Jonathan Richard, MD

Beginning in the late 1980’s, Wall Street recognized that Healthcare was a “growth market” and pharmaceutical companies discovered and introduced revolutionary new medications for the treatment of hypertension, high cholesterol, depression and gastrointestinal disorders like acid reflux.

Insurance companies introduced healthcare coverage in the form of HMOs - Health Maintenance Organizations.  This basically gave them more control over determining the cost of services.

Due to the formation of HMOs, doctors had to group together in order to have some negotiating power in dealing with insurance companies.  If you weren’t in a group, the HMOs could choose to not include you in their “networks’” or let you join but give you a crappy contract.  I know, because it happened to me when I was a sole practitioner in 1992.

Many HMO contracts then were based on what is called “Capitated Care.”  The doctor was paid a certain amount of money each month for each patient that had selected them to be their “primary care physician,” which is when this term first entered the healthcare environment.  A certain amount of money was also budgeted for costs related to lab tests, radiology tests, medications, hospitalizations and services provided by specialists.

If costs in all these areas were kept under budget, the doctor or the group they were in received the leftover funds from the different areas.

Unless you stopped taking care of complex, sicker patients (like many Family Practice physicians did), you made less money with this arrangement, even if you joined a nationwide physicians' group.  After trying to make this work for a few years, many doctors stopped participating in HMOs and insurance companies no longer had enough physicians in their “network” to be able to get large contracts with major employers.

This is when PPOs (Preferred Provider Organizations) were developed.  However, the insurance companies retained much of the control that they had gained through the HMO programs.

During this time, hospitals also formed larger and larger groups and pharmacy corporations became larger, acquiring more and more locations in order to deal with the insurance companies.

A new equilibrium was reached between insurance companies, hospital groups, and physician groups.

This being America, the champion of capitalism, however, hospitals, pharmacy companies and some physicians started figuring out where money could be more easily made - surgical/procedure centers, neighborhood emergency rooms, “urgent care” facilities, mail order pharmacies, “boutique” clinics for treating estrogen or testosterone deficiencies, bariatric surgical clinics, and “Concierge” medical practices.  This is why you see either pharmacies or urgent care facilities or emergency rooms on what seems like every corner.  This is also why insurance companies, in cooperation with pharmaceutical companies and pharmacies, have “preferred medications” or different “tiers” of medications.

Pharmacies were allowed to start giving vaccinations and have even been allowed to install small clinics, staffed by nurse practitioners.

So, what’s wrong with all this?

Your healthcare gets more and more fragmented.  One entity doesn’t know what the other entities are doing or what your different diagnosis are.  If you have a “primary care physician,” they are not informed of what is going on with your healthcare and you have not had the benefit of their knowledge and experience to help you decide just exactly what you do need.  You get sold unnecessary vitamins and supplements, get talked into having unnecessary procedures and get prescribed medications that have interactions with other medications you are already taking.  Then, when you do have a drug-drug reaction, you cannot get into your specialist to be seen or end up talking to someone (who may not even be a physician) on the phone who doesn’t know you or who doesn’t want to be bothered “after hours.”

Also, money gets siphoned off for more expensive procedures or evaluations and is therefore not available for essential healthcare needs.

You experience complications from unnecessary procedures - your health is worse after having something done that you didn’t even need.

You go through unnecessary stress and expense due to unnecessary tests having “false positives.”  Every test has a certain percentage of results that are incorrect - either incorrectly positive (false positive) or incorrectly negative (false negative).  The percentage of false positives increases when the patient has a low likelihood of having the disorder that the test is supposed to assess.  What happens when one test is “falsely positive?”  Another test is performed - usually a more expensive or more invasive test - meaning possibly more painful and likely with more risk for injury.

And this doesn’t even address the damage being done by the “electronic medical record.”  But that’s a topic for a separate discussion.

I loved the first “The Incredibles” Disney movie - particularly the part where Bob Parr is called on the carpet by the insurance company president, who complains that his clients that he has helped are “penetrating the bureaucracy!”  Bob asks him, “aren’t we supposed to help people?”  The executive shouts, “YES, but starting with OUR people - our stockholders!”

The first thing, the main thing and the last thing to keep in mind about health insurance companies (which I will just call insurance companies from now on) is that their goal is to MAKE MONEY.  Their bottom line is to MAKE MONEY.  Supposedly, this is for their stockholders, but really, it is so that insurance company executives can get huge bonuses.  I mean huge, humongous, astronomical bonuses like the one the CEO of U.S. Healthcare received when it was acquired by Aetna in the early 1990’s - 800,000,000 dollars.  That’s right, Eight. Hundred. Million. Dollars.  That is the equivalent of 16,000 people making $50,000 per year - all in one payout.  Talk about greed.

