Market Medicine in El Salvador


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.

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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.

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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.