Any day now, the nations’ health insurance companies expect to have a huge influx of new clients. If they can not defeat the Democratic presidential candidate this fall, some form of universal healthcare is likely to be passed by Congress. If the industry has its way, they will be allowed to continue business as usual, except with some tax breaks and government subsidies to help them do even more of the business that they already do. The only problem is that under a universal healthcare plan, they will be expected to provide care for
sick people , and let’s talk turkey here. The health insurance industry did not become the lobbying powerhouse it is today by coddling a bunch of whiny invalids.
What we are seeing now is the industries major players---the plans that think that they will survive the shake up and emerge part of Hillarycare or Obamacare---test out methods for denying services under universal healthcare. And---no surprises here---since the problem (from the insurance companies’ point of view) is that they will be forced to insure the sick alongside the well, they are dusting off the underhanded methods they refined in the 1990s to use with HMOs.
I.
Capitation Capitation:A method of payment to a provider of medical services according to the number of members in a health benefit plan that the provider contracts to treat. The plan sponsor agrees to pay a uniform periodic fee for each member. (Capitation means by the head, or per person.) Because the fee is independent of how many services are performed, the doctor has an incentive to keep costs low. The doctor's incentives not to render only minimal treatment include professional integrity, the risk of malpractice suits, loss of business if patients are dissatisfied, and the risk of simple illnesses becoming more severe and costly to treat.
http://insurance.cch.com/rupps/capitation.htmWe all remember the nightmares of the 1990s---bad dreams that have lingered into the 21st century for some of us. Health insurers that tell us what doctors we can see, what surgeries we can have, what drugs we can take. Plans that suddenly drop our providers or hospitals or drugs
for no stated reason forcing us to scramble to seek new care with new doctors at new facility and get on new medications that may have taken months to fine tune. That was the wild and wacky world of medical managed care---Health Maintenance Organizations or HMOs they were called in the 1990s. People paid their premiums and the insurance plan was required to accept new members regardless of their pre-existing medical conditions. In exchange for being able to get insurance even though you had chronic Hepatitis C or Lupus or diabetes, you gave up the right to see any doctor in the phone book and had to see a doctor in the HMO’s directory. When they were signing you up, they always made it sound so easy----nothing was going to change. If your family doc wasn’t on the HMO, he soon would be. They promised.
Right away, you learned the truth. At HMO,
Member Services always lied . Their job was to get you to sign up, because they got paid per head. Once you were enrolled, you learned the truth. As long as you were a healthy person who only intended to use your HMO if you were in a car wreck, you and your HMO would get along just fine. But if you planned to get ongoing, state of the art, reliable medical care for a serious chronic medical condition, you were either going to have to learn to fight for your rights---or you would be better off on some other insurance.
The last is how HMOs made their money. They drove sick people off their plans. They required people to jump through hoops to get specialty care. They paid primary care doctors a flat fee out of which
they had to pay the cost of medical care for sick patients so that the primary care doctors would have an incentive to find excuses to drive sick people away .
I will let you in on a secret. Remember the part in the Michael Moore film
Sicko in which the insurance companies try to find reasons to cancel people’s policies after they have gotten sick or hard surgery?
Doctors are way better than any insurance company at getting people to leave a practice—or an insurance plan—because they are sick and require medical care. “Your case is too complicated. “You do not need to see an oncologist to manage your lung cancer. I can do that for you.” “I don’t like the specialists you have been seeing. I am going to change your specialists to the ones I like.” “I only see HMO patients one afternoon a week, and you can only discuss one problem a visit.”
These are all
real things said by real doctors to HMO patients the first and last time that the patients saw them, before they came to see me. Doctors on a capitated HMO plan can spot a money sink---a new patient who is going to accrue a lot of medical bills—the minute she or he walks in the door. An unscrupulous doctor knows just what to say to turn that patient around and send him back out to another doctor.
So, imagine my alarm when I read the headline on the Feb. 11, 2008 issue of the
American Medical News the weekly newspaper put out by the AMA.
Can Mass. Blues Revive Capitation? Wtf? Massachusetts has a system of universal health care, right? Why do they need HMOs? Everyone in that state should be able to get insurance despite pre-existing health conditions…
Oh, now I understand. Those pre-existing health conditions must be eating a big hole in the wallet of Mass. Blues. Face it, under our current medical system---the Medical Industrial Complex, which gets big, fat and bloated by taking care of the end results of years of neglect with expensive therapies---the only way that a health insurer makes money is by collecting premiums from healthy people and shunning sick people, who get dumped on the VA or SCHIPs or Medicaid or Medicare or County Hospitals.
The above article quotes the AMA
“The AMA strongly encourages physicians to exercise extreme caution prior to entering into a capitation agreement and ensure that the quality of patient care is not threatened by inadequate capitation rates. It is important that physicians avoid undue economic pressure that can lead to a culture of denial.”
But a
culture of denial is just what Mass. Blues and other insurers want, especially as they move into the brave new world of universal health coverage in which they will accrue more clients, but at the risk of getting stuck with even more outlays for medical expenses.
It looks
bad when Cigna denies a dying girl a liver transplant. How much better if the HMO can count upon her physicians to tell the family “There is nothing we can do. She has a terminal condition.” Families trust doctors. Or at least, they do right now. Back in the 1990s, when capitation was everywhere, many doctors were not trusted, because patients could not be sure if their doctors were looking out for their patients’ best medical interests or for their own financial best interests. But if you take it to court, nine times out of ten, a jury will still side with a physician, which is a lot of sweat off Cigna’s brow.
