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You Can Survive The Healthcare System

The entire healthcare system is rapidly changing. Despite the flaws in the Affordable Care Act (ACA), I believe it’s a positive that virtually everyone now has access to medical care. When one of America’s poorest states, West Virginia, enrolled tens of thousands of impoverished citizens over a period of a few weeks, physicians observed a real decline in clinical depression. The ACA empowered this group, giving them a sense of hope as they joined the ranks of the insured.

The two most grievous aspects of the ACA are that it’s literally owned by the private insurance industry and that the current supply of people working in healthcare is inadequate. A tsunami of new health insurance enrollees is upon us, along with incomprehensibly complex ACA provisions, rules, and regs, and there simply aren’t enough physicians to handle it.

Just glance at this ACA Summary link, scrolling down quickly to see the provisions for you but also the rules and regs that I have to follow. You might also take note of the sponsors of this website, the Four Horsemen of the Apocalypse: Blue Cross, Aetna, Cigna, and Humana. (I’ll bet UnitedHealthcare was too chintzy to contribute.)

Your experience with the ACA
You may already be feeling the changes driven by the ACA. Some are good (“I finally have health insurance”), some not so good (“I didn’t realize the premium would be so expensive,” “I can’t get in to see a doctor,” “I can’t find anyone I like”).

As for doctors, along with the enormity of the ACA we’re in the midst of a quiet but steady rebellion from being primary care physicians, family practitioners, internists, and ob/gynies. Slammed on three fronts by waves of new patients, precipitous declines in insurance reimbursements, and incomprehensible new regulations, one of the most overlooked side effects of the ACA is that primary care docs are exiting in droves and not being replaced by doctors-in-training…because the latter are avoiding primary care as a career. About one fourth of the new patients I see give “retirement of previous doctor” as their reason for joining WholeHealth Chicago.

Immediate care centers and minute clinics have been envisioned as one approach to fixing all this. You’d get your strep throat swab in the back of Walgreen’s (“just past the sushi bar, turn left, walk through the wine department”). There was also talk of training more nurse practitioners via accelerated online training and forgiving medical school loans if students chose primary care.

But with reimbursements from health insurance for primary care in free fall, and the sheer hours of life a doctor’s loses forever completing soul-numbing paperwork, I seriously doubt if Mother Theresa, Albert Schweitzer, or Jonas Salk would consider careers as primary care docs in the 21st century US.

Quiet rebellion of primary care doctors moves along three paths
The first is early retirement: time to take another look at the IRA, tell the kids they’re on their own, and buy a smaller house in Boca Raton than you’d planned on. Lots of docs are doing this.

A huge second group of primary care docs are closing their offices and moving themselves and their patients into one of the region’s multi-specialty mega-groups, patients and doctors alike being absorbed into a division of Northwestern, Advocate, or Resurrection. With a move like this, your doctor relinquishes her autonomy (“You’ll work in this room and see 40 patients a day”), but also relinquishes her paperwork headaches, which are shifted into the skulls of the extremely well-paid CEOs and medical directors who run the system.

Under this arrangement, your doc gets a paycheck every two weeks. And while she has the comfort of a regular paycheck she may also be told, “You’re not seeing enough patients, you’re ordering too many tests, giving too many specialist referrals, prescribing too many brand-name drugs. We don’t think you’re a team player.” She’ll see different patients each day and sometimes never the same patient twice. The practice she brought with her—her long-term patients–simply gets lost in the crowd. Soon she too may be rechecking her savings and looking at early retirement.

The third group of rebelling primary care physicians is screaming “No!” “Enough!” “Be off with you, insurance company devils incarnate!” and walking away from their take-it-or-leave-it network contracts. “You,” more and more docs are saying, “had your chance and blew it. You murder innocent people with your profit-motivated denials, your team of so-called medical directors who couldn’t diagnose their way out of a paper bag setting the rules for making diagnoses and selecting drugs, specialists, and hospitals. Your decisions aren’t based on what’s best, but rather what’s cheapest.”

