Health Care and “Insurance”


There is an unmistakable revolution occurring in Healthcare. As a direct consequence of this, you are losing control of your health care provider and your money spent on health care insurance. You may not even be aware of this. The government and insurance companies would like you to think this problem is due to “greedy doctors.” In fact, the problems we are encountering are not new or unique to the United States but are throughout the Western World. No country’s solution to the problem of providing wide access to Health Care at a reasonable cost has been adequate. Canada’s Health Care System has struggled in the past with care access but has improved. Britain turned full circle from private fee for service to a pure government-subsidized Health Service back to the partial reinstitution of private care. This is largely due to inefficiencies in a highly bureaucratic government-controlled system where cost outweighs quality, and the social and personal impact of health problems are ignored rather than incorporating them into the complex equation. Sweden has excellent health care with a nationalized health care delivery system contributing to a large tax burden on the public. The United States is currently groping in unexplored territory with a Health Care System which most would agree is little more than a huge experiment. We also have the largest cost for treatment which is fragmented. This is clearly a result of Lobbying by Private Health Care Insurance companies monetary considerations and a lack of regulation.


The history of American Medicine is important in understanding why we have our current problems. Health Insurance did not exist prior to 1937. It was created in response to the Great Depression and the inability for hospitals to survive when few had money to pay. Health insurance companies were given special antitrust protection because of this unusual situation, and they continue to retain this special protection despite a very different world and healthcare landscape. On the other hand, individual physicians are still treated as large corporations. They are not allowed to speak about what they charge, nor act together as a unified group despite the fact that what they charge is unrelated to what they are paid; if they are paid at all. Large hospital groups and Insurance Companies, on the other hand, use your health care premiums to advertise on billboards, TV, and Newspapers, for care which they don’t provide and pay little or nothing for. “Managed Care” should be more appropriately called “Managed Profit” or “Managed Racketeering”! Most patients are happy with their own doctors even when they are unhappy with their shrinking coverage for care. Despite inflated claims of insurance companies, they provide less every day to you, pay less to your providers of care, and have decreased insurance premiums little or more often increased them. Depending on your carrier, over 20% of your health care dollar is taken as profit by your insurance company which accepts less and less risk, while the physicians are forced to accept more.

Nearly all the driving force behind the health care revolution is purely monetary. There is little or no competition if the only survivors in the new order are large conglomerate groups of physicians battling over a shrinking dollar and they are pitted against one another by insurance companies whose motive is primarily to profit their investors, and not to improve health care to their patients. Since this article was written more than 10 years ago, many changes have occurred which have only made the situation worse. I believe everyone should have access to affordable health care. Unfortunately, the “Affordable Care Act” has allowed “Insurance Companies” to have even more control of your Health Care Dollar. They hold money and pretend that there are “errors” in the submission of billing. They continue to increase your copays while providing less service. Even with “good coverage”, you essentially pay for everything despite having “Insurance”. The Hospitals also remain well positioned, controlling more of your Health Care Dollar as well. There is little or no hospital oversight, and you only need to be hospitalized once to see the enormous charges quickly created.


It is important to realize that your only Health Care advocate is your physician in an increasingly complex health care landscape. Without your doctor, nobody is going to make sure you get what you need. Some physicians are more dedicated to this than others. This is not related to practice employment, hospital affiliation, or part of a large multispecialty organization. Most physicians maintain high ideals and continue to practice the Hippocratic Oath, placing patient care ahead of all other considerations. You must realize that these physicians do this at risk to their own professional survival for your well being.

You are the most powerful advocate for your own health care. You alone can improve the situation.

Physicians are generally felt to have too great a financial interest to be unbiased. Because of this, we have great difficulty in influencing legislation. In addition, those who are your strongest advocates have the least time to direct at political change. Most physicians practice the best medicine they can, utilizing the highest standards they know. There is a scientific basis in treatment and rational care is based on personal experience and training. We are currently attempting to further validate what we do to show what works best and what should be deleted from the medical armamentarium. Outcome studies are the new order of highly sensitive tools to capture what you think about your health care and what needs improvement. The best person to collect this information is your physician. He or she is trying to work to improve your health care and learn the most expedient route to the best result. In the hands of Insurance Companies, this information may be easily misinterpreted without complete knowledge of the long-term benefits of treatment. It is unfortunately easy to examine today’s costs without considering tomorrow’s related savings. A simple example of this is the elderly patient with a hip fracture. Without adequate care, this patient will end up in a Nursing Home for a long time or the rest of their life. When treated appropriately, this same patient generally is home within one or two weeks and continues to function as a valuable member of society at a reduced overall cost.


Technology is often cited as the reason for the inflation spiral in health care costs. Certainly, technology needs to be used judiciously, however, much of what we do now is so much more cost-effective than 5 or 10 years ago, that it is absurd to blame technology on medical costs. In Orthopaedics, only 20 years ago femur fractures were treated with 6 weeks of traction in the hospital. Now, routine intramedullary internal fixation allows the patient to be walking the day after surgery and often return home one or two days after surgery. Not only are the direct cost differences enormous, but the indirect cost difference to society in a rapid return to work and the psychological improvements are inestimable. The same is true with ligament injuries. Ten years ago they were routinely treated with open knee surgery and required over a week convalescence in the hospital. Now, routine ligament reconstruction occurs with Arthroscopic techniques. This is more technical, but the results are more reproducible, and often the patient returns home the same day as surgery or at most stays overnight in the hospital. These patients are treated without casts and may return to light work within a week or two of surgery. The cost to treat these patients is low in relation to the long-term benefit gained. More important are the ethical considerations involved in medical decision making. Decisions regarding medical or surgical treatment options are best made with patient, family, and physician together. These decisions are not always easy, but families and patients generally choose what is best for themselves, and the physician need only listen. Medical decisions need to be made by you, not your insurance carrier, government, or employer.

Choosing your Insurance

You have power when you decide what insurance you purchase. Unfortunately, you may not have a choice if your employer offers only one or two options. In this way, the Insurance Companies have gained even more power by removing your influence on your health care one step further. If you can choose between several alternatives, pick whatever gives you the most freedom to choose your physician. Ask exactly what is covered, what your co-pay is, and for what. Often patients are not aware that co-payment is required or that payment is denied for simple things like crutches, braces, or even surgery. Truly the only thing that Insurance Companies “insure,” is their own profits. Be a savvy consumer and write your legislature.

Remember that the future of Health Care in this country is in your hands!

Compliments of Sports Medicine and Orthopaedics, East Providence, Rhode Island