We Want You To Die

It’s funny how the mind works. You find yourself in a particular situation and as you mull over what to do, all of a sudden up pops a line from a movie. Good old Freud, always reliable when it comes to mining your subconscious.

The question, from the aliens-invade-earth action flick Independence Day, is posed by the US president to a decidedly uncuddly ET, whose response is chilling.

“What is it you want us to do?”
“Die!”

You probably saw the movie. Vicious aliens brutally attack Earth, destroying city after city, zapping millions of innocent people with their WMDs operated from flying saucers. I thought it endearing the way their weaponry ran on Windows. Either they’d tapped into our systems or, possibly, Bill Gates was an alien.

Now, though, it’s the mephitic maw of the health insurance industry that opens, that same threatening line roaring out. In this scenario, Earthlings are represented by the rapidly declining number of primary care physician offices around the country, their bewildered patients casualties as well. I can only report first-hand on what Blue Cross of Illinois is doing to us at WholeHealth Chicago, but from what I’ve been reading in the New York Times and Medical Economics, what’s happening to us is pretty much a national phenomenon, with all insurers blasting away at all primary care offices.

Because this affects you, the patient, and how your medical care is changing, I urge you to read all the way through today.

ACA brings major changes

Everyone knew the Affordable Care Act (ACA) would bring big changes to the health care delivery system. Some months ago, I reported on a talk given by a Blue Cross medical director, breaking the news to a roomful of depressed doctors that their fee-for-service system was doomed because insurance companies could no longer afford to pay for health care under the PPO model. Their plan? Phase out all fee-for-service care during the next few years, replacing it under the ACA with low-cost care standardization.

And with this, the once-inalienable right of patients to get–and doctors to provide–whatever care they needed (tests, specialists, medical equipment) was history. Essentially, the insurance industry now calls the shots. And while for the past 25 years the insurance industry has always been an extremely powerful player in how medicine is practiced (best documented in Michael Moore’s film Sicko), never have all physician day-to-day decisions been so closely scrutinized for cost as they are now.

The medical director went on to tell us that small practices with a mainly PPO patient base would likely be unable to tolerate the reduced physician fees planned under the ACA, and that these practices would gradually be acquired by large medical centers. This didn’t mean a small medical office would close up shop completely. Instead it would become “a Division of…” with the doctor a salaried employee of the larger entity. When hundreds of physicians and thousands of hospital beds are all controlled by one system (e.g., Northwestern, Advocate, Resurrection), everything is standardized and insurance companies like that. Fees for every possible test and procedure would be pre-negotiated between medical center and insurance company. The medical centers would be financially rewarded with increasingly favorable reimbursement rates if patient care met certain quality standards, set by committees made up of medical center and insurance company employees.

Here’s an example of the inherent danger in this. If one of the reimbursement objectives is to ensure every patient’s cholesterol is low, your prescription for a statin will be based not so much on your well-being as on the bottom-line improvement of the medical center. And if you don’t take the statin and your cholesterol remains high, you’ll be targeted as an undesirable non-compliant patient, actually affecting the financial bottom line of your doctor’s group.

As I write this, large medical centers are absorbing one practice after another, a mad scramble to accumulate as many warm bodies as possible in order to negotiate the best rates with insurers.

End of the individual PPO

In the final months of 2013, virtually all of you who had individual PPO plans received a letter that terminated your coverage and advised you to buy health insurance under the ACA. When you attempted to do so, you found yourself paying a lot more for a lot less. I explained to surprised patients that they’d been buying a product—the PPO–that their insurer hated to be selling because it usually lost money on each enrollee. Why do you think they spent so much time ferretting out pre-existing conditions? Because anyone with PPO coverage who had just about any medical problem was a money-loser for them. On the other hand, employee group PPOs continue to survive because the insurance companies figure if you’re well enough to go to work every day, there can’t be too much wrong with you and you won’t be a loss for them.

Having terminated individual PPO enrollees and escalated charges on employee group PPO members, we’re now nine weeks into the ACA and it’s apparently time for insurance companies to scrub the US clean of the costly individual primary care office. They really don’t want us closed in the sense of boarded up–I mean, they do acknowledge the US will need a few doctors out in the trenches–but they want us under the control of one of the major medical systems.

Make no mistake. The health insurance industry wants the likes of WholeHealth Chicago on a short leash. (“Nutritional counseling?! Just give them a goddamn statin and tell them to stop whining.”)

No matter how much they want primary care PPO physicians to disappear, however, health insurance companies recently discovered they can’t simply terminate contracts with physicians via a letter that says “Thanks for your service over the past 20 years. Things have changed and it’s hasta la vista, baby.” UnitedHealthcare attempted this with 2,250 physicians in Connecticut and got blocked by a court order.

But what an insurer can do is make life so thoroughly miserable for physicians that they leave voluntarily, selling their practice to one of the Big Boy Medical Centers.

Making your doctor’s life hell

The easiest way to make life miserable for a medical group is to set up systems to delay payment for services already rendered. This is done by generating scads of unnecessary procedural paperwork. United, Humana, and Cigna are past masters of this tactic, Cigna setting a new record by being 14 months in arrears. Patients can’t fathom this. I tell them, imagine you’re the proprietor of a restaurant or a hair salon or a toy store. In January, 2012, in walks a customer, takes your product, and says “Your check will arrive in March, 2013.”

