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Shirley Crandall (her name and circumstances have been altered slightly in the interest of privacy) has been a patient in my office since late October last year.  She’s a hard worker who’s held a demanding job for many years as the financial manager in a home improvement business.  She’s survived a fair amount of hardship in recent years-- a divorce, pain from gallstones and then surgery, a temporarily disabling knee injury—but she’s always bounced back.

Things changed, however, this summer when her boss went on a rampage, violently slamming his fist on her desk, yelling to her face, looking for a victim upon which to blame his own business failures.  She became frightened, unable to sleep, unable to eat properly.  She felt jumpy and was unable even to drive in the direction of her work without developing feelings of intense anxiety.  She had developed a form of post-traumatic stress disorder.

As her physician, I provided some supportive counseling, prescribed medication, advised some time away from work, offered referral to a specialist, and, as the law requires, completed a report called "Doctor’s First Report of Occupational Illness or Injury":

Chapter 7. Division of Labor Statistics and Research
Subchapter 1. Occupational Injury or Illness Reports and Records Article 1. Reporting of Occupational Injury or Illness
§14003. Physician.  (a) Every physician, as defined in Labor Code Section 3209.3, who attends an injured employee shall file, within five days after initial examination, a complete report of every occupational injury or occupational illness to such employee, with the employer's insurer, or with the employer, if self-insured. The injured or ill employee, if able to do so, shall complete a portion of such report describing how the injury or illness occurred. Unless the report is transmitted on computer input media, the physician shall file the original signed report with the insurer or self-insured employer.

The process is fairly straightforward and is designed to protect a worker’s right to employment, to provide for income, and to pay for medical care. But as a method of providing health services the system is incredibly wasteful and counterproductive.

Ms. Crandall’s experience was no exception. Returning less than three weeks after her initial visit, Ms. Crandall was in worse shape.  The process of dealing with the paperwork required by her employer’s workers’ compensation carrier, "a nightmare" in her words, had exacerbated her feelings of anxiety and left her even more incapable of returning to work.  

With more specificity I again referred her for therapy and added to her medication. Just a day previously her claim had been accepted by the worker’s compensation carrier.  This was an important milestone, since had there been objection, a roadblock could have been erected. In California (the workers’ compensation program varies state-by-state), an employers’ insurer may object to taking responsibility for a claim and can in this way delay an employee’s access to care.

But even absent major delays (the approval for care came on day 20), the system operates glacially.  The process of getting access to a psychotherapist required multiple calls to the nurse serving as the medical case manager at the insurance company, each back and forth consuming a few days, at least.  It is hard to interpret the case manager’s role.  I was the doctor who assessed my patient’s condition.  Ms. Crandall, herself, was impaired by her disability, but was functional enough to look for a therapist, to make and keep appointments with me and to make phone calls to the case manager.  Ultimately, it seems her role could only be seen as one of producing delay in the name of service.

Eventually, my patient received a listing of insurance approved psychotherapists within a ten mile range of our zip code. I knew four of the sixteen names on the list. Ms. Campbell, however, called them all.  She had to. Nine denied accepting workers’ compensation patients.  Two never called back despite repeated messages.  Two were taking no new clients.  One had a disconnected phone number. One wasn’t a therapist. And the final one said he might consider her as a patient after a review of her medical records if she agreed to pay up front and deal with the insurance company on her own.

It was December 2 before Ms. Crandall finally saw a therapist (I won’t belabor the other trials and tribulations), six months after her initial consult.  Frankly, by this point time itself had helped her improve.  Maybe that’s the idea behind the insurance company delays, but at what cost?  She’s missed six months of work, time for which the insurer has had to pay. And she has suffered way more than was needed.

I could rail against the workers’ compensation insurer but the problem is more fundamental.  It just doesn’t make sense that health care should be paid for through a complex morass of different sources. In my practice alone, I am paid by dozens of different payers, each with different payment schedules, different referral networks, and different duplicative bureaucracies. There are HMOs, PPOs, HSAs, PPNs, and EPOs. There is Medicare, Medical (one of fifty different state Medicaid programs), SCHIP, Healthy Families, and Healthy Kids. There is health insurance, auto insurance, homeowner’s insurance, liability insurance, and, as in this case, workers’ compensation insurance. Sometimes the patient pays herself.

Although the same service, health care, is needed in every case, our country has developed an unbelievably complex network of bureaucracies which focus an inordinate amount of time and money "passing the buck". There are innumerable reasons why our health care system needs change (Check out Ten Excellent Reasons For a National Health Plan by Dr. John Geyman for a few.); Shirley Crandall's story is just one.

