Blue Cross Blue Shield Gets Ready to Game Universal Healthcare ...

Damaged Care 2008: Blue Cross Blue Shield Gets Ready to Game Universal Healthcare | Posted by McCamy Taylor in Health | Thu Mar 06th 2008, 02:10 AM
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What we are seeing now is the industries major players---the plans that think that they will survive the shake up and emerge part of Hillarycare or Obamacare---test out methods for denying services under universal healthcare. And---no surprises here---since the problem (from the insurance companies’ point of view) is that they will be forced to insure the sick alongside the well, they are dusting off the underhanded methods they refined in the 1990s to use with HMOs.
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At HMO, Member Services always lied . Their job was to get you to sign up, because they got paid per head. Once you were enrolled, you learned the truth. As long as you were a healthy person who only intended to use your HMO if you were in a car wreck, you and your HMO would get along just fine. But if you planned to get ongoing, state of the art, reliable medical care for a serious chronic medical condition, you were either going to have to learn to fight for your rights---or you would be better off on some other insurance.

The last is how HMOs made their money. They drove sick people off their plans. They required people to jump through hoops to get specialty care. They paid primary care doctors a flat fee out of which they had to pay the cost of medical care for sick patients so that the primary care doctors would have an incentive to find excuses to drive sick people away .

I will let you in on a secret. Remember the part in the Michael Moore film Sicko in which the insurance companies try to find reasons to cancel people’s policies after they have gotten sick or hard surgery? Doctors are way better than any insurance company at getting people to leave a practice—or an insurance plan—because they are sick and require medical care. “Your case is too complicated. “You do not need to see an oncologist to manage your lung cancer. I can do that for you.” “I don’t like the specialists you have been seeing. I am going to change your specialists to the ones I like.” “I only see HMO patients one afternoon a week, and you can only discuss one problem a visit.”

These are all real things said by real doctors to HMO patients the first and last time that the patients saw them, before they came to see me. Doctors on a capitated HMO plan can spot a money sink---a new patient who is going to accrue a lot of medical bills—the minute she or he walks in the door. An unscrupulous doctor knows just what to say to turn that patient around and send him back out to another doctor. ...
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II. Excluding Providers

Georgia Blues is being sued. Georgia, like many states has an Any Willing Provider Law which means that any doctor or hospital or other provider of medical services who is willing to accept an insurers terms must be offered a contract.

Well, Georgia Blues has an HMO product, and like all good HMOs it has found that one of the best ways to keep costs down is to make it absolutely impossible for anyone with an actual medical condition to get medical care. You do that by limiting the number of providers and making sure that their offices are all located in out of the way places (on top of mountains would be good) and that the specialists are swamped (booked up for months would be ideal) and that the only hospitals that do necessary services are six counties away and the only pharmacy that takes your card has two hour waits and the only primary care doctors who take your insurance also see a lot of workman’s comp and “diet” patients so you have to sign in and wait your turn.

This article is in the February 16 issue of AMA News and is called Ga. Blues Sued Under any-willing provider law and describes the plight of 100s of North Georgia cancer patients who now have to drive hours to see an oncologist, because Ga. Blues terminated its contract with their doctors.

The ability of an insurance plan to exclude or drop providers goes way beyond simply limiting costs. It is a tool that insurers can use to get rid of whole panels of unusually sick people under universal care—by dropping a few doctors. For example, some doctors tend to treat people with more severe illness. People with chronic disease have been shown in studies to be more drawn to female physicians. Insurance companies create profiles of their providers, so they know which doctor spends how much money. They also know whether that money is well spent—i.e. if the patients that doctor sees are really sick enough to warrant those expenditures. When I was in practice, a large local HMO complained to me regularly that I was spending too much money on my patients who just happened to have a much higher illness burden than most other family physicians. The amount of money spent was actually lowish compared to their illness burden, because I kept most of them out of the hospital, but the HMO still tried to terminate me, because they wanted to save money---and getting rid of me would have meant getting rid of a bunch of my chronically ill patients who would have changed insurance plans so that they could keep seeing me. ...