REDEFINING INSURANCE FRAUD

Want to hear MY definitions of "insurance fraud”? I'll tell you anyway.

Insurance fraud is when an HMO sells you a policy at an exorbitant rate and then finds all manner of ways to frustrate your pursuit of benefits.
 
Insurance fraud is when an HMO impedes access to procedures and specialists by requiring further "review" or "investigation.”

Insurance fraud is when an HMO denies coverage for pre-existing conditions.

Insurance fraud is when, to demolish any chance one might have of effectively communicating requests or complaints, an HMO deliberately hires morons to staff its customer service department.

Finally, insurance fraud is when an HMO not only plays these games but also joins with other HMOs to mount lobbying and advertising campaigns against the development of alternative health insurance systems.

A subversive I may be, but I've never been of the militant variety. When the SDS was blowing up banks in the early '70s, I was expressing my displeasure with the establishment by intentionally omitting zip codes—THAT’LL jam their gears!

And, however grudgingly, I‘ve come over time to accept capitalism as a permanent reality. A given.

But this managed care business, which is to say, capitalism of a blatantly predatory stripe, is making me ponder actions way off my normal spectrum.

I’m finding it increasingly difficult to sit still for a category of capitalism in which people demonstrably unqualified to participate in a free market economy—for whom capitalism is too heady a system—routinely commit what amount to acts of violence against their customers. (Messing as they are with other people's very lives, you have to wonder how these HMO creeps were brought up, what kind of parents they had.)

Of course, much as I'd like to, I could never dispatch each and every HMO administrator to his local ICU all by myself. I'd need help, and on a broad scale. But the prospect of getting such help is dim. The vast majority of us, after all, are reluctant to so much as question, let alone rise against, even the ugliest manifestations of a broader system that promises every American a piece of the serious action—and this despite how false that promise is for all but a relatively few, or how destructive may be the indignities our belief in it obliges us to suffer. Most of us remain willfully stupid in this regard (which, in another context is one of the reasons the Enron scumbags who amputated their employees' futures are still alive).

In fact, most Americans (including the majority of the 41 million who go without insurance because they can't afford the premiums), disdain even the civilized alternative of a not-for-profit, government-operated health care system. It apparently hasn't occurred to them that there's no significant risk to capitalism in this solution. We've already got "socialized" institutions in this country—police and fire departments, for example—that hardly infringe on our freedom to take advantage of one another. Even a few more would still leave us with plenty of opportunities to put one over on our fellow man. (And the notion that dealing with a government bureaucracy would somehow be more brutal than dealing with Aetna, Prudential or Oxford, well, that's a joke, isn't it?)

So what’s left to do when revolt is no more in the offing than government intervention is?

Unfortunately, beyond fantasizing that our growing population of serial killers (folks who’ve made it clear that accumulating money isn’t their first priority) will develop a sense of civic responsibility to go with their skills and proclivity, I haven’t come up with much. Certainly nothing that promises more than the smallest of rewards at the price of considerable personal sacrifice.

I’m speaking of getting sick a lot; using, you know, the hell out of my policy. By constantly contracting illnesses that require extended hospitalization, frequent doctor visits and enormous quantities of pharmaceuticals, I’d have the satisfaction of at least putting a dent in an HMO's profits.

Yeah, I know. But I like the pharmaceuticals part and it WOULD be a step up from omitting zip codes.

Exec.Summ. Are there positive inducements which can be offered people to reduce demands on the health care system? I think so. They are not consistent with the “Western values” referred to below. They are consistent with very pervasive practices in Western society.
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 I first attempted to raise the issue of rationing health care in Ontario with the then Minister of Health in 1986. I was [of course?] ignored. Between the work of Daniel Callahan, Gov. Lamm and others there is really little that need be said as regards the economic aspects. Gov. Lamm’s approach either makes obvious sense or it is simply morally wrong as Dr. Mitteler finds it.
 As a hospital chaplain I have seen instance after instance in which health care providers make decisions about who is worthy [in terms of anticipated benefits? “Morally—in terms of the patient’s life history?” “Morally—in terms of some value I the health care provider hold?”-- of what treatment The involvement of patients/substitute decision makers varies from extensive to none. Covertness of the process guarantees arbitrariness.
he one [still] edifying aspect of all this here in Canada is that ability to pay is not a consideration. As Governor Lamm noted last year, in Canada, there is growing awareness that no publicly-funded health care system can provide everything that someone would find medically beneficial. One of the key figures in the establishment of the Canadian publicly-funded hospital & physician-care system in the late 1960’s recently commented that it was never contemplated that this system would provide for the costs of chronic & long-term care. The politics of openly rationing health care is, however, still impossible.
 My work as a chaplain in Long Term Care Facilities heavily influences my perspective.
 The question for me is whether there are any places “outside the box”. Which box? “The discussions regarding health care cost containment were conducted on a level that did not violate or offend the value system of Western society, in which all individuals’ lives are presumed to be equally important.”
 --Osgoode, Nancy J., Barbara A. Brant & Aaron Lipman Suicide Among the Elderly in Long-Term Care Facilities NY: Greenwood Press, 1991,p.157
 I agree that making decisions about the quality of life of others sets us up for Hitler’s approach to what to do with socially useless human material. So, as I say, the problem is one of societal attitudes. Most of us do not regard life as a cycle. We see it as something linear [which might just keep going]. The former is the outlook found in most traditional cultures. Paradoxically, our new technological capabilities may warrant a return to such an outlook. This of course is not a solution to the crisis of health care costs in the time-frame required.
 Anyone interested in discussing short-term approaches to inducing people to reduce demands on the health & long-term care systems? jwouk@ottawahospital.on.ca

I certainly agree with Former Governor Lamm. As a nurse I have had a large number of elderly patients receive high cost procedures that only provide some benefit, or are taking costly drugs like zocor, epoeitin and many others when they are already quite chronically ill and often well into their 80s and 90s. I feel the attitudes amongst elderly have changed significantly even in the last 10 years. My grandparents would never have expected CABG, renal dialysis, organ transplants or thousands of dollars a month of drugs to sustain their life in their eighties and nineties. Today's elderly want as much health care as they possibly can get. Prior to the enactment of medicare, the elderly paid out of pocket for health care expenses, making you chose wisely what care you would receive. Medicare, and to some degree Medicaid, has created a whole new type of moral hazard. I do not see my patients taking any sort of fiscal or personnel liability for their health care. Instead of realizing medicare is funded on the back's of our children, the want more coverage to include prescription medications and lower copayment. If in fact we limited life-sustaining procedures, and high cost tech at the end of the life span, and perhaps even for babies below a certain birthweight, then we probably could offer seniors prescription coverage for their more basic needs. Instead we operate under some fantasy that because we don't want economic principals to apply to healthcare, then they don't apply. Other countries have better health outcomes than us, spend far less on their health care per capita, and seem to have equal if not higher quality of life markers. One added note, giving the elderly every bit of tech health out there is no guarantee they will have a higher quality of life in their last year. The united states should be looking at diverting some of the money wasted on cholesterol and colon cancer screening for 90 year olds into susidizing long term care in the future.

Dr. Mittler, I certainly get the sense of what things you believe have failed in health care. It also sounds like you have had some frustrating experiences bringing the public into this dialogue, for which you should nevertheless be commended. Given all of this, what do you think are appropriate next steps in improving the classic healthcare triad of quality, cost, and access?