The following was originally posted to KevinMD.
My introduction to health insurance companies was very abrupt and simple.
I received my medical training in the U.S. Navy and served three years after that. Then, I was finally discharged. I had treated thousands of patients as a Navy doctor, but I had never charged one, nor did I even know how to charge for services.
My partner in the civilian practice I joined made the transition easy: “Sign this contract from Blue Shield, or you won’t be paid!”
Since then, there have been many contracts and insurance company regulations, but most use the same methodology: “Sign, or you won’t get paid,“ and “Capitulate, or you will lose.” This “business by extortion” satisfied the greed and avarice of the insurers, so they always made a profit. Now, they damage their insureds’ health and well-being and adversely affect the lives they enjoy.
When insurance companies arbitrarily deny patients certain medicines or force doctors to switch patients to less appropriate ones, the wise patient can ask the cost. If their doctor feels it is absolutely the best medicine, the patient can opt to pay for it out of pocket.
Likewise, when the insurer prevents an individual from seeing the best doctor for their illness — even one chosen by their PCP — the prohibition of ”He’s not in-network!”), means the patient can only see that doctor is willing to pay individually. Or insurers can refuse to cover care even when it’s at the hospital/clinic best suited to treat their illness because — It’s out of network! These scenarios are even more problematic since these medical bills (denied by the insurer) can be tens of thousands of dollars.
The insurers blackmail the doctor into going along with this penny-pinching scheme using the same logic that I encountered so many years ago: “Cooperate with us in our (mis)treatment of your patient or you won’t get paid.” At least you, the patient, can keep the trust and confidence in what your long-standing PCP has to say.
But the insurers now have inserted themselves in that most sacrosanct of relationships — the one of doctor to patient. Most offensive and evil is their attempt to disrupt these long-term connections between patient and PCP.
Most patients work hard to find a PCP to whom they can entrust every aspect of their health care, relying on that doctor to have their best interests at heart, speak honestly, be available and reliable. Enjoying that type of relationship improves their sense of well-being, since it allays anxieties about health and, subsequently, makes them better people!
For an insurance company to arbitrarily — without warning either PCP or patient — to sever that relationship is a great disservice to the patient and the doctor. It harms them both. It fulfills the criteria of an evil act. It can cost lives — literally.
A case in point: an insurer was pestering us to renew our contract of 30 or 40 years. When we delayed, begging for more time, they sent letters to their insureds for whom I was the PCP, saying I was no longer available, and assigned them a new PCP. I contacted an executive, and he assured me it would be corrected. That Monday, one of those patients, a 52-year-old father of three, called the office for an appointment, mentioning some vague chest pains over the weekend and asking if we would see him, even though technically I was not his PCP any longer. Of course, I agreed. He came at 1:40 that afternoon.
During the exam, I determined that something was not right. I was very worried about this man. I had his wife drive him directly to our local emergency room. He arrived there at 2 p.m., was immediately shipped downtown, arriving at 2:45, and at 3:30, had a stent put in his one-hundred percent blocked coronary artery. He recovered and went home the next day, sent by the all-knowing and all-prescient “downtown doctors.”
That Friday night, he suffered a cardiac arrest at home; his student-nurse-daughter resuscitated him. He is fine today, but the possible consequences of either of us letting the insurer’s letter delay his treatment make me shudder. It makes me angry. What right do they have to disrupt this long-standing doctor-patient relationship — and risk his life over pennies?
Here’s another, different perspective: A 60-year-old lady, at the end of her appointment, said she wanted to ask me a question. “Are you going to retire?” “Yes,” I replied, “I don’t want to leave the office feet-first” “When?” was her next question. “I have no plans, but why are you so concerned?” “You’ve been taking care of me since I was 12,” she replied. “I don’t want another doctor!” My jaw dropped to realize that the once 12-year-old girl was standing in front of me 48 years later!
Well, this seemed impossible! She must be exaggerating! So, I reassured her but went to review her records. In the archives of patient records, I found the first visit: an eighth-grade physical! While leafing through the record, I listed every visit on an Excel spreadsheet:
Physicals, 9th, 10th, 11th, 12th grade, then entrance to junior college. Then a premarital physical (plus one on her fiancée at her parent’s insistence).
A few years later, three months pregnant (followed by an appendectomy at four months pregnant). I delivered a beautiful baby girl six months later, followed in a few years with pregnancy and delivery of two more babies.
Later, we got through extensive back pain that required a disc-and-fusion operation, and a few years later, breast cancer.
The total was 145 visits (plus 100 visits of well-child care at which she was present). This is the kind of record that the insurance company bean-counters need to look at before telling a patient they can’t see their PCP anymore and arbitrarily assign them a new one with no regard for age, sex, location, or even specialty! (Family practice and internal medicine are vastly different specialties.)
I don’t think I am being over-dramatic by calling this activity evil.
It is uncalled for, harms the insured (the patient), and infuriates the provider.
There is no discernible benefit to any participants except the perpetrator; the insurer uses these pernicious actions to enforce their contracts. It is manipulation and mistreatment at its worst.
The provider takes an oath to “First, do no harm.” Does the insurer have any obligation to their insureds (or to their stockholders) not to commit evil and depraved acts in their name? Do business schools even have courses in business ethics? When you have an ethic perverted from, “If it is right, it is good, and if it is wrong it is evil,” to one where, “If it is profitable, it is good, and if it loses money, it is evil,” then we have a significant segment of our society off the track. Worse still, our families, neighbors, friends, and colleagues — our entire community of citizens — is being profoundly harmed.
Who is going to bell the cat?