Wednesday, September 09, 2009

Insurance Ruins the Doctor Patient Relationship

Insurance Ruins the Doctor Patient Relationship

For thirteen years I was a Business Manager for what became a five-doctor Internal Medicine practice. This gives me a unique perspective on some of the changes in health care financing that preceded the clamor for reform.

Primary care medical offices in the early 1980s operated as “payment at the time of service.”We filed Insurance as a COURTESY for patients in nursing homes and hospitals. Overhead was low.

As large employers offered health plans that required doctors to sign up to be on their “preferred provider" list, we began to accept insurance in order to keep patients. Referrals were required before patients could go to an ER or a subspecialist. Patients had small copays if they stayed in their network of doctors (preferred providers.) We hired more people to handle the referrals, claims, and posting of insurance payments, plus the follow up on lost or denied claims.

If you treated a Medicare patient, you HAD to file their insurance and accept Medicare rates. We computerized the practice in the late 1980’s in order to handle the volume and to file electronically to insurance companies.

Smaller practices struggled economically, as the small number of doctors could not support more personnel and computerization. For primary care doctors this caused decreased professional satisfaction as their practices were bought out and merged to larger groups with emphasis on “productivity” and how many patients they could see in an hour etc. Patient care suffered or else the bottom line suffered. Practices went under or sold out.

Some practices expanded as we did. Five doctors were able to maintain an office where the staff had the same paid benefit plan the doctors had for health insurance and profit sharing. Malpractice costs were low. (I know that contradicts the media, but good primary care doctors are rarely sued.)

Even 20 years ago, there were less than ten big players in the insurance field. Their negotiated rates or fee schedules were remarkably similar. Current fear of no competition sounds good when it comes to insurance coverage, but the fact is, we have been sliding to this moment for a long time.

The increased cost to buy insurance so you can pay higher copays to go out of network does not make sense. If you have kids away at school or live across state lines, you have to think about emergency out of network medical care.

What about private pay patients- those with no insurance or pre-existing conditions? They get hit with a bill for the full rate. In 2009, I personally saw a common lab test charge go from $160 to $18 depending upon if I was paying or my insurance was. How did that rate get so skewed? It is because of something called UCR (Usual customary rates) that were set each year. The insurers paid a percentage and doctors, hospitals, and labs write-off the rest. If providers do not keep raising the rates, they end up with low fee schedules. Sounds a lot like government- “if we don’t spend everything we asked for in our budget, then they will cut it next year!”)

Why is health insurance tied to employment? Medicare isn’t and it is portable- so retirees can use it all over the country with no increase in rates. Medicare seems to be running out of money, because there is no incentive to shop for what you NEED in health care. When care is essentially free, once you’ve paid the premium, people don’t worry about the cost. Nor do they worry about necessity. Do we really need an mri or cat scan? Do you have to see a specialist or can your family doctor handle it? Do you know the difference in cost? Do you need all those drugs they advertise? Is anyone paying attention to how many over the counter chemicals people pop to counteract their unhealthy lifestyles?

I personally think we need to decide; first, if health care should be an insurance issue. And if it is, should all health care be insurable?

Should we just insure against accidents and catastrophic events, such as procedures and hospitalizations, and not office visits?

Should drugs only be covered after you spend $500 or $1000 a year?

It may be that when the patient and doctor get back to a professional relationship with the insurance company out of the middle, both health care quality- and its costs- will improve.

Christine Brauer Mueller
Lawrenceburg Township


deadparrot said...

I'm holding out for what Dan Brewington thinks about health care and insurance.

jsb said...

The Obama speech last night indicates he's pushing on with reform with payment for those reforms supposedly coming in part from savings on eliminating waste and fraud in the system.
If they know how much waste and fraud exists (since they know it's enough money to pay for this) why hasn't it been eliminated before?

Dan Brewington (not really) said...

Some interesting reading on this topic, especially if you are a dead parrot:

broker Lorne said...

Well, it was great to read your point of view, since you have a lot of experience in the field. As for my opinion, I think it is not bad to insure all the different kinds of stuff - not only heath and catastrophic events, but also weather, weddings, and so on. Firstly, though, everybody should have at least a basic health insurance.