doctor and his receptionist. No nurses,
no staff, no large group practices, and no offices jammed with secretaries
and insurance filers. There is only the receptionist out front that
makes your appointments, takes your payment, and writes your receipt.
A routine office visit costs about $35.00, cash or check. There
is no mention of insurance for these routine services. Any dealing
with this issue is strictly between you and your insurance company.
The physician's role is to provide service, receive your payment,
and hand you the proper receipts. Furthermore, all the doctors I
have dealt with in San Salvador have their personal cell phone numbers
printed on their business cards.

I recently
took my son for his regular medication update. It is a routine visit,
something we do every three to four months. The pediatrician's visit
goes something like this: I call and the receptionist, who recognizes
my voice, makes an appointment for 6:00 PM the next day. My son
and I arrive and, because of the hour, there is usually only a brief
wait. We are greeted by name and ushered back to see the English-speaking
doctor. Since he ordered blood work on our last visit, he goes over
the results in great detail, taking the time to talk to me about
my son's progress and growth. The doctor gives my son a complete
physical and records the findings. On any given visit, the doctor
answers his land-line and cell phones three or four times to receive
updates on patients or to discuss various ongoing treatments. These
calls rarely last more than a minute or two. This never seems disruptive.
Indeed, I am impressed with the doctor's efficient use of time.
When he is finished, he writes the prescription and sends us on
our way with a firm handshake. Back in the outer office, I pay cash
and we leave.

The same pediatrician
also doubles as our family physician, seeing my wife and myself
on routine cases. On one visit my wife, still suffering from a lingering
sinus infection, went along with me and my son. When called, we
all went back to the examining room. The doctor examined both my
wife and son. In the end, he did not charge for my wife's visit
and gave her enough sample medication for the first 24 hours of
an additional round of treatment.

The doctor,
having read some recent updates on my son's medication, suggested
an EKG and wrote out an order. He also phoned ahead and said that
the cardiologist would be ready for us in 15 minutes. I was, of
course, in full conditioned response mode, panicked at the hassle,
time, and cost this EKG would surely entail. As it turned out, the
cardiologist's office was just upstairs. I sent my wife and son
ahead while I settled up the bill with the pediatrician's receptionist.
When I arrived at the cardiologist's ten minutes later, they were
done! Another ten minutes and I had two copies of the EKG. I paid
$25.00 in cash and we were on our way, not one hour beyond our original
appointment with the pediatrician.

High-tech specialists
follow a similar pattern. My wife's sinus problem proved to be more
serious and required surgery. The otolaryngologist came highly recommended
and we made an appointment for later in the week, no problems, no
"referral." We arrived at another private hospital to
discover a beautifully appointed waiting room with a single receptionist.
The doctor's office was equipped with very latest video and endoscopic
technology. After a thorough examination, he ordered a CT scan.
Since it was after 6:30 PM, he called ahead. The radiologist agreed
to stay late to complete the procedure. We drove a short distance
and found another amazing set up: one receptionist, one CT technician,
and a female radiologist. Her office contained just one CT machine,
obviously the very latest, all in a storefront at a shopping center
two blocks from the hospital. The procedure was not cheap at $265.00,
but we were done and on our way in less than an hour, the typewritten
diagnosis and CT films in hand. Such convenience and efficiency
in an American medical practice is difficult to imagine.

Labs and
pharmacies also show careful attention to customer service. The
lab we use is not in a medical complex, but in a small commercial
office building. It is open on Saturdays, very helpful when my son
needs to arrive in a fasting state. The receptionist at the counter
reads the doctor's lab order, looks up the prices, rings up the
total, and presents the bill. Here I pay with my debit card. In
the next room, a technician draws blood with an attitude of cheerfulness
largely missing in the American scene. On one visit, my son had
his blood drawn by the owner of the lab himself, a well-respected
San Salvador pathologist.

In El Salvador
numerous pharmacies, national chains and independent stores alike,
compete in a vigorous marketplace that places high value on customer
service. Pharmacies routinely post the prices of popular medications,
the majority of which are available without an MD's prescription.
Often two or three stores from competing chains are in the same
block, sometimes in the same building. If they are out of stock
on any given medication, the clerk will phone another location nearby.
The pharmacy's motorcycle delivery man will ride over, retrieve
my prescription, and deliver it right to my front door. As always,
customer service comes first.

Quality, low
overhead, excellent service, payment when services are rendered
– these are the hallmarks of a market system. If only the would-be
healthcare reformers would use El Salvador's market medicine as
the example of what could be in the United States.


  1. El Salvador
    also has a state-run healthcare system. Since I have had no personal
    contact with that aspect of Salvadoran medicine, I can offer no
    information on that subject.

Dunlap [send him mail]
has lived in El Salvador since 2005.

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