Consumer Health Interests Are Not Being Served by the Health Insurance Companies

by Thomas Hinton

Every week, it seems like there's another news story in the newspaper, or on the television, about the plight of someone who has been denied vital medical care. I'm talking about American citizens who have health insurance and pay their bills.

Let's review the case of Scott "Scotty" Eveland, a 17-year old senior at Mission Hills High School in Oceanside, California, who was severely injured and paralyzed while playing for his high school football team last fall. While Scotty is making a slow recovery, doctors who are treating him at a San Diego County hospital, are cautiously optimistic about his progress and recommended to Blue Cross of California that he remain at their facility to receive daily physical therapy.

But, Blue Cross of California decided Scotty's care was costing too much money and ordered him moved to another facility. Despite the protests of Scotty's doctors, family, and the Oceanside community, Blue Cross of California refused to change its ruling. The family appealed the health insurer's decision but lost. The have made a final appeal to California state regulators who can -- and should -- overrule Blue Cross of California.

Blue Cross of California noted in its decision that similar care was available at a lower cost, non-medical facility. The family and physicians tending to Scotty strongly disagree. Something tells me they know best since they are involved in his recovery and care every day.

Given this scenario and the gut-wrenching experiences people and patients must suffer through, I must ask the ultimate question: Why is it that health insurers like Blue Cross of California serve as both judge and jury in these matters?

Something is fundamentally wrong here with the health care system and how it is managed. For two years, the American Consumer Council -- along with other consumer-oriented organizations and government agencies -- have rallied against the health care management establishment to challenge the injustices and unfair practices of companies like CIGNA and Blue Cross of California who serve as both judge and jury. In essence, claimants pay their insurance premiums and then, if it suits the whims and financial goals of the health insurers, they decide whether or not people like Scotty recover or remain in a vegetative state. As harsh as it sounds, that's what medical directors and other so-called "health care professionals" are deciding every day. It's a sham!

Is it possible that medical directors, who once swore allegiance to uphold the best care of their patients when taking the Hippocratic Oath (an oath traditionally taken by physicians pertaining to the ethical practice of medicine), have been bought-off by health insurers and compromised in their ability to make unbiased decisions? I think so. How else does one explain their decisions to deny care? Certainly, these men and women are intelligent people. But, it appears they've lost their ability to act rationally and in the best interest of their patient-claimants in order to save their employers a few thousand dollars! Yes, it's really money, but, it's also about the dignity of human life!

When you read the Hippocratic Oath, which dates back to the Fourth Century, and is attributed to the father of medicine, it states unequivocally what is expected of a physician. This includes the medical directors of health insurers who also took this oath:

1. To teach medicine to the sons of my teacher.
   
2. To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them.
   
3. Never to do deliberate harm to anyone for anyone else's interest.
   
4. To avoid violating the morals of my community. (Many licensing agencies will revoke a physician's license for offending the morals of the community).
   
5. To avoid attempting to do things that other specialists can do better.
   
6. To keep the good of the patient as the highest priority.
   
7. To avoid sexual relationships or other inappropriate entanglements with patients and families.
   
   

Clearly, sections 2, 3, and 4 appear to be in question with the continuing care and treatment decisions of certain medical directors of health insurers. This raises some interesting legal questions that consumer groups are exploring. For example, if the "Community" were to sue a health insurer's medical director (or other licensed medical personnel), and a jury found that individual to be guilty of violating their Hippocratic Oath, could the guilty medical director be suspended from practice?

Perhaps it's time for community leaders and families of patients to raise the stakes and organize major boycotts and protests at these companies so that legislators will take action to fix a broken system.

While many health care proposals have been put forward -- including an impractical proposal by Governor Schwarzenegger of California to require all Californians to purchase health insurance -- the ultimate answer, we believe, is for the federal government to adopt a universal health system that provides primary and urgent care for all citizens. Such a plan was introduced by the American Consumer Council and can be viewed at: www.americanconsumercouncil.org

In the final analysis, there must be a national health care program that eliminates health insurers and removes life-and-death decisions from the hands of people who have been compromised in their ability to make unbiased decisions because their allegiance is not to the patient, but rather, a for-profit company that mostly cares about making a profit and not improving the health of the patient.

About the Author. Thomas Hinton is the president of the American Consumer Council and can be reached at tom@americanconsumercouncil.org

New Year's Resolutions for Everyone Except Me!

by Bill Kalmar

Now that I have your attention, let me explain. This year I will enter a very special age group, namely, those people eligible for Medicare. The magical age of 65 provides one with certain mystical rights—Medicare benefits, of course, which means we’ll be swimming in extra disposable income. Yeah, right! And how about another increase in social security benefits without having to endure a performance review! And most importantly, the removal of all vestiges of political correctness, as if that ever encumbered me!

An added benefit is moving into the 65–69 age group for competing in sporting events or, as it’s sometimes referred to as “65 to death.” For those of you who may be runners you know that I will now be the youngest in a group of runners vying for prizes given only to the first three finishers in each age group. Not that this makes for a significant advantage because in my last 10K (6.2 mi) race, I was roundly beaten by a 72-year-old. I wonder if he passed the drug test.

In any event, I no longer have to make any New Year’s resolutions because changes to my lifestyle at this juncture could be injurious to my health, well being, and mental acuity. For me to make any personal resolutions would be a waste of time and thus I’m making them for all of you. Just chalk it up to senility.

Here’s what I’m proposing for 2008:

• I resolve that all wait staff in restaurants pay attention to me while taking my order and quit looking around to view other activities that may be going on in the restaurant. If I’m not the center of attention then perhaps my waiter should extract the tip for my meal from the people he or she is so attracted to. Is it too much to ask that the wait staff at least appear to be focused and interested in providing me with exceptional customer service?

