Sunday, May 15, 2016

Medical Insurance Companies: Heroes or Villains?

Physicians are expected to be hostile to insurance companies.  Indeed, a prior Whistleblower post directed arrows in their direction.  They are an easy target, often vilified for their greed and perceived indifference toward those they insure.  Ask most of us if we think insurance companies favor profits over patients, and most of us will respond that profits prevail.

Insurance companies are businesses, not charitable undertakings.  Sure, we all like free stuff.  Or, if it’s not free, we prefer that someone else pays for it.  We are outraged at the costs of chemotherapy, hepatitis C treatment and biologic treatments such as Humira and Remicade, leaving aside the zillions of dollars it takes to research, develop, manufacture, market and monitor innovative new drugs. 

We want to drive a Cadillac, but only pay for a Chevy.

We want to pay for this...

...and drive this.

No person, business or organization is wrong all of the time.  Consider the following practices.  Who’s side are you on here? 

A patient has chronic back pain and ran out of his pain medications on the weekend.  He calls the doctor and is connected to a weekend covering physician who declines to refill the medicine.  The patient then proceeds to an emergency room, where he is evaluated and given the desired prescription.  Who should pay for the ER care?

A patient is seen in the office and prescribed a 2 week course of antibiotics for diverticulitis.  The medicine nauseates him and he stops them in 3 days.  He does not contact his physician.  Ten days later, he develops severe abdominal pain and fever and needs to be hospitalized for severe diverticulitis.  He is in the hospital for 5 days and is seen by numerous medical specialists.  Who should pay the costs of this hospitalization?

A 55-year-old individual has never had a colonoscopy performed.  His primary care physician advises him to proceed, but the patient declines.  A decade later he is discovered to have colon cancer and needs to be hospitalized for surgery and evaluation by an oncologist.  Who should pay for the costs of his care?

If a patient with high blood pressure, skips appointments and his medications, and a complication develops…

I’m not carrying water for the insurance companies.  I am pointing out, however, that we often expect them to pay for medical care that is either inappropriate or should not have been necessary.  That’s not reasonable or fair.   Don’t we have a responsibility to be personally responsible?


  1. While I agree with personal responsibility your scenarios imply that medical science can foresee or forestall all medical conditions. Treatments and screenings are not perfect and can often do harm themselves (who should pay for that?). Insurance can and should pay for major medical expenses but those expenses should be priced at affordable levels, not at the high levels seen today. Let's face it, today's pricing includes costs that have nothing to do with medical care (administrative costs, bigger fancier hospitals, and yes, profits).

  2. I think an earlier blog I wrote this year is relevant to this discussion ( It highlights the concept that health care is not delivered by physicians of health systems alone, it is co-produced by "providers" and patient together. It may be best to view this not as a personal responsibility issue but as a co-producer competency issue. Without a competent and engaged patient (and perhaps family) partner in creation of health care outcomes, the outcomes will always be suboptimal. Whether specific investments in optimizing this (?patient education) or changes in incentive structures can improve engagement is an open question. There may be specific individuals where no amount of investment will help.

  3. Appreciate comments above. @anonymous quickly drifted away from my primary point - the primacy of personal responsibility. @MC, uncertain I grasp your point that personal responsibility should be morphed into a 'partnership' between patients and professionals. I think in medical care and in life we need to accept the consequences and enjoy the benefits of our decisions. If a physicians advised a screening colonoscopy to an informed pt, and the procedure is declined, then future (or present) unwanted growths in the colon are solely the patient's responsibility. If a financial advisor recommends an investment, and I decline to invest, is it both our responsiblities of the investment's return soars and I have missed out? I think across society there are ongoing attempts to blame others for adverse events.