Editor's Note: This article is an adaptation of Tim Norbeck's presentation to the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery San Diego, California, September 23, 2002. This adaptation is intended for audiologists and hearing instrument specialists.
Does it matter that healthcare professionals today feel isolated, powerless and even faceless? Does it matter that many healthcare professionals feel bought or sold, hired and fired, swapped and traded, intimidated and browbeaten? It matters to me as a patient, and as a friend, and it matters to your patients!
A few months ago, it was mentioned in a news story-with little fanfare or attention-how the three giant Blue Cross and Blue Shield companies that provide over half the health insurance in Pennsylvania have stockpiled huge cash surpluses in recent years while at the same time charging subscribers higher rates and further squeezing physicians and other caregivers.
The companies, all nonprofit organizations, hold more than a $3 billion surplus-about $2.2 billion more than the reserves required by the Pennsylvania Insurance Department. Here you have Pennsylvania physicians who already pay among the highest malpractice insurance premiums in the country and who receive the lowest managed care reimbursements. What about helping the physicians who helped create that unnecessary surplus? They have been cut to the bone on reimbursements while insurers sit like mother hens on golden eggs. Meanwhile employers deal with unnecessary rate increases and subscribers pay more for coverage. And that's just the tip of the iceberg.
As we have come to know all too well, insurers are not exactly known for their generosity. There's the story about the director of the homeless shelter who made an appointment to talk with the CEO of a large HMO who had a reputation as a real skinflint. She began by saying, ''Our records show that you have a very large income, and yet you rarely donate to any local charities. Wouldn't you like to contribute in some way?''
Snarled the CEO in response: ''Well, do your records also show that my mother is dying and has enormous medical bills?-that my sister's husband died in an auto accident, leaving her penniless with three children? Do they show that my brother is blind and confined to a wheelchair?''
Very embarrassed, the woman apologized and said, ''I had no idea''...but the CEO cut her off in mid-sentence. ''So if I don't give any money to them,'' he said, ''why should I give any to you?''
HMOs are beginning to understand that image is important and that theirs has taken a real beating. And we can never underestimate the importance of image. Early in the summer of 2002, the American Association of Health Plans-you know, the HMO Association-retained the big time William Morris ad agency to help it get access to key writers, power brokers and Hollywood directors so they can create the illusion of a softer image.
Relishing that new role, a senior Vice-President at William Morris stated emphatically ''there's some great stuff that HMOs do.'' Well, like what, exactly? He claims that ''managed care takes care of 170 million Americans and saved many lives.''
Really? I always thought physicians and other healthcare professionals took care of those patients-not managed care. His rhetoric reminds me of the former mayor of Washington, D.C., Marion Berry, who commented proudly '' that D.C. had one of the lowest crime rates in the U.S.-if you don't count the killings.''
Do you wonder exactly where that HMO image campaign money will come from? Of course it will come from healthcare professionals' reimbursements, just like it always has.
While I am not proud of the fact that our beautiful state of Connecticut is known as the Insurance Capital of the World, I am immensely proud of our state medical society and its stand-up physician leadership, including K.J. Lee (President of the AAO-HNS).
Like so many other state medical societies, we tried to communicate and negotiate with HMOs, and our state legislated and regulated. Our legislature, despite the many pressures applied by insurers, stood firm and passed managed care reforms introduced by the Connecticut State Medical Society. But after losing the legislative battle, the HMOs merely ignored the reforms-including a terrific prompt payment bill.
My personal favorite was the urologist from Middletown, CT who performed lithotripsy on a patient after receiving pre-authorization for the procedure. When he hadn't been paid by the insurer after 90 days, he called and was told that they never approved it. Angry, he stated to the clerk that he was holding a photocopy of that signed authorization in his hand as they spoke. Her arrogant response: ''No you aren't!''
I know of no better way to best characterize the feelings of America's professionals today-not just Connecticut physicians but certainly most healthcare professionals who see patients - than to tell you of a true story from about 200 years ago:
The U.S. Federal Government sent General Benjamin Lincoln to negotiate a peace treaty with the Creek Indians. The chief greeted the General and asked him to sit down next to him in the middle of a very long and narrow log. After sitting down, Lincoln was asked to move over. In a few moments, he was asked to move still further.
