Don’t Tell Me You Think Insurance Will Actually HELP

I never paid a great deal of attention to politics, until I realized that health care had become politics.

I may be the last of a generation that learned, in medical school in France, that the responsibility of a doctor was to keep a record of cash transactions, something best done in a bound notebook with no pages ripped out, and only a single line to cross out errors, so that integrity would not be questioned.

The same year I entered medical school, President Richard Nixon signed the Health Maintenance Organization Act of 1973.

Wealthy industrialist Henry J. Kaiser, billionaire shipbuilder, and steel and aluminum magnate (as well as staunch Republican and major contributor to the Nixon campaign) was the first person to establish a “for-profit” hospital.

Before this time, nobody would think of running a hospital for profit any more than they would think of running a fire department for profit.

But Kaiser had the President’s ear and he had a keen idea for generating huge profits with privately-owned hospitals.

It is a small step to see how his relationship influenced Nixon’s promotion and passage of the HMO Act.

The truth came out in the infamous White House tapes that surfaced when President Nixon resigned under threat of impeachment. Here is the transcript of the 1971 conversation between President Richard Nixon and John D. Ehrlichman that led to the HMO act of 1973:

John D. Ehrlichman: “On the … on the health business …”

President Nixon: “Yeah.”

Ehrlichman: “… we have now narrowed down the vice president’s problems on this thing to one issue and that is whether we should include these health maintenance organizations like Edgar Kaiser’s Permanente thing. The vice president just cannot see it. We tried 15 ways from Friday to explain it to him and then help him to understand it. He finally says, ‘Well, I don’t think they’ll work, but if the President thinks it’s a good idea, I’ll support him a hundred percent.’”

President Nixon: “Well, what’s … what’s the judgment?”

Ehrlichman: “Well, everybody else’s judgment very strongly is that we go with it.”

President Nixon: “All right.”

Ehrlichman: “And, uh, uh, he’s the one holdout that we have in the whole office.”

President Nixon: “Say that I … I … I’d tell him I have doubts about it, but I think that it’s, uh, now let me ask you, now you give me your judgment. You know I’m not to keen on any of these damn medical programs.”

Ehrlichman: “This, uh, let me, let me tell you how I am …”

President Nixon: [Unclear.]

Ehrlichman: “This … this is a …”

President Nixon: “I don’t [unclear] …”

Ehrlichman: “… private enterprise one.”

President Nixon: “Well, that appeals to me.”

Ehrlichman: “Edgar Kaiser is running his Permanente deal for profit. And the reason that he can … the reason he can do it … I had Edgar Kaiser come in … talk to me about this and I went into it in some depth. All the incentives are toward less medical care, because …”

President Nixon: [Unclear.]

Ehrlichman: “… the less care they give them, the more money they make.”

President Nixon: “Fine.” [Unclear.]

Ehrlichman: [Unclear] “… and the incentives run the right way.”

President Nixon: “Not bad.”

Private enterprise running health care and making a profit certainly appealed to the pro-business Republican philosophy.  But what put the icing on the cake was Kaiser’s stunning idea that : “… the less care they give them, the more money they make.”

After the “for-profit” era of medicine started, insurance had to be an added cost for doctors.  An intermediary insinuated itself between the patient and doctor, and that had to be paid.

And then the insurance company may hire added consultants.  I don’t mean medical consultants, such as specialists who would actually help the patients and add value to medical treatment.  I mean consultants who are basically reviewers–bean-counters who go through all treatment plans to see how they can cut costs (usually by cutting services and prescriptions and tests and appliances).

This review process increases the added cost to the patient, who is less and less likely to receive what the doctor actually thinks they need.

And the medical decision about what medically necessary is taken away from the doctors and handed to clerical staff.

That’s right, when the decision to give you health care is decided, it is generally by insurance company employees who may not even have a bachelor’s degree (let alone a medical school degree) and are armed with a checklist of “inexpensive alternatives” to actual medical treatment which might cost the insurance company some of the money you’ve already paid to them.

I entered private practice in 1992 after being a military psychiatrist and then a medical school professor.  I had also recently gotten married and my husband was a businessman who wanted to help me set up an independent practice so I could help people the best way I knew how.

HA! – the joke was on me.

At that time, the HMO and PPO programs were at their peak of popularity and power, and the common wisdom was for a doctor to join as many programs as possible so as to have access to as many patients as possible.

