SICKO Part Two

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This continues my urging for you to see (and act upon) Michael Moore’s movie SiCKO, his devastating critique of our health care crisis.

Our current health care mess really began in 1971 when President Nixon signed a law that ended further debate about government-funded universal health care. Until that point, doctors had been making good money in the now historical fee-for-service system (the only remaining fee-for-service physicians today are cosmetic surgeons). Doctors were fearful to the point of paranoia about so-called socialized medicine, and very worried about what was being created up in Canada.

Nixon’s law made it economically very profitable for corporations to go into the health care “business.” Some had been life insurance companies (Aetna, Cigna) and others were simply created to take advantage of the potential gold rush (Humana, UnitedHealth Group, Unicare).

The Blues (the network of Blue Cross companies) knew something about the business already, and they’ve turned out to be the most profitable of all. The Blues, ironically, refer to themselves as not-for-profit, but that simply means “tax-exempt.” Their executives are doing very well, as are all the others.

How well? If you’ve been holding UnitedHealth Group stock during the past decade, you’ve done nicely. Bill McGuire, MD, the CEO, has “earned” more than $3 billion (yes, billion) heading this most profitable of health care companies. On the other hand, we keep on our office bulletin board an uncashed check from UnitedHealth–our reimbursement for one patient’s office visit. It’s made out for exactly five cents.

If you have health insurance–and remember, 47 million of us don’t–you’re either in a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization), two elegant euphemisms for health coverage that has placed us 37th in the world rankings of how healthy we are as a nation.

In a PPO, your doctor and certain hospitals have signed a contract with the insurance company to accept the fees the company is willing to pay. This usually means a 30-40% reduction of previous rates, but doctors were so fearful of being left out in the cold they hurriedly signed on. The companies had a take-it-or-leave-it attitude and doctors rarely fought back.

If these companies paid their doctors and hospitals as promised, that would be one thing. What actually happens is something else: endless deliberate delays, like requests for photocopies of notes, phone calls doctors must make for “pre-approvals” and “prior authorizations” to treat their patients, and so forth. What this boils down to is that a doctor seeing a typical PPO patient in January is lucky if her reimbursement for that visit shows up by May.

When you try to explain the HMO reimbursement system to a non-doctor, the most frequent response is “You’ve got to be kidding.”

Keep mind I was formerly a medical director for a physician group that was responsible for 20,000 HMO members. I left it because I simply couldn’t deal with the endless compromises physicians had to make caring for their patients in order to enrich the shareholders of the insurance companies. The deliberate delays and denials were, and continue to be, dangerous to patients’ health.

In this system, the HMO company–after collecting the monthly insurance premium you and your employer have paid–gives a small portion to your selected primary doctor, even before you two ever meet. If you don’t select a primary physician, the HMO delightedly keeps that money, too.

But once you select your doctor, everyone involved–doctor and insurance company alike–try their level best not to spend a dime of it on your health care needs.

The HMO system is designed so that everyone–doctor and insurance company alike–makes the most money if you, the patient, never show up in the office or emergency room or buy any medication. When you actually start using the system, you are depriving everybody of their profits. For “over-utilization” (too many tests, referrals to specialists, brand-name vs cheaper generic drugs) the insurance company actually financially penalizes your doctor.

If you’re an “Expensive Patient” (lots of office visits, lab tests, medications, referrals to specialists), you are tapping into the insurance company’s profits and they don’t like you. You are a “medical loss” (their term) eluding their physician-gatekeeper (also their term). They will bend over backward to deny you coverage, especially when you appear to be a potential expense. Then they’ll pull out such phrases as “non-coverage of pre-existing conditions.”

The only way doctors can make any money themselves in either the HMO or PPO system is to agree to be responsible for as many patients as possible. This leads to the fabled five-minute office visit, with doctors seeing 40 to 60 patients per day. Since doctors share with your insurance company any unused dollar reserve, they’re financially motivated to deny referrals to specialists, deny certain tests you may want, and deny medications other than the cheapest of generics. In their hearts, they know better.

As an example of how doctors feel about all this, nearly 75% of physicians discourage their children from entering medicine as a profession.

People ask why it’s so difficult to purchase an individual health policy. It’s simple, really. The insurance company wants nothing to do with you if you’re going to cost them any money. The moment you apply for a policy, you give permission for them to review all your medical records. And, boy, are they efficient. If they find any condition that looks like it might erode their future profit, you’re not worth the risk and they deny you coverage.

Physicians themselves know this system is terrible and are far more open to universal health coverage than they were in 1971. In fact, an organization called Physicians for a National Health Program exists and its website contains well-researched answers to many frequently-asked questions about national healthcare. Click here for the link.

The Journal of the American Medical Association (JAMA) reported last year that US citizens are now sicker (and have shorter life spans) than those in any developed country with universal health coverage–essentially because of our capitulation to insurance companies.

If I haven’t made you slightly nauseated by how the system works, check in next time when we’ll look at how other countries do a better job of delivering care to their citizens.

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