What If You Didn't Have to Worry About Health Care?

After 40 hours of hospitalization with IV fluids, IV antibiotics and oxygen, I began to resume humanoid form. Perhaps the salient evidence of this was that I began to worry, most specifically about the looming financial calamity of being a self-employed, sole provider without income for an extended illness.

As a psychologist, my daily encounters with profit-driven managed care had prompted me to buy the best health insurance available. At least, I thought naively, I don't have to worry about more than 20 percent of my medical bills.

My physician appeared, presumably to update my initial progress, yet instead told me that an erstwhile physician, now serving as my health insurer's spokesperson, had left a scorched earth telephone message refusing to pay for my hospital stay.

Citing Milliman and Robertson, he had stated that bacterial pneumonia and pleurisy should be treated at home, with home nurse visits plus IV's and oxygen, even though the three physicians who examined me insisted that I required hospitalization. Milliman and Robertson is the Holy Bible of Managed Care, a higher authority by which your insurer can refuse to pay for your care. Over 70 years of age and in need of cataract surgery? Milliman and Robertson dictate that you can have one eye done, but not two. Such edicts conjure a slippery slope toward sending our elderly and infirm off on ice floes, the ultimate solution to escalating costs in a profit-driven, Darwinian health care system.

The idealistic concept of managed care was unassailable and very welcome: Scrutinize providers and hospitals to identify price gouging, excessive utilization and inappropriate treatment. The profit driven reality of managed care is denial or harassment of necessary care, cost-shifting, drastically discounted fees to providers and tremendous profits to managed care entrepreneurs, all camouflaged under an umbrella of "quality assurance."

Corporate health care gives us MBA navigators and MD bombardiers dealing in euphemistic "soft targets" for profit, with little reason to fear the consequences. The bombardiers of managed care retreated temporarily after their Milliman and Robertson preemptive strike. My brain was left in a firestorm of righteous indignation that physical incapacity kept me from enacting. Admittedly, feeling enraged was an effective temporary distraction to being hypoxic, dehydrated, short of breath and scared, with coughing spells and chest pain that felt sure to recreate the most graphic scenes in the movie "Alien." Perhaps this was merely my insurer's benevolent plan for speeding my recovery by distraction and I should be grateful? Yet, I felt like Yossarian facing insurer-controlled health care: If I could not protest, my hospitalization would most assuredly be deemed nonreimbursable; yet, if I was physically able to muster a counterattack, surely I was not sick enough to be hospitalized.

As fate would have it, that same day my wife had a serious car accident requiring repairs that cost nearly twice my entire hospitalization, despite comparatively modest premiums. The repair was made with no criterion of "automotive necessity," no scathing utilization review, no denial of repairs to boost company profits and no battle over whether a body shop was the appropriate level of care.

After my discharge, my insurer, whose earnings increased 42 percent during the quarter I was hospitalized, then sought retroactive denial of reimbursement. The form letter stated, in so many patronizing words, that this fight was between them and the hospital and didn't involve me. I understand their wish to argue with a hospital whom they already have in a stranglehold rather than an angry customer. Yet, my monthly premiums, just raised to over $620 per month and reflecting a 43 percent increase in premiums in less than two years, after societal medical expenditures had already flattened, mean this fight most certainly does involve me.

At 45 years of age, with no significant medical history, my family and I have been a cash cow to the health insurance industry for many years. I cringe monthly at the staggering premium, knowing that the high deductibles mean I will see no discernible benefit unless, presumably, one of us lands in the hospital. Yet, I've continued to pay for a high-dollar, indemnity policy with the largest, once most trusted, nonprofit* insurer in Maryland, intent on avoiding the bottom feeders in today's crazy patchwork of deny-for-profit health care.

Days after my premium increase, and six months after having paid the bill, the insurer has again denied payment retroactively. For the entire "episode of illness," my "80/20" policy paid 27 percent of inpatient and outpatient charges. Good-bye Blue Cross & Blue Shield; hello Medical Savings Account plus catastrophic policy. It may be a lousy way to run a health care system, but it is the only way to diminish insurers' control of the system while our society careens toward overdue reform.

My story is extraordinary only because it is so ordinary in today's health care "marketplace." This company had just rolled out a new national marketing campaign which pictures their logo beside the ironic and deceptively simple question, "What if you didn't have to worry about health care?" Their question is a timely one for our society, but their answer is all wrong. A better company slogan might be a paraphrasing of the old blues standard, "You picked a bad time to leave me Blue Shield!"

The American economy is an enviable juggernaut; the stock market has registered unfathomable growth; personal income continues to rise, except for healthcare workers; unemployment is low; and, the deficit has been trimmed. Yet, we have over 40 million uninsured and a health care system which has merely shifted profits to a different set of players by denying, obstructing, discounting and delaying care to our citizens while savaging choice, autonomy, privacy and quality. In a recent Harris poll, only 11percent of Americans think "the health care system works pretty well and only minor changes are necessary." In another national survey, three out of four Americans believe that there are "serious problems" with the quality of health care.

Although low hanging fruits have all been picked and health care costs are on the rise again, investors and managers in corporate health care expect hefty returns. The needs of corporate health care are on a collision course with the needs of Americans. To sustain profits, the desirable cutting of fat has deteriorated to the unconscionable cutting of bone. Managed care has raised our awareness about the cost of health care, but it is a power and money grab disguised as "reform."

A socially responsible, democratic health care system must be inherently anti-Darwinian, with cost controls that are largely patient-centered and, when necessary, rationing that is conducted by a regulated and financially disinterested third party. Rather than accepting self-serving, corporate solutions to our worries about health care, it is time to contemplate genuine reform.

Steven Shearer, Ph.D., is a partner with the Anxiety and Stress Disorders Institute of Maryland and a faculty member in the Department of Family Practice at Franklin Square Hospital in Baltimore. He serves as representative-at-large for the Maryland Psychological Association. A shorter version of this commentary appeared in The Baltimore Sun on August 5, 1997.

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