After five years of declining “reimbursements” (an incorrect term for the amount a doctor is paid for each procedure done on a patient) and rising costs to be a “panel member” (have the franchise to see patients from a certain company such as Blue Cross) and more and more restrictions (being forced at my peak to hold privileges to admit patients to ten different hospitals since each insurance company contracted with specific hospitals and there patients could only go one place), I said “ENOUGH.”

In 1996 I resigned from all insurance programs and became a cash-only doctor.  From then on, I had the luxury of laughing at insurance company flacks who would phone me and say that there was a cheaper way to treat somebody. My choice was for effective and safe treatment, free of side-effects that eventually got a lot of the drugs recalled from the markets and the manufacturers sued.  I wasn’t worried that there was a cheap way out that would leave the patients miserable and worse than when they were untreated.

When you pay your hard earned money to an insurance company for coverage, you probably think that the company has a responsibility to you.  WRONG! The company has a responsibility to its stock-holders and the CEO and other officers who are expecting profits and fat bonus checks.  That’s why you see stories like telling you that 10 to 15% of medical tests are denied.

The state insurance commissioner is saying that maybe the decision to do this was made by people who were not qualified.  Remember the treatment reviews I mentioned earlier?

But even with this outrageous situation, Senator Rockefeller continues talking about a lower percentage maybe being acceptable.

How many, Senator? Should 10% of the people needing a crucial cardiac test be denied it?  Or maybe only 5%? I guess our leaders have determined that third party providers – not the patient or the doctor – can decide who lives and who dies.  They are just arguing over how many will die.

I bet if Senator Rockefeller had been in this situation, with life-threatening chest pain, he wouldn’t have to worry.  You see, the Senators get a terrific health coverage plan as part of their job.  It’s much better than what you can purchase through Kaiser Permanente or any other company.

And of course, we all know about the wealth of the Rockefeller family — HE would have paid for his own test.  It would probably be pocket change to him. The missing statistic is how many of those people denied this “crucial test” (as MSNBC called it) died. These are the folks, saving money for all concerned by denying tests.

You may think that this is a great service, as we want to eliminate all wasteful use of expensive resources.

But wait a minute!  Are we psychic?  I don’t think most doctors are, and I don’t think most “utilization clerks” are.  How does anyone know if a test is necessary or not?

Put yourself in this position – You find a suspicious lump or mole or other symptom you have heard might indicate you are developing cancer.  Of course you are worried and want to get it checked out.

You go to a doctor who refers you to a hospital to get tests – maybe a mammogram or an MRI or even a simple biopsy.

The test comes back negative and you breathe a sigh of relief.  Not only you –but your whole family and all your loved ones are happy that you don’t have such a serious disease.

But how would you know if it was cancer without the tests?

What if you go to a doctor, and the staff that he has to pay extra for to process all the insurance rigmarole calls in to the “treatment advisor” who looks on some guidelines and sees that in six out of ten cases such as yours, there is a negative test?

Test denied.

When you come back months later and the symptoms have progressed or even worse symptoms have arisen, the doctor tells you that you might have had a lot better chance if the cancer was detected early.

Insurance is a gamble.  The reason it was developed many centuries ago was to offset risk.  Statistics are used to see how often something negative might happen – a car accident, a house fire, or a disease – and insurance is set up to provide a pool of money to help out in these eventualities.

Insurance is not a pay-off for a sure bet.

On the up-side – if you need to find a job, there are companies that are aggressively advertising to find people to deny tests.  Some only hire you if you have a nursing degree, but there are others with a lower standard of acceptance.  Just look on Career Builder or Job Monster or those types of bulletin boards on-line. They are advertising for all kinds of people except physicians.  They are building layers that add no value to services rendered to a patient and may take away some value.  And many of them are owned by pharmaceutical or insurance companies.

Obviously it bothers me if a doctor cannot order a test and gets it refused multiple times.  People are dying and it is not clear to me how to stop this. Maybe we should be grateful that Senator Rockefeller’s senate commerce committee reviewed this. However, I am not commerce, nor are you.

We are human beings, and we are American citizens who pay for insurance and pay taxes for a government to give us protection and rights.

Medical tests were made to diagnose conditions, and the better they get, the better the chance of saving lives.

Yet, as time goes by, we see more and more obstacles to the simple doctor-patient relationship.

If Med Solutions and Blue Cross of Delaware stop a patient from receiving tests or treatments, they are committing murder.  It is obvious that nobody is stopping them.  Instead, their actions are promoted as noble and cost-effective.  That’s what the politicians call “spin.”  And yes – it has become politics.  It has become commerce.  It is no longer healthcare or medicine.