Here is something that should give people pause. It is from the March 3, 2008 issue of American Medical News.
Blues Stops Asking Doctors for Rescission Help California Blues has been sending letters to some of its members’ primary care doctors for several years, asking the physicians to go over their patients’ charts, looking for evidence that can be used to cancel the members’ insurance. The letter gives specific tips about things to look for in the medical record that can be used to invalidate the initial agreement, such as date of last menstrual period etc. The AMA has criticized the practice as stifling doctor-patient communication since it limits what people will tell their doctors since they know it may be used against them.
Recently, these letters became public knowledge, and California Blues was forced to stop using them. However, what worries me—and what should worry you---is the part of the article that says
The letters had been sent out “for several years” without complaint, Garcia said.
Obviously, a lot of doctors felt that they had a duty to protect the financial wellbeing of their patients’ insurance carrier that superseded their duty to establish a relationship of trust with their patients.
Now, imagine that these same doctors are the only group of internists in your small community, and they are capitated—meaning they have been paid X dollars a month by your insurer to pay all your bills--- on the insurance plan you chose as part of your brand new universal health care plan. You show up in their office with your list of twenty name brand medicines—none available as generic—and your list of specialists, including the clinic where you get dialysis and the doctor who will be doing your renal transplant just as soon as they find you a suitable kidney.
The only red carpet you will see is the one they will roll out for you as you leave in a huff. “I’m sorry. You will have to delay your dialysis, until we can get copies of your medical records and go over them to make sure that you are on the appropriate treatment. You can go pick them up yourself. A day won’t hurt.” “Yes, I know that the local hospital does transplants. But the HMO has a special contract with the teaching hospital seven hours away, and their team is excellent. You will get much better care there.” “No, there is no need for you to see any of these specialists any more. I did electives in all these fields when I was in training. I am confident that I can handle any problems that arise.”
At least the lady at member services will be nice to you. “Did they really? Yes, I understand. No, ma’am. You don’t have to wait until next year to change insurance plans. HMO will be happy to let you tear up your contract and select a new insurance provider. It is the least we can do. Continuity of care is the most important thing. “ Hangs up the phone. High fives the member services rep in the next chair. “This is so easy now that we have capitation.”
II.
Excluding Providers Georgia Blues is being sued. Georgia, like many states has an
Any Willing Provider Law which means that any doctor or hospital or other provider of medical services who is willing to accept an insurers terms must be offered a contract.
Well, Georgia Blues has an HMO product, and like all good HMOs it has found that
one of the best ways to keep costs down is to make it absolutely impossible for anyone with an actual medical condition to get medical care. You do that by limiting the number of providers and making sure that their offices are all located in out of the way places (on top of mountains would be good) and that the specialists are swamped (booked up for months would be ideal) and that the only hospitals that do necessary services are six counties away and the only pharmacy that takes your card has two hour waits and the only primary care doctors who take your insurance also see a lot of workman’s comp and “diet” patients so you have to sign in and wait your turn.
This article is in the February 16 issue of AMA News and is called
Ga. Blues Sued Under any-willing provider law and describes the plight of 100s of North Georgia cancer patients who now have to drive hours to see an oncologist, because Ga. Blues terminated its contract with their doctors.
The ability of an insurance plan to exclude or drop providers goes way beyond simply limiting costs. It is a tool that insurers can use to get rid of whole panels of unusually sick people under universal care—by dropping a few doctors. For example, some doctors tend to treat people with more severe illness. People with chronic disease have been shown in studies to be more drawn to female physicians. Insurance companies create profiles of their providers, so they know which doctor spends how much money. They also know whether that money is well spent—i.e. if the patients that doctor sees are really sick enough to warrant those expenditures. When I was in practice, a large local HMO complained to me regularly that I was spending too much money on my patients who just happened to have a much higher illness burden than most other family physicians. The amount of money spent was actually lowish compared to their illness burden, because I kept most of them out of the hospital, but the HMO still tried to terminate me, because they wanted to save money---and getting rid of me would have meant getting rid of a bunch of my chronically ill patients who would have changed insurance plans so that they could keep seeing me.
If insurers in the brave new world of universal health care are allowed to terminate physicians, then they can look for those who work in poor, minority areas or who treat people with more severe, chronic disease and they can drop them from their plans with no reason given. Inevitably, their sickest, most costly patients will hurry to change insurance plans so that they can continue seeing their old doctor---and their old insurance company will have reaped an enormous savings.
This is in addition to the savings from the “hassle factor” which having too few doctors creates. People may decide that driving two hours to see a dermatologist just isn’t worth it.
The sad thing about both of these tactics---capitation and provider exclusion---is they will be used in cheap HMO products which insurance companies will present to state and federal officials as a solution to the high cost of providing universal health care through for profit insurance companies. “No problem,” Blue Cross Blue Shield will say. “We have this capitated plan with $30 copayments for $150/month for your working class family that can not afford
good .” Never mind that the plan sucks for anything but catastrophic coverage. Congress and the President will pat themselves on the back for providing “universal healthcare”---and the nation’s health insurance industry will wait exactly three and half years, until right before the next election to scream that it is going bankrupt and can not pay its bills with the pittance that it is being paid.
And everyone will declare universal healthcare a great big disaster.
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