Hello, All:
There have been posts recently about insurance coverage -- I thought this
comment from another listserv's member would interest you. I removed all
references to the listserv, with the exception of the identity of the author
of the post.
Regards,
Margaret Tuchman (54yrs, dx 1980)

Subject: Medical insurance without insurance company

I read in the papers yesterday that 330 physicians in the Dayton area are
trying to group together and form their own managed care system bypassing
the insurance companies as middle men. The article wasn't very detailed
but the idea really intrigued me. Under the system they are attempting
to devise, the physicians would again be the only ones making the
determinations as to what is appropriate medical care (not some
uneducated flunky at a phone bank in an insurance office who has to
answer only to the accountants) and there would be no gag rule (legal
in some states) forbidding HMO doctors from even telling you about
often viable treatments that the HMO does not cover (ignorance is bliss?)...
Does anyone (doctors on this LIST) want to comment on this? Has it
been accomplished in other areas? There is some feeling that the group has
to be quite a bit larger to garner support from corporate benefit
programs (the managed care system I use has 1,700 doctors in it) but it
seems like a step in the right direction.

One doctor's response:

Here we sit, in the midst of managed care: the Clintons, only four
years ago, had set this as the proudest diadem in the crown towards which
they aspired, and seemed utterly crushed when the plan did not make it
through Congress. Well, don't feel sorry for them: legal mandates
would have been only the icing on the cake - economics forces were already
at work, and the business of medicine (including the pharmaceutical
industry, which is why I am currently sweating out what is going to
happen to my department, my company and myself when the FTC finally
allows Sandoz to merge with Ciba) was already undergoing massive
change.

But I am getting ahead of myself. The idea of the physicians at
Dayton is not a new one - in fact, it came long before the managed care
industry became as it is today. Once medicine became more of a
science than an art, the sophistication made it virtually impossible for any
single human brain to span the entire realm of medical knowledge. As
a result of this, the phenomenon of "specialization" and "sub-
specialization" became the order of the day: when I became ill as a
child, I went to the family doctor; my mother and father went to the
same doctor. Sometimes, the doctor came to us - no, this was not in
the middle ages: it was in the 50's and 60's of *this* century. Referral
to specialists took place, but it was somewhat exceptional. Pretty soon,
however, generalists like the doctor under whose care I grew up
became rare, and everyone became a specialist. That's when someone had a
brilliant idea: "Hey, let's make medicine like a department store!
Medical arts buildings, with one stop shopping for all your medical
needs! In fact, let's all become partners in what will amount to a
huge group practice!" This became very popular in the late 70's and early
80's, and these groups called themselves "health plans" or even
"health maintenance organizations (HMO's)," staffed by doctors and run by
doctors. Great idea, right? Theoretically, yes (and I wish those
physicians in Dayton all success) - but there was a basic problem.

Physicians are, as a rule, *lousy* businesspeople (that's why I got
an MBA at University of Phoenix online; and I *still* don't have real
business savvy). Despite the fact that they are characterized as
making lots of money, they never know what to do with it (which is why
investment counsellors call them constantly), and soon after they
organized HMO's, they started going bankrupt left and right. So they
appealed to folks who really know how to handle money: insurance
companies.  For those of you who are not aware, insurance companies
are *not* in the business of protecting you from catastrophe - they are
in the business of making money for their investors; that's fine for
the investors, and, to be fair, it does work out well for many people
paying the premiums - but I have heard a lot of expressions of
dissatisfaction, and that is to be expected - because if everyone were
satisfied, I daresay the managed health care industry would be in the same
straits as were the HMO's fifteen or twenty years ago.

So where does that leave all of the consumers? They wax nostalgic
over the days of the art of medicine, despair over the dehumanizing
transition to the science of medicine, and complain bitterly over
the current business of medicine - except some of them don't simply
complain and chuckle at comic strips like "Jump Start" and "Close to Home"
which lampoon the crazy state of medicine, which pleases neither
practitioner nor patient - they act!

Who acts? Connoisseurs and all of the hundreds, soon to become thousands, of
people in this and other newsgroups, not to mention the millions who
are surfing the net (25% of them in search of medical information). And
the situation is ripe for change: let me illustrate with a common example.

What if you were to take your automobile into a mechanic because the
engine didn't sound quite right. When you came back later in the day,
what if the mechanic were to announce: "Yeah, it was making a noise,so
I replaced the exhaust system and the transmission and all the belts
and valves and there's no more noise so I guess it's fixed. That'll be
$1588.99." How long would that mechanic stay in business once you
told all your friends about him?

Well, gentle readers, you may think medical establishments and
insurance companies are too large to be subject to the kind of pressure you
and your neighbors might be able to bring to bear on that mechanic (and I
am not saying he is necessarily a *bad* mechanic - just a highly
inconsiderate one) - but I contend that nothing is beyond the power
of economics: if it could destroy a bureaucracy as ponderous as the USSR,
it could eat a managed care organization for breakfast and still have
room for dessert. And in order to facilitate this change, which will
be be brought about by "We the Consumers," medicine will make one more
transition, to The Discipline of Medicine - and doctors will become,
more and more, what their name means: from the Latin "doceo," "to
teach," - they will become teachers/consultants to their patients.
Just as that mechanic should have used his expertise to examine what was
wrong with your car, and then *educated* you so that you could make
an intelligent decision, so the physician should *educate* you to make
an informed decision about your health and your body (or that of your
loved one, if you are a caregiver).

But there is still an important question: who is going to pay for all
of this? And the answer is, simultaneously, the simplest and most
complex part of this entire tale: we are. We may pay for it in taxes, we may
pay for it in bills, we may pay for it in insurance premiums, but
whatever means are worked out by governments or corporations, we are going
to
pay for it! So, since we are going to pay anyway, we might as well get
value for our money. Therefore, I encourage and exhort each and every one
of you: demand value! Learn as much as you can, and if you have
questions, ask - and don't stop asking until you are satisfied. You are
ultimately responsible for your care - don't give anything less than your
best effort to that responsibility.

And, if we all do that, we shall surely live long and prosper.



<=-----------------------=>| "There's no point in
Mark David Grebenau, MD,PhD| being grown up if you
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