This is a complicated subject so bear with me while I give you a little historical background. In “pre-conquest times” (the 80s), you were an individual by the name of Mr. P. You would have established a direct relationship with my practice and my responsibility to you was clearly outlined by the Hippocratic Oath I took on graduating medical school.
You were responsible for following my medical advice and paying your bill. I was your doctor and responsible for delivering the best medical care available.
My chart note would have started with something like this:
“Mr. P. is a 34-year-old white male, father of 3, executive, smoker, appearing healthy and slight overweight, here today for . . . Appropriate lab was done and reviewed, and he was given a script for cefoxidril two times a day for 1 week and told to see me if he failed to improve. Counseling for smoking cession was begun.”
At checkout, you would be billed for a short visit and given follow up instructions. You would have been asked to pay at the time of service; and in 1984 a short office visit would have cost you around $30 dollars plus the cost of your lab. You would have been given an itemized bill for your records.
We, my patient and I, were responsible to each other. There was no third party involved. If you had insurance, you would deal with them directly. I was free to deliver whatever care you needed or desired.
Now, flash forward to present time. I refer to the present as “post-conquest” times. My profession came under attack in the 90s. The enemy, the insurers of America, used an ancient trick to enslave us. The “Trojan Horse,” known as Major Medical Insurance, promised to help you deal with catastrophic medical bills. Things went downhill from there. At first, the insurers offered docs contracted rates for their care. Over time, they offered to cover more and more services and my patients, colleagues and I accepted their proposals. We were rounded up and lead into a pen and the gates were slammed behind us and padlocked.
Physicians were no longer able to negotiate contracts. Two “suits” came into my office and handed me a contract to sign. They worked for one of the largest insurers. I told them I would read it over and get back to them. I’ll never forget their response. “Dr. Segal, you obviously don’t know who we are. There are no negotiations! Either sign this contract or lose 30% of your practice as we insure 30% of your patients.”
I reached into my desk and pulled out my recorder and asked them to repeat the threat. I told them I was going to the State’s Attorney as I felt that I was being strong armed into signing their contract. The only thing they said as they left was, “You’ll be sorry!” They were right. It took years for me to get a contract from them and the only way I could see their patients was to join a hospital-based group.
Now, to get to my point. In today’s world, I am no longer a doctor who works for you. I am a provider of care covered under a contract that my patient (customer) purchased. When you register, you are labeled as a PPO, PSO, HMO, Medicare or some other ridiculous abbreviation. The letters assigned to your account determine what care you receive and who is truly in control. There are now preferred labs, hospitals, specialists. They are “preferred” by your insurer, not necessarily by your provider or you.
Your office note is now computerized. Your “provider” is paid based on the number of boxes he/she checks so they will spend a great deal of the visit checking boxes. You are now a customer of XYZ Insurer and there is now a rule book that all involved in your care must follow.
The note no longer says lab done but instead says ‘lab ordered at in network lab, to be reviewed at follow-up visit.” Everything your provider does will be assessed by your insurer and accepted or rejected by them. Your order for cefoxidril will be declined and the pharmacy will blackmail your provider into prescribing Amoxicillin.
The following is the conversation wherein your provider is blackmailed:
This is Paul, the pharmacist at ABC Pharmacy. Cefoxidril is going to cost your patient $400 dollars and his insurance will provide Amoxicillin for $4. Your patient can’t afford $400. What do you want me to do.?”
Your provider chose generic cefoxidril as, theoretically, it has better coverage for what ails you. However, $400 is absurd so he/she, weighing risk vs. benefit, makes the switch. He/she will remember having to switch and, in the future, will save himself/herself extra work by prescribing the cheapest products possible according to your plan’s formulary.
At checkout, you are now a “99214” with a diagnosis code “J36.” You are also a “F17.201”. Further, you are coded for a “99207 and a notation was added stating 14 minutes of which 50% was counseling was made.”
As your former doctor, I have been demoted to a provider and dehumanized. I am now a trained monkey following the rules of my new master. I am no longer paid for my services nor do I have the right to set my own value. I am reimbursed, at a later date, at a rate set by my new masters. Ultimately, I get paid the same $30 dollars I got in 1984 but I now have 4 employees in my coding and billing department driving down my income.
As a patient, you have been dehumanized into a series of checkmarks and codes that mean nothing to you. You now pay a $20-dollar copay but get a bill for $250. The insurers have purposefully driven up the LISTED COST OF CARE INSURING THAT YOU CAN’T SURVIVE WITHOUT THEM.
I seriously believe that today’s insurance industry is the legal branch of organized crime! I have a present for those of you who read this article in its entirety. Tomorrow, I’ll give you my solution.