President-elect Obama has asked us to contribute our ideas for change and has said that the need for control of health care costs is a fundamental reason for undertaking health care reform.

The problem with President-elect Obama’s supposed emphasis on the costs of health care, however, is that his proposals fail to deal with the biggest source of wasteful expenditures, our dependence upon private health insurance.

His plans, by continuing to embrace a role for the multiplicity of private health insurance "options" in our system, weds us to the waste, profiteering, and venality of an industry that thrives on taking our money and spending as little of it as possible on the objective, instead seeking to increase the proportion of its revenue reserved for profits by directing its expenditures first to marketing, underwriting, "product development", and executive compensation.

For my patients, and me, I’d prefer my health care dollars be spent—surprise!- on health care. Only a move towards single payer "Medicare for All" can do that.


Originally posted to doctoraaron on Mon Dec 15, 2008 at 07:13 AM PST.


I am going to log on to and tell Obama and Daschle

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Comment Preferences

  •  Single payer would simplify the system. (15+ / 0-)

    Part of the reason it's debilitating now is because it's so complex.
    If the cure is simple, the disease will be cured.
    If it is complex or access to it is hindered too much, it's not really a cure or treatment.
    Anything that promotes anxiety is counterproductive here.

  •  One addendum (28+ / 0-)

    I encourage you to scroll down my diaries and read the initial December 7 "Tales of a Family Doctor" entry for a further discussion of the trials of our health care system from the perspective of a family doctor.

    Dr. Aaron Roland is a family physician in Burlingame, CA.

    by doctoraaron on Mon Dec 15, 2008 at 07:22:08 AM PST

    •  I already DID log on to (5+ / 0-)

      and submit just this question.

      Well, actually, I submitted a two-part question:

      Will you increase payments to primary care physicians, ensuring more of them will accept Medicare and Medicaid, and thereby reducing the number of extremely expensive ER and Urgent care visits by those unable to find a primary care physician?  And what about Universal Single Payer Healthcare vs Insurance?

      From my, in the weeds, viewpoint (I work in a small primary care medical clinic), this is the overwhelming problem with healthcare in These United States.  

      Healthcare Insurance is available to almost anyone, even the poor (who qualify for Medicare and/or Medicaid).  

      Finding a doctor who will accept that insurance?  Now, that's a whole nother kettle of fish.

      Why don't we have enough money to provide reasonable, preventative and regular primary care to our citizens?  We're busy throwing about 33% of every healthcare dollar in the insurance pit, never to see the light of day, or provide a single bandage or aspirin to a patient.  

      Where does it go?  Insurance profits, executive insurance company pay (more than $350 million for the four heads of the biggest insurance companies for the year 2007) and 'administrative' costs is where all that dough goes.

      Just ask yourself (and then, PLEASE, ask your state and federal legislators), how much more healthcare could be provided for that 33%?

  •  UHC denied covering my meds for (5+ / 0-)

    an appeal process that lasted six weeks. My doc said there was no way they weren't going to cover the meds, they just wanted no to for six weeks.

    Single payer now!

  •  This case goes to show, among other things, (2+ / 0-)
    Recommended by:
    ER Doc, cynndara

    that people without interpersonal skills should never end up in management positions. But all too often--in my experience--they do, and they cause an awful lot of damage in lost productivity and frayed employee morale.

    I know that wasn't the real point of your diary :)

    Single-payer healthcare may not directly help situations like those that caused this woman to file for worker's comp--but it will help a lot else about our healthcare system.

    Thanks for posting.

    •  why single payer makes a difference here (12+ / 0-)

      If we had single payer then there would not be the issue about who and how this patient could get the care she needed. She and I would confront a simplified system which we could deal with.

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Mon Dec 15, 2008 at 08:51:42 AM PST

      [ Parent ]

      •  Also, while looking for a new job would still be (11+ / 0-)

        daunting in this economy, she wouldn't have to worry about whether she'd have health insurance if she decided to leave the employ of an abusive boss.  

        Nor would she have to worry that this condition wouldn't be covered.  And if his bad business decisions took the company down, she might have to worry about keeping her house or food on her table, but she wouldn't have to worry about what would happen if she got sick or injured again while she was out of work.

      •  There cold still be some issues (0+ / 0-)

        when it comes to mental health care. This is definitely the case in the UK, where I live--there is a shortage of therapists willing to work for the NHS, when private-pay patients are so much more lucrative (and, often, more healthy and so less "difficult"). I've spent over a year trying to get a course of CBT therapy for my autistic son, who also suffers from depression. Admittedly that's a specialist call, as most CBT providers haven't worked with people with ASD, and their practice does need to be adapted for this to work. But honest to god, I could have completed a degree and started doing the work myself (I know, unethical with your own kid but I'm making a point) in the time it has taken to get to the evaluation stage.