Who is paying for this idiocy? We The People.  The ones who we are told all through our school years control the government and ARE the government. Those of us who are paid to do jobs.  Those who have sought stability in life.  Those who have insurance premiums deducted from their paychecks thinking they are the lucky ones, who are “insured.”

We have been lied to. Insurance companies are in bed with the government.  Nobody, in the case before the Rockefeller commerce committee, has thought of doing anything to an insurance company and the reviewing company it hired.  Their job is not to help people get better healthcare – it is to improve revenues, stock prices and dividends. The government issues no sanctions.  No bills have been introduced in congress.  Nothing has been done at all. Oh yes — They “educated” their staff. Doesn’t that make you feel better?

For years I have advised people to dump their insurance and open a”health savings account.”

This type of plan gives you a tax break on the money you tuck away in a savings account to take care of health issues that arise – generally the milder, out-patient type.  Maybe a broken arm, or stitches or a procedure such as a colonoscopy.

Nobody tells you what you can or can’t do with the money (well, within reason) as long as you take care of medical expenses.

Then you can supplement this by also carrying an insurance policy called “catastrophic health insurance” or a high-deductible health plan.

These tend to charge low premiums and are intended for those things that are less likely to happen – but can be catastrophic when they do happen. Things like critical operations and long recovery times – things you certainly hope never happen, but occasionally do to at least a small portion of the population.

These are often coupled with the health savings account and also offer some tax advantages for the money you pay for premiums.

It is difficult to save money and to put it away for a medical emergency, but at least the government has made an effort to make this a little easier.

And you are REALLY gambling if you have a standard health and hospitalization policy and expect it to cover you when you need it most.  Because the minute you look like someone who actually needs medical care that may actually cost something, expect the insurance company to dump your request — and maybe, to dump you. To avoid looking like a one-sided zealot, I really do have to address the question of unnecessary tests and the accusation that doctors pad their bills at the expense of insurance companies and tax-payers.

I know a lot of insurance fraud goes on.  I’ve known doctors who were horrible about this.  They sometimes had justifications – but it didn’t change the fact that they were doing wrong.

Both private insurance companies and government programs have progressively reduced how much money they pay doctors.  After all, both are accountable to their funding parties (either share-holders or taxpayers) to cut costs and eliminate waste.

This is often taken to ridiculous extremes, and that’s one reason I opted-out of insurance-based medical practice.  Doctors have been reduced to what are essentially low-paid civil servants.

The average worker may not think an institutionally-employed doctor is low-paid (compared to a cab driver or a waitress), but for somebody who spent anywhere from eight to twelve years in expensive specialized education and has expensive malpractice insurance as well as all the other expenses of life, making $50 to $75 per hour is actually not all that great.

Some doctors double-dip, charging twice for doing the same service.  Others might just fabricate billing, saying they did things for patients that they never did.

These things are wrong – and just because you think an insurance company makes huge profits is no justification for cheating them.

Excess testing gets a lot of press.  People think doctors are making big bucks by sending people for unnecessary tests.

Usually, a doctor has no financial interest in testing.  Most states don’t allow a doctor to own a lab or a pharmacy or the specialized imaging machinery to which that doctor’s patients are referred.

My personal philosophy on testing – First, I need testing for certain things.  A psychiatrist is totally justified getting thyroid tests, and blood glucose and other such tests when they might indicate that the symptoms for which a patient is seeking treatment are caused by a medical condition.

All the antidepressants in the world won’t cure your depression if it is caused by a bum thyroid.

These things are supposed to be caught by a general doc before the patients see a specialist like me.  That is supposedly how an HMO operates.

Unfortunately, that is NOT how it works.  Thanks again to cost cutting and “efficiency experts.”

The art of diagnosis is not practiced – I don’t even know if it is taught any more.  If a patient goes to an HMO gatekeeper (usually a nurse practitioner or physician’s assistant, but sometimes a Family Practice MD) and even utters the word “Depressed” or some synonym – it can be an immediate referral to a psychiatrist.

Even that is changing.  Now the HMO will allow the Family Practice doc to dish out antidepressants, even though that doctor really doesn’t have all the necessary training to handle such specialized drugs and probably doesn’t do the proper screening (such as checking for the bum thyroid). Current statistics show that 80% of all antidepressants are prescribed by general practice docs.

There is one very important question to be asked about any — yes I mean any — medical test, before it is requisitioned.  The question is, “what difference does it make?”

Another way to ask the same question is to ask a treating physician “how would this test change what you do to me?” The best people to trust are doctors –NOT insurers. However, when the line is blurred – when the doctor takes marching orders from the insurers — you must be wary.