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A Doctor Speaks Out
He's Mad As Hell and Won't Take It Anymore.

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This comes from an internist. He has had a primary care practice in the New York metropolitan area for more than 20 years. For obvious reasons, he asks to remain anonymous. I've met him and can vouch for his identity.

Right now, I have dropped my participation in every insurance plan except Medicare. I can tell you from first-hand experience that the private managed care plans are out of control with their denials, pre-authorization requirements, and drug formulary restrictions. Plain old Medicare is the last bastion of health care insurance that actually allows the doctor to make a decision on what a patient needs without having to fill out reams of paperwork or spend endless amounts of time on hold, waiting for insurance company representatives who barely have a high school education to tell me if I can provide needed procedures or specialist referrals for patients they've never laid a hand on.

Has anyone looked at the expenses of a primary care physician's practice vs. the ridiculous insurance company reimbursement schedules for E&M (evaluation and management) services? That is, for actually talking to and caring for patients instead of cutting and irradiating them? My average reimbursement for a 15-minute office visit by a patient covered by a private managed care plan is about $50 vs. Medicare's $70. Too bad it currently costs me $92 to provide that same service. And can anyone explain to me why I have to pay $50,000 in salary and benefits for someone in my office to sit on a phone all day long fighting for my patients' health care needs? Especially when I'm attempting to authorize procedures I believe necessary that I will not earn a penny on? At the same time, radiologists and other overpaid subspecialists get to bill hundreds of thousands of dollars a year on the procedures I have to fight to authorize for them?

Or maybe someone would like to explain the insurance companies' wonderful new managed care formulary departments, which approve medication authorizaation requests -- or don't. Three times in the last two months they have rejected my requests for more "expensive" diabetic medications, invoking the requirements that all diabetics be given generic Metformin as a first-line agent. Unfortunately, these patients all happen to have weakened kidneys (common for diabetics) and would get lactic acidosis if I prescribed Metformin. It would likely kill them! But I guess dead patients cost the insurance companies less money than living ones. And I guarantee that some busy primary care physician's office will get one of these form letters and blindly sign it without taking the time to check the patient's renal function numbers ... but of course only the physician can be sued for a mistake like this, not the insurance company.

How about the patient I'm trying to treat with Symlin, a new diabetic drug specifically for Type II diabetics already on maximal treatment (including insulin) who are not reaching the goal of controlling their hemoglobin A1C levels? The formulary morons rejected my request for authorization based on the fact that my patient's sugar numbers were -- get this - too high! I've tried for three weeks to get the insurance company physician who denied the authorization on the phone, but he's never in the office; and every time I'm told he'll call me back within 24 hours, he never does. I've reported this to the Commissioner of the New York State Insurance Department, but the case could take months. Meanwhile, this poor patient is suffering a slow death from her uncontrolled disease.

Yet all I see in the press is how it's the greedy doctors -- broad brushed as an undifferentiated class -- who are driving up costs of health care. Take a look at the disgusting piece printed by The New York Times earlier this month, headlined Survey Finds High Fees Common in Medical Care, about doctors charging exorbitant rates for out-of-network care. Guess who provided the survey data? American Health Insurance Plans, a lobbying group for the insurance companies! ("The health insurers, saying they felt unfairly vilified, gave the report to The New York Times ... explaining that they wanted to show that doctors' fees are part of the health care problem.") I bet they and the Times reporter had to dig down pretty deep to find what amounts to 0.0000001% of the problem with the current system.

I can tell you for a fact that in the past 20 years, my reimbursement rates have dropped to about 30% of what they were in 1988, while my costs have at least tripled. My income has steadily declined every year over the past 10 years. It's now down to about half of what it was during my peak earning days. Meanwhile, the CEOs of the health insurance companies are making $10 million and more a year, with lord knows how much in deferred compensation and stock options. The CEO of United Healthcare walked away two years ago with $1.5 billion in compensation over his last five years running the company. Imagine how much care you could provide with a fraction of that money?

And so I am currently working on my exit strategy, as are many of my friends in primary care medicine. And if you think there are younger people eager to fill my spot ... think again! With an average of $300,000 in student loans, eight years of college and medical school, and four years of indentured servitude at minimum wage as a resident physician in a hospital, these poor fools will be starting out on their own at age 30 and often older in a job that might earn them $100,000 a year ... and that's if they're lucky.

Yes the system is badly broken, but not by my primary care colleagues. It's broken by the greed of the insurance and pharmaceutical giants who have sucked every dollar out of the system, and by the politicians who are in bed with their lobbyists, take their money, and do their bidding. So enjoy your new health care system. Nurse practitioners and foreign medical school graduates will be your new primary care providers managing 95% of your needs. I hope you don't come down with something serious that would actually require someone with knowledge and experience, to say nothing of the training ... as my friends and I will all be long gone.

You can sign me:

20 Years of Primary Care Practice and Totally Fed Up ...

Done.