        There's also the issue of licensing--many of the people out there who are providing therapy are not properly licensed.

        That said, this was no easier when we were part of two different HMOs in the US, and considerably more difficult (impossible, in fact) when we were saddled with "junk insurance" in the US.

        I beleive a single-payer system has the most promise for effecting REAL mental health parity.

        Political Compass says: -8.88, -8.67
        "We never sold out cos no one would buy."--J Neo Marvin

        by expatyank on Tue Dec 16, 2008 at 12:59:12 AM PST

        [ Parent ]

        •  Mental, dental, vision are also healthcare. (1+ / 0-)
          Recommended by:

          The fact that they are split out as separate from "medicine" is appalling to me. The complications from an abscessed tooth that sent me to the emergency room would not have been an issue if dental was covered by the healthcare plan. I mean, GAD, I wound up with a CAT scan on top of everything else! And then I had to shell out several thousand dollars I had slated to pay medical bills with to have an expensive root canal and crown done that could have been avoided if (a) the "affordable" dentist I initially went to had not been incompetent and told me the pain I was having was not due to my tooth, (b) I had been able to afford to get a second opinion, OR (c) my doctor could have said to me "I think your pain may be dental in nature; I'll give you a referral to a dentist" and then have that visit covered just like a referral to any other specialist would be.

          I just do not understand why every body part except for the eyes, the teeth, and the brain (which is where the "mental" comes from, after all) is considered "medical" but those exceptions are not. Just because it takes a specialist to manage, for example, renal issues, does that mean that anything having to do with the kidneys ought to be split out of the healthcare equation?

          Diseased teeth, mental illness, and problems with the eyes (and ears, too) can certainly impact a person's overall health. I think it's penny-wise, pound-foolish on the part of the healthcare system to carve them out and ignore them like they do.  Ultimately, if for no other reason than people have to cover the exorbitant costs of these "non-medical" healthcare essentials out of pocket as well as their doctor bills, their other "medical" healthcare providers likely will not be paid or will be paid very, very tardily (as in my case).

          No wonder people delay getting care and wind up self-medicating themselves in ways that contribute to even more poor health. We need a more holistic approach.

  •  What if you could have.. (6+ / 0-)

    ...billed for the hours wasted on paperwork?  Lawyers bill for every single minute, door-to-door, for each single half minute of time spent on a client's case, but physicians?
     Many years ago, shortly after insurers started requiring prior authorization for everything, the nurses in the oncology office where I practiced found themselves spending long minutes of time waiting for the glacial responses of the case managers.
     Mind you, this oncology practice had about 40 oncologists in the practice, and a huge presence in the area.  The word came down from our CFO that the nurses were to note down the amount of time spent on hold, and then the practice sent a bill to the insurance companies for the time the nurses spent on the telephone.
     Back then, this little act of payback made a difference.  The various insurers, finding themselves hit with bills for making RN's wait on the phone starte expediting the prior authorizations.
     Sometimes it helps being an 800-pound gorilla.
     But that was back then.
     That would not work now.  They'd just laugh and start slowing down payments even more.

    "Respect for the rights of others means peace" Benito Juarez

    by drchelo on Mon Dec 15, 2008 at 09:01:45 AM PST

  •  very valuable diary, thank you n/t (1+ / 0-)
    Recommended by:
    ER Doc

    Dream, that's the thing to do (Johnny Mercer)

    by plankbob on Mon Dec 15, 2008 at 09:12:42 AM PST

  •  outrageous profits (4+ / 0-)

    When United Health paid (later recinded) a golden parachute to its resigning CEO in the amount of over $1 Billion (with a "B") -- I knew the waste in our health care system had to be eliminated. That means the waste, fraud, ungodly profits and complications of the private health insurance companies

  •  We have lawyers that write the law (2+ / 0-)
    Recommended by:
    cynndara, Kharafina

    Lawyers make money when someone is blameworthy.

    No blame means no money.

    You certainly wouldn't want to pay for the damages caused by my negligence, right?

    From Pennsylvania's new adultBasic program benefits manual:


    In the event that legal grounds for the recovery of health care costs exist (such as when an illness or injury is caused by the negligence or wrong-doing of another party), Keystone has the right to seek recovery of such costs, unless prohibited by statute or regulation. When requested, the member must cooperate with Keystone to provide information, sign necessary documents and take any action necessary to protect and assure the subrogation rights of Keystone

    And, if there was no culture of blame and no hell, the collection plate would be less loaded on the Sabbath.

