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Friday, June 24, 2005

The Pursuit of ..........?

TRD101: The Pursuit of ......?


Will someone please explain to me how the current health care system helps promote “Life, Liberty and the Pursuit of Happiness”? Those who can’t afford or can’t get health insurance only seek treatment when they absolutely need it, often too late to be cured. Some have been denied needed treatment because of inability to pay their bills expeditiously. Most of us who do have health insurance are increasingly worried about losing it, especially those of us of child-bearing and child-raising age or are nearing retirement .Those of you lucky few who aren’t worried about losing their health insurance still have to deal with an increasingly bureaucratic and bizarre healthcare system. Trying to get treatment is not for the sick.

I’m one of the fortunate ones to have excellent healthcare coverage, through my wife’s employer. However, she works for a small business that had a scare of possibly losing its coverage. Fortunately, the scare was unnecessary, it was an administrative mix up, but all employees and their families were very nervous until continuing coverage was confirmed.

The coverage is PPO, Preferred Provider Organization, which means that you have to select a PCP, Primary Care Provider, from the insurer’s recommended list, it’s “network’ of healthcare professionals. Some insurers allow you to keep your existing out-of-PPO-network PCP and some don’t. PPOs differ from HMOs, Health Maintenance Organization, by allowing you to use an ONP, out-of-network provider, provided you get a referral from your PCP first. That I have to know what the acronyms PPO, HMO, PCP and ONP mean is worrisome.

I have a medical condition that requires the periodic review of a specialist. Even though I live in the greater Boston area, which has the greatest concentration of and some of best doctors in the world, it’s a pain in the keister to go into Boston, unless absolutely necessary. I’ve found a local specialist, but he’s an ONP. I’ve being seeing him for approximately one year and had no insurance problems previously. Out of the blue, his staff informed me that I had to get the approval of my PCP before they’d agree to set up the appointment.

I like this specialist a lot because he doesn’t suffer from MD - Me Doctor - syndrome. We jointly review my status and decide on changes to the treatment program. Since I have the time and resources to find current research on my condition, I do the research, and he accepts that I’m not a doctor wannabe trying to tell him what to do. Or he hasn’t told me that I’m not a doctor wannabe telling him what to do, yet.

So I called my PCP. Her full-time insurance administrator informed me that I couldn’t get a referral because the specialist was ONP. I called the insurance company’s customer service and explained my situation, including their previous payments. No problem, the representative told me, just set up the appointment. Which I did - but now I couldn’t be “squeezed in” for six weeks.

Six weeks minus one day later, I get a phone call from the ONP’s full-time insurance administrator cancelling the next-day’s appointment. Three days and eight phone calls with the PCP’s administrator, the ONP’s administrator, and the insurance company later, I get the appointment rescheduled - squeezing me in five weeks later - but, only if I prepaid the doctor’s fee. What choice did I have?

Eleven weeks from the day of my first phone call and three hours in an overheated waiting area, I finally get in to the ONP specialist’s office. I asked his nurse-practitioner what was the problem. She told me since I was out-of-the-specialist’s insurance network, my status was changed to “referral only”. No referral, no appointment. I asked what had changed over the past year of visits. She looked into my file.

“Nothing has changed. We made an administrative error in changing your status. We have had a number of patients who are on referral status who haven’t paid their bills, but you have.”

The doctor came into the room. He looked at me and shook his head, “Why weren’t you here eleven weeks ago when you were supposed to be?” I told him, in explicit detail. After all, I was paying for his time to be there.

He scheduled my next monthly appointment, right there and right then.

As management consultants, my partners and I had to deal with some of the most screwed-up companies in the world, but since we didn’t specialize in healthcare, we had no healthcare clients. Healthcare companies, like most industries in trouble, believe their industry is unique and require being managed differently. Unless you specialize in healthcare consulting, then supposedly you “don’t know the business”. Oh, I know their business, all too well.

In retrospect, I don’t know if not consulting in healthcare was good, because we might have been able to effectuate some changes in the system, or bad, because we would have driven ourselves crazy in the process trying to get any changes made. This craziness has to be infuriating to doctors, who did enter the profession to help sick people, not totally unlike consultants trying to help sick companies.

As a patient today, you have to spend way too much time pursuing the opportunity to get to see the doctors pursuing their passion. The current insurance company controlled system is too costly and inefficient. A single payer health care system would let doctors be doctors and patients not have to have extraordinary patience.

If I were a doctor, I would refuse having the insurance companies control my life, demand the liberty to treat patients as necessary and pursue my happiness to practice medicine, without being buried in paperwork. I especially would be torqued off being told what I know is good medicine by someone who doesn’t know the patient, hasn’t seen what I’ve seen, heard what I heard, or experienced what I’ve experienced.

Until the doctors take action, then the rest of our lives, liberty and pursuit of happiness are increasingly at risk.

TRD101 knows this: Sick companies only get well when the management and employees know they need to change and work together to make change happen. The US healthcare system is very sick and will only get well when patients and doctors work together to defeat the interests of the health insurance industry and change the current system.

And that's The Real Deal's basics for today, like it or not.

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