{"id":4021,"date":"2011-06-21T01:20:42","date_gmt":"2011-06-21T06:20:42","guid":{"rendered":"http:\/\/wholehealthchicago.com\/?p=4021"},"modified":"2021-09-08T21:47:56","modified_gmt":"2021-09-09T02:47:56","slug":"the-fox-guarding-the-hen-house","status":"publish","type":"post","link":"https:\/\/wholehealthchicago.com\/blog\/2011\/06\/21\/the-fox-guarding-the-hen-house","title":{"rendered":"The Fox Guarding the Hen House"},"content":{"rendered":"\n

I apologize for another health tip on troubling trends in the healthcare industry. I know you prefer articles about supplements that can melt away your love handles, firepower your libido, or transmogrify your skin to the smoothness of a baby\u2019s behind, but these professional secrets will have to wait.<\/p>\n\n\n\n

(If you\u2019re desperate, click over to mercola.com<\/strong><\/em>, leave your credit card, and then hit the \u201cback\u201d button to finish this article.)<\/p>\n\n\n\n

Whether or not a doctor is a member of the AMA (only one doctor in three is–I am not), its weekly newspaper shows up in every doctor\u2019s mailbox. Every issue should be bordered in black because each one delivers gloom and doom on the troubled state of health care: declining insurance payments, increasing malpractice premiums, physicians declaring bankruptcy, rising rates of anxiety and depression among physicians, and where to buy a decent 1990 Toyota Corolla (only kidding on that one). Peruse a couple of issues<\/strong><\/em><\/a> yourself to learn why 75% of physicians actively discourage their kids from becoming doctors (as I did with my own).<\/p>\n\n\n\n

One recent front-page article entitled \u201cInsurer-owned clinics bid to offer more patient care,\u201d stirred in me all the clich\u00e9s we associate with fear. You know these from the back cover of any Stephen King book–blood runs cold, lump in throat, deer in the headlights. Reading the article, I felt paralyzed with helplessness, physician Gulliver tied down by health insurance Lilliputians.<\/p>\n\n\n\n

\u201cInsurer-owned clinic.\u201d The concept of a health insurance company owning its own clinic likely means nothing to you, but this is old stuff to me. Twenty-five years ago, my dealings with \u201cinsurer-owned clinics\u201d almost compelled me to walk out of health care altogether for the peace and quiet of my own Dunkin\u2019 Donuts franchise, pouring coffee, counting Munchkins.<\/p>\n\n\n\n

I\u2019d thought clinic experiments by the insurance industry had finally died in the early 1990s. Forgotten names like PruCare, Share, ChicagoHMO, and Michael Reese Health Plan may not even register with you. Even Humana owned its own hospitals and clinics. But trust me on this: you\u2019d rather have the zombies from \u201cNight of the Living Dead\u201d come back to life than insurer-owned clinics resurrected.<\/p>\n\n\n\n

I have difficulty getting a few facts about insurance companies across to people <\/strong><\/h3>\n\n\n\n
  • All insurance companies make profits for their investors by collecting money (premiums) from the innocent and naive and then keeping as much as they can for themselves.<\/li>
  • Only in the direst of circumstances and under the greatest of pressure will insurance companies part with this money.<\/li>
  • Although they\u2019ll cancel your policy if you\u2019re a few days late on your premium payments, they shift to slo-mo when it\u2019s time for them to write anyone a check. Health insurance giant CIGNA is now one full year behind in physician payments with their State of Illinois enrollees.<\/li>
  • When it\u2019s something obvious, like the euphemistically named life insurance, you\u2019d think there would be no problem forking over the money to your loved ones after you died. But even after you die, they\u2019ll meticulously comb through your doctor\u2019s notes, any forms you filled in long ago, and so forth, looking for something\u2014anything–to weasel out of payment. To answer your unasked question, yes, our office gets \u201crecords requests\u201d from life insurance companies when one of our patients dies.<\/li><\/ul>\n\n\n\n

    When it comes to your health, common sense tells you you\u2019ll need a trained professional (c\u2019est moi!) to find out what\u2019s wrong with you and help you get well. And this is important to remember: Your physician\u2019s decision-making process is always based on what\u2019s best for you, and never what\u2019s best for your health insurance company. Financial considerations–i.e., does the patient have insurance and, if not, can she afford the care–play a role in the doctor\u2019s thinking, but these considerations are always secondary to what\u2019s best for you.<\/p>\n\n\n\n

    So when an insurance executive uses the phrase \u201cwe want to control healthcare costs,\u201d he really means \u201cwe need to figure out a new way to avoid paying benefits because doing so chips away at company profits.\u201d After all, the $102 million salary recently awarded to the CEO of United Healthcare has to come from somewhere.<\/p>\n\n\n\n

    \u201cWhat\u2019s best for the patient\u201d is so ingrained into a physician\u2019s psyche that during the 1970s and 1980s, when the health insurance industry tried to change this thinking and teach doctors to put finances first, they met an intractable and insurmountable wall of physician resistance.<\/p>\n\n\n\n

    And this is where my own story applies<\/strong><\/p>\n\n\n\n


    I was involved in the debacle of insurance-run clinics a couple of decades ago, when I was employed as medical director of a 50-plus doctor group, where virtually all of the patients were enrolled in the newly invented HMO (an ironic euphemism, \u201cHealth Maintenance Organization,\u201d harrumph! Snort!). Although our group was not owned by any single insurance company, the situation was actually worse. At least a half dozen of the insurance giants watched our every move, with me as the point person to call if they saw something they didn\u2019t like. Which, naturally, was often.<\/p>\n\n\n\n

