Who’s making the decisions about your health care?

Are insurance companies making more decisions about the health care you receive? While a decade or two ago utilization nurses working for insurance companies had some power to approve or reject certain treatments, the reach of insurers into the patient-physician relationship is lengthening.

In March, I reported that insurers were sending questionnaires to policyholders newly insured under Obamacare asking about their health conditions and medical needs. And some people were filling them out. But insurers are also going after policyholders like me who have been with them for a long time.

We are reaching a crossroads in this country in terms of physician autonomy, a point made by Dr. Luis Collar on KevinMD.com. In a cogent essay, Collar argued, “Despite the foul smog of competing interests that permeates this new delivery paradigm, one thing is clear — physicians are no longer calling the shots.” Collar wrote that for the medical profession’s collective integrity to be relevant there must be access and trust.

“We now equate ‘access’ with health insurance,” he said. “And doing so allows some to declare victory each time a new patient registers on Healthcare.gov. Quantifying access requires a broader perspective. Does five minutes with a physician constitute access?” If five minutes is not enough time to for a doctor to evaluate me and develop trust, does that mean I need a health coach paid by an insurance company to take over the job of my doctor?

In my case, I received a letter from Aetna, my Medicare supplement insurance carrier. The letter was an advertising pitch for getting “started on a healthier lifestyle” by taking advantage of help from a nurse who would act as my own personal health coach, part of a disease management program included in the benefit package my former employer apparently purchased.

The health coach was supposed to help me reach my best health by lowering my cholesterol, losing weight or helping me with serious conditions like diabetes. He or she could also review treatment plans and help me understand medications and discuss online resources. “Because of your health history, we think you might benefit from joining our program,” the letter read.

What health history were they talking about? I don’t have a weight problem. I don’t have high cholesterol. I don’t have diabetes. I exercise and know about preparing healthy foods, having taken oodles of nutrition courses in college. What in my medical records that Aetna scrutinized could have triggered such a letter? What did this coach want to discuss? Were my eye medications getting to be too costly for the company? Were they trying to switch me to a different eye med? That’s my biggest medical expense. Why would a coach know more about ophthalmology than the doctor I’ve been seeing for 20 years? Annoyed, I called the insurer.

The customer rep described Aetna’s coaching service as a health education program. And when I asked what in my file warranted the letter, she replied it was an “outreach letter to let you know about the program.” If there were anything I wanted to work on, the coach would be there for me.

I told her I was not interested. But the fact that she had my records in front of her and was prepared to pass them along to a coach whom I would know only on the phone got me thinking about whether my medical information was indeed as confidential as the outreach letter promised. It seemed like my record was an open book just waiting for the commerce of medicine to exploit.

It was clear the customer rep did not have an eager customer, but she still asked, “Can we call you?” if any concerns came up. After I said no, she said she had to ask one more thing. “On our calls we have to screen for depression,” she told me.

The rep said they are supposed to ask if callers are “down or depressed.” If I were, which I wasn’t, why would I tell her? “You’d be surprised how many people say ‘yes,’” she said. What if you say you are down you are down in the dumps because it’s been too cold for days on end? Does that mean Aetna’s coach will send you to a therapist? The rep did mention behavioral health as a service they provided.

My conversation with her illustrates Collar’s point. Who’s making the decisions about your health care?

Trudy Lieberman is a journalist and an adjunct associate professor of public health, Hunter College, New York, NY. She blogs on the Prepared Patient blog.

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  • Dr. Drake Ramoray

    My Endocrine practice is in an underserved area. We have a relatively lenghthy waiting list to be seen because are service area covers about 1/2 of two states. Several months ago we changed our wating list from prioritizing Medicare patients for the waiting list because of lower reimbursement to diabetics regardless of insurance because of the very things listed in this article.

    We get paid less for Medicare visits but we got tired of the hassles, call backs, prior authorizations, and red tape that went with taking care of diabetics. So we just see all comers for general endocrinology problems because it is less hassles. This is also one of the reasons why my long term direct pay plan does not included diabetes. Formularies are excluding medications as equivalent even when tolerability, safey profile, and phamacokinetics may vary. If I choose not to follow their treatment algorithms it is endless headaches and red tape.

    I haven’t struck out on my direct pay practice yet, but if pay for performance gets coupled with insurance formulary plans and all the red tape that goes with diabetes I plan to be ready for it.