    Pay up all ye sinners.

    •  So crappy negligent doctors would get a (0+ / 0-)

      free pass? And continue harming patients through falling below a minimum standard of care?  Great system.

      Basically what the paragraph on subrogation you quote means is that if you get hit by a car and injured, then you can be forced to sue and the insurance plan gets first crack at the recovery to gets its money back.

      Example: my sister in law was injured in a crash where the only benefit was $50,000 from her auto insurance. The hospital bills were $40,000. Her healthcare insurer took it first leaving her with $10,000 for help while she was recovering outside the hospital, some required home remodeling and medical expenses the rest of her life. Some of the injuries were permanent and she had to give up her career as a Dentist (for which she was still paying student loans).

      The health insurance was entitled to that money because of a subrogation paragraph like that one. There was no lawsuit and no lawyers because the auto insurance paid automatically under their uninsurance coverage.

      We are in a time where it is risky NOT to change. Barack Obama 7-30-08

      by samddobermann on Tue Dec 16, 2008 at 12:40:59 AM PST

      [ Parent ]

  •  They have features people want (1+ / 0-)
    Recommended by:

    There are HMOs, PPOs, HSAs, PPNs, and EPOs. There is Medicare, Medical (one of fifty different state Medicaid programs), SCHIP, Healthy Families, and Healthy Kids.

    HMOs - everything covered
    PPOs - access to specific doctors
    HSAs - healthy people and the system save money
    Medicaid - we can't let the poor die, but they need to know their place
    Medicare - older folks vote since they don't have other things to do
    SCHIP - society cares more about children than adults
    Healthy Families - they can pay something, let's get their money

    •  Revised list (9+ / 0-)

      HMO's: tightly restricted network of providers
      PPO's: big deductible and co-pay
      HSA: work only for the rich and those who imagine they'll never get ill
      Medicaid: second class care for poor people
      Medicare: the highest patient satisfaction of any other U.S. based health health system
      SCHIP: How many different bureaucracies, public and private can we create?

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Mon Dec 15, 2008 at 12:05:34 PM PST

      [ Parent ]

    •  Features people want? (0+ / 0-)

      I have to say, I feel that you are one of the poor people in this country who have been brain-washed into believing that the 'free market' is the best way to provide our nation with a healthy citizenry.

      Those of us who are concerned with the overall healthcare of the nation believe that the best, most cost-effective way to provide that care is through a Universal Single Payer program.

      I am all for allowing the private insurance companies to offer supplemental coverage for all elective care.  But for basic preventative care and catastrophic care, we can no longer afford, as a nation, to allow 1/3 of all money spent on healthcare to go for insurance profits.  

      We can provide healthcare to all of our citizens, or we can leave 1 out of 5 people with NO CARE, and continue to fund the insurance companies.

      Which one of these choices is better for the nation, as a whole?

      •  Angie, it's not PROFITS taking the big bite out (3+ / 0-)
        Recommended by:
        cynndara, John Minehan, doctoraaron

        It's administrative expenses which includes the salaries of every employee many of which are needed to deal with the providers and patients that want their bills paid. And it also includes the ridiculously extreme compensation and perquisites of the top echelon.

        Administration costs includes billboards touting the hospitals and plans, the glossy brochures and other PR and marketing.

        Profits are a small part of the waste of having health care support the "free enterprise system" of health care.

        We are in a time where it is risky NOT to change. Barack Obama 7-30-08

        by samddobermann on Tue Dec 16, 2008 at 12:50:22 AM PST

        [ Parent ]

        •  When I say Insurance Profits (0+ / 0-)

          I mean, in the generally accepted usage of the term Profits.

          As in every business, Profits are the gross 'earnings' of a company.

          Net Profits, are the Gross Earnings, minus the Costs of Doing Business (employee salaries, advertising, etc).

          Hence, my use of the term 'Insurance Profits'.

    •  Snark, right? (0+ / 0-)

      Has to be. HMO's cover everything? That is HYSTERICAL!!!

  •  Workers Comp far worse in NY State. (2+ / 0-)
    Recommended by:
    arlene, cynndara

    After years of struggle, our rural family medicine practice has reluctantly been forced to drop Workers Compensation from the carriers we accept. This was done with the greatest regret, because it is a genuine hardship for our patients who will now have to travel 50 miles to an occupational medicine clinic. But here's the thing: Workers Comp almost bankrupted our practice.

