Health Insurance

Good doctors believe that an annual health check up is a must, not just for patients, but for doctors themselves. All of us know this, the problem always lies in compliance and systems. Was chatting over dinner with Tanmay Panchbhai, who is a lung replacement specialist in the US. To quote: ‘Systems is a defining characteristic of the United States medical system. I think it is both, their biggest strength and their biggest weakness.’

The systems issue was highlighted by a real life incident narrated by my friend Bhushan. His uncle was staying in Chicago. He had started on his morning walk and was crossing the road next to his house, when a car, thankfully being driven by a nurse, hit him. Unlike the standard hit-and-run accidents of India, the nurse immediately arrangted for an ambulance and uncle was transported to the local Hospital. The local Hospital, realising that it was not equipped, arranged for a helicopter ambulance to transport uncle to the bigger hospital.

Bhushan got a call from his sister informing him about this accident. He was discussing this accident with one of his doctor friends, Dr Bapat. Bapat predicted that your uncle is going to pass away in a week’s time. The prediction was septicemia and multiple organ failure. This was exactly the story as it happened. Dr Bapat explained later that in such accidents, an aggressive treatment helps. We have to locate the source of internal hemorrhaging, and operate the patient to clean up that area. Sometimes you operate just to locate the bleeding area. Given the systems and laws loving society of the United States, no American doctor will take this risk. As a result, the bleeding stops on its own, but the infection spreads internally and organs start failing, one by one. Doctors try out piecemeal solutions, but at the end patient death is inevitable. Uncle’s family was saddled with a bill of $ 400,000, which obviously was paid for by the insurance companies.

Having systems does have advantages. US medicine does not suffer from practices like the C-U-T system in India. Only half the earnings of Indian General Practitioners is derived from patients. The other 50 % comes from referral fees that they get when they send patients to hospitals or recommend diagnostic tests to patients. In the United States, this practice is not just looked down upon, but can also lead to imprisonment of doctors.

Another plus point of systems is flexibility. Tanmay’s wife, Pradnya, is in the internal medicine department at Cleveland Clinic. This department handles patient admissions during night time. The team is 85 strong. She has a targeted number of hours that she needs to work every year. How she does it is entirely left to her. So she can skip work for 10 days and then she can work for 10 days continuously. I think this is possible when you have a bench strength which is large. You can rely on law of averages to ensure that someone or the other is available. Some of the doctors also do moonlighting. And this helps to build up the buffer in case of emergencies.

But there are also problems when the customer is not the consumer. Imagine you buying yourself a meal. Now imagine you buying a packed meal for a friend. Now imagine you being the purchase manager and ordering food for the workers in your factory. There is a difference between you spending your own money on yourself versus you spending someone else’s money to buy something for someone else. In marketing jargon, in the US, the patients are definitely the consumers, but it is the insurance companies that are the customers. 80 percent of revenues of US Hospitals are derived from insurance companies. One would assume that this would lead to insurance companies pushing for healthier lifestyles. But both doctors and insurance companies have vested interests in not letting US citizens become overtly healthy. Lip service is paid to this cause, and symptomatic treatment is bandied out. Hospitals overcharge, and to keep insurance premiums reasonable, companies underpay.

One interesting practice started by insurance companies is paying for quality. After surgeries, patients who survive are called by an independent federally appointed agency. Family members are asked to rate the hospital on different parameters. The ratings decide the revenue of the hospital. Another interesting ‘practice’: If a patient returns back to hospital in less than 30 days, then the insurance company does not pay the hospital anything for this patient. The hospital concern levels are at their highest for the first one month. Patients are actually given 30 days prescriptions of medicines when they leave the hospital. Follow-up calls are made; visits by social workers are arranged. But on day 31, the hospitals heave a collective sigh, and letting go of this patient, and hoping to see her back soon!