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Humorous
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send us your jokes and
humorous stories about the managed care industry.
Ground rules: Jokes must be "G" or
"PG." No jokes disparaging our patients. No jokes disparaging
particular individuals. Try to credit your source or indicate
that the source is unknown. We solicit jokes from patients,
providers, and others. In the spirit of fun and fairness,
managed care executives and reviewers are urged to send in jokes
about themselves, their competition or fee-for-service
physicians.
GERALD. KLEE M.D.
Hippocrates on HMOs
Where was I to find the
answers? Should I participate in HMOs or not? Should I allow
someone else to come between me and the patient and tell me how
to practice, or should I refuse to participate and find myself
with very few patients left? If I do not participate' many of my
patients will feel abandoned. If I do participate, I run the
risk of abandoning the principles of medical ethics and harming
patients. Having had no luck finding answers elsewhere, one
night I wearily sat down at the computer. Searching the
Internet, I got a lot of information, but no answers. In
desperation, I decided to go right to the top to find out what
the father of medicine would say. I keyed an address:
http://ancient greece/medicine.hippocrates
A face took shape on the
screen and Hippocrates himself asked, '"What can I do for you?"
Stammering with surprise and embarrassment I replied, "I'm sorry
to have disturbed your sleep.''
Hippocrates: "It doesn't matter. I can't sleep."
Me: "Why
not?"
Hippocrates: "It's the news about managed care. After 2400
years, the HMOs are back, ruining medical care, and destroying
the profession of medicine. Building on the past, your
generation has brought medicine to undreamed-of heights. Now,
the HMOs are driving medicine over the cliff, just as they did
in my time."
Me:
'`Excuse me, sir. How do you know about this'? Where are you?"
Hippocrates: "In Hades, of course. But it's not the same as what
you call I hell. We have all the amenities here, including
medical journals, newspapers, cable TV, and PCs. We're on the
Internet and the World Wide Web. We have access to all the news
media. The only thing that makes it resemble hell is that no one
will listen to us."
Me: "You
said you had HMOs in your time?'
Hippocrates: "It was during the period you call the fifth
century BC, the I Golden Age of Greece. In Athens, it was the
Age of Pericles. Philosophy, art, and science flourished
throughout the world Moreover, good hearth I was worshiped and
access to medical care was considered a necessity These were the
best of times, but they soon became the worst of times ''
Me: "How'?"
Hippocrates: "Because the
services of physicians were so highly valued, Hellenic Medical
Organizations (HMOs) were formed. These were idealistically
designed to provide good quality medical care to everyone at a
nominal cost. The HMOs grew slowly at first and worked
reasonably well for a few years. Alas, not all Greeks were
lovers of truth. There was an influential group of
pseudophilosophers known as sophists who taught that truth and
morality are merely matters of personal opinion. As a result, we
had some highly sophisticated liars end thieves among us. It
wasn't long before those rascals spotted a business opportunity
in HMOs. A revolution in health care soon took place."
Me: "Really? What was it
like?"
Hippocrates: "It followed a pattern that should be familiar to
you. Business managers took over. They cut costs by cutting
services and reducing physician fees, then put most of the
savings into their own pockets. They relegated physicians to a
subordinate role and told them how to diagnose and treat
patients. Physicians were allowed very little time with
patients. In undermining the relationship between the patient
and the physician, they destroyed the patient's trust in the
physician and with it the therapeutic alliance. The quality of
care deteriorated, but the managers persuaded the people that
they never had it so good. Besides, if something went wrong,
they told the people it was the physician's fault.
'`Before
long, most Greeks belonged to HMOs and, despite reservations,
most physicians chose to participate, if they could, in order to
continue seeing patients. Except for one or two honest HMOs, I
refused to participate on ethical grounds. My major objections
to HMOs included their interference with patient care as well as
the loss of confidentiality between the patient end the
physician. Whatever secrets the patient imparted to the
physician had to be passed on to the HMO. Soon, this private
information was being gossiped about in public."
Me:
'"What happened to your practice?,'
Hippocrates: "I lost a great deal of my practice. Although I had
serious financial difficulties, I managed to survive on the
little island of Cos and to find patients among the very poor
and among those who shared my distrust of HMOs. I knew it was
only a matter of time before the fiasco would end. But who could
say exactly when or how? Finally, the stone struck. You have
heard of the plague of Athens?"
Me: "Is
that the one Thucydides wrote about?"
Hippocrates: "Very good. But Thucydides didn't tell the whole
story. It was a terrible event. People were dying left and right
in Athens and chaos reigned. No one knew the cause or the cure.
The HMOs were of no use. The HMO managers took all the money and
fled. Those HMO physicians who had not perished in the plague
were driven out by angry mobs. Their innocence and good
intentions were not enough to save them. Pericles, the aging
leader of Athens, sent a message to me at Cos, begging me to
come. I could not refuse.. In a while the plague was over, the
dead were buried' and a semblance of order was restored."
Me: "How
did you accomplish that?"
Hippocrates: "It is said that I drove out the plague by lighting
fires in the public squares. That is not true. The plague was
not a single disease as many believe, but a variety of illnesses
that had been silently taking hold of the people during the
years they had submitted to HMOs. One last disease, probably
coming in from abroad, was enough to trigger the final
catastrophe. The HMOs were the real plague of Athens. In classic
fashion, after reaching a crisis, the people of Athens cured
themselves by expelling the offending agent---the HMOs."