Why is it so hard to understand your healthcare policy?  The insurance companies do this so that you can be deceived, misled and confused.  They are performing the proverbial “shell game” - while you are looking at one shell, the ball is moved to another shell or off the table altogether.  When it comes to money, the more complex the situation is, the more easily it is to commit fraud.  Every part of your “coverage” is designed to help THEM, not YOU.

“Deductibles” give you the incentive to NOT see the doctor or go to the emergency room if you are sick.  “Preferred medications” are deals with pharmacies and pharmaceutical companies to get certain drugs cheaper or get payback if a certain volume of a particular medication is prescribed.  “Usual and customary” payment is a way of paying the doctor less than what he charges, by claiming that his charge is above what they usually pay doctors.  (When asked by the AMA to explain how they arrived at these numbers, the insurance companies never explained how they arrived at these amounts.  If all of us doctors are charging more than the “usual and customary,” why isn’t the “usual and customary” higher or some doctors getting paid exactly what they charge?)

They create barriers for doctors to appeal nonpayment of procedures, lab tests, and expensive medications.  They latch on to ANY excuse to not pay for something.  I can give you example after example.

While we can all thank “Obamacare” for higher insurance costs and deductibles, there is one good thing I can say about it. It mandated payment for preventative healthcare such as having an annual physical or screening for breast and colon cancer.  You are not supposed to have to pay for these now.

What is the solution to this mess?  The only thing I can think of is to pass a law so that all healthcare insurance companies are NONPROFIT.  Or that dividends be paid to patients and stockholders.  After all, what are their profits?  The excess money they charged in the first place.  And maybe it could be put in the law that insurance company executives' salaries or bonuses are restricted.

But something like this will never happen unless there is a constitutional amendment for term limits of senators and congressmen.  That way the insurance company profits cannot be used to “buy influence” on Capitol Hill.  But that’s another topic for a separate discussion.

The electronic medical record (EMR) is one of the worst things to happen in healthcare.  Your doctor (or their physicians' assistant/nurse practitioner) now pays more attention to the computer screen than to you or what you are saying.  Yes, they hear your response to their questions, but many times they are concentrating on getting your answer into the computer, not thinking about your symptoms or trying to figure out what the problem is or what you need. This has worsened the problem of doctors not thinking. A lot of doctors don’t think - they react. They have a “knee jerk” reaction or response to the patient’s situation or complaints. The electronic medical record also aggravated the problem of doctors spending less and less time with a patient during an appointment, as the EMR slows the process down.  If you see a doctor who only schedules 15, 10 or maybe even 5 minutes per appointment, it is easy for them to address all the areas that are necessary if you have no complaints or are being seen for a follow-up of a chronic condition.  If you are having problems or medical complaints, they can only afford to address one problem, superficially, during your appointment. If they cannot think of a “knee-jerk” solution, they refer you to a specialist.

The other bad thing about the EMR is that it makes it extremely easy to commit fraud. I get progress notes from specialists all the time which show that they have examined the patient’s head or neck or chest or lungs or heart or abdomen or extremities or neurologic system, where I KNOW that all they examined was the system they are specialists in. I know this as my patients have told me so and because their records show certain areas are normal on exam when I know that they are not normal. Why do they do this? Because now they have the documentation to justify billing the insurance companies a higher charge since, on paper, they have done a more extensive exam as part of a more complex office visit.

Another downside to the EMR is that it is accelerating or worsening physician burnout.  Survey after survey of doctors shows this.  Your doctor is now spending more time at the office working on the medical record and spending time weeknights and during the weekend to stay “caught up” with entering in the data to your medical record.  How do you think they feel about having less time with their family or less recreational time or the fact that they are working harder but not getting paid more?

Another bad thing about the EMR is that it gives insurance companies and Medicare direct access to your medical record.  In the next year or so, Medicare will require your doctors’ electronic medical record to be accessed by their computers for the purpose of rating how good a Medicare patient’s healthcare has been.  It is expected that commercial healthcare insurance companies will follow suit.  One thing we know about the government is that when it is allowed to monitor something, it gradually expands what it monitors and eventually controls what it is monitoring.  The insurance companies will use the information to either pay the doctors less or charge you more.

Do you really want Medicare or the insurance companies to know everything that is in your medical record? Would that make you less honest with your doctor? What if the doctor or nurse made a mistake entering the information into your record, would that concern you?

On top of that, the fact that some outside entity can access your medical record means that there is a possibility it can be “hacked” into.  There are already cases where a doctors EMR has been accessed by hackers and then encrypted so that they cannot access the data unless they pay a ransom to get access. Haven’t heard about that have you?  It’s one of the dirty secrets about the EMR. What if these hackers can get access to your records and use the information to blackmail you? In today’s electronic, internet connected world, information is money and as we have seen, there are many people and corporations that want to make more money.