To answer this question we need to explore the practice of medicine within our health care model, to look into the relationship that has developed between the health care providers and the insurance companies, and to examine how these health care providers have been either indoctrinated (or coerced) into practice patterns governed by the insurance company.
At the onset, the system is destined to fail because health care is part of a massive for-profit industry. Insurance companies are businesses, and many are publicly traded with the intent of maximizing profits for their stockholders. If you owned stock in General Motors, you would hope to not lose money on your investment. The same applies to investors associated with these large health insurance companies. In simplest terms, the corporations overseeing your state of health are for-profit businesses, with defined expenses, salaries, profit margins and performance benchmarks.
A basic premise of any business, from the mom-and-pop store to the multinational corporation, is that revenues must exceed expenses. In health insurance this revenue is generated through subscriber premiums, contracts with businesses for employee coverage, and some government subsidies (for Federally sponsored programs like Medicaid or Medicare). This is their income. They do not produce a product or a widget that can be manufactured and sold, like an iPhone. These defined revenue streams, less expenses, effectively set their total profits.
Expenses in the insurance industry are administrative costs plus your health care. If less money is spent on your health care, more profit that can be passed on to the stockholders. The math is really pretty simple; you can be sure that the actuaries and bean counters working for these companies are acutely aware of this equation.
This is a classic example of the fox looking after the hen house. Through obstructionist techniques such as exclusions buried in your policy contract, limited medication formularies, and deflections of your doctor’s medical recommendation with the concept of a “pre-approval” for a procedure or drug, insurance companies mandate and limit your care. This maximizes their profits.
Contracts with “in network” providers are subject to the whims of policy changes, and reductions of reimbursement. Assuredly your medical provider has received a letter sometime in the last two years that looks something like this:
“Dear Dr. Resnick,
Thank you for being a Blue Cross provider. You are an exceptional part of our healthcare team, and we greatly appreciate your hard work and dedication to our shared patient population.
“Unfortunately, due to reasons out of your control, we are cutting your reimbursement for all of your services by 8%. So sorry! We realize that you have fixed expenses that follow the customary increases, along with cost of living expenses, increased costs of supplies, and increases of your own employees’ health care policies. With this in mind, we recommend that you work through lunch, squeeze in all the extra patients that you can, and shorten your patient visits.
“We will continue to request preapproval for most of your recommended tests, and forget to pay you for services already rendered, so you will probably have to hire another employee or two to audit our EOB’s and keep up with this paperwork.
“Thank you for being a part of the great Blue Cross team!”
Okay, I realize that I might have taken a bit of poetic license with this letter, but assuredly this dynamic is in play continually for each of your in-network doctors and their clinics. This is a part of the equation that contributes to your poor health. Doctors are prevented from ordering and utilizing the best diagnostics and therapeutics. Why recommend a better treatment or drug when your professional opinion will likely be ignored? Why pay an employee to spend hours on the phone pursuing a pre-approval or pre-authorization that makes your business no money?
Current Score from denying payments and procedures:
Insurance company 1
So you go to your doctor’s office with a headache, which is compounded by an hour in the waiting room and another 15 minutes shivering with a crepe gown in a grey-walled exam room. Doc X rushes in, smelling of a stale granola bar (her lunch). She cocks her head when you tell her you’ve had a headache for several days, and without a good exam (she just doesn’t have the time) pops a request for a CT scan into the computer along with a prescription for ibuprofen and a muscle relaxant. You return two weeks later for your results with the requisite wait, again paying the insurance “copay”. You are told that the scan was negative, you have no tumor, and to continue taking the medicine. This allows for some improvement, but the headache returns when you get the $1000 bill from the radiology department and another $200 bill from the radiology group. What happened?
Unfortunately your deductible had not been met, and the scan wasn’t covered. You are now in for the exorbitant fees charged from the X-ray provider to the insurance carrier. This is a wash for the insurance company, as they simply deflect the fees back to you. They also now have the benefit of knowing that you don’t have a brain tumor—on your dime. Ka-ching! Had you chosen to pay the X-Ray company directly without going through insurance, you may have obtained the same test and qualified interpretation for around $300 (actual number). And now the headache, prompted by stress all along, and easily diagnosed if your doctor had spent more than 3 minutes with you, returns in force.
Current score from harried medical evaluation and unmet deductible:
Insurance company 1.5
Radiology Department 1
Finally, established protocols mandated to in-network doctors don’t allow insightful medicine to be practiced. Patients are routinely awarded with perfunctory lab tests, clinical ‘door prizes’ that offer little insight into a their physiology and biology. What if you request an advanced lipid panel, one that looks at sub-fractions of the lipids in you blood, and not simply the old-fashioned cholesterol test with a calculated (not measured) LDL value? You have correctly heard that half of people who have heart attacks have normal lipid panels, and that lipid fractionation can help your doctor to see if you have the smaller, denser lipid particles more destined to promote heart disease.
Sorry, this isn’t covered by your policy. If your doctor orders it you will likely have to pay the top dollar charges submitted from the lab (Quest, LabCorp) to your insurance company. Is your deductible met? It may not matter. If the insurance company has determined that this test is not covered, you will have to pay the exaggerated prices out-of-pocket. Sadly patients are often not being tested correctly or thoroughly because the best test is not “covered” by their policy. I often wonder who is deciding how to test and treat the patients, the doctor or the insurance company?
What about inflammation? As a medical professional with more than two decades of clinical experience in my field, I (and many others) feel that this is one of the most important measurements that can be made to assess a patient’s health. I check an hs-CRP (high sensitivity C-Reactive Protein) on nearly all of my patients, and joke that if I could only order one test, one single test on each of my patients, I would order this one. However this test, which costs around $20 or so, is summarily declined by Medicaid. Go figure.
Here’s what I suggest. Health insurance should be used as it was conceived: to safeguard for something catastrophic like a broken hip or a heart attack. I recommend a “catastrophic” medical policy with a lower monthly deductible. Use the money that you save to see a qualified Functional Practitioner, preferably an MD. Get the correct testing done with a doctor who spends time to understand you, evaluates your medical conditions with advanced and insightful testing, and addresses your health needs with an eye on diet, nutrition, behavior and wellness.
Dr. Scott Resnick
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