    In New York State, the Workers Comp system still works under legislation originally written in the 1930s, and repeatedly patched, modified and band-aided since. As a result it is an absurdly complex and adversarial system. Employers' Comp insurance carriers have a strong incentive to "controvert" claims, or deny that the injury is work-related. If a patient presents with, say, a back injury, the Comp carrier frequently controverts the claim, alleging that the injury was incurred at home. This immediately freezes all payment. We are still obligated to see the patient and provide care; we submit claims to the Comp carrier, but not a dime is paid. We can't bill the patient's primary insurance, because it's a controverted Comp case. Something like 18 months later there will be a 'Comp hearing', at which a Compensation Law Judge will rule on the case, most often deciding that, yes, it is a Compensation injury. At that point he/she directs the carrier to pay us. The Comp carrier then frequently "downcodes" every claim. Every regular visit is downcoded to brief, every brief visit to "minimal", every complex visit to regular. Doesn't matter how much documentation we submit to prove our case. We can appeal this, but the cost in clerical and physician time exceeds any potential redress.

    In our experience, Workers Compensation carriers controvert 40% of claims. This means that for 40% of our Compensation patient visits, we don't see a dime, often for one year, two years, even three or more. All that care is effectively provided for free. When we do get paid, a high percentage of claims are downcoded. Our calculations show that on average our practice loses $41 for every Workers Compensation visit. In years past, we could (barely) subsidize these losses via better reimbursement from private insurers; but these payers have also ratcheted down on costs, so we just can't do it anymore. Our practice has lost money for the last three years straight, and is in danger of going under. We have an obligation to care for our underserved rural population; so we have to drop Workers Compensation.

    This system sucks.

  •  letting the private sector compete (1+ / 0-)
    Recommended by:
    John Minehan

    We'll get to single payer system that will reduce the paperwork logjam quicker if we let private payer compete with medicare.    

    •  The problem with competition (2+ / 0-)
      Recommended by:
      arlene, cynndara

      in this way is that it precludes one of the central administrative savings of single payer, namely allowing for global budgeting for hospitals and relieving providers of the burden of dealing with a multiplicity of payers.
      Furthermore, private insurers in this model are going to do what they can to make it difficult for sicker people to sign up for their plans thus creaming the healthy patients for their networks, leaving the sick to join Medicare.
      A Medicare option, without the tightest of regulatory systems (limits on advertising, marketing, underwriting, and policy structure, at least), is a recipe for a two teir system and is more likely to defeat the possibility of single payer forever than to make it happen.    

      Dr. Aaron Roland is a family physician in Burlingame, CA.

      by doctoraaron on Tue Dec 16, 2008 at 05:56:22 AM PST

      [ Parent ]

      •  ouch (1+ / 0-)
        Recommended by:
        John Minehan

        if we go with competition, I hope you are wrong.  I'm afraid you are probably right.

        In order to allow competition to succeed, we would have to legislate away the pre-existing conditions terms the private insurers use to get rid of patients.  The administrative nightmare we currently have and the overhead would be more difficult to tackle.

        As a parent of 2 young adults whose pre-existing conditions (diastrophic dysplasia and achondroplasia) have precluded them from not only health care, but also made potential employers who own small businesses regard them as a potential economic catastrophe and find excuses not to consider them for employment, I'm really all for a nationalized health care.

        Our health care system puts our entire economic system at risk as well as families and individuals.

  •  Please read (0+ / 0-)

    Article "Doctors struggling..."


    "Never get out of the boat."

    by tlemon on Tue Dec 16, 2008 at 07:16:30 AM PST

  •  Article here (0+ / 0-)

    "Never get out of the boat."

    by tlemon on Tue Dec 16, 2008 at 07:17:57 AM PST

  •  Whaaa? (0+ / 0-)

    You can make a Workers' Comp claim for the boss pounding on your desk and screaming in your face?  Or at least, if it makes you jumpy and reluctant to go to work afterwards?

    Who'da thunk it?  I thought that was just the way lawyers and surgeons behaved.  Honestly.  If my lady-lawyer wasn't having a tantrum at least once a day, she was seriously under the weather.  My oral surgeon only turned into a volcano once a month, and after the first time, I learned how to prick his bubble and make him laugh.  But seriously, I was such a nervous wreck by the time the law firm fired me (for having the nerve not to quit despite "pressure", I think), that I was just relieved it was over.  I didn't know you could file claims against people for acting like that. It's pretty normal in working-class life.  Usually the people who can't deal with it in some way quit with other health problems brought on by the stress.

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