It's a nice fantasy to think about what I would do to change healthcare if I were elected president. But first let's understand that changing healthcare has become a politically charged buzz phrase that is often devoid of any meaning because it is so broad a topic and vulnerable to manipulation to suit the public.
With that disclaimer, if I were able to accomplish change, the first issue I would address is the deregulation of insurance companies. Insurers have far too much power and therefore an inordinate and inappropriate level of involvement in patient care. I could list countless encounters while advocating on behalf of my patients that range from annoying to unconscionable. Pre-existing clauses in insurance policies would suffer a swift death in my first term, as I would work to enact legislation to abolish this practice. I would also address the various ERISA loopholes insurers utilize to deny care while claiming infallibility when there is a negative outcome as a result of the care that was denied.
Let's face it — no matter how stiff the language in insurance policies is, rendering a decision to deny medical care is a medical decision and doesn't suddenly fall under the categories of policy and administration just because these companies say so. ERISA requires employers to disclose insurance and pension plan finances, and holds company and union officials personally accountable for sufficient funding.
To achieve this, federal courts ruled that employees forfeit their rights to jury trials and any potential compensatory and punitive damages if they sue an insurer for wrongfully denying coverage. This protection was felt to be sufficient to motivate insurers to continue to provide coverage. Unfortunately, it has provided what amounts to a cloaking device to conceal decisions that are far more about profit and cost cutting than about patient care. Patients have little if any recourse to fight an insurance company and all too often doctors and their staff are too burdened with the insane amount of administrative work generated by the same insurance companies to be able to aid their patients in their fight for fairness. Resorting to legal remedies is expensive and provides no guarantee for a satisfying outcome.
One of my particular pet peeves with the insurance industry is prior authorization. Countless times I have had to discuss my decision making with individuals who have far less training and experience than I do and who are armed only with silly algorithms developed in corporate boardrooms with the main focus of denying more expensive treatment in favor of cheaper treatment.
One summer it took me almost two months to get a medication for restless leg syndrome approved for an obese patient of mine who was crippled by post-polio syndrome. The initial denial letter demanded that he try four other medications — all of which were not FDA-approved to treat RLS, before the one I had been using would be paid for. Because the patient was on Social Security disability and Medicare, that meant doing without medication until I was finally able to track down a personal cell phone number (carelessly posted online) of someone higher up in the pharmacy management company and threaten to go public with this.
Another company has the bewildering policy that begins with the denial of medications at the pharmacy when a patient attempts to fill a prescription, prompting a call or fax from the pharmacy to me, at which point it is my responsibility to contact them. Interestingly, there are no drug-specific prior authorization forms on their website. Why? Because first, I have to submit a coverage review determination request so that they can inform me of what I already know. Only then do I receive a prior authorization request form to fax back.
It is built-in delays like this that are also eroding the quality of and indeed access to adequate healthcare. It has to stop. In my term as president, never again would there ever be any financial bailout of an insurance company. Not when, for instance, in fiscal year 2010, Aetna CEO Ronald A. Williams, in his last year as CEO, was compensated $72 million, including $14.3 million in stocks that vest later and depend on performance. And not when, in fiscal year 2009, UnitedHealth Group CEO Stephen Hemsley's total compensation was $101,959,866!
Since there has been talk of pay-for-performance clauses and the use of patient surveys and patient satisfaction in determining things such as physician compensation and renewal of board certifications, it would only be fair to develop some form of legislation that attached those same measures to insurance company income and salaries, particularly at the executive level. Insurers are not the only problem, though; the pharmaceutical industry has been part of it, though that industry has been policing itself in more recent years.
Our nation's public education system also would play a role under my term as president. Health classes are mandatory, but I think schools can play a greater role in health education to promote wellness, prevention, and maintenance. To do so, our schools need a much larger base for funding, which could possibly be at least partly achieved with an education tax on the insurance industry. Hey, why not, this is all a fantasy, right? Such a tax would be used to improve the nation's educational infrastructure and provide the influx of staff needed to improve the health of our children. Maybe schools, with the help of major logistics support from various agencies and professionals, could even adopt the model developed by CVS Pharmacy with their Minute Clinics, which provide health screenings, vaccinations (flu shots, for instance), and other limited forms of healthcare. Every visit would not only assess and address whatever problem was occurring at the time, but also include mandatory education and support for the child and the family.
And my colleagues in medicine, most of whom really care about their patients, but many of whom are burning out prematurely, need to step up and take leadership roles if there is to be any meaningful change. Becoming better communicators with our colleagues, our patients, and yes, even the insurance industry would only lead to good things. Of course, any improvement in healthcare will also require ongoing research into wellness and disease and the ability to fund that research while ensuring that there is ethical oversight to make sure the research standards are being met.
In sum, my tenure as president would be one marked by major paradigm change in how healthcare is developed, delivered, and funded.
To quote Thomas Kuhn from "The Structure of Scientific Revolutions," "The transition from a paradigm in crisis to a new one from which a new tradition of normal science can emerge is far from a cumulative process, one achieved by an articulation or extension of the old paradigm. Rather it is a reconstruction of the field from new fundamentals, a reconstruction that changes some of the field's most elementary theoretical generalizations as well as many of its paradigm methods and applications. During the transition period there will be a large but never complete overlap between the problems that can be solved by the old and by the new paradigm. But there will also be a decisive difference in the modes of solution. When the transition is complete, the profession will have changed its view of the field, its methods, and its goals."
Daniel B. Block, MD, is board certified in adult psychiatry and is in private practice. He attended medical school at Temple University School of Medicine and completed his residency at Thomas Jefferson University Hospital in Philadelphia. He lives in Kennett Square, Pa., with his wife of 23 years, Julie. They have two sons, both in college, and a daughter in high school. In his leisure time he enjoys hiking, gardening, writing, music, and exercise.
This article originally appeared in the November/December 2012 issue of Physicians Practice.