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Solutions to
the Rising Cost of Healthcare
Meet the Giant Filter at
a Managed Care Organization
SOURCE: Information gathered by the American Policy
Roundtable
Compiled by Professor Charles McGowen, M.D. and Chief
Medical Advisor to the American Policy Roundtable; August
11, 2008.
On May 10, 2005 an op-ed
piece appearing in The Providence Journal contained a
by-line which posited the question, How Can a $124.8 Million
a Year CEO Make Health Care More Affordable? That is a
reasonable question in deed, especially when the costs that
the CEO of whom it speaks is allegedly trying to control in
order to make your healthcare and mine affordable involve
physicians whose incomes amount to one tenth of one percent
of that which United Health Care (a Health Maintenance
Organization-HMO) was paying its CEO. The short answer to
the article’s question is, “He can’t!”
The commentary was a
startling expose about huge pay packages for corporate CEOs
in general and germane to my specific interest in this
series it mentioned the awesome $124.8 million total
compensation of United Health Group (parent of United
Healthcare) CEO William McGuire. What the article did not
include however, were two significant letters that should
have followed William McGuire’s sir name; specifically M.D.
You see, before becoming an HMO administrator, Dr. William
McGuire, had done what I did for 31 years; he practiced
internal medicine and at the time he joined United Health
Care, the average taxable income of an internist was around
$150,000 per year.
To view it from a United
Health employee's perspective, had Dr. McGuire, who is also
a United Health employee, been paid only a cool million
(which was more than six times what he had previously earned
in a most respectable profession), and the difference had
been apportioned to United Health Care’s other employees,
each of the 40,000 workers could have received an annual
bonus larger than $3000. To look at it from the viewpoint of
the health care system he supervises, the $124.8 million in
Dr. McGuire’s total compensation, himself a single United
Health Care employee (the CEO), could pay the entire
salaries of 833 general internists at their current average
incomes. Or, ignoring either of the previous options, the
$124.8 million could fund the costs of managing one
reasonable size community hospital for an entire year.
That CEO’s office only
represents one layer of that massive, health management
corporation‘s organizational chart. The 40,000 employees
mentioned above are distributed throughout the association,
in layer upon bureaucratic layer, each of which has a
particular responsibility of one sort or another to
supervise our heath care and improve the HMO’s bottom line.
It is through those multiple layers that your doctor’s
request for a procedure (therapeutic or diagnostic) must
filter before his best interest in your well being can be
approved, or disapproved, depending on the mood, knowledge
and understanding of the filter person. A filter is commonly
used to remove something that passes through it. That which
is removed may be something good or bad. A colander is a
type of filter which saves the good stuff, i.e. rinsed
broccoli, shrimp or boiled pasta noodles. Filters on
furnaces trap undesirables as do oil filters in our autos.
The filtering processes at United Health Care and other HMOs
separate out those procedures (diagnostic or therapeutic)
that some medically untrained clerical person decides you
don’t need and which would be undesirable in regard to the
company’s corporate profit; the proverbial bottom line. Just
remember this very important, patently obvious and painful
reality; the bottom line in any HMO or MCO (Managed Care
Organization) ledger is not your well being, it is sadly
their financial solvency. They are out to please their own
innate greed and improve the health of their stock holders'
portfolio.
One case out of the many
episodes of filtering that I could cite deserves mention
here. I had a 40 year old female patient who three years
earlier had undergone a mastectomy and breast reconstruction
because of breast cancer. She was followed periodically by
her surgeon and an oncologist. One day she came to see me
because of an unrelenting headache that had been present for
one week. My obvious concern was the possibility of a brain
metastasis; a not uncommon area for her breast cancer to
spread. When I called her HMO to request permission for an
MRI it was denied by a girl who asked me to spell
metastasis. She said that I should try Advil for the
headache, not knowing that the patient had already done that
on her own for the past week. We went ahead with the MRI
without the permission of the HMO and unfortunately she did
have a metastatic tumor. Her husband fought and won his case
for reimbursement. My experiences with the HMOs are not
unique; just ask any other primary care physician.
Other layers of the
bureaucracy are less obvious to the physician and the
patient being covered by the HMO plan. One such stratum
involves the negotiating team who meets with employers for
the purpose of getting you the least health care for your
employer’s dollar amount. Another layer involves those
clerks and secretaries who shuffle the massive reams of
paper work that go into a bureaucratic operation of this
sort. Another layer involves a surveillance team that goes
into physicians’ offices and determines if they are in
compliance with certain inane rules and regulations
established by the HMO or MCO brain trust. Those rules, one
of which I will further describe, have nothing to do with
the manner in which your doctor discovers the cause of and
treats your medical problem.
There is an obtuse,
simple-minded and insensitive rule that requires a physician
to initial every laboratory and/or radiological report
before it goes into a patient’s medical file; we call that
“busy work” and it serves no valuable, clinical purpose.
There is no requirement that insures any follow up on that
report, just the presence of an initial. One HMO nurse found
that I was not in compliance with that rule and so
acknowledged in a statement that I received from the CEO of
that particular HMO. The case in question involved a 58 year
old male’s X-ray report (ordered because he had coughed up
blood) in which it was declared that he had a suspicious
looking mass in his left upper lung field. The patient was a
smoker and I had documented the numerous attempts on my part
that encouraged him to stop that dangerous, carcinogenic
(cancer causing) habit. I did not initial the X-ray report
but after reading it I did call the patient and arranged for
him to have a CAT scan for further clarification regarding
the suspicious mass. I also had him make an appointment with
me for follow up. I soon received the CAT scan report, read
it, did not initial it, but did discuss the need for a
thoracic surgery consultation with my patient and when he
gave his permission I did so. I then called the thoracic
surgeon, explained the problem and asked that he see my
patient expeditiously. When the pathology report came back
following his lung surgery, I did not initial it either but
had a documented discussion with the patient and the surgeon
about a follow up visit with a radiation oncologist. When I
received the oncology report outlining the planned
treatment, I filed it in the patient’s chart; again I did
not initial it. The patient received excellent care despite
my failure to comply with United Health Care’s ridiculous
rule.
Having properly managed
that man’s case, without initialing his various reports, I
was criticized by the CEO of that bureaucracy known as a
Health Maintenance Organization for a failure to chicken
scratch my initials through out his file. Had I done so,
while ignoring the X-ray report in which the suspicious
cancer was noted, I would have met the HMO’s requirements,
while my patient would have soon met his untimely death.
This is the very kind of needless bureaucratic bungling we
must eliminate by reinstituting a free market, consumer
driven, health care system; maintained by knowledgeable
physicians, not administrative bureaucrats. We must restore
a system that is free of the managers that occupy the
numerous layers in the hundreds of HMOs which dot our
landscape and deny our care. In coming weeks I will explain
how that free healthcare market works. That is when we will
explain the cure for our ailing health care system. Next
week however, I want to tell you a sad tale regarding a
small town practice in Appalachia. If we have national
health care it will be a story that is repeated time and
again, and not just in small towns, but through out the
larger cities in America as well.
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