On The Opportunity To Profit From Uninformed Patients

On The Opportunity To Profit From Uninformed Patients

The American Medical System is in a difficult and dangerous place right now. Healthcare services have become incredibly expensive, and the entire system has become so complex that few people fully understand it and even fewer can successfully navigate the system to get appropriate care that they can reasonably afford. My experience is that many people don’t see value in much of the care they receive or with many of the actors connected with their care. They know they need insurance to afford their care, but they really can’t see what value their insurance provides – it often appears to be more of a frustration than something most people appreciate. The same can be true for primary care, anesthesiologists, and the variety of healthcare benefits that employers may offer to their patients. There seem to be lots of people ready to profit from healthcare, but not a lot of people ready to provide real value to the people who need it.
 
These sentiments are all generalizations, and of course many people really do see value in at least some of their healthcare and are grateful for the care they receive. However, the complexity, the lack of transparency, and the ever climbing costs of care have people questioning the entire system, especially at a moral and ethical level. I think a great deal of support for Medicare for All, or universal healthcare coverage, comes from people thinking that profit within medicine may be unethical and from a lack of trust that stems from an inability to see anything other than a profit motive in many healthcare actors and services.
 
Gerd Gigerenzer writes about this idea in his book Risk Savvy. In the book he doesn’t look at healthcare specifically, but uses healthcare to show the importance of being risk literate in today’s complex world. Medical health screening in particular is a good space to demonstrate the harms that can come from misinformed patients and doctors. A failure to understand and communicate risk can harm patients, and it can actually create perverse incentives for healthcare systems by providing them the opportunity to profit from uninformed patients. Gigerenzer quotes Dr. Otis Brawley who had been Director of the Georgia Cancer Center at Emory in Atlanta.
 
In Dr. Brawley’s quote, he discusses how Emory could have screened 1,000 men at a mall for prostate cancer and how the hospital could have made $4.9 million in billing for the tests. Additionally the hospital would have profited from future services when men returned for other unrelated healthcare concerns as established patients. In Dr. Brawley’s experience, the hospital could tell him how much they could profit from the tests, but could not tell him whether screening 1,000 men early for prostate cancer would have actually saved any lives among the 1,000 men screened. Dr. Brawley knew that screening many men would lead to false positive tests, and unnecessary stress and further medical diagnostic care for those false positives – again medical care that Emory would profit from. The screenings would also identify men with prostate cancer that was unlikely to impact their future health, but would nevertheless lead to treatment that would make the men impotent or potentially incontinent. The hospital would profit, but their patients would be worse off than if they had not been screened. Dr. Brawley’s experience was that the hospital could identify avenues for profit, but could not identify avenues to provide real value in the healthcare services they offer.
 
Gigerenzer found this deeply troubling. A failure to understand and communicate the risks of prostate cancer (which is more complex than I can write about here) presents an opportunity for healthcare providers to profit by pushing unnecessary medical screening and treatment onto patients. Gigerenzer also notes that profiting from uninformed patients is not just limited to cancer screening. Doctors who are not risk literate cannot adequately explain risks and benefits of treatment to patients, and their patients cannot make the best decisions for themselves. This is a situation that needs to change if hospitals want to keep the trust of their patients and avoid being a hated entity that fails to demonstrate value. They will go the way of health insurance companies, with frustrated patients wanting to eliminate them altogether.
 
Wrapping up the quote from Dr. Brawley, Gigerenzer writes, “profiting from uninformed patients is unethical. medicine should not be a money game.” I believe that Gigerenzer and Dr. Brawley are right, and I think that all healthcare actors need to clearly demonstrate their value, otherwise any profits they earn will make them look like money-first enterprises and not patient-first enterprises, frustrating the public and leading to distrust in the medical field. In the end, this is going to be harmful for everyone involved. Demonstrating real value in healthcare is crucial, and profiting from uniformed patients will diminish the value provided and hurt trust, making the entire healthcare system in our country even worse.

Healthcare Profit and Subsidization

Healthcare Profit and Subsidization

Medicaid simply doesn’t pay enough for many medical providers to make a profit. The reimbursement rates often cover only fixed costs, and don’t really cover the full operating costs of a service. Medicare pays slightly better, usually covering operating costs and sometimes providing just enough for a small profit. Private insurance, however, pays a lot more than the two main public funding sources for health care in the United States. It is in private insurance that profit is to be made for medical providers.

 

As Dave Chase writes in his book The Opioid Crisis Wake-Up Call, “While employer and union health plans are roughly one-half of all health care spending, they likely represent over two-thirds of health care industry profits because they often wildly overpay for health care services.”

 

Think about who is most likely to need healthcare services: elderly and disabled individuals. Our system of Medicare pays just enough for providers to make a tiny profit, most of the time, for elderly patients. Our patchwork of state Medicaid systems, which many poor, minority, and often disabled individuals rely on for health care coverage, pays below operating rates for many procedures. While we have more elderly people utilizing the healthcare system and while we have more low income individuals with disabilities relying on healthcare, services for these two groups is not where profit is generated in healthcare. Instead, profit is generated from the reasonably healthy people who work steady jobs and heave employer provided insurance. The charges to private insurance companies are so high that even though their patients use less care, they provide a much greater percentage of the providers’ profit margins.

 

The first implication of this system that I want to highlight is the inequality in terms of access that arises within the system. If you rely on Medicaid, you may have trouble finding a provider who will take you. That is because the provider knows that while they will get paid for treating you, they might not actually break even for their time. There are other patients out there who offer more profit to the provider than what your Medicaid coverage will offer.  Because of the low reimbursement rates of Medicaid, many providers cap the number of Medicaid patients they see, making it harder for people on Medicaid to receive any services at all. For Medicaid patients, care is strictly rationed.

 

The second piece that I want to highlight is a way of framing the costs in this scenario. Providers lose money on Medicaid, maybe make money on Medicare, and jack up their prices for private insurance to ensure they make a profit at the end of the day. A lot of times providers will justify this approach by describing their high rates to private insurance patients as subsidizing the meager rates they receive from seeing patients covered by public plans. In a country that hates the idea of government redistribution and direct subsidizing of healthcare for the poor through taxes to support universal healthcare, we are already subsidizing the care of those who can’t afford care.

 

Most healthcare providers generally want to help people, it is usually a big part of what pulled them into their work in the first place. And even without Medicaid, many of them would likely still treat some people with no means to pay, writing off the free care they provided and potentially charging other patients more so they could afford to take on some charity cases. In a system built on empathy and care for the health and well-being of others, there is no way to avoid subsidizing other people’s care, at least a little bit.

 

I think we should be honest with the fact that we are already subsidizing healthcare to a large extent through our private health insurance system and the charges from providers for patients with private health plans. The incredibly high charges to private health insurance means higher premiums for everyone on those plans. For some reason we hate the idea of having to pay higher taxes for free health care, but are willing to shove out unreasonable healthcare premiums for expensive health insurance.
Self-Insured Health Plans

Self-Insured Health Plans

“A self-insured health plan,” writes Dave Chase in The Opioid Crisis Wake-Up Call, “is established when an employer sets aside some of its funds to pay for employees’ medical expenses. Employees then contribute to the plan rather than pay traditional premiums.”

 

In the United States, it is not uncommon for large employers to chose to be self-insured rather than to offer health insurance provided directly through an insurance carrier such as Cigna or Anthem. Chase explains that self-insured plans shift risk from the insurance carrier to the employer, with the benefit of reduced administrative costs and changed financial incentives. Large carriers are often still contracted with in a self-insured system for some administration and bill paying functions. In a traditional relationship, as Chase explains, employees pay premiums and “if the premiums exceed the medical expenses, the carrier wins.” Self-insuring eliminates this aspect of health insurance, reducing the total amount that employees should need to contribute by eliminating a profit motive for the carrier.

 

Chase highlights another benefit of choosing to self-insure, lower taxes and fewer regulations to abide by. In the United States, each state has an insurance commission that sets its own standards and requirements for insurance (auto, home, medical, etc…). The benefit according to Chase is that, “the Employee Retirement Income Security Act of 1974 [ERISA] states that a private, self-insured health plan is administered in accordance with its [ERISA’s] terms and federal rules. So, these plans aren’t subject to conflicting state health insurance regulations or benefit mandates.”

 

This is an important point that I have been thinking about in Nevada. My state requires that health insurance cover ABA treatment for children with Autism until they turn 21. However, not all of the plans that Nevadan’s have through their employers actually cover ABA treatment and some only cover ABA treatment until a child is 7 years old. While selling insurance across state lines (as in buying an insurance plan sold in California and according to California statutes and regulations) is not legal, offering a plan from a self-insured employer based in another state is legal. Some employers in Nevada are very large, are self-insured, and have headquarters based outside the state. These plans are not subject to the changing health insurance demands of every state since they are regulated by ERISA. So many Nevadans, despite state law, do not have coverage for their child’s ABA therapy.

 

It is important to note that self-insuring can reduce costs for employers, give them more control over the plan they design for employees, and can offer tax advantages along with easier implementation by reducing regulations and applicable laws. Employers should move in this direction to create better health plans that give them better access to their own data and needs. At the same time, we should recognize that these types of plans can be hard to regulate and present challenges to patients, employees, and lawmakers who want to see specific changes or policies. Employers should strongly consider self-insuring to get away from the profit motive of health insurance carriers, but should recognize that avoiding individual state health insurance requirements by self-insuring could lead to a backlash against self-insured health plans.