Me: So
you don't take any credit for saving Athens from the plague?"
Hippocrates: "Of course not. I always taught that with the help
of the gods, the patient heals himself. That is what happened in
this case. The physician can only promote the process of
healing. I am happy that I had enough wisdom to stay out of HMOs
and avoid aggravating the problem."
Me: "When
did you write the Hippocratic Oath?"
Hippocrates: "I did not write it. The Athenian people composed
most of it. After their experience with HMOs and plague they
insisted that physicians must put patients first and give them
their very best. Nothing and no one should come between
physicians and their sacred duty to their patients. The oath was
published in the Journal of the Aegean Medical Association (JAMA),
of which I was editor. Perhaps that is how my name was
mistakenly attached to it."
Me: ``The oath seems
pretty reasonable. Why do you think some people now say it is
outdated and should be discarded?"
Hippocrates: "Some of it
is out of date. But you'll have to figure out for yourself why
anyone would not want to put the patient first. The HMOs in
Athens didn't put the patient first and look what happened. When
do you think the plague will strike in your country?"
Me: "Do you really
believe that? No, it couldn't happen here!"
Hippocrates: "See I told
you no one listens."
Me: "Do you have any
advice for me? Should I or should I not participate in HMOs?
It's a tough decision. There is so much at stake."
Hippocrates: `'You
haven't been listening."
Me: "Please, tell me what
I should do."
Hippocrates: "I would not
presume to tell you what to do. Physicians in my time were faced
with the same predicament. When they sought my advice, I
responded with an aphorism that has since become widely quoted.
Perhaps you are familiar with it. It goes like this: Life is
short Art long opportunity fleeting experience treacherous,
judgment difficult. The physician must be ready, no not only to
do his duty himself; but also to secure the cooperation of the
patient of the attendants, and of the externals. "
The screen clicked off
and I woke with a start.
GERALD D. KLEE M. D.
Dr. Klee is a
psychiatrist in private practice in Towson, Maryland, and a
lecturer in
psychiatry at The Johns Hopkins University School of Medicine.
Maryland Medical Journal April
1996 p289-291
Reprinted with permission.
Maryland Medical Journal is a publication of the Maryland Med
Chi
Visit the Med Chi Web Site
Denial Upheld
To: Greenmountain
Health Care
Division of Denials
Dear Sir or Madam:
I am writing in response
to your denial of coverage for my patient's extensive orthopedic
and rehabilitative care. I am, as requested providing more
detail. However, I fail to understand why, since the accident
occurred last month, you are coding this as a "pre-existing
condition.".
Joseph Sweatjock, MD
Orthopedic Surgeon
My patient, Buddy Light, is
a bricklayer by trade. On the day of the accident, he was
working alone on the roof of a new six-story building. When he
completed his work, he found he had some bricks left over which,
when weighed later, were found to weigh 240 lbs. (At your
request, we have sent the barrel and bricks to your offices by
UPS.) Rather than carry the bricks down by hand, he decided to
lower them in a barrel by using a pulley which was attached to
the side of the building at the sixth floor. Securing the rope
at ground level, he went up to the roof, swung the barrel out
and loaded the bricks into it. Then he went down and untied the
rope, holding it tightly to insure a slow descent of the 240 lbs
of bricks. You will note on the hospital admission form that his
weight was 135 lbs. (At your request, we have submitted evidence
from an outside contractor that our scale is accurate to within
1/16 lb.)
Due to his surprise
at being jerked off the ground so suddenly, he lost his presence
of mind and forgot to let go of the rope. Needless to say, he
proceeded at a rapid rate up the side of the building. In the
vicinity of the third floor, he met the barrel which was now
proceeding downward at an equally impressive speed. This
explains the fractured skull, minor abrasions and the broken
collarbone, as listed in the admission form and confirmed on the
radiology report (at your request originals of all 385 x-rays
are enclosed.)
Slowed only slightly,he
continued his rapid ascent, not stopping until the fingers of
his right hand were two knuckles deep into the pulley (see notes
of abrasions on admission physical). Fortunately, by this time
he had regained his presence of mind and was able to hold
tightly to the rope, in spite of the excruciating pain he was
now experiencing. At approximately the same time, however, the
barrel of bricks hit the ground, and the bottom fell out of the
barrel. Now devoid of the weight of the bricks, the barrel
weighed approximately 50 lbs.(Again, please refer to the
patient's weight as listed in the admission document.) As one
might predict, using the principles of Newtonian physics, he
began a rapid descent down the side of the building. (At your
request, we have faxed you the entire text of Principia
Mathematica by Sir Issac Newton.) In the vicinity of the third
floor, he met the barrel coming up. This accounts for the two
fractured ankles, broken tooth and severe lacerations of his
legs and lower body. (Again refer to the 385 original x-rays
that YOU requested we send you.)
At this point, my
patient's luck began to change slightly. The encounter with the
barrel apparently slowed him enough to lessen his injuries when
he fell into the pile of bricks. Fortunately only three
vertebrae were cracked. I regret to report that, as he lay there
on the pile of bricks, in pain, unable to move and watching the
empty barrel six stories above him, he again lost his composure
and presence of mind and let go of the rope. (At your request,
we have sent the rope by Overnight Express--note: the noose was
added later.)
Please reconsider
your denial of payment for these services. As you can see, the
injury occurred three years after he signed up with your HMO.
Please explain how this constitutes a "pre-existing condition."
First