Franz Kafka and Health Insurance

Posted 11/02/2010

I visited the ancient city of Prague in the Czech Republic a couple of weeks ago, where the novelist Franz Kafka, now considered one of the most influential writers of the 20th century, has grown into a local cultural hero.

Being a dead hero might be the best option given what else fate might have had in store for Kafka had he not died rather young in 1924. A few years later, the Nazis would have gassed him at Auschwitz (as they did his sisters), and after the war the communists would have sent him to Siberia as a “decadent bourgeoisie.”

So as I moseyed through the Kafka Museum, gathering along the way my Kafka T-shirts, cups, and tote bags and pondering his stories and novels, I couldn’t help but notice a parallel between his themes and our health and disability insurance.

A recurring Kafka theme is the helplessness of the individual against an endlessly complex bureaucracy set in buildings with long corridors and closed doors and staffed by vaguely threatening, always unhelpful, clerks. The protagonist is always told “nothing can be done” and to “come back tomorrow.” To get a feel for this nightmare,
you could read one of Kafka’s two great novels, The Trial or The Castle , or simply watch Tony Perkins and Orson Wells in the masterful 1962 film “The Trial.”

Every day I hear sentences from patients concerning health insurance that could be quotes from Kafka:
• “They’re never really rude, but they’re never helpful.”
• “They never return my calls.”
• “The person I speak to one day always disappears when I call back.”
• “I get directed to nonexistent connections.”
• “I’m told they lost my paperwork.”
• “They claim I wasn’t covered when I was sick.”
• “I’m not in their system.”

And believe me, it’s not just private insurers. Medicare, Medicaid, and the VA system are just as bad, just as inept, unhelpful, and vaguely threatening.

Physicians, as you may know, face Kafkaesque barriers when they try to collect for professional services honestly rendered. Claims are endlessly delayed, paperwork “lost,” definitions of what is “covered” and “non-covered” changed randomly, all with one single-minded purpose: the insurance company keeping as much money as it can for itself.

With such a gloomy picture (and, by the way, there are no happy endings in Kafka– ever), what might both patients and physicians do?

Most physicians now simply join large group practices and let the group’s own billing bureaucracy fight the bureaucracy of the insurance industry in US healthcare’s version of The Hundred Years War. In a slow but steady trend, especially in larger cities, individual primary care physicians are simply opting out of all insurance billing, becoming “cash only.” At the end of your office visit, you pay in full for your services and are given a completed insurance form for you to submit to your insurer, with the attitude “it’s your insurance–you deal with them.” (Actually the success rate is better when you submit than when the doctor does).

A second trend is the conversion of primary care offices to “concierge practices.” In this system, you pay your physician a fixed amount of money every month, usually around $150, and for this, by keeping his or her practice relatively small, you get 24/7 access to your doctor, a next-day appointment if needed, and other niceties available to the well-off. You’re given a completed insurance form after every visit, which allows you to get some of your money back. Lab work and hospitalizations are covered by your regular insurance.

Clearly, this system is for the financially secure. The word “concierge” alone should tell you that (they’re also called boutique practices).

I’ve watched four neighboring primary care practices go “concierge” during the past few weeks, and there’s now a private company that guides a physician through the conversion process, taking a percentage of the profits for its work.

This to me is a most worrisome trend, and let me assure you WholeHealth Chicago is not going this route. With a serious shortage of primary care physicians, it’s more than unfortunate that the remaining few might be available only to the wealthy.

What can you do to avoid the endless corridors, closed doors, and telephone menus filled with “prompts”? (Kafka would have loved those.)

• Avoid the entire system as much as possible by keeping yourself healthy. You (the patient) will not need any of us (doctors) if you very consciously eat a healthful diet, keep your weight under control, regularly exercise, and avoid risky lifestyle choices (like smoking and excess alcohol).

• Learn to take care of minor health problems yourself. Most illnesses are short-lived, self-limiting, and need no medical intervention. If you develop a condition that might require an antibiotic, such as a bladder infection, use one of the mini-clinics at a Walgreen’s or CVS and pay cash. They’re far less expensive than doctor’s offices.

• Use alternative medicine. Chiropractic, traditional Chinese medicine, and herbal medicine are all less costly than conventional Western medicine.

• Learn the phrase “Do I really need that?” when talking to health care providers about expensive tests, prescription drugs, surgical procedures, and even alternative therapies like endless chiropractic or acupuncture sessions.

• Shop around. An MRI of the spine costs about $2500 at Northwestern and about $350 at one of those free-standing MRI centers. Often, the smaller centers even have better equipment. Here are two sources for investigating local costs: The Artists’ Health Insurance Resource Center and LesliesList.

• If you’re essentially healthy, the only health insurance you really need is Major Medical or Catastrophic. Both cover only emergency room treatment and hospitalization (either of which could bankrupt you in days). Health insurance companies rarely promote these policies because they don’t generate much revenue. They’d rather sell you pricey “cover everything” policies because people rarely use them. I wrote about these in an earlier health tip.

In sum, if you want to avoid the endless corridors and closed doors of your own personal Kafka healthcare novel, your very best bet is to…