  • LeoHolmMD

    Insurance company profits have been linked to the provision of care. So now they are going to be doing all sorts of things, like data mining, under the guise of care. They will troll for business, even make people sicker like the Medicare Advantage plans were recently discovered to be doing. Health care bills and utilization will continue to soar as the whole world becomes a patient.

    • DeceasedMD1

      You said that very well. I can see the MIC (medical Industrial complex) gaining from data mining, but forgive my ignorance, How does an insurance company profit from offering more care?
      They make a steady income monthly from premiums and wouldn’t they benefit more if they did not have to pay for services?

      • Arby

        Data mining to assess risk and figure out premiums to charge employers, and preventative care to reduce actual outlays of care for the consequences of things ike obesity and quitting smoking. The coach’s pay is far less than a physcian’s and tailing on the phone is a cheaper treatment than medical care.

        • DeceasedMD1

          Well that’s a bunch of malarky but no doubt it works for them. anything to save a buck. But I find this confusing about assessing risk. I though with the ACA that they could not charge more based on health risk?

          • Arby

            I mean aggregate risk not individual. Premiums for your employer.

          • DeceasedMD1

            I guess from this article I finally actually read, it looks like insurance has an effective way of targeting your business as a pt. And the last part asking about depression is incredibly intrusive and unethical. What if you say yes you are suicidal and have no mental health coverage? The whole thing is absurd and is always worse than I realize.-and for a pessimist that’s saying a lot.

          • Patient Kit

            Which is why it is very important that potential employers, who offer a good health insurance benefit, not know that I was diagnosed with cancer last year.

        • DeceasedMD1

          Let me understand the details of this a bit better as far as privacy is concerned. So in data mining, supposedly they deidentify you (only to perhaps identify you later). OK so if I am a 400 pound employee with all the risk factors for MI, how do they find me (legally)? How do they know that I personally am obese and how to contact me? Is insurance working with my employer to do this? Or does insurance just call me at home or on the job out of “concern” for my health?

          • Arby

            At my place of employment, every year a mini health questionnaire was sent out by my insurer with a small reduction in my portion of the premium if I answered it (carrot). Self-reported questions on smoking, height/weight, cholesterol, BP, known health conditions and meds were answered online through insurer website. I believe this is how my name went on the list to be offered health coaching. Not all employees got the calls. However, my identifiable information was not shared directly with my employer. I’m fairly certain the aggregate data of all employees was shared with my employer when policy pricing discussions were held with them.

            My last year in corporate we got a big carrot ($300 off our cost) to complete a personal health evaluation. Given by a company called Interactive Health Solutions (they advertise to employers as a way to save them money on insurance premiums). Same questions on health but with screenings for anxiety, sleep apnea, depression and stress and a lab draw given by their own lab contractors. They provided a nice little booklet with the results of your screening, your labs and a coronary health risk assessment. For anything that raised a red flag they provided some canned advice and encouraged you to speak with a health care or mental health provider. They also had a field online where you could have them send your information directly to your PCP if you wished. Again, my employer did not know my personal information, however this company, like my insurers previously know the information is mine.

            I am not sure if under ACA employers can raise an employee’s portion of health premiums for behavioral risk factors such as smoking, obesity or whether they particpate in these types of health screenings (how it becomes a stick). Perhaps Margalit will let us know.

          • DeceasedMD1

            Well you have just explained it all Arby. How long before medical care will go well beyond 20 % of the GDP?
            These “contracting” companies are making a mint, doing nothing but expending valuable resources. It is interesting that they are spending more time with you than the average PCP who has 12 minutes.

            Do you think Obama has a clue of how his law has been contorted and where the health dollars are going? Thank you for explaining the actual way they game the system “legally” and “privately”. This should be a news story for the public to hear. But seems like all the public cares about is the “savings” part. It reminds me of big Pharma giving out “free” coupons to pts so that insurance will pay for it. In the end there is no savings involved for them-just the illusion of it of course.

          • Arby

            Hmm, I hadn’t thought about them spending more time with me than my PCP, but that is the sad truth.

            I have no idea what anyone in government thinks beyond their own self-interest. For them it all about votes, and votes bring them influence which brings them money from Corporate America and allows Corporate America to make even more money to buy them off with. It is a win-win situation for all except us common folk.

          • DeceasedMD1

            We just vote for them. !$#@!

