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Does your insurance company prevent you from seeing your doctor?

That is an interesting question that I believe is true, based on what I am seeing in my own primary care practice and as a national trend. Having practiced medicine for over 40 years in two countries with very diverse systems, let me take a moment to share my insight into our evolving American medical landscape.

In light of the perceived emphasis that insurance companies place on prevention and wellness, I think that this concept is really directed more to the patient's responsibility rather than to the doctor's practice of medicine. In fact, I believe that there is a conscious effort on the part of the insurance industry to prevent you from going to see your doctor as they feel that once you step into the doctor's office, it is going to cost them money and affect their bottom line. These efforts, on the part of the insurance industry are destroying the Doctor/Patient relationship.

This belief, is all predicated on the fact that in order for the insurance company to make more money, in addition to raising your premiums, it is to avoid spending money and reduce their expenses. Since their expenses come in the form of having to pay for medical services rendered by your doctor, it behooves them to find ways to limit this exposure. As crafty business executives, they have devised numerous ways to accomplish this end and have a play book of tricks that grows day by day.

Why do I think that? Well let me count the ways.

COMPLETE PHYSICAL EXAM: No longer is the complete physical exam performed by your doctor covered by insurance companies or Medicare. They have replaced the doctor exam with a non doctor performed "Wellness Exam" which is a simple recording of data such as Height, Weight, Blood Pressure and Pulse and some simple screening blood tests for Cholesterol and Glucose. These can be performed by a Medical Assistant, thus taking the doctor out of the equation.
SCREENING TESTS: Other than simple low cost screening blood tests, and a colonoscopy for certain age groups, your insurance company does not pay for screening for anything else. As an example they are recommending we no longer do annual Pap Smears and Mammograms for women and PSA testing for men. Bone Density Testing for osteoporosis screening and Electrocardiograms to detect silent heart disease are also discouraged from being performed. The recommendations come from panels of pragmatic doctors who make these recommendations based on large population groups where they determine that the cost savings would out weigh the loss of life. Who's life are they talking about? Your life or theirs?

They infer that we doctors do these tests for the sole purpose of scamming the system and making more money, what they are really trying to say is "if they can prevent us from doing these tests and treating disease early, they will be making a ton of money in the savings". They reason that it costs less to bury you (your expense) than it does to fix you (their expense).
SEE THE DOCTOR ONLY WHEN YOU ARE SICK: This is the current recommendation that is being expounded as they do not want to spend needless dollars looking for early signs of disease. In other words, they want you to only see the doctor for symptom based, reactive care, not for routine maintenance, preventive care. Unfortunately this model often gets you to the doctor too late in the course of your illness and leads to poorer long term outcomes.
DOCTOR ENCOURAGED TO DO LESS: As primary care physicians we are constantly bombarded with new recommendations that in order to save the system money we need to do less testing and follow rigid clinical guidelines that are based on large population studies. Therefore, depending on what complaint you have, we are supposed to offer you a predetermined treatment plan with no variance based on individual needs. Thus, no personalized treatments can be offered. If we vary from this plan, we may face punitive action.
HIGH INSURANCE DEDUCTIBLES AND CO-PAYS: High deductibles insurance plans put the burden of cost of care, squarely on the patient, so as a result, many patients defer going to see the doctor because they cannot afford the office visit. This also applies to higher co-payments and co-insurance, which again many people cannot afford to pay along with the already high premiums.
HIGH INSURANCE PREMIUMS: The premiums for even basic insurance are exorbitant and the insurance companies are unregulated allowing them to charge us anything they want. With high premiums, many people elect to not get insurance and subsequently avoid going to see the doctor. This creates a system of haves and have nots, where those that can afford the premiums go to private doctors for their care and those who cannot receive their care through emergency rooms and public clinics, which absorb their cost of care. This allows the insurance industry to cherry pick their customers to only service those who can pay, which are usually the healthier in our society and those who cannot, fall into to the public system.
INSURANCE COMPANY NURSE PROGRAMS: Insurance companies are now setting up programs that request that you call THEIR nurse first for any problems that you may have so that it may allow them to divert you away from calling your own doctor. This is definite attempt to subvert the doctor patient relationship.
LIMITED TIME WITH DOCTOR VISITS: The insurance companies pay their providers extremely low rates forcing the doctor to create a high volume practice to generate more revenue just to keep up and see more patients per hour. This creates long wait times not only in getting an appointment but also in the waiting room. In addition, it also limits your time with the doctor and the number of complaints that can be handled in the short amount of time you have with him/her (6 minutes). This may often lead the doctor to tell you that your time is up and any of your remaining problems would have to be dealt with at a second visit. This of course is inconvenient for the patient as they have to take more time off work and pay additional co-pays. The overall patient and doctor experience in this system is poor which then dissuades the patient from making further visits to the doctor. The insurance company knows this and realizes that many patients will elect not to come back, which leads to the insurance companies saving money.
DOCTOR PROFILING: Insurance companies track all sorts of statistics about your care. This includes the type of visits the doctor performs in the office. If the doctor is spending too much time with the patient, the doctor gets a letter from the insurance company telling them that they are statistical outliers and they need to be more like the other doctors - spend less time with the patient. This powerful scare tactic is changing the way doctors are practicing medicine and setting a new standard of care based not on quality but on cost alone.
INSURANCE EMPLOYED DOCTORS: More and more, I hear where insurance companies are setting up their own clinics and employing doctors to provide services to their members. Well isn't this akin to putting the fox in the hen house? At the end of the day you get the type of medical care as determined by the insurance company, as the doctor becomes their agent. I consider, the Medicare Advantage Programs to be in this category.
HOSPITAL EMPLOYED DOCTORS: This is no different from #10. It is no secret, that there is a determined national effort on many fronts to get rid of the private practitioner and drive them into an employed hospital model. It is believed that having doctors in private practice is like herding cats and by having them as employed physicians their behavior can be controlled more effectively. In other words have them follow company policy, rather than what may be in the best interest of their patient.
DEMISE OF PRIMARY CARE PHYSICIANS: Each year we see fewer and fewer doctors choosing to become primary care physicians and more and more existing primary care physicians going out of practice. There are many reasons for this that are too numerous to expand on here, but the question here, is who is going to fill the void, considering that the future model supposedly is focused on more primary care? I am afraid that this level of "doctor" primary care is going away and it is going to be replaced with a triage system which will be protocol driven and directed by lesser trained para-medical personnel who will direct you to the various specialties. Undoubtedly, this will result in a chaotic, fragmented system with no continuity of care and the patient will bounce from specialist to specialist with numerous redundancies performed. This fly's in the face of what we are being told - "our system needs more primary care physicians" but in reality they mean "our system needs a better, lower cost triage system".
HEALTHCARE PROVIDERS: The insurance industry began using the term "Provider" in all of their literature, to lump all medical providers to include, doctors, nurses, nurse practitioners, physician assistants, medical assistants, therapists, pharmacists etc, into one general category, attempting to cloud the differences in their training, so that the public would think that anyone wearing a white coat is capable of providing equal care. This allows them to direct your care to a person of lower cost and give you a sense of reassurance that you are getting the best care available. This in many instances is simply not true. As doctors, we let this happen by employing many of these entities to be our surrogates, in an effort to generate more volume/revenue in our offices. Now it has come back to haunt us, as the insurance industry feels that these lesser trained, lower cost individuals can do just a good a job as the real thing.
ACCOUNTABLE CARE ORGANIZATIONS: Coming down the pike is what is called an Accountable Care Organization (ACO). This is another name for HMO. You all remember the horror stories about denials and substandard care from the 1990's. Well it is back with another name. This type of organization is paid a fixed dollar per month per patient and the providers in this organization profit by what is left over at the end of the month. That means less care = more profit.
COOK BOOK MEDICINE: There is a new buzz word permeating the medical community and it called "Evidence Based Medicine". This is where a series of standards are established to care for certain diseases and the doctor MUST follow these standards to the tee. Should he/she vary from these standards they would be held accountable and be subject to some sort of penalty. Should you as a patient require treatment outside of these standards, good luck in finding it.
REGULATIONS: It seems that every day, some agency is establishing new rules and regulations which put an immense burden on the small operator. In our case it is the private solo practitioner. These regulations are more intended for large institutions and we are held to the same standards. As a result of this immense administrative burden, many physicians are giving up the ship and either retiring from practice or going to work for either insurance or hospital clinics, which result in the problems identified in #10 and #11.
WASHINGTON LOBBYISTS: I hate to tell you this but regardless of the political party in power, healthcare policies are being written by the lobbyists (insurance, hospital, pharmaceutical) and at the end of the day any policies that are written are going to benefit them. Yes, the patient and the doctor get excluded from any benefits. You pay more and get less services, they get more money and deliver fewer services. As doctors we have no say in what happens, as our lobbying efforts in Washington are weak, as are yours.
FEE SCHEDULE MANIPULATION: I wanted to save the best for last as this is the most sophisticated scheme of the lot, for just as in the game of chest, it involves a multitude of well planned moves to get a check mate.

The first part of the game is to identify the areas of high utilization and cost and then manipulate the fee schedule to get rid of both. It works something like this. The examples I will give you are real, as in the past few years insurers identified that there was high utilization of both cardiac imaging and bone density testing being performed at the point of care, in the doctors office. The patient found this office performed service convenient and in many instances it was covered by only their small co-pay. A similar service done in the hospital would often cost a lot more and would also hit the patient's deductible and therefore put a greater burden of the cost on the patient.

To decrease the doctor's office utilization in these two areas, the insurers (Medicare and Commercial) slashed the fee on both services to less than 50% (but it was only for those services performed in the doctors office, leaving the hospital fee intact) and in some instances, restricted their use to only certified labs. Subsequently, the doctor's fee was so low that it made providing this service in the office too costly and consequently many doctors stopped performing these services in their offices. In addition, because their revenue then went down substantially, it drove many of them out of private practice and forced them to be employed by hospital clinics.

The fallout from this masterful insurer effort was the following:
- It reduced the utilization of these services and therefore the cost to the insurer.
- It drove private physicians out of business and into the employed model - see #10 and #11.
- It limited the service to be performed only in the hospital lab where the cost to the patient was higher (total cost and hit their deductible rather than co-pay), therefore indirectly causing the patient to not want the service at all.
- It made obtaining the service more inconvenient (long wait times and inconvenient location) so the patient may delay ever having the test done.
- It increased the revenue of the hospitals by driving the business to their facilities.
- It created a panel of doctors to then say these tests were unnecessary in the first place.
  
  CHECK MATE

CONCLUSION

I am embarrassed to say that the once proud, and pinnacled American Healthcare System has deteriorated into a dysfunctional business model focused on profit and controlled by greed. These efforts on the part of the insurance industry are destroying the Doctor/Patient relationship. What once was a service business controlled by doctors, with a focus on healing the sick with compassion, has deteriorated into a big business, that is controlled by money managers and politicians, who have accepted the loss of life based on greed, as the cost of doing business.

It used to be that all of my energies as a doctor were spent helping my patients to prevent and cure their disease. I can't believe that now half my time is protecting my patients, not from the traditional diseases, but from the same entities that my patients hired to protect them in the first place - their insurance company and this new disease called "greed".

As a solo primary care physician, trained in a time where healing the patient was our only focus, I am determined to stay on course and with a measured and decisive response, I have developed a membership practice, that I consider to be a safe haven in a sea of turmoil, where we dedicated physicians can continue serving our patients needs.

As a result, in our new membership practice, we can prioritize individual patient needs, re-kindle the doctor patient relationship, and focus on prevention of disease and easy access to the physician, who can focus only on what is in the best interest of your health and wellness and give you the care you need when you need it.