Pro Tip: Not the patients and not the doctors.
In the USA, it’s being run by corporations whose CEO’s have a fiduciary obligation to return a profit to the investors. The concept of CEO fiduciary obligation is not good or evil on its own. It just means that the CEO of Mars Chocolate has a legal obligation to make decisions that are in favor of the stock holders and no others. If he or she offers a free bag of M&M’s to a child, it is not the child he or she is doing this for. It is being done in anticipation that the child will like M&M’s and buy more in the future, thus, sending a profit to the shareholders. It”s all about money, nothing but money and only about money to a few people. That’s how it works. That’s the law.
And that’s how much of our medical care is managed in the USA. Those who hope for a more just system, a system shared by all the developed nations of the world are told by some of our leaders that that such ideas are just theoretical debates that can never ever happen. To them, the shareholders and their profits are the only reality.
A few months ago, after losing my job and with that, health insurance for my wife and me, we began the arcane journey through the “Health Connector” and the ACA, aka “Obamacare”. At first, I thought it was my wife’s inexperience with the websites and procedures but soon it became clear that clarity is not the goal of those in control. What doctors are on this plan, on that one? How much is the co-pay for my test on this, on that? How do I compare? A call to the insurer coupled with the call to the billing departments of a prospective health care provider often yielded the same advice, just sign up, get the procedure, and after we submit the bill, we’ll tell you how much you owe, or do not owe.
Talk to anyone who works in a medical billing office and they will tell you that they spend half of their time on the phone with insurance companies or patients trying to figure out what something costs, who pays what percentage, and so on. Worse yet, the process is always changing. Today’s allergy shot and exam was covered with a $15 co-pay and the balance paid by the insurer, that is no guarantee that this will be the case on the next appointment. So, anything learned by today’s four hours on the phone will be of little use tomorrow.
Your doctor prescribed Advair to manage your asthma and you’ve been on it for twelve years? Well guess what!? The insurance company just decided that since you’ve been symptom free for the past ten years, it’s time to reduce your medication to a less costly drug. You get pissed off and worried and hope that you won’t have to go to the ER again. You talk to your doctor and he tells you that we’ll just have to give it a try and see. Then he tells you that he’s just as pissed off because he received notice from the insurance company that all 45 patients of his on Advair are being switched, so now he has to spend an hour of more writing new prescription orders.
Sure, this is all personal anecdote.
Then I read this letter in the Globe.
Insurers also have more insidious ways of turning a profit. One of these ways is to require time-consuming prior authorizations for certain services in apparent hopes that clinicians will be discouraged from trying to access those services.
In a study colleagues and I conducted, we found that emergency mental health care workers spent an average of one hour on the phone with insurers, obtaining permission to hospitalize suicidal youth. Given that authorization ultimately was granted in every single case, this is an administrative hassle whose sole purpose seems to be to dissuade clinicians from seeking care they deem necessary for their patients, even though every extra minute spent in an emergency room increases risk for both the patient and health care workers.
Another way insurers profit is by not maintaining accurate lists of providers who are in their network and accepting new patients. In a separate study, we used insurer databases of supposedly “in-network” providers and found that many practices were full and that the list was replete with wrong numbers. We were only able to secure appointments 26 percent of the time.
Insurers have no incentive to ensure that people receive timely, needed care. As Angell so eloquently notes, they need to be removed from health care entirely and replaced by a not-for-profit system whose sole motivation is to get people the care they need.
Dr. J. Wesley Boyd
Needham
Insurance companies trying to delay, confuse, deny is nothing new. It’s part of how they make their money. It’s how each of the CEOs of the Big Five for-profit health insurance companies all took home at least $10 million in 2014, according to each insurers’ annual filings with the Securities and Exchange Commission. Business is business and no doubt, one business learns from another. Credit card agreements are written on average at a 12th grade reading level, making them not understandable to four out of five adults, according to a CreditCards.com analysis of all the agreements offered by major card issuers in the United States.The average American adult reads at a ninth-grade level and readability experts recommend important information — such as credit card agreements — be written at that level. Only one in five adults reads above a 12th-grade level.
