WWWWF:
A Look at Wichita Falls on the Web

As much as the nation bemoans the lack of people with health insurance, few realize just how much influence such companies have on health care decisions. And I mean in ways beyond just what procedure the company will pay for.

Chapter 5 helps bring the notion frighteningly home.

Groopman paints a picture of "gatekeepers," those medical professionals who help steer patients in other directions, whether that's a specialist or a trip to the sofa, such as pediatricians and family practice folks. What really comes through, though, is how the patient loads needed to make a living as a physician can lead to oversights while the insurance companies that have come to dominate payment structures can demand changes in those thought processes. Groopman uses a great analogy of those caseloads, comparnig them to a passing train "Imagine watching a train go by. You are looking for one face in the window. Car after car passes. If you become distracted or inattentive, you risk missing the person. Or, if the train picks up too much speed, the faces begin to blur and you can't see the one you are seekin. 'That's what primary care medicine is like,' Victoria Rogers McEvoy told me."

The good doctor also gives good insight on how far the insurance pull is. Take this nugget on how a pay rate got established:

Many primary care physicians find their practices taking on a similar frenetic quality, and for similar reasons. Insurance companies seriously underreimburse doctors for primary care, a legacy of the period when surgeons headed the medical societies that negotiated with insurers about what was a "customary" payment for services. A specialist who performs a procedure -- a brochoscopy, say, or a surgical operation -- gets a substantial payment form the insurance carrier. But if a pediatrician or another primary care provider, a general practitioner or internist, spends an hour with a complex set of medical problems trying to arrive at a diagnosis, or probing the emotional fallout from an illnes or its treatment, the payment is meager. For this reason, many general pediatricians 'feel like they are running up a hill of sand,' McEvoy said.

Scarier still, here's a look at insurance companies' sway:

Not long ago, one of my neighbors told me that she had returned from a visit to her internist, who is a member of a large practice in a Boston hospital. I know the internist, and he recounted to me that he had recently been instructed by the practice's administrator to cut thirty-minute visits for follow-up to fifteen minutes, and sixty-minute appointments for new patients down to forty. When the doctor protested, the administrator told him that there was an electronic solution to make this all possible -- a template would be on his computer screen. As he spoke with a patient, he would fill in the form. This would help, the administrator added, not only in economizing his time but also maximizing his revenue, since it would make it easier for the billing office to submit invoices to insurance companies based on his template documentation of the history, physical exam and treatment recommendations.

Eric Cassell expands on the danger that clinical care is being squeezed by the efficiencies of the marketplace: "In healthcare planning, it is natural that each service might be seen as a commodity or product. The calculus involved in determining the cost of providing the service, the factors affecting reimbursement, the required number of such services, and other factors all promote the commodity view ... Medical care -- in all of medicine, not just primary care -- is a human interaction between patient and doctor within a context and in a social system. As such it is not a commodity."

Then it comes back to haunt folks in pediatric settings

In the course of a day, a full-time pediatrician may see two dozen or more children

In fact, a recent study showed that over the past decade, taking inflation into account, the incomes of physicians like pediatricians have fallen. Many doctors have reacted by truncating visits to ten to fifteen minutes and increasing the volume of patients they see in a given day. This speeds up the train and fosters the kinds of errors that Pat Croskerry and Harrison Alter fear when the ER doctor is spinning plates. Working in haste can not only increase cognitive mistakes but impair the communication of even the most basic information about treatment. A study of 45 doctors caring for 909 patients found that two thirds of the physicians did not tell the patient how long to take a new medication or what side effects it might cause. Nearly half of the doctors failed to specify the dose of the medication and how often it should be taken."

I've always been quite happy with the health coverage offered by the paper (the big joke with a co-worker is that the insurance is the real reason my wife married me since she has three kiddoes from a previous marriage), but in the big scheme of things, the fiscal control such companies wield over health care may be at the root of some of the problems.