Monday, January 21, 2013

Good Intentions

When I was 12, I used to watch soap operas up in my parent's bedroom after school.  In retrospect, most of the content of those shows was probably inappropriate for someone my age.  But nonetheless, I would imagine myself living a glamorous lifestyle when I got older, just like the actresses I saw on TV. 

One of my favorite settings was always the hospital.  It seemed like such a romantic place.  A man would wake up from a coma to find his true love holding his hand at his bedside, and gently brush away a single tear running down her cheek.  Or a woman would suddenly stand up and walk after being paralyzed from a nasty fall off a horse, no doubt as a result of a murderous plot by her evil twin sister.  Of course, her adoring boyfriend would be there to see her take her first steps.

I had this idea that health care system possessed a mystical power not only to cure the sick, but to improve their love lives as well.  At the center of it all was the hospital administrator.  A beautiful woman with a perky haircut, carrying a clip board and checking on all the patients.  And wearing a pink suit.  That was the job I wanted. 

Fast forward to college.  I was a political science major with thoughts of a career in public administration.  During my junior year, I took a health policy class and learned about Medicare and Medicaid.  Medicare is government-sponsored insurance for the elderly and disabled and Medicaid is insurance for poor people.  That was the first time I became aware of the fact that there were people who didn't qualify for any of those programs and were uninsured. 

After college, I decided to get my master's degree in health care administration.  I chose the health care field so I could help people.  Even during my master's program, it was clear that I was in the minority.  Everyone else in my class aspired to be the CEO of a large health system and make lots of money. 

I graduated at a time when HMO's were the new trend in health care.  Everyone thought they were the devil, denying care and restricting choices, but I would defend the managed care companies.  I believed that we were trying to encourage people to lead a healthier lifestyle.

After spending the last 20 years of my life working in the health care industry, I have realized that health insurance companies are just like any other corporation.  The sole purpose of their existence is to make a profit.  And the non-profit insurance companies are no different than the for-profit ones.  I work for a large non-profit health insurance company and our CEO earned over $4 million in salary and bonuses last year.

I have been feeling frustrated at work for some time now, but it didn't occur to me until recently exactly why I feel that way.  My parents are on Medicare now and they happen to get their insurance through the same company where I work.  Watching them become victims of the system has crystallized my view of exactly what is wrong with health insurance.

At best, it is a series of good intentions gone bad.  At worst, it is criminal negligence and fraud that is being perpetrated on the government by the insurance companies and doctors.  In reality, it probably falls somewhere in between. 

The government pays the insurance companies a fixed amount each month for every person on Medicare.  This is called capitation.  The amount that the government pays the insurance company is risk adjusted.  That means if a person is sicker, their capitation rate will be higher.  Most insurance companies do the same thing with the doctors.  They pay them higher payments for taking care of sicker patients.

In addition to risk adjustment, the other way that insurance companies get paid more is through their quality rankings.  These are called STARs ratings.  If a company has a higher STARs rating, then they are rewarded with higher capitation rates.  All of this sounds perfectly logical until you watch it play out in the real world.

My Dad has been generally healthy for his entire life.  In fact, there is rarely a time that I have seen him sick.  Last year, he got a letter in the mail from his insurance company.  It suggested that he go for a visit with his doctor to get a health assessment completed.  But it did not stop there.  The insurance company started calling the house 2-3 times a week with automated phone call reminders for my Dad to go see his doctor.  Then the doctor's office started calling too.

Finally, my Dad went to see the doctor and she did the assessment.  My Dad told her that the insurance company must be paying her a lot of money for that assessment  And he is right.  Part of the STARs program is for each Medicare patient to have a health risk assessment completed each year.  And his doctor is paid a bonus for getting him in.

She also gave him a flu shot and a pneumonia shot, as required by the STARs program.  My Dad ended up with a case of pneumonia within a few days of getting that shot, but of course his doctor denied that the shot gave him pneumonia.  All doctors deny that the shots give you the disease, yet there are thousands of stories of people becoming ill from vaccinations.  After three weeks of being sick and a few more doctors visits, my Dad got over his pneumonia.  And luckily it is a one time vaccination so he doesn't need to go through that again.

This year at his annual assessment, my Dad's doctor found something even better.  She asked him to take a breathing test and took the best three out of four results.  Apparently, my Dad was just below the allowable threshold, so he got a new diagnosis of COPD.  That stands for Chronic Obstructive Pulmonary Disease. 

Even though my Dad had none of the major symptoms, except for the occasional shortness of breath, the test showed he was within the range so he got the diagnosis.  And with that diagnosis, the doctor just increased the monthly payments from the government to his insurance company and from the insurance company into her bank account.

With his new "diagnosis" also came a prescription for an inhaler that costs over $200 each.  That means more money for the pharmaceutical companies too.  Unfortunately, the inhalers make my Dad sick.  His voice is raspy and he sounds a lot like he did when he had pneumonia last year.  He has to take the inhalers for a few months and then he will take that test again to see if his COPD is "cured."

But it won't stop there.  Insurance companies also have something called revenue management.  That means they want to make sure they get the highest capitation possible for each person they insure.  Because my Dad had a diagnosis of COPD this year, he will show up on the insurance company's list for next year.  And if the doctor does not diagnose him with COPD again next year, their payments will go down.  So the insurance company will start calling the doctor's office and asking her to bring my Dad in for another visit to see if he still has COPD.  It will go on and on.

I am not suggesting that people should never go to the doctor, or even trust what their doctor advises them to do.  There are many examples where people benefit from medical screenings and preventive health services, like early detection of cancer.

What I am suggesting is that the financial incentives be taken out of the picture and the care decisions be put back into the hands of the doctors and the patients. 

To highlight my point, the STARs program at my insurance company is a part of the Finance Department.  It is not driven by the clinical or quality management teams.  It is motivated by pure profit.

It is time for me to give up my illusions about the health care industry being there to help people.  And to give up my fantasies about walking the halls of the hospital in my pink suit.  Life just doesn't work that way.

I cannot fix what is broken in the health care industry.  The only thing I can do is heal myself and get out as soon as possible.  And start doing some research on WebMD so I will be ready to respond to whatever my Dad's next "diagnosis" might be.

2 comments:

Anonymous said...


Like this Bill Maher quote

"If conservatives get to call universal healthcare 'socialized medicine,' I get to call private, for-profit healthcare 'soulless, vampire bastards making money off human pain.'" --Bill Maher

Cupcake said...

Agree! Great quote.