• Speaking of restaurants, I resolve that all establishments serving food leave the hot water valve on in the restrooms. How many times have you encountered a restroom sink that only has cold water? I have a confession to make in that regard. On a regular basis when I discover a lack of hot water, I instinctively reach under the sink and turn on the hot water valve, which inexplicably has been turned off. On some occasions, I have even used my handy Swiss Army knife to override the system. How the wait staff washes their hands with cold water is beyond me. So next time you visit a restroom at McDonalds, Wendy’s, or Burger King and the water is hot, you have me to thank for it.

• I resolve that all phone calls I make in 2008 don’t contain the message: “For quality purposes this call may be recorded or monitored by a supervisor.” Do we really believe that someone is hired specifically to listen to phone calls all day? At one point in my career I managed a customer service telephone area and we found it just as effective by practicing “management by walking around” and overhearing the representatives rather then listening to reams of recorded messages at day-end. If there is to be a phone message I recommend that it be: “For truth of disclosure purposes, this call is not being monitored because we’re tired of fooling you to make you think that it is.”

• I resolve that when executives are released from an organization the words “Leaving to devote more time to other activities and family” be fully explained. What are those other activities and what does his or her family have to say about the executive's sudden arrival on the home scene? Is the family happy and content or would they rather the executive just focus on those “other activities.” Just when you thought you have heard all the reasons for someone to depart an organization try this from global chief growth officer Thomas Hernquist who spearheaded Hershey Co.’s premium and dark chocolate portfolios and who resigned from the company effective December 31. Hernquist said he intends to work on ventures that “leverage strategic consumer insights.” Wow! That is just too cerebral for my soon to be 65 year old brain! Why couldn’t he have just said that he was pursuing other activities? Or my favorite: “Leaving so I can function in a jerk-free environment.”

• I resolve that the words “merger of equals” and “synergy” be banned from business jargon forever. We all know that there is no such thing as a merger of equals—Daimler-Chrysler certainly proved that. In a merger there is always one dominant party and thus synergy means “We will look for ways to combine our processes but ultimately we bought your company so our processes will be used.” If that sounds cynical on my part, I think it’s also realistic. I, along with many of you, have been through mergers and frankly none have been pleasant. So for 2008 let’s substitute the words “Full court press take no prisoners buy-out” for “merger of equals.”

• I resolve that when organizations release staff because of the company’s desire to “go in a different direction” that new “direction” or strategy should be spelled out to the remaining staff and the shareholders. What if the new direction is contrary to the expectations of those who will now have to implement it?

• I resolve that all meetings start and end on time. In that regard, let me share with you the thoughts of two captains of industry on being punctual. First, Bob Iger, President and CEO of Walt Disney:“Meetings need to start on time. I’m zealous about that because my day needs to be managed like clockwork. If people are late for meetings, the meetings tend to go late, which throws off my agenda thereafter. I frequently start the meeting even if all the people expected to be in attendance aren’t there. I don’t need to say to people, ‘Be on time’, they know.”

And this from Simon Cooper, president and chief operating officer of the Ritz-Carlton Hotel Co.: “I’ve always believed that if you’re late, it says something about the lack of value you have for other people’s time. Being on time for all meetings is the best use of time in the workplace. I hope I’ve instilled that in my staff. I certainly embarrass them if they’re not.” That pretty much sums it up for me. One other comment and that is at the end of a meeting if someone leaves without an assignment that person wasn’t needed at the meeting and shouldn’t be invited back for subsequent meetings on the same topic.

• I resolve that all establishments that imprint a survey request on receipts provide me with on the spot reimbursement for completing the survey. Over the years I have completed surveys for every department store, coffee shop, bagel store, and sundry other establishments without benefit of a thank you. Sure the receipt indicates that I have been entered into a drawing for $5,000 but I doubt it. Just the other day I asked the Barista at a local coffee shop if he was aware of anyone who had ever won a cash prize by completing a survey and of course the answer was a resounding “No.” So from now on, I want a free coffee or bagel for completing the form.

Well, those are just some of the resolutions for all of you for 2008. If I sound like the fictional deranged character Howard Beale from the movie Network when he said, “I’m as mad as hell, and I’m not going to take it anymore,” so be it. At my age I think I’ve earned it and, yes, I am feeling a bit deranged from service expectations not being to my liking especially when it comes to hot tap water in restrooms. Does Medicare cover my idiosyncrasies?

Just so you don’t think that I’m bonkers, I want to make one resolution of my own. That is that you the readers of QualityInsider continue to invite me into your offices and homes for another year. I thoroughly enjoy the relationship with the experienced and professional staff of the publication and how they make me look so good each month. I also resolve to provide you with some thoughts on quality and customer service and other pertinent topics that hopefully you will find interesting, informative, and perhaps even humorous.

Now time to retreat into my ice-covered hammock. If some of my resolutions have left you perplexed and troubled just keep in mind the words of comedian Joey Adams when he uttered: “May all your troubles last as long as your New Year’s resolutions.”

About the author
William J. Kalmar has extensive business experience, including service with a Fortune 500 bank and the Michigan Quality Council, of which he served as director. He has been a member of the Malcolm Baldrige National Quality Board of Overseers and a Baldrige examiner. He’s also been named quality professional of the year by the Detroit Chapter of ASQP. Now semi retired, he’s a freelance writer for the Detroit News; writes a monthly column for Mature Advisor newspaper; is a mystery shopper for several companies; is a frequent presenter and lecturer; does radio voice-overs; and competes in duathlons.