Prepare to Defend Yourself ... How to Navigate the Healthcare System and Escape with Your Life

Chapter 8. The Business of Medicine: The Best Things in Life Are Free, but I Still Need Your Co-pay

C H A P T E R 8 THE BUSINESS OF MEDICINE THE BEST THINGS IN LIFE ARE FREE, BUT I STILL NEED YOUR CO-PAY 174 CHAPTER 8 THE BUSINESS OF MEDICINE 175 M ost people go into medicine because they want to help people. It’s a noble principle and speaks well of their motivation . In order to do this, they study the intricacies and mysteries of the human body, the pathologies that assail it, and how to counteract them. In short, they want to save lives, improve the quality of those lives, and minimize disease, misery, and pain. It’s with pain in mind that I’d like to talk about the business of medicine. It’s really ironic, because after all the training and effort that a healthcare practitioner goes through, the one area that goes educationally underserved for them is the business and law of the practice of medicine. In the past when physicians were sort of stand-alone entities, business acumen and understanding weren’t such a big deal. Traditionally, physicians would adjust their fees based on their knowledge of the ability of a patient to pay. In the most primitive state, the exchange for treatment and cure would be by barter. Many years ago a country doctor could often expect payment in terms of livestock or a promise of the sale of a crop. That concept gave way to partial payment and the installment plan. In some cases a physician could waive a fee entirely. Now, the mechanics of compensation, authorizations, co-payments, co-insurances, and healthcare underwriting is a complex, bewildering, fatiguing, and frustrating series of steps that do not always follow a logical or predictable progression. So you understand the reference to misery and pain! At the very least, it is an additional distraction and irritation during an already stressful time. At its worst, the delay in authorization can result in a threat to life. What you are up against is that health care in the United States is big business, and it falls into a few major categories: managed care, pharmaceuticals, insurance, and medical services. To put this in perspective, table 3 illustrates the earnings of the major players in health care in 2011. What does this mean? It represents the potential influence on public health policy and law and what recourse you as a consumer will have. Think that is not important? Look at the amount spent in lobbying efforts. During the Affordable Care Act debate, the industry spent $102.4 billion in 15 months. According to the Center for Responsive 176 CHAPTER 8 Table 3 Healthcare EARNINGS 2013 Insurance and Managed Care Revenues Profits Rank Company $ billions 1 UnitedHealth Group 110.0 5.56 2 WellPoint 61.7 2.65 3 Humana 39.1 1.22 4 Aetna 36.6 1.65 5 Cigna 29.1 1.62 6 Coventry Health Care 14.1 .487 7 Health Net 11.5 .122 8 Centene 8.7 .0019 9 WellCare Health Plans 7.4 .1847 10 Molina Heathcare 6.0 .0098 Medical Facilities Revenues Profits Rank Company $ billions 1 HCA Holdings 36.8 1.605 2 Community Health Systems 15.0 .256 3 Tenet Healthcare 10.1 .152 4 DaVita HealthCare Partners 8.5 .536 5 Universal Health Services 7.8 .443 6 Health Management Associates 6.8 .164 7 Vanguard Health Systems 6.5 .057 8 Kindred Healthcare 6.2 — Pharmacy and Other Services Revenues Profits Rank Company $ billions 1 Express Scripts Holdings 94.4 1.312 2 Quest Diagnostics 7.5 .5557 3 Omnicare 6.2 .1949 4 Laboratory Corp. of America 5.7 .583 THE BUSINESS OF MEDICINE 177 Pharmaceuticals Revenues Profits Rank Company $ billions 1 Johnson & Johnson 67.2 10.853 2 Pfizer 61.2 14.57 3 Merck 47.3 6.168 4 Abbott Laboratories 39.9 5.9629 5 Eli Lilly 22.6 4.0886 6 Bristol-Myers Squibb 17.6 1.96 7 Amgen 17.3 4.345 8 Gilead Sciences 9.7 2.5916 9 Mylan 6.8 .6409 10 Allergan 5.8 1.0988 11 Biogen Idec 5.5 1.380 12 Celgene 5.5 1.4562 Medical Products and Equipment Revenues Profits Rank Company $ billions 1 Medtronic 16.5 3.617 2 Baxter International 14.2 2.326 3 Stryker 8.7 1.298 4 Becton...