Again, with personal anecdote as evidence, I can relate. My mother had a health insurance policy that we assumed looked bullet proof. It stated that should she require care in a skilled nursing facility, the insurance company would pay in full, no co-pays, no deductibles, no limits for the life of the insured. At the age of 94, my mother fell, was badly injured and because she lived alone, was not discovered for a day. She broke her shoulder and wrist and was severely dehydrated. An ambulance took her to the hospital and after a week, she was transferred to a nursing home. While at the nursing home, she developed dementia, and while her bones and wounds healed, her general condition had worsened. She was unable to feed herself, clean herself, and needed constant observation to make sure she did not fall out of the bed. That’s when we were told that her insurance would no longer be covered by her insurance. I did not understand. I called the insurance company and was told that my mother was covered for any services that required “skilled” nursing and that “skilled” nursing is defined as wound care, IV drugs, and physical therapy. Since my mother no longer required any of that with her bones healed, she was no longer covered. I reminded the insurance company that my mother still required someone to feed, clean, and be with her round the clock and they said yes, but while that may be nursing care, that is not “skilled” nursing care and the policy clearly stated that only skilled care is covered.
Yes, lesson learned for me, but then, I only have one mother and this knowledge is of little use to me now. Who knew that there is “nursing care” and “skilled nursing care”? My wife is an RN and even she did not notice this costly wrinkle when we examined the policy. I’ll wager that the company that wrote that policy did extensive research as to what people would assume and buy on those assumptions, knowing full well what comes next: profit for the shareholders.
The only way to fix this is to remove the insurance companies. And the only way to do that is to elect representatives in government who pledge to do so.
Massachusetts used to have price controls in health care 20 odd years ago. Then, the health care market got liberalized. There must have been a reason why that happened – I seem to remember hospitals were going bankrupt, because they could not keep their costs under control, while medical procedures were under price controls.
So, what’s the lesson in these 20 years that have passed? Are we heading back to the future?
Fiduciary duty means to do what is best for the entity for whom or for which “you” are the fiduciary. So if maximizing profits means flooding the market so that the company ceases to exist – violation of fiduciary duty. If paying bloated salaries to the CEO and upper management and directors means underpaying employees and causing turnover – this is actually a violation of fiduciary duty. If the actions taken by the CEO and the Board in fact lead to a shorter life and lesser true value, even if quick profits or short term profits result, this is actually a violation of fiduciary duty. What Harvard Business School allegedly taught as to maximum profits for shareholders at the expense of corporate viability is, itself, teaching violations of fiduciary duty. The lack of long range planning, and, if you will, understanding of what actually benefits a corporation and society has done great harm.
It means that all decisions are based on the needs of the shareholder, not the customers, not the environment, not the country. Just the shareholders. Period.
There are at least eight players here who are all contributing to these problems in various ways: insurance companies, providers, businesses, government, pharma/devices, health IT, patients, taxpayers. The insurance companies are the intermediaries between payers (mostly businesses) and employees. Government programs like Medicare are the intermediaries between taxpayers and recipients. It’s true that insurers are acting according to self-interest but they are also following the directives of their clients (payers) to save money. Physicians, hospitals, pharma, and other providers of services are both helping, by curing disease, and hurting, by charging a lot to do so. Patients demand the best care at the least cost while often refusing to follow doctor’s orders. IT companies may join with providers or insurers to create proprietary systems which add complexity. You can’t just single out one player in the game and ignore the contributions of all the others.
If you observe the system from any point it looks quite dysfunctional, but no one involved sees his/her own position as part of the dysfunction.
