Aetna outraged?

Aetna Insurance Co. is suing six New Jersey doctors for what it calls “unconscionable “ medical bills. One example was some alleged billing of $56,980 for a bedside consultation, another for an ultrasound alleged to have been charged at $59,490.

Of course those charges, if true, were ridiculously high. But what’s really going on between the lines. It’s the large insurance corporation trying to gain control over “out of network” physicians. You see for all the political ranting about the importance of our “free market” system, the insurance corporations believe that only applies to them. They should be able to double their premiums every three to four years and lower the coverage at the same time.

When managed care hit the pick your own doctor policies in the 1980s the insurance companies were in effect forcing doctors to join as member physicians. That meant that doctors had to agree to the insurance company’s determination of the value of their service. If the doctor agreed they were then listed in the directory and patients knew that their only financial responsibility would be their deductible and copayment. If you went to an out of network doctor the co pay amount could be higher because the out of network doctor could charge at a higher price and the patient would be responsible for the difference between what the insurance paid and the doctor’s charge. But along the way somehow it became okay for the insurance company to pay a smaller percent of their allowed charges to the out of network doctors.

Think about that for a moment. Two licensed physicians performing the same service but one gets paid more than the other because they are “in network”. The insurance companies were allowed to blackmail the doctors into signing up as “in network” and give up their rights to free market pricing. In fact, former California Governor Pete Wilson passed a bill that allowed doctors to have different prices for the same service. Previously it had been illegal to have different charges for the same service so that doctors couldn’t charge less to their cash patients and charge the insurance companies more. But that had to change to allow the doctors to begin charging the insurance companies less than cash patients.

Of course once the insurance companies got the doctors under their thumb, they started lowering their reimbursements for procedures each year. This is all part of the decline in the quality of health care that has occurred over the last few decades.

In 2007 Aetna tried to impose caps on out of network doctors and the New Jersey Department of Banking and Insurance said, “No.” They were fined $2.5 million. In 2009 Aetna, UHC, Cigna and WellPoint were forced to pay $90 million to settle underpayments to out of network physicians by the New York Attorney General.

So what this amounts to is Aetna and the other big insurance companies are fighting back by trying to take the offensive. Claiming that out of network doctors are ravenous scoundrels taking advantage of the poor insurance companies and their insured. And, that they must be controlled—by the insurance companies who will be best able to determine a fair price (is my sarcastic tone coming through?).

First off, anyone who doesn’t ask in advance what a service will cost is silly. You do it with the auto mechanic or with a home contractor, why wouldn't you do it with medical services. If the doctor has an outrageous price, fire them and go somewhere else. But, to put the insurance companies in charge of the value of the doctor’s services is akin to putting the fox in charge of the chicken coop. Remember, corporations are solely motivated by their own bottom line profit. Ask any CEO what his fiduciary responsibility is to the shareholders. The fact is that they have taken advantage of us, the premium payers, doctors, employers, everyone, in every opportunity they could. And will continue to unless they are stopped.

Health care reform could make things better, but most citizens have been bamboozled into thinking that the government can’t be trusted with the administration of health care. But if you stop and think about it, neither can the for profit insurance companies. At least we can vote politicians out of office. Can you vote the CEO of Aetna out of office? Well I suppose you could if you were a wealthy elite and owned many millions of shares of Aetna stock, but then you probably wouldn’t want to because it would hurt your portfolio earnings.

Also, sometimes the value of something extends in ways that can’t be measured with numbers. If health care isn’t profitable but provides greater health and productivity to our community increasing the quality of individuals’ lives how does one measure that in terms of corporate profit? You can’t, but the corporation’s mandate doesn’t care, because bottom line profit is the goal.

I for one will be interested to see if those doctors were really charging the outrageous fees claimed, but if they were, and it was legal to do it, is that any different than the big insurance companies doing whatever they want because they can get away with it.

At some point it’s my hope that we can get back a sense of fairness in our culture instead of the “if I can get away with it, why not” attitude. That applies to corporations and individuals alike.

Peace and keep reading between the lines.
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