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            They can and they do, up to 50% more. Wrote about it a year ago http://onhealthtech.blogspot.com/2013/03/the-shell-game-of-health-contingent.html

      • LeoHolmMD

        New revenue streams: disease management, wellness checks, etc. Why pay physicians to do these things when you can do them yourself for less and then bill for it? They do get paid for these services, they are just extracted from higher premiums for patients and lower reimbursement for physicians.

        • DeceasedMD1

          Thanks for most quick reply. Are you saying that insurance has their own “clinicians”? I know they have nurses calling at times to “educate” pts about their conditions. Is this the sort of thing you are referring to where they get excessive funding for? And pts never even ask for the call. but once they receive the call they do not realize they have beenindirectly billed for the service they did not ask for?

          • LeoHolmMD

            You are billed if you like it or not. If your employer has a wellness program, for instance, you are paying for it with decreased wages and so forth. That is if you use it or not. Same for these insurer provided services.

          • DeceasedMD1

            That is outrageous. Thanks for clarifying. Have any idea the costs or percentage wasted on this? Wish this was in news. You just explained a lot. thanks again.

          • LeoHolmMD

            Google Al Lewis.

          • Patient Kit

            But scroll past Grandpa Munster to the other Al Lewis. ;-)

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Not really. Here’s the funny part: the ACA limits the medical loss ratio (MLR) for insurers from below, so they must spend a certain percent (85% on the group market) on “patient care”, or return the money to customers. These things are considered patient care.So as both Arby and Dr. Holm pointed out, it’s cheaper to pay “coaches” than to pay doctors enough to allow them ample time with their patients, plus the need for data for their predictive analytics engines, plus the need to do well on plan quality measures (HEDIS), which are also a bean counting exercise (such as how many patients were screened for depression), and you have a perfectly insane system in action.

        • LeoHolmMD

          In a wild paradox, the only way an insurance company can increase profits is by increasing medical expenditures now. Initially this will have to do with what you suggest, taking market share from physicians. Once that plays out, it will be back to increasing utilization, increasing patient base by adding services and consolidating….sort of like our current messy system.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Precisely, and since larger portions of premiums are subsidized by government, they need not worry so much about what people can actually pay. Just this morning I saw some headline that AHIP wants the government to subsidize catastrophic plans too. What’s going to happen here is that already expensive services will be allowed to skyrocket, so hospitals and insurers can prosper, and cheaper services, like primary care, which will now be paid out of pocket, will be forced by the “free market” to tank. I can’t think of a better way to make health care more expensive in a very short period of time.

        • DeceasedMD1

          wow. I recall the 85 percent on pt care with ACA, but I figured that they could not spend it on coaches, only medical care that the pt seeks out. Has anyone besides yourself figured this out and written about this? This is indeed insane and driving up prices. how much money -or what percentage goes into ‘coaching?”

          • LeoHolmMD

            As much as is needed to substantiate short term profit objectives. If true cost savings are encountered and patients get refunds, the 15% profit side goes down. Your insurance company is going to provide as much care as you need, like it or not.

          • DeceasedMD1

            so this law that was meant to protect the public, the 85 percent rule, has just been manipulated in a different direction. Wonder if Obama has a clue? My guess probably not.

          • LeoHolmMD

            I will call him and let him know.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Oh no, All things considered quality improvements and wellness, go into the MLR. Everybody in the “industry” knows that, but I am not aware of a good source, listing the items and the amounts of money spent on each “service”…. I would love to see something like that in our new and oh so much more “transparent” world :-)

          • DeceasedMD1

            well this has been rather educational in a very bad sort of way.

          • Patient Kit

            It is very depressing but necessary to know how our enemies operate and think. Blissfully ignorant or hopelessly apathetic is exactly where they want us. We can’t fight or change what we don’t know.

  • QQQ

    “Who’s making the decisions about your health care?”
    —————————————————————————————————
    “The most difficult thing is the decision to act, the rest is merely
    tenacity. The fears are paper tigers. You can do anything you decide to
    do. You can act to change and control your life; and the procedure , the
    process is its own reward.”
    -Amelia Earhart-

  • Suzi Q 38

    The insurance companies relentlessly call me.
    I always have said “No, I don’t need assistance.”
    I think they are just trying to get more information to justify the right to drop you from their insurance.

    • Patient Kit

      What health info about you would justify your insurance company dropping you? They’re not supposed to be able to discriminate because of pre-existing conditions anymore. My insurance companies never called me offering “assistance”.. Not Blue Cross in the recent past and not Healthfirst, which manages my Medicaid plan now.