The request was repeated several more times until the general reached the end of the log, whereupon the chief said: ''move further.'' The general, clearly annoyed by now, replied: ''I can move no further.''
''Just as it is with us,'' said the chief. ''You moved us all the way back to the water and then you told us to move further.''
Professionals do not want to move any further. Instead, the time has come for insurers to occupy a seat on that log.
We asked ourselves four very important questions, to which, unfortunately, the answers were all identical.
- Why do insurers arbitrarily delay, deny, down-code and bundle claims? The answer, of course, is because they can.
- Why do insurers ignore managed care reforms enacted by concerned legislatures all over the country? Because they can.
- Why do insurers offer professionals one-sided, coercive and unfair contracts? Because they can.
- And why do insurers overrule medical necessity decisions made by physicians and your colleagues around the country who spend up to one-third of your lives in formal education so you can do the best possible for your patients? Because they can.
The days of ''because they can'' must come to an end.
There is a time to communicate and negotiate, a time to legislate and regulate. We tried them all. There is also a time to draw a line in the sand and fight, and that time had come for us. We made good faith efforts to resolve our many differences with insurers, but we learned that when you put a limit on what you will do, you have put a limit on what you can do. Silence gives consent. And, when the eagles are silent, as Winston Churchill reminds us, the parrots begin to jabber-a truism in professional societies, as many of you know!
Patients are sick people who are forced to trust. Importantly, all of us are patients sooner or later. And too many of us come to discover, too late in our dealings with insurers, that what the large print giveth, the small print taketh away. And let us remember that these are the same folks who brought us 24-hour mastectomies and drive-thru deliveries.
After weighing carefully the egregious actions of the HMOs and considering our past efforts, which were rebuffed by them-every step of the way-we decided that the ultimate action was necessary.
So, on February 14, 2001, the Connecticut State Medical Society filed class action lawsuits in Connecticut State Court against the 6 largest health plans-and added a 7th four months later. The lawsuits allege that these health plans systematically breach the terms of their contracts with physicians and engage in illegal policies and deceptive practices. These suits take direct aim at health plan policies and practices that place critical medical care decisions in the hands of insurance company bureaucrats instead of physicians where they belong.
The insurer response was twofold and would have been almost humorous if they were not so annoying! The industry pointed to the progressive managed care reforms passed by the Connecticut General Assembly as some kind of defense. ''Why sue,'' they asked,'' if we in Connecticut have such good legislative reforms?''
Why indeed? What they didn't say is that they fought tooth and nail against each and every one of them, measurer by measure, before they were enacted. Now they wanted to hide behind them. ''Why don't we talk further?'' they asked.
The reason that further talk is fruitless is that it is impossible to play cards with someone who holds nothing but trumps. And is there anyone, anywhere who doesn't believe that harsh reality-that insurers do, in fact, hold all the trump cards? Certainly not the healthcare professionals! And you know what they say about compromise: The lion and the lamb can lie down together, but the lamb won't get much sleep.
The supreme power of the health insurance industry today reminds me of an old comment Joseph Stalin made when Lenin's widow started to complain: ''If Lenin's widow does not behave,'' Stalin said, ''we will appoint someone else as Lenin's widow.'' Unfortunately, many healthcare professionals have been thrust in that same position.
We felt that we could no longer go on promises...that things will get better, that legislation or regulation will solve our problems...that somehow-some way-something will come along and save the professions and the professional-to-patient relationship. We need to understand that the knight in shining armor is not coming. Not now. Not ever. We in Connecticut, felt that we must act to solve our own problems. There is no one else who is going to do it for us. The Patient's Rights Bill is not going to get thru Congress, and won't do that much even if both parties do agree on it. And as comedian George Carlin reminds us: ''The word 'bipartisan' usually means some larger-than-usual deception is being carried out.''
