The Healthcare Industry is all about earnings per share for their stockholders, whereas health care should be about health, healing and care.
What goes around comes around. Physicians (poor business persons and poorer “team players”) long ago agreed to buy into the “third person payor” concept by billing insurance rather than the consumer, thus setting the stage for insurance company management of healthcare. Patients time after time have defeated “single payer” ballot measures and other plans to eliminate the huge dollar drain into the pockets of insurance executives and their stock holders, thereby insuring that costs will remain the same and physicians will have no more than the average six minutes time to spend with each patient.
The Healthcare Industry is all about earnings per share for their stockholders, whereas health care should be about health, healing and care. (Do you see a conflict of interest here?!) “Healthcare” should not be publicly traded because at that point it is not about healthcare but about profits per share for the industry.
THE PRESENT SITUATION
Healthcare is presently provided by four types of providers: Physicians and other healthcare providers in medium to large-sized medical groups or loose associations; governmental-type organizations and clinics; independent providers who may or may not accept PPO insurance but do not participate in managed care; and non-physician/paraphysician healthcare providers such as naturopaths, chiropractors, herbologists, purveyors of dietary supplements, etc.
Medical groups hire physicians to provide “large volume” medical care. The large groups survive by making up in volume for the very low reimbursement they receive from managed care organizations. Governmental organizations, community clinics, etc., survive via tax payers “donations” via income and sales taxes trickled down through governmental fingers as well as real and in-kind donations from charity organizations and well-meaning individuals.
Independents (brave folks who have not yet sold, or have reclaimed, their souls from the devil) survive only if they are hard headed and have a “niche”–are well-known, have specialized skills not found in the average medical care practice or provide a service not obtainable via managed care (including taking time with and truly listening to patients).
Non-medical healthcare providers and purveyors of supplements and nontraditional and experimental therapies flourish as they are the only providers in the system that insurers will not reimburse, thus re establishing a direct provider/consumer relationship where the consumer is aware of the true cost of the product or service. The public (you and I) gladly shell out the same bucks to see these providers that we are unwilling to part with to physicians because “…my insurance should cover it…”.
Why does your managed care doc only have an average of six-seven minutes (based on national statistics) to spend with you? Reimbursement is fixed at low and lowering rates. At the same time overhead expenses increase. Professional liability insurance, staff salaries, rents, etc., etc., all rise at or beyond the cost of living. The average medical office must have twice the number of employees it had years ago, including personnel to follow the complicated insurance-mandated billing process and even employees specifically designated to deal with the 10-20% of bills that are automatically denied to increase insurance industry profits. New insurance industry and governmental rules mandate both extra paperwork that takes away physician’s time that used to be devoted to patient care. Physicians have less time with patients, less time to accurately chart notes, less time to read and keep current. At the same time, medical knowledge has increased exponentially. There is simply more known about health and diseases, more medications, more tests, more procedures, more therapies than there was even a decade ago.
The providers (physicians) and consumers (patients) of medical services have become merely the tools to provide profits for the managed-care industry.
HOW IT USED TO BE
Back in the “dark ages” physicians were paid for their services just like plumbers, electricians, attorneys, veterinarians, auto mechanics, hair dressers, gardeners and so many other personal service providers. To this day, no one expects these providers to “bill insurance” and then accept only a percentage of their usual fee. Can you image your hairdresser billing insurance for your $100.00 color and styling and accepting $51.00 and your $5.00 co-pay as “payment in full”?? You don’t walk out of Best Buy with a big screen TV unless you or the bank has paid the bill!
The traditional US private practice medical model gave leeway to the practitioner to adjust his/her fee as necessary and to accept installment payments and barter as a practitioner saw fit. Additionally, and most importantly, the traditional model allowed and fostered the role of practitioner as ombudsmen for his client, “the patient”. Traditionally, in the fee-forservice medical model the physician represented his client, “the patient”. As we shall see, this now all-but-gone-practitioner was the only representative the consumer was to have.
HOW IT GOT TO WHERE IT IS NOW
Free enterprise is the American way. As Henry Kaiser said “find a need and fill it”. The powerful insurance industry, always on the alert for a new product, did just that. Insurers saw a huge opportunity in the unorganized entrepreneurial medical community. Their stepwise approach was genius, taking them from a less than 5% slice of the medical pie less than 50 years ago to an approximately 35-40% (off the top presently). Yes, the managed care industry takes $0.35-0.40 cents of your healthcare dollar off the top. Adding in the additional $0.05-0.10 cents taken out by professional liability insurance and lawsuits, your healthcare dollar, after these interlopers have gotten their cuts, is really only worth $0.50-0.55 cents!
It all started with insurers selling a product, initially directed to the consumer and subsequently to employers as well, that would essentially pay all or a percentage of medical and hospital providers fees. Providers set their own fees; there was not outside interference with the marketplace, including provision and consumption of services, and fee structures.
Approximately 30 years ago, canny underwriters saw a chance for unheard of profit, taking advantage of disorganization amongst providers, no organization amongst consumers, and the disinclination of government to look out for consumer’s interests. Successfully playing both ends against the middle, insurers went concurrently to providers and employers. To the employers they said, “We can save you money. We have physician’s groups (which they did not yet have) who will provide care at a discount in trade for an exclusive contract… Just Sign Here…” and to the providers, they said, “We have all of these employers signed on who employ a majority of your patients. You had better sign or you will have no patients”. Insurers promised providers good reimbursement with only a minimal discount.
