The Governor proposed, and the Legislature passed, a new law which came into effect late last year requiring everyone in Massachusetts to have health insurance, or pay a penalty, unless they couldn’t afford it (as determined by the state), in which case a subsidized insurance plan is made available.  Employers of more than a small number of employees are required to make health insurance available (but not necessarily to pay for it).  The penalty for persons who do not purchase insurance may increase to the point where it is distinctly regressive.  Although this program is a step in the right direction, it is far from a satisfactory solution.

In the interest of full disclosure, I should mention that my son and his wife are physicians practicing in Massachusetts, and my son-in-law is a physician practicing in Florida.

The key ingredient to health care is the primary care physician, also known as the family doctor or the general practitioner.  Without them, the system cannot work. Yet, a combination of insurance company practices and state policies are driving these front-line providers out of state.  Many come to our fine local medical schools to get educated, and/or do their residencies in our world-famous hospitals, then go elsewhere.  And what is driving them away?  High premiums for professional liability (malpractice) insurance, bureaucratic micro-managing of methods of medical practice, government mandates removing discretionary physician decisions, and complicated insurance reimbursement procedures, under which the doctors wait a long time to get paid just part of what is billed.  A recent court case imposed liability on a doctor for an accident caused by one of his patients.  If we want to retain the people who provide the health care, these conditions must be changed.

Part of the problem is large health insurance companies, which consume a very substantial percentage of all health care dollars to support highly paid executives and huge bureaucracies.  Despite their “feel good” advertising, these companies, which euphemistically operate as “non profits,” frequently underpay doctors, while at the same time often dictating what medical services and prescriptions their patients are to receive, and requiring burdensome copays from the insured for any service received.  They are also, inappropriately, in the business of deciding which doctors will be allowed reimbursement and which doctors a patient can see, as though a Massachusetts doctor's license alone were insufficient.  Indeed part of the problem is that health insurance - which should be paid by all of us so that our neighbor can benefit when ill and when it’s our turn to benefit we can do so - is run as a business and not as a service.  Perhaps the best solution would be to entirely restructure health insurance to return to its medical service mission rather than that of an essentially profit-making business where the patient is not a patient but a “client.”

A small family practice with which I am familiar includes four part time physicians and, among other staff, three full time persons whose job is to attempt to fulfill the myriad of requirements for various insurers.  These extra people end up being part of the cost of health care with no benefit to the patient.  Insurers may alter what the doctor believes best for the patient by refusing reimbursement for certain procedures, tests, or medications.  Denial of reimbursement for specific medications by insurers can be a threat to the health of patients.  For example, if a doctor gives a prescription for a certain medication for blood pressure control to a patient who is denied that medication because the insurance company will pay only for a different medication, then the patient will continue with uncontrolled blood pressure  until and unless the situation is resolved (of course, another part of the problem is the exorbitant prices sometimes charged for medications by pharmaceutical companies).  Although doctors often work 12 or 15 hour days, partly devoted to contending with the insurance companies, you can be pretty sure that the insurance bureaucrats are out the door by 5 p.m.  In many other states, the insurance situation far less burdensome, indicating that it really doesn’t have to be as difficult for patient or physician as it is here. 

A relatively trivial example of wasteful insurance company activity from my own experience:  my insurance company includes as a benefit $100 for eyeglasses every two years.  What you’re supposed to do is get a form to claim the $100, and submit it with a copy of the optician’s paid bill.  Which I did.  Sometime afterwards, I received a check for $100, and shortly thereafter, a pretty nasty letter, saying in effect that I tried to claim, say $300, for glasses, and you can’t do that, because it’s limited to $100.  So I called up, and eventually got through to someone.  Their response was, just ignore the second letter.  So here’s your health insurance bureaucracy at work:  someone writes the letter, instigating a telephone call, which someone has to answer.  If they do this for every eye-glass reimbursement claim (and I know my instance was not unique), it would appear that a lot of person-hours go to absolutely no effect, but some jobs are created for the bureaucracy – to say nothing of the time wasted by the patient. 

I don’t believe there’s any evidence that people who work for big companies are any less in need of medical services than those who work for small companies, or that those who work for small companies are any less sick than individuals or the self-employed.  Yet, the premiums for each of these categories of people have sometimes been different, with big employers paying far less than small employers, and small employers paying less than individuals or the self-employed.  There are large differences in how much employers are willing to contribute to employee health insurance.  (There is some thought that premiums should be less for those who attempt to live a healthy life.)   Until recently a “family” of two people has frequently been charged a higher premium than the sum of premiums for two people who aren’t married.  Some of these indicia of price discrimination are therefore being rectified.  They may have made sense to the business plan of an insurance company, but they don’t make sense to me and they are a far cry from what would be indicated by the philosophy behind insurance in general.

My suggestions, in summary, are these –

• Each insurance company would offer each person the same premium, with a discounted rate only for families with underage children.
• Each insurance company would use the same forms for medical providers to complete – i.e. a standardized billing system - eliminating errors, delays, and refusals to pay.
• Insurance companies could continue to compete by offering the same services, but at competing prices for premiums, perhaps with a range of deductibles.
• De-link health insurance from employment status (this is after all a relic from a situation during World War II when it was invented as a device to give the coal miners a raise without giving them a raise which would have violated war-time regulations).
• Eliminate price discrimination between larger employers, small employers, and individuals.
• Employers (if the system remains employer-based) should be encouraged to subsidize health care premiums for all employees not otherwise covered, or alternatively required to pay significantly into a fund to provide insurance for those not covered.  Unions could, of course, collectively bargain in this connection.
• No one could be turned down by reason of “pre-existing conditions.”
• Eliminate the tedious business of “insurance referrals” which wastes time for both the referring doctor and the referred-to doctor (fortunately this practice has been disappearing).  Also elimination of prior approval for tests and prior authorization for medications would be helpful.
• Unnecessary burdens and mandates should be removed or ameliorated for primary care practitioners so that more of them opt to remain in Massachusetts providing better access for patients to primary care in a less pressured situation.