These rebellious doctors bring to mind that great scene in the 1967 film “Network”, where on national television a semi-deranged Peter Finch tells everyone to protest, shout to the world that you’re “as mad as hell and not going to take it any more.”

It’s important to add that this departure from an insurer-physician contract is a two-way street. The insurance companies are combing through their data and farming out practices with the highest costs. You’ll be hearing the term “narrow network,” and it’s pretty much what it sounds like. If an insurer can slice away expensive practices (those that in its view order too many tests, send patients to too many specialists, and the like), they can save some real money. I mentioned in last week’s Health Tip that UnitedHealthcare unceremoniously dropped more than 2,500 physicians from its network. This is soon to occur among all insurers nationwide.

The narrowest of narrow networks is the old HMO model, in which the doctor actually earns more money by doing less for you. HMO physicians (or their group practice) receive an annual fixed fee from your insurance company. If they can avoid spending anything, they keep the difference. If they overspend, their group absorbs the costs. Obviously, HMO-based practices pray their patient base is made up mainly of healthy young people who never show up in a doctor’s office.

Years and years ago, I was medical director for an immense citywide group of 50-plus physicians that had contracted to several HMOs. I left the job (and conventional medicine), exhausted from being harangued daily by health insurance executives because my physician group was “spending too much money on patient care.”

My personal attitude about HMOs is best portrayed in this 20-second clip from the 1997 film “As Good as It Gets.” Helen Hunt is the angry mother of an asthmatic child made worse by limited HMO treatment. The late, great Harold Ramis plays an independent doc whose visit to Hunt’s kitchen has been paid for by a mysterious benefactor. Audiences cheered when Hunt let loose with a string of epithets describing HMOs.

Next week, the difference between in-network and out-of-network physicians and what’s best for you.

Be well,
David Edelberg, MD


Leave a Comment

  1. Jennifer F says:

    Hi Dr. E, just wondering what recourse as patients we have to not let the insurance company get away with this crap. Why aren’t people getting angry at how we are treated and doing something about it?
    After all our premiums pay their salaries!

  2. Jeff Lupetin says:

    Thanks David..
    Very informative and insightful.
    This stuff is so creepy having non Docs decided the care of us all, or at least those not in government work..politicians need not worry…Understand the need for cost control but ….let the experts lead. like you…

  3. Mike says:

    Jennifer you pose the question what can we do? How about voting out the politicians that passed the ACA and voting in some people who will pass a law that actually works and doesn’t make the healthcare crisis worse. Which would include reigning in the insurance companies. Dr. I know you support the ACA but to me the negatives far outweigh any of the positives. I’m not sure why you support this. It seems like we could cone up with a better solution than what I’ve seen do far with thus law and the worst of it is yet to come. They have yet to start enforcing any of the mandates. It’s frightening.

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Far and away, the commonest phone call/e mail I receive asks about COVID-19 diagnosis.
Just print this out, tape it on your refrigerator door, and stay calm.


• Runny nose
• Sneezing
• Red, swollen eyes
• Itchy eyes and nose
• Tickly throat
• No fever

• Runny nose
• Sneezing
• Sore throat
• Mild muscle aches
• Mild dry cough
• Rarely a low fever

• Painful sore throat
• Hurts to swallow
• Swollen glands in neck
• Fever

FLU (Standard seasonal flu)
• Fever
• Dry cough (no mucus)
• Sudden onset over few hours
• Headache
• Sore throat
• Fatigue, sometimes quite severe
• Muscle aches, sometimes quite severe
• Rarely, diarrhea

• Shortness of breath
• Fever (usually above 100 degrees)
• Dry cough (no mucus)
• Slow onset (2-14 days)
• Mild muscle aches
• Mild fatigue
• Mild sneezing

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