Editorial: The state of the disunion

November 1, 2000




The state of the disunion

During World War II, the American people held together remarkably well in the face of incredible adversity. Many men went to fight, while many women ran their households and assumed vacant factory jobs to support the war effort. As a matter of necessity, the government froze wages and salaries to curb the inflation that can be rampant in wartime. As the war progressed, employers, wanting to reward loyal workers but unable to raise wages, started offering fringe benefits like hospitalization insurance.

After the war, wages rose but employers continued to provide health insurance benefits to their employees. At the time, this made perfect economic sense. Reimbursement was limited predominantly to inpatient care and hospitalization was inexpensive in the days of low-tech medicine.

In the fee-for-service system, a patient went to her physician with a health problem and he took care of it. Inherent in this relationship, on the patient's part, was trust and faith in and loyalty to the physician. For his part, the physician could be confident that he was in control of the patient's care, using whatever diagnostic or treatment tools he felt necessary to ensure her return to health. The patient-physician bond was strong. Physicians were proud of their practices, and patients, in turn, generally held physicians in high regard. The relationship typically was effective and enjoyable.

A physician's most serious concern about reimbursement may have been whether a patient paid for services rendered in cash or by check. If a patient had insurance, the physician usually submitted the claims and could feel confident that reimbursement would be received in timely fashion. The patient had little or no interaction with her insurance company. From the 1950s through the 1970s, the patient-physician-insurance company triad could have been represented by Diagram A:



In the intervening years, the solid and dotted lines have been reversed, because of many changes in our health-care system. Hospitalization insurance gradually was overtaken by health-care insurance, which covered a far wider variety of services. Today we talk of covering virtually all health-care events, which is far from practical. The high-tech era has arrived and the professional liability crisis seems to be here to stay. Is it any surprise, then, that health-care costs are approaching 15% of our gross national product?

Enter Congress, Mrs. Clinton, and finally Wall Street. Managed care ushered in an era of health-care rationing and gatekeepers, which caused destabilization of the health-care system. This resulted in less choice and autonomy for the patient and lower income, less independence, and crippling bureaucracy for physicians. And the patient-physician relationship has suffered for it.

In the past 20 years, patients have had to struggle more and more to get their insurance companies to provide reimbursement for diagnostic and therapeutic care. Physicians have been forced to have a direct and time-consuming relationship with insurance companies, to the point of needing to hire additional personnel to cope with slow payments, disallowal of reimbursement, and refusal to authorize necessary care. By denying care, many insurance companies have made physicians look bad in the eyes of their patients. This has bred distrust and unhappiness, and in some cases, has pitted physicians against their patients. The patient-physician relationship now looks something like Diagram B.



Now I ask you, doesn't common sense demand that we return to the original model? Shouldn't the patient-physician relationship be more significant than the patient-insurance company relationship? Patients who have paid for insurance shouldn't have to grovel for necessary care.

For the most part, physicians have done their best to preserve the invaluable relationship they have with patients. Their effort could be greatly improved if the insurance companies stopped trying to practice medicine and just did what they are supposed to do: reimburse for care. The fat is gone from medicine. Having so many bureaucratic workers forcing interminable paperwork on the health-care system is counterproductive.

The main issue is to get the practice of medicine to go back in the direction of Diagram A. To accomplish this, each of the players involved must perform specific tasks. The patients have to convince employers that they don't want an insurance plan unless it provides choice and autonomy and clearly spells out up front which medical services are covered and which aren't.

Physicians must not lose sight of their mission to serve their patients, no matter how much bureaucracy stands in their way. The patient-physician relationship is our most valuable asset. If we don't do well in our negotiations for reimbursement, perhaps we should alter our strategies. In future negotiations, why not ask for concessions with regard to forms, documentation, and authorization? These may seem like small improvements but they will translate into dollars for the physician in the long run. We would all save money if the bureaucracy were to become less complex. We must also fight for a role in the administration of health-care plans.

Insurance companies, for their part, must be forthright in stating what they pay for and what they don't. Then they must remove the roadblocks to health care and eliminate the bureaucracy that engulfs it today.

John T. Queenan, MD, Editor in Chief, is Professor of Obstetrics and Gynecology, Georgetown University School of Medicine, Washington, D.C.


John Queenan. Editorial: The state of the disunion. Contemporary Ob/Gyn 2000;11:8,11.