Employers saw the opportunity to save a few bucks, so they signed contracts. Physicians were worried about losing their patients (and, after all, they were “promised” good reimbursement, so they signed.
Thus managed care was born. And the squeeze began. Managed care companies, behindthe- scenes manipulators of the increasing cost of healthcare, need profits for the industry and their stockholders, and profits must steadily increase. As there are no price controls on drug costs, overhead, employee salaries, supplies, etc., it is obvious at whose expense these profits derive: The consumer and the providers.
After initially promising physicians “fair reimbursement” managed care organizations embarked on systematic reductions of both reimbursements to physicians and available care to consumers, the only two unrepresented players in the system. Physicians are paid an average of 5-20% less for their services now than they were 20 years ago, and managed care consumers must jump through many more hoops to get less care than what was available to them previously. The difference: the $0.35-0.40 cents of each healthcare dollar that goes directly into the pockets of the powerful insurance/managed care industry.
WHY THINGS WON’T CHANGE
Oh, there will be window dressing. Powerful industrial interests will NEVER voluntarily allow either the public, government or healthcare providers to regain control over the healthcare system.
It is paradoxical that the only two entities that truly belong in the arena–providers and consumers–have been so co-opted by big money. A majority of people do not like to pay for medical care (although we will easily plunk down $2000 for a large flat-screen TV) and the public are so easily fooled by the lies pomulgated on those nifty 30 second TV spots the insurance industry rolls out each time a managed care reform proposal or legislation increasing insurance-industry control comes around. (A single-payer plan, which would have all but eliminated the gouging of the system by insurers was defeated 75%-25% in Oregon two years ago by an “enlightened electorate” believing insurance company TV mis-education).
Not only do insurers decide how much (or how little) they pay providers for a given level of service or diagnosis, but they decide who they will present contracts to, usually excluding small independent practitioners and small groups. This inexorably alters the physician-patient relationship. The providers (physicians) and consumers (patients) of medical services have become merely the tools to provide profit for the managed care industry. In order to survive in a managed care environment, physicians must either band together as a “physician’s organization” or have an employer/employee relationship with large managed care companies or medical groups. In either case, primary allegiance to the patient is lost to primary allegiance to the group or managed care company. Of bureaucratic necessity, the advent of corporatized managed care has lead to even more middle men, managers, etc., sucking money from the system.
The sad and most nefarious result of all of this is that the consumer has lost their only ombudsman, the only person they used to have in their corner in the healthcare system. Where the physician used to spent time with his or her patient and was the patient’s only representative for proper care, the managed care system has taken away both the time and the incentive for this representation (remember: the more care provided, the less profits for “…The Industry”).
The only ombudsman the patient/consumer has ever had–their physician–is NO LONGER able to advocate for his/her patient. Even if your doc had the time (which (s)he doesn’t), patient advocacy is anathema to the managed care model. As much as (s)he would like, your managed care physician can no longer be in your corner.
WHAT CAN PHYSICIANS AND CONSUMERS DO?
Both physicians and consumers are in a box of their own making. What can consumers expect when they are looking for the cheapest way out and have the attitude that someone else should pay for their healthcare? You do get what you pay for or what the politicians you elect decide upon.
Consumers must participate in the process if change is to be forthcoming. Support equitable, single-payor or shared responsibility healthcare legislation for all Americans, allowing physicians to provide unencumbered basic care for all, while keeping alive the fee-for-service system for levels of service above the basic health enhancement and maintenance/maternity-childcare services/urgent-emergent services, etc.
Things will not get better (what do you expect when, going in, your dollar is worth only 55 cents!). A whole new generation of physicians are “hitting the pavement”. No longer are they entrepreneurs. No longer are they used to being ombudsmen for their patients. No longer are they willing to work long extra hours for little thanks and less reimbursement. The days of “9 to 5, 6 minute-a-visit” medicine are upon us. Perhaps consumers have gotten just what they asked for in managed care: cheaper , no frills, and no representation. In an interesting fallout from physicians not having the time or willingness to counsel patients fully about the medications they prescribe (and the fact that physicians are not “salesman” and don’t “promote” what they prescribe), patients spend billions of dollars on sham therapies “prescribed” and promoted by eager pseudo-medical retailers who tell them that the (frequently beneficial) therapies prescribed by their physicians are harmful, and then provide sham “studies and proof” (nothing more than advertising testimonials) to show that their “Proprietary Formulas” cure everything from dizziness to impotency to obesity. The public easily drops the proven medical therapy for the frequently expensive, slickly presented, ill-tested product from someone they do not know, who may not even have a college education. Why? Because that person has the time to talk with you, relate to you, listen to you, and knows how to appeal and sell to you.
What can you as a patient do to get the best possible care in the “managed care world?” (And remember, the huge majority of managed-care physicians are caring, intelligent, welltrained and have your best interest in mind. They are not salespeople. The system they are in limits the time and attention they have for you.)
1) Go in with a list. What questions do you wish answered? 2) Get your answers. 3) Get a prompt return appointment when you need it. 4) Ask about alternatives including different medication delivery systems. 5) Ask about what to expect, side-effects, how long it may take for the therapy to take effect. 6) Most importantly, understand that you are responsible for your own health and healthcare.
You can’t be a couch potato, eat unhealthily and in excess, not follow instructions and expect an individual therapy, pill or potion to “pull you through” Unhealthy people live shorter, less happy, less vigorous lives.
Dr. Michael Goodman is an independent gynecologist specializing in menopause, pelvic support, vulvo-vaginal aesthetics, sexual counseling and bone density in Davis, California.