Since our HMO lawsuits brought a year and a half ago on St. Valentine's Day, I have had the opportunity to travel throughout this country discussing the situation with the physician leadership of many medical societies. As we have maintained all along in those suits-our complaints against the HMOs are not indigenous to Connecticut, but exist in every state.
As one New York physician put it: ''It isn't just one HMO; they're all arrogant about overruling our medical judgment and denying our requests for authorization. They think they are in charge ... and they are. Most doctors are too intimidated to fight back.''
A Tennessee physician likened the despair to the five stages of response terminally ill patients are said to go through in accepting the reality of what they face - you know them as denial, anger, bargaining, depression and sometimes acceptance.
A Washington physician, forced by the times to move to Dallas, expressed his frustrations this way: ''Physicians used to be high priests practicing an arcane art with unlimited autonomy; now we're the customer-service representatives of a sprawling bureaucracy, meting out small helpings of treatment under the constraints of a web of rules and jargon. We're 'healthcare providers,' in the same sense that the lady on the phone at the Sprint help desk is your 'long distance provider!'''
During a House of Delegates discussion in another state over whether or not to join our lawsuits, one physician said that he feared that HMOs would get mad at the state medical society and physicians if they sued. It was kind of like the old story of the two men condemned to die by the firing squad who were asked by the commandant as he adjusted their blindfolds if they had a last wish. ''Yeah,'' one of them spoke up, ''Why don't you go to Hell.'' ''Be careful what you say,'' the other admonished him, ''you don't want him to get mad at us.''
And then there is the physician speaking for so many of his colleagues throughout the country, who as someone pointed out sounded just like George Washington at the end of every military dispatch he sent from his Valley Forge encampment to the Continental Congress: ''Is anyone there? Does anybody care?''
Our message to insurers is not that we are trying to destroy them but, instead, that health insurers should facilitate the quality of care-not undermine it. Insurers must be balanced and not heavy-handed.
There needs to be a new order where the people who receive the care and those who render it are once again respected and recognized as the most important and vital components in that care-and that the healthcare professional-to-patient relationship is honored, safeguarded and strengthened.
Healthcare professionals are not as powerless as they think-and you must remember what you are fighting for. Your future and patient care are at stake.
One of Ronald Reagan's favorite lines, and very appropriate for our situation, was probably borrowed from Churchill. ''I do not believe in a fate that will fall on us no matter what we do,'' he said. '' I do believe in a fate that will fall on us if we do nothing.'' We don't have to accept the way things are.
It is something that is indigenous to your profession; in being a healthcare professional, in helping people, in feeling that you matter, in being looked up to, and in achieving something important. That is what you are. That is what you do. That is your everlasting mark on society. You are a health care professional. You worked hard to become one. You will always be a professional -even long after you have seen your last patient. Isn't that worth fighting for?
One hundred years ago, there was a very serious and debilitating coal strike in the United States. The public complained that nothing was being done to address this crisis. Finally Senator Henry Cabot Lodge paid a visit to President Teddy Roosevelt and said: ''Isn't there something that we can appear to be doing?''
Appearing to be doing something about the egregious actions of HMOs is not acceptable. We have the opportunity to change this system for the better, and it is likely to be our only one. We must get it right! If we do not have the stomach for this fight, future healthcare professionals and patients will rightfully be able to point their finger at professionals and their organizations and say: ''How hard did you fight for us? How much did you risk for us? How willing were you to make the necessary sacrifices for us?''
And that leads me to a final story before closing. With all the intrusions and incursions sabotaging your efforts to do the best possible for your patients, there is a story that certainly is appropriate and something I hope you will remember during these trying and challenging times.
It involves a rather famous entertainer who was traveling back from a two-week public relations trip to China. On the same boat was a medical missionary who had worked with the poor and infirm in China for many years. When they docked in New York, the missionary saw a huge crowd waiting at the pier complete with posters and confetti-all of them fans of the entertainer. The medical missionary gazed at the adoring, cheering crowd.
''Lord, I don't understand,'' the missionary said. ''I have given 42 years of my life to helping people and making them better, and he gave only two weeks-yet there are thousands welcoming him home, and there is no one here to welcome me.''
''My friend, the Lord replied, ''You're not home yet.''