    And what they didn\u2019t like was easy: spending good money on something as mundane and inconsequential as patient care. Each company had its own suggestions on cost control, each its own policy and procedure manual. Every trend in our group\u2019s medical decision-making was scrutinized by an insurance company team consisting of the insurance company\u2019s medical director, a \u201cutilization review\u201d nurse, and several MBAs (the initials really stand for Management By Arrogance and to this day I am uncomfortable in the presence of one).<\/p>\n\n\n\n

    The team never examined our clinical skills, compassion, or whether our patients were happy with their care, but rather how much money we were spending per patient. Whether the clinical decisions involved something inexpensive (such as a blood test) or expensive (like hospitalization), their attitude was always, \u201cHow can we reduce our costs?\u201d or \u201cDid you really have to order that (test, procedure, referral)?\u201d<\/p>\n\n\n\n

    True story: As medical director of our group, I met with one of the insurance company medical directors every few weeks to review expenses. During one such meeting, we were in a restaurant and this man was admonishing my group for sending too many patients to podiatrists for foot care. In the middle of dinner (I kid you not), he reached into his pocket and pulled out a pair of toenail clippers and starting clicking them in the air above our food. \u201cI carry these wherever I go,\u201d he said. \u201cWhen any patient wants a referral to a podiatrist, click, click, I trim his nails. Saves us a fortune and patients love it. They tell their friends, \u2018My doctor clips my toenails!\u2019 I think you should buy a set of toenail clippers for every doctor in your group.\u201d<\/p>\n\n\n\n

    I pictured the look on the face of our bookish psychiatrist, our prominent neurosurgeon, as I handed out toenail clippers to everyone. I also realized in this \u201ctoenail moment\u201d that healthcare was heading for big trouble. To the detriment of this particular medical director, he applied his bizarre frugality to himself. He was opposed to colonoscopies between ages 50 and 60 (the standard recommendation) as being too costly. The price? He died rather young of undiagnosed colon cancer.<\/p>\n\n\n\n

    What finally compelled these insurance-owned clinics to close up shop was their inability  to generate enough profit for themselves despite their incessant harping on physicians to reduce costs. Understand this about any doctor\u2019s training: from high school graduation to becoming a practicing physician is a minimum of 11 years of education, including years of hospital work. By the time a doctor is educated enough to treat patients, thousands of inviolable rules are ineradicably etched into his or her brain, rules like \u201cfollow up on an abnormal chest x-ray with an MRI,\u201d or \u201cevery patient with chest pain needs to be sent to an emergency room.\u201d No insurance company can ever change that, even one whose medical director waves around toenail clippers.<\/p>\n\n\n\n

    Years later, I was speaking with a now-retired health insurance executive and asked what finally killed off the insurance-owned clinics. He answered, \u201cThe doctors! We couldn\u2019t control the doctors.\u201d<\/p>\n\n\n\n

    Back to the future<\/strong><\/h3>\n\n\n\n

    So why are CIGNA, United, Humana, and all the usual suspects going back into the clinic business? Because there\u2019s a delicious smell of money in the air: Obamacare. Remember, there\u2019s no public option. Under the new law, everyone \u201cchooses\u201d a private health insurance company and the government picks up the tab. So the insurance companies open clinics in areas dense with the politically voiceless: low-income Americans, immigrants, the elderly. Put up flashy signs and give every new enrollee a free iPod for signing onto their plan and wait for the money to pour in.<\/p>\n\n\n\n

    But this time they\u2019re smarter. This time they\u2019re not going to bother with those pesky doctors. To really control costs, they\u2019re going to limit the clinic staff to nurse practitioners and pharmacists, and make them all employees of the insurance company. No physicians to push back against insurance greed.<\/p>\n\n\n\n

    Really there\u2019s nothing wrong with nurse practitioners or physician assistants as healthcare providers in underserved areas or at the clinics you find in drugstores, especially with the looming shortage of family physicians. But when any health-care provider is an employee of your insurance company, you, as the patient, automatically become the victim of an egregious, frightening, and potentially dangerous conflict of interest.<\/p>\n\n\n\n

    The insurance company fox is guarding its neighborhood clinic henhouse and licking its chops.<\/p>\n\n\n\n

    Do me a favor and please\u2026<\/p>\n\n\n\n

    Stay well,<\/p>\n\n\n\n

    David Edelberg, MD<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

    I apologize for another health tip on troubling trends in the healthcare industry. I know you prefer articles about supplements that can melt away your love handles, firepower your libido, or transmogrify your skin to the smoothness of a baby\u2019s behind, but these professional secrets will have to wait.<\/p>\n","protected":false},"author":2087,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2,45,203,3],"tags":[1263,1264],"class_list":["post-4021","post","type-post","status-publish","format-standard","hentry","category-blog","category-f","category-health-insurance-issues","category-knowledge-base","tag-hmo","tag-insurer-owned-clinics"],"yoast_head":"\r\nThe Fox Guarding the Hen House<\/title>\r\n<meta name=\"description\" content=\"Whether or not a doctor is a member of the AMA (only one doctor in three is--I am not), its weekly newspaper shows up in every doctor\u2019s mailbox.\" \/>\r\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, 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