Meet the Giant Filter at a Managed Care Organization

On May 10, 2005 an op-ed piece appearing in The Providence Journal contained a by-line which posited the question, How Can a $124.8 Million a Year CEO Make Health Care More Affordable? That is a reasonable question in deed, especially when the costs that the CEO of whom it speaks is allegedly trying to control in order to make your healthcare and mine affordable involve physicians whose incomes amount to one tenth of one percent of that which United Health Care (a Health Maintenance Organization-HMO) was paying its CEO. The short answer to the article’s question is, “He can’t!”

The commentary was a startling expose about huge pay packages for corporate CEOs in general and germane to my specific interest in this series it mentioned the awesome $124.8 million total compensation of United Health Group (parent of United Healthcare) CEO William McGuire. What the article did not include however, were two significant letters that should have followed William McGuire’s sir name; specifically M.D. You see, before becoming an HMO administrator, Dr. William McGuire, had done what I did for 31 years; he practiced internal medicine and at the time he joined United Health Care, the average taxable income of an internist was around $150,000 per year.

To view it from a United Health employee's perspective, had Dr. McGuire, who is also a United Health employee, been paid only a cool million (which was more than six times what he had previously earned in a most respectable profession), and the difference had been apportioned to United Health Care’s other employees, each of the 40,000 workers could have received an annual bonus larger than $3000. To look at it from the viewpoint of the health care system he supervises, the $124.8 million in Dr. McGuire’s total compensation, himself a single United Health Care employee (the CEO), could pay the entire salaries of 833 general internists at their current average incomes. Or, ignoring either of the previous options, the $124.8 million could fund the costs of managing one reasonable size community hospital for an entire year.

That CEO’s office only represents one layer of that massive, health management corporation‘s organizational chart. The 40,000 employees mentioned above are distributed throughout the association, in layer upon bureaucratic layer, each of which has a particular responsibility of one sort or another to supervise our heath care and improve the HMO’s bottom line. It is through those multiple layers that your doctor’s request for a procedure (therapeutic or diagnostic) must filter before his best interest in your well being can be approved, or disapproved, depending on the mood, knowledge and understanding of the filter person. A filter is commonly used to remove something that passes through it. That which is removed may be something good or bad. A colander is a type of filter which saves the good stuff, i.e. rinsed broccoli, shrimp or boiled pasta noodles. Filters on furnaces trap undesirables as do oil filters in our autos. The filtering processes at United Health Care and other HMOs separate out those procedures (diagnostic or therapeutic) that some medically untrained clerical person decides you don’t need and which would be undesirable in regard to the company’s corporate profit; the proverbial bottom line. Just remember this very important, patently obvious and painful reality; the bottom line in any HMO or MCO (Managed Care Organization) ledger is not your well being, it is sadly their financial solvency. They are out to please their own innate greed and improve the health of their stock holders‘portfolio.

One case out of the many episodes of filtering that I could cite deserves mention here. I had a 40 year old female patient who three years earlier had undergone a mastectomy and breast reconstruction because of breast cancer. She was followed periodically by her surgeon and an oncologist. One day she came to see me because of an unrelenting headache that had been present for one week. My obvious concern was the possibility of a brain metastasis; a not uncommon area for her breast cancer to spread. When I called her HMO to request permission for an MRI it was denied by a girl who asked me to spell metastasis. She said that I should try Advil for the headache, not knowing that the patient had already done that on her own for the past week. We went ahead with the MRI without the permission of the HMO and unfortunately she did have a metastatic tumor. Her husband fought and won his case for reimbursement. My experiences with the HMOs are not unique; just ask any other primary care physician.

Other layers of the bureaucracy are less obvious to the physician and the patient being covered by the HMO plan. One such stratum involves the negotiating team who meets with employers for the purpose of getting you the least health care for your employer’s dollar amount. Another layer involves those clerks and secretaries who shuffle the massive reams of paper work that go into a bureaucratic operation of this sort. Another layer involves a surveillance team that goes into physicians’ offices and determines if they are in compliance with certain inane rules and regulations established by the HMO or MCO brain trust. Those rules, one of which I will further describe, have nothing to do with the manner in which your doctor discovers the cause of and treats your medical problem.

There is an obtuse, simple-minded and insensitive rule that requires a physician to initial every laboratory and/or radiological report before it goes into a patient’s medical file; we call that “busy work” and it serves no valuable, clinical purpose. There is no requirement that insures any follow up on that report, just the presence of an initial. One HMO nurse found that I was not in compliance with that rule and so acknowledged in a statement that I received from the CEO of that particular HMO. The case in question involved a 58 year old male’s X-ray report (ordered because he had coughed up blood) in which it was declared that he had a suspicious looking mass in his left upper lung field. The patient was a smoker and I had documented the numerous attempts on my part that encouraged him to stop that dangerous, carcinogenic (cancer causing) habit. I did not initial the X-ray report but after reading it I did call the patient and arranged for him to have a CAT scan for further clarification regarding the suspicious mass. I also had him make an appointment with me for follow up. I soon received the CAT scan report, read it, did not initial it, but did discuss the need for a thoracic surgery consultation with my patient and when he gave his permission I did so. I then called the thoracic surgeon, explained the problem and asked that he see my patient expeditiously. When the pathology report came back following his lung surgery, I did not initial it either but had a documented discussion with the patient and the surgeon about a follow up visit with a radiation oncologist. When I received the oncology report outlining the planned treatment, I filed it in the patient’s chart; again I did not initial it. The patient received excellent care despite my failure to comply with United Health Care’s ridiculous rule.

Having properly managed that man’s case, without initialing his various reports, I was criticized by the CEO of that bureaucracy known as a Health Maintenance Organization for a failure to chicken scratch my initials through out his file. Had I done so, while ignoring the X-ray report in which the suspicious cancer was noted, I would have met the HMO’s requirements, while my patient would have soon met his untimely death. This is the very kind of needless bureaucratic bungling we must eliminate by reinstituting a free market, consumer driven, health care system; maintained by knowledgeable physicians, not administrative bureaucrats. We must restore a system that is free of the managers that occupy the numerous layers in the hundreds of HMOs which dot our landscape and deny our care. In coming weeks I will explain how that free healthcare market works. That is when we will explain the cure for our ailing health care system. Next week however, I want to tell you a sad tale regarding a small town practice in Appalachia. If we have national health care it will be a story that is repeated time and again, and not just in small towns, but through out the larger cities in America as well.