An amusing example mentioned above is Dr. Boyd’s contention that insurance companies purposely use bad address lists to confuse consumers. I sympathize with Dr. Boyd’s frustration in general. But unless he is keeping track of all the addresses connected to his NPI, DEA number, tax ID, billing addresses for various payers, various locations he might be working from, board certifications, medical licenses, and so forth, I’m sure he has some bad addresses out there.
It’s called capitalism.
It’s like Domino’s Pizza’s “problem” with dealing an outdated computer system that some how managed to underpay workers at least $565,000 at 10 New York stores.
Funny how all these “mistakes” and mishaps all benefit the corporations? None benefit the public. What are the odds of that happening?
… but I think I will pass, considering that I’m not a clinician and might embarrass myself in front of others on this board. I am not convinced, however, that whatever happened here was primarily about costs.
John, what do you make of the fact that whatever is going on with pharmacy benefits, there has been a huge strain on payers because of the off-the-charts prices for new hepatitis C drugs? That is not the fault of the insurance companies. If there’s a solution in sight, it is going to involve “capitalism,” as competition is finally driving down the prices, since more pharmaceutical firms are coming out with their own products.
I’m asthmatic. I’ve been so since I was a child. A visit to the emergency room at least once a year was a common thing. Once on Advair, that stopped. Every doctor I had over the years was in full support of prescription. Then the prescription was changed by the insurance company’s “pharmacist” because according to their records, I had not used a “rescue inhaler” for the past year. They were correct. I have not needed one, nor had I needed to visit the ER. Their reasoning was that I was now over-medicated and could step down a notch. After switching, my asthma got worse, not terribly worse. Then in March of last year, after a bad cold, I developed pneumonia in my lower left lung. I simply did not have the strength to expel it. So “bingo”, my doctor contacts the “pharmacist” at the insurance company and I am allowed to return to Advair. (I put pharmacist in quotes because we’re really talking to their bookkeeper, eh?) Once on Advair, I am well again.
Then I lost my job and have to find new insurance. Guess what? The first one covered the Advair but the new one does not. Looks like I’ll have to tough it out again.
It’s all about costs. It has to be about costs. Remember, the company that makes the decision about my health has a fiduciary obligation to protect the profits of the shareholders. So in a tie, I lose.
As to the Hep C drug, sure, that’s a big cost but look at the huge profits from the other drugs. Drive through parts of Essex Connecticut where the big wigs of Pfizer live and see the mansions. My favorite is the one owned by a 50 year old recently retired marketing executive of the company who had a $20 Million Dollar palace built along the Connecticut River. It’s a sight to behold. I wonder where she stands on Universal Single Payer and how much does she “donate” to political causes?
Doctors love the new system; don’t let them fool you with their “complaints.” For the first time they have guaranteed payers walking in the door. The AMA very quietly supported the current system 100%. And that, my son, is a fact.
The AMA ain’t what it used to be. For most of my life, my doctor was a guy who had an office adjoined to his house. You know, like Marcus Welby who, apparently, bought the place from the Clevers after Beaver and Wally grew up and June and Ward moved to Florida. Doctors were self-employed. They had privileges at the local hospital where they would visit patients in the morning and then have office hours in the afternoon.
That world is gone. Wally, Beaver, Marcus, and Steven Kiley are all retired. If any of their children are general practitioners, they are not setting up shop on Colonial Street. Nope. They are now employees who work in office buildings and have a strict schedule that is set by their employers. “Twenty Four Patients a day, Five Days a Week” is the slogan my doctor has to wrestle with. He’s a cog in the wheel, just as most of are now. He’s making less now than he was 20 years ago and working more, just as most of us are. So who’s not complaining about the new system and the guaranteed payers? Look farther up the food chain, son. It’s not the doctors, it’s the management that owns the business.
FWIW, only a small minority of doctors belong to the AMA these days, and its membership is dominated by older doctors and those in specialties. My wife is a physician and neither she nor any of her colleagues or friends belong.