This, by the way, is why WholeHealth Chicago avoided being in network with these villains. Patients often asked, “Why aren’t you in network with such-and-such an insurance company?” Quick answer: “We’ve got rent and a payroll to meet. We need a cash flow to survive.”

Blue Cross of Illinois, since it’s both non-profit and originally founded by physicians, was always more reasonable, paying fairly promptly and keeping unnecessary paperwork to a minimum. But with the ACA, times have changed. Their CEO is currently paid $16 million a year (never knew not-for-profits were so profitable, did you?), they too want to keep as much money as possible for themselves, and, like everyone else, want docs out of the fee-for-service model. So Blue Cross has joined the ranks of egregiously slow payers.

To delay payment to a doctor, an insurer–any insurer–seeks out potential violations in something you’ve never heard of called a “provider manual.” This is a document so immense that no living human has ever actually read one. I once went online, hunted it down, and guessed it at about 1000 pages of rules and regulations.

Here’s an example of how they delay a payment. Let’s say I order a vitamin D level for you. Since low vitamin D is now associated with umpteen diseases (from cancers and heart disease to autism) and Chicago is singularly unsunny, vitamin D deficiency is very common. The journal American Family Physician recommends vitamin D be included in health screening tests. An insurance company, however, might allow your in-network physician to measure vitamin D levels only when diagnosing an illness and not when screening for low vitamin D.

So when our reimbursement check for physician services and labs we provided for you arrives, payment for the vitamin D level is conspicuously absent. Instead, they send us a form letter asking some questions:

(1) you money-wasting quack, why did you order that ridiculous test?
(2) as long as you did order it, what was the result?
(3) to make sure you’re not trying to cheat us, copy and send the chart notes from the day you ordered the test.
(4) let’s see what you did with the test results–send us those notes, too.
(5) and then, when we’ve got everything, we’ll give some thought to paying you, but don’t get your hopes up.

Language of their letter slightly altered (but not much) to capture intent.

Gathering all this data takes an enormous amount of a doctor’s staff time (insurance company grins lewdly at the thought), keeps the doctor’s staff from doing its usual job (insurance company laughs obscenely), and when the documents finally arrive at the insurer, with a hearty Rabelaisian or Chaucerian guffaw the meticulously collected correspondence is tossed unceremoniously into a “To Do” bin, where it may languish for months.

In 2013, I wrote about 50 (yes, 50) letters regarding reimbursement for food sensitivity testing. After six months of silence, I called and was told (god’s honest) “Oh, we wondered why those letters kept arriving. We didn’t know what to do with them.” And in three weeks, reimbursement for all 50 was summarily denied.

What routinely happens after this “delaying documentation” is returned to the insurer is that after some weeks, when your doctor’s billing department calls about the claim status, the robotic answer is “We’re still working on it.” Cigna’s specialty was to say the paperwork never arrived, but then adamantly refuse to provide a fax number. To be honest, after decades running a small office, these deliberate payment delays come with the territory. For years we’d receive a handful of delays each month and just deal with them, the way a small shop owner deals with the occasional bad check.

But not paying for services rendered is theft, pure and simple. Are health insurers actually thieves? Just ask the Medical Society of the State of New York. When physicians in New York state realized UnitedHealthcare had been deliberately underpaying them for years, they took the case to court and won a settlement of $350 million.

Then came the ACA, with its planned extinction of small private medical offices. Ready for this?

Swamped with letters

Last week alone, an avalanche of 30 letters requesting “further documentation before payment” arrived at WholeHealth Chicago. So our doctors and billing clerks sat down and set up a system to answer them efficiently. Then, on March 6, 2014, the morning mail came in a bag, 76 letters in a single day. Here’s a photo.

If that’s not bizarre enough, these latest “requests for further documentation” include such sentences as:

“Why did you order orthotics (shoe inserts)?” when none had been ordered.

“Why did you order anesthesia?” when the patient came in for a thyroid check and was never anesthetized.

“Why did you order a TSH (thyroid-stimulating hormone)…or vitamin D…or cortisol test?”

Of course you’d like to call someone at Blue Cross and ask “What gives?” But there’s no signature on the letter. The 800 number is just the main Blue Cross phone line and utterly useless. And it’s not just us. According to our physician and chiropractic friends, everyone is being swamped with these letters.

If the insurance companies were honest, we know what they’d say in answer to the question “Why are you doing this?” They’d respond (straight out of the alien from Independence Day), “We want you to die.”

My next Health Tip will discuss how these changes affect patients. On the one hand, the days of a lengthy office visit with a doctor who’s known you for years for a $20 co-pay are drawing to a close. The ACA will bring in far more patients than the current system can handle, even with all doctors working at energizer bunny speed.

On the other hand, Dr. Rubin and I founded WholeHealth Chicago on one underlying principle: that we’d never place ourselves under time constraints with our patients. If a patient arrived with a list of problems, the visit wouldn’t end until every item was addressed. Unless this deliberate insurance company harassment stops, we may be compelled to throw in the towel and go out of network with Blue Cross.

But here’s a fact. Fully half of WholeHealth Chicago’s patients are already out of network. And while they’d rather we accept their insurance, we hope we offset that by providing all our patients, in network and out, an exceptional knowledge of integrative medicine, a broad variety of services, and an unhurried atmosphere. That’s what our patients tell us makes coming to WHC worthwhile.

You know what’s coming next. If you work at your health by eating well, exercising, and so forth, you really won’t need us much. In network, out of network, keep away from us and your health care costs should remain really low.

We’ll talk soon and, oh, stay well,
David Edelberg, MD