      • Coder

        Great. Another adult on Medicaid. When you are getting free healthcare you say nothing.

        • Patient Kit

          I’m not getting “free” anything. I’ve paid heavy taxes for my entire adult life from age 18 into my fifties, during which I worked full time, even when I was in school. I’ve been on Medicaid for a little over a year since I was diagnosed with ovarian cancer after a layoff from a job I had for 18 years and lost the Blue Cross plan that came with that employment.

          Medicaid was the only way I could get life-saving cancer surgery fast. Now, a year later, I’m busy job hunting and interviewing. In fact, I have another interview tomorrow. Hopefully, I’ll be off Medicaid soon. Hopefully, I won’t be working but uninsured. I’ve contributed plenty to the government and feel absolutely no guilt about accessing the “free” government safety net that saved my life. I appreciate my excellent doctors, don’t use the ER, never no show or even cancel an appointment, not even in a snowstorm.

          Clearly you don’t know me at all if you expect me to “say nothing” just because I am currently being covered by Medicaid. Here’s hoping you or anyone you love ever needs it. Thankfully, I don’t in any way need your approval to do what I had to do to save my life.

        • Arby

          As much as I get on P. Kit about her naive view of the poor and blindness to how government harms them in many ways, this was a rather crass thing to say.

          • Patient Kit

            Thank you, Arby, for sticking up for me here. You and I do disagree on a lot but I don’t think I’m quite as naive as you think I am. I’ll cop to being hopelessly optimistic and even to retaining fragments of my younger idealistic self. But not naive. When it comes to the poor, I try to neither demonize or romanticize people and I definitely try not to generalize, by economic class or any other demo. I have no illusions about our government or politicians. But it is our system so I try to work with it where I can. But my world is not all working class heroes and selfless politicians. People are real and flawed, myself included.

          • Arby

            There is no need to thank me. I can strongly disagree with your views on single payer, and some of the doctor issues, and still understand that you have a caring heart.

            To someone raised on hard-knocks, I have to say you sound as naive as a beauty pageant contestant whose dream is to solve world hunger. Although I wouldn’t wish my background on anyone just so they could see my perspective, I hope you will consider how prejudice against the poor will work against them even in single payer and why politicians never live by the laws and programs they write for their constituents; there is a reason for this.

            Other than that, I pray your health improves and you find a googd job soon.

        • Suzi Q 38

          Obviously, you don’t have empathy for people who have to use medicaid. There are some people who unexpectantly lost their job in the throes of having a life threatening condition.
          When you lose your job, many times you lose your insurance. What do you suggest one do with this dilemma? Go home untreated and get worse?

          • Patient Kit

            Thanks for understanding, Suzi. I’m very happy to still be alive and kicking and planning my comeback. Phoenix rising in Brooklyn this year!

        • DoubtfulGuest

          Hi. That was one heck of a first comment. I’d be pretty embarrassed if I were you. PK makes a great contribution to this blog. Why don’t you read and absorb a bit more and then see if you might have something constructive to add?

          • Patient Kit

            Thanks, DG, for coming to my defense and sticking up for me. I appreciate it.

          • DoubtfulGuest

            I really should have let you reply to Coder first PK, sorry. And re: my own assumptions, I was talking only about my difficulties understanding doctors. Nothing at all to do with Medicaid. I’ve just learned a tremendous amount here from people who have vastly different points of view than mine and I enjoy that — that’s all.

            I’m glad it looks like things are going to be okay here, and I hope you feel better soon. You have lots of people here who want everything to turn out great for you.

          • Patient Kit

            I was otherwise occupied (in job interviews) so I’m glad you and others spoke up in response to Coder’s initial post. It would have been very disheartening if nobody responded or upticked my own response. I too really enjoy the exchange of different ideas and experiences here at KMD. I’ve learned a lot in the short time I’ve been participating here.

            I just celebrated a birthday last week and I’ve dubbed the coming year my Phoenix Rising from the Ashes year. (The two years I swam with a slow-healing fractured femur, a friend nicknamed me Soars With Broken Wing). I guess I like to name things. Things are looking up on the job front. I’m sure I’ll be working again soon even if that means no health insurance and no doctors for a while. Whatever happens next, I’m always hoping for the best and striving for a happy ending. Thanks again, DG.

