Roll Forever Not What The Doctor Ordered
Feeling poorly? Too bad. The kind of treatment you get isn’t up to you or your physician. In medicine today, insurance companies call the shots—and the companies are more worried about their health than yours. A Texas doctor’s story.
LIKE MANY PHYSICIANS Dr. B did not read the contracts carefully. He didn’t note the clause stating he could be fired at any time. The idea that an insurance company would dare tell him how to practice medicine never crossed his mind. Sometimes while he was waiting to be fired, Dr. B found himself wondering how something so obvious could also be so secret. America’s largest insurance companies had taken over the practice of medicine, yet no one seemed to notice. He worked for five of them now and saw evidence of their power everywhere. He saw it on the highway, where his eye was always drawn to Aetna’s billboard urging him to “Be Happy. Be Healthy.” He saw it whenever he entered a drugstore, which more often than not featured a merry banner—“Welcome Sanus Health Plan Members!” –thanking yet another insurance company for its business. He saw it in his mail, which was full of cheery correspondence (“Welcome to the MetLife Family!”) and less-friendly updates on what the companies called his “economic progress”—his contribution to their bottom line.
He saw it too in the way the efficient young clerk from Blue Cross inspected his office, telling him not only where he must put his fire extinguisher but also what kinds of questions he must ask the patients Blue Cross insured—about drugs, alcohol, and other personal information that he once investigated with archaeological delicacy. But mainly he saw it in his patients, who were bewildered and angry because their insurance companies—instead of their doctor—were now in charge of their care.
I have known Dr. B. for almost twenty years. He is in his forties, a product of good schools, divorced, irascible, and somewhat theatrical. The classic solo practitioner, he is a doctor in for the long haul; he beams when he talks about new patients who are the children of old patients. Dr. B. didn’t become a physician because of family imperatives, the chance to get rich, or because the world of medicine was the only one in which he felt comfortable. In choosing a career after college, he found that he simply believed in the power of one person to heal another. He believed too that practicing medicine was as much art as science; having little interest in the glamorous, lucrative world of high-tech medicine, he reveled in his small office, where his receptionist wore jeans and his patients—artists, professionals, eccentrics—reflected the population of his inner-city neighborhood. No one much cared that his equipment was not the latest of that he kept the TV on during the baseball playoffs, or that he never wore a lab coat. His patients usually called him by his first name. “I don’t want everyone to like me,” he sometimes said. “If you practice bland medicine, then no one’s happy.”
But several years ago Dr. B. began to realize that he wasn’t happy. He sensed that somehow he had become an anachronism, that there was no longer a place for the kind of personal medicine he liked to practice. His colleagues were realizing it as well: At hospitals, over coffee, at cocktail parties, the docs gathered in groups and whispered among themselves. They couldn’t treat people the way they needed to anymore because of the insurance companies. They were on the phone all the time, haggling with insurance company clerks instead of practicing medicine. They were referring patients to doctors they didn’t know or didn’t trust because of insurance company rules. They talked about how they were going broke while insurance companies were getting richer and richer—the health insurance industry took in $265 billion in premiums in 1993. Dr. B., diagnosing his own condition, admitted that his anger had become chronic. He felt himself becoming a medical Cassandra. It was for this reason that one of our casual discussions evolved into the possibility of an article, and Dr. B. agreed to be interviewed. His one request was that his identity be protected. Like many doctors interviewed for this story, he feared retaliation from insurance companies. Even so, he thought that people needed to know what was happening to their medical care.
Maybe you are like one of Dr. B.’s patients, and you are only dimly aware that a change has taken place in your health care. If you are like most people, you’ve spent the past few decades worrying far more about the cost of care than the quality; you just want to be sure that you and your family are shielded from the catastrophic expenses that accompany catastrophic illness. What has been most important to you about health insurance is that you have it. Whether you belong to a health maintenance organization (HMO) or a preferred provider organization (PPO) or whether you participate in the old-fashioned reimbursement arrangement is of only passing interest. You want to be sure you are covered—and if you are, you probably followed the Clinton administration’s effort to reform health care from a distance and with some apprehension. Maybe you were even relieved when nothing happened. No change, you might have reasoned, is better than a change for the worse.
Yet despite events or nonevents in Washington, change has come, and because of the failure of the Clinton plan, the existing system is the one we are likely to have for a long time. It is known as managed care. This means that in an effort to control ever-increasing medical costs, insurance companies have changed the way they pay up. In the old-fashioned indemnity plans, customers paid their premiums and the insurance company reimbursed them for at least 80 percent of their expenses—for almost anything. Doctors were in charge; they treated and insurance companies paid. Now insurance companies are in charge. To save money, employers who offer health benefits are turning increasingly to HMOs and PPOs. In the former, insurance companies pay doctors a set amount per patient; patients are insured through their employers and can see only the doctors who belong to their particular health maintenance organization. In a PPO, doctors discount their fees to insurance companies that allow the physicians access to the companies’ vast patient pools; the patients, like those in HMOs, choose their doctors from these networks and pay a small fee each visit—typically around $10. Managed care sounds like a great deal: Patients save on out-of-pocket expenses, employers save on premiums, doctors are guaranteed a seemingly endless supply of patients, and insurance companies make money.
But managed care is not without its price. Costs, after all, cannot be contained without strict controls. Maybe you noticed the problem during a pregnancy, when, among hundreds of other concerns, you had to call the insurance company for approval before leaving for the hospital to deliver your baby. Maybe you noticed it the day your pediatrician ordered a chest x-ray for a sick child, and you had to wait, while his fever raged, for approval of the procedure. Maybe, new on a job, you felt a twinge of anxiety before you found your longtime doctor’s name in the booklet of approved physicians provided by your employer’s insurance company—the only doctors your employer would pay for you to see. Or maybe you felt just a whisper of a qualm when a new doctor asked you a question that seemed far too personal for a first meeting. “So do you have sex with men or women?” a physician asked an unmarried friend of mine and noted her answer on a chart.
Most likely you dismissed these incidents as minor annoyances. They seemed inconsequential, compared with the larger fact that your care was paid for. But what if things were different? What if, for instance, your insurance company wouldn’t pay for an experimental drug that might save your life? What if your insurance company would only pay for treatment in one of its own day clinics, but your doctor thought you needed to be hospitalized? Or would pay for your dialysis treatments only if you visited its health center across town instead of the one in your neighborhood? Or compromised your doctor’s allegiance, so that he felt more loyal to the insurance company, which paid his salary, than to you? What if, in short, all the criticisms of the Clinton plan—that patients couldn’t choose their doctors; that innovation would die; that bureaucrats, not doctors, would be running the system; that health care would be rationed—came to pass without a single congressional vote? And what if the primary obligation of American medicine was no longer to the patient but to the stockholders of America’s multibillion-dollar insurance companies? These questions are not hypothetical; they reflect what is happening in Dr. B.’s practice right now—and in medicine in Texas and the rest of the country. As Dr. B. likes to say with a sorry grin, “Managed care is fine—as long as you don’t get sick.”
The Victors
THE HEART OF AMERICAN MEDICINE can no longer be found in a hospital, clinic, or doctor’s office, but in innocuous office buildings like the smoked-glass box on Houston’s North Loop near U.S. 290. Inside is the South Texas headquarters for Aetna Health Plans of Texas, a subsidiary of Aetna Life and Casualty Company, one of the fastest-growing health insurance providers in the state. Joseph T. Blanford III, the vice president of health services management, and Dr. T. Michael Cryer, the market vice president, administer the company’s managed-care plans in Texas, and to speak with them is to understand the extent to which the insurance industry has absorbed the medical profession.
They don’t look like the cold, insensitive bean counters Harris County physicians describe with fear and unmitigated scorn. The gray-suited Blanford is bland and reasonable in the manner of a high school principal. Cryer, tall, balding, and blazered, is soothing and affable in the manner of a family practitioner, which he once was. What distinguishes them is their confidence: Unlike almost everyone else in America—certainly most physicians—they know they have found a solution to the country’s health care costs, and it is managed care.
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