The health insurance system: a crash course

Pub date June 6, 2006
SectionNews & OpinionSectionOpinion

OPINION I am a family practice physician who recently opened a solo office in San Francisco. Since deciding to make a go of it on my own, I have, by necessity, undergone a crash course in the politics of medicine.

Change in our current system will only come about as the result of an educated public insisting on it. So, in terms as simple as I can manage, here is how it works:

You sign up for health insurance. You and/or your employer pay a monthly premium, and your insurer promises to cover some (but not all) of the health care costs you incur.

In exchange for the insurance company listing him or her as a network provider, your doctor agrees to accept the company’s payment rates and abide by its complex policies. These include rules to verify your insurance, document the visit, and submit the bills.

Your doctor has to hire someone to collect all your insurance information and verify the accuracy with your insurer before each visit. A second person is hired to review the charges and make sure they comply with the endless rules the insurance company has put in place.

In order to pay for the two new layers of bureaucracy, your doctor shortens the amount of time he or she spends with you. This allows him or her to see more patients per day.

The insurance company then comes up with all sorts of excuses for why it won’t pay for services you received, or won’t pay the amount it originally promised.

Your doctor now has to hire someone to fight the insurance companies for payment. Your doctor shortens appointment times further to pay for this additional level of bureaucracy.

Your doctor no longer has enough time to explore and discuss lifestyle factors that may be causing your symptoms. Instead, he or she takes the more time-efficient route of ordering a slew of lab tests and expensive studies when you come in with a complaint.

You never see the bills associated with your visits to the doctor and the testing performed, which creates the illusion that you are getting all this medical care for free.

The unnecessary testing drives up the cost to insurers.

The insurance companies see their profits decline and take steps to correct this, such as denying insurance to those with "preexisting conditions" (often something as simple as a brief period of depression).

Now your doctor has to hire someone else to deal with all the paperwork this additional bureaucratic level creates.

Again, appointment times are shortened. Not only do you have an endless wait to be seen, but you have to come back multiple times to get your questions answered.

The cost to insurers goes up further.

The insurance companies see their profits start to decline once again, so they pass the cost on to you or your employer by increasing your premium.

The patients are dissatisfied.

The doctors are dissatisfied.

And the insurance companies? Well, their shareholders are quite pleased. SFBG

Samantha Malm, MD, is one of a growing number of physicians who have decided not to contract with private insurance companies.