      • Suzi Q 38

        I just know that they are not doing it to assist me in a sincere way.
        they are probably doing it to get information about my medical conditions.
        Maybe they want to cancel me, or maybe they want to charge me more.
        At any rate, I will avoid answering them at this point.

        • Lisa

          Susie, at this point, under the ACA insurance copmanies can’t drop you for prior medical conditions. If they offer a plan on the exhanges, they have to take all comers. Furthermore charges are related soley to age, not to your medical conditions.

          • Suzi Q 38

            Thank you.
            I have trouble thinking of anyone associated with my insurance company as being on my “side.”
            I don’t want them to make a rush to judgement about the conditions that I may have or may develop in later years.

          • Lisa

            Susie, I was suspicious too, just on general principle.

        • Patient Kit

          Oh, I totally agree. If my insurance company called me I too would definitely assume an agenda that was not about assisting me. I just never had the experience of them calling me trying to “assist” me.

      • Arby

        It is to estimate the rates they will charge employers. I worked for two large corporations and over the nine years there I was contacted five times to enter into this coaching. I did twice, and it was pretty awful. They don’t really listen to what you say as they try to stick to their scripts if all possible. And the phony, cheery pablum attitude with coaching that is nothing more than a cheerleading session gets old pretty fast.

      • LeoHolmMD

        An insurance company is a risk management organization. Their job is to assess risk (get all the info they can about you), then mitigate it. Mitigation used to involve dropping, lifetime limits, cost shifting. Some of those things have been dealt with by the ACA. The new models include data mining, disease management, cost shifting of another variety.

  • Patient Kit

    If health insurance companies are making medical decisions and, in effect, practicing medicine, can health insurance companies be sued for malpractice when they delay or deny approval for treatment and that delay or denial results in a bad outcome for “their” patient?

    • LeoHolmMD

      You wish. The excuse is: they are not denying care, they are just not paying for it.

      • Patient Kit

        I do wish. But believe me, I have no illusions about the purpose of health insurance companies — to make money for them. This whole thread is just so depressing. Health insurance! Can’t live with it and can’t live without it! Remind me again why people are so dead set against a single payer system that either eliminates or, at least, defangs the evil health insurance companies? Oh, yes, the government is just as bad, if not worse than private profit-driven healthcare companies! So, if people don’t want healthcare via insurance or government, what would work better? Cash? Lots of cash? Credit??? Lots of credit?? Seriously though, if insurance is going to continue to have the big role they play, they need to be held more accountable.

  • Arby

    My neighbor and her husband had the same type of interview. The interviewer seemed really interested in whether they smoked or not. i guess it makes sense for insurers to care when they perceive that every bill they pay for you is less money for them, organizationally or individually. But when will “caring” about your health become controlling your health? They are offering a carrot now, but soon it will be a stick. And sticks are what the government wields better than anyone else does. All for your own good of course.

  • FEDUP MD

    When I was pregnant recently I got the same kind of thing. I politely declined and they got pushy then I wasn’t so polite. My pregnancy was my and my OB’s business, thanks.

  • DoubtfulGuest

    I can only speak for the part of your reply meant for me, but I do appreciate it, Coder. I’ve had my eyes opened here, to learn what other people go through. And it’s kind of a long process to get over some of my own assumptions. I have to be away more than usual this summer but I look forward to future lively discussions.

  • Patient Kit

    Apology accepted, Coder. You sound sincere. But I won’t lie. You actually made me cry. This last year has been the hardest year of my life. Contempt from people who don’t know me or my story is hurtful. I hope you’ll keep that in mind when dealing with other Medicaid and Medicare patients in the future. We’re not all the same. I understand that there is a lot of abuse, but there are also many people with stories like mine.

    When I started posting here at KMD a few months ago, I hesitated to tell my personal story because I knew it would draw contempt from some. But I decided that my story was worth telling, even if it made me feel vulnerable here, because people need to know how our healthcare system is working or not working for people in situations like mine.

    I spent a big chunk of my life advocating for others who are less fortunate than me. Turns out that work prepared me to be a pretty good advocate for myself when needed, as you may be able to tell from my first response to you. I wasn’t trying to justify being on Medicaid. But I did want you to understand. I do understand what it feels like to be burnt out. I’ve been there myself at points. I hope this serves as a bit of a wake up call to you, especially if you interact with patients in your work. We never know what others have been through, so it’s best not to snap judge.

    Welcome to KMD. This is a terrific forum and home to some very good and important discussions. I look forward to chatting with you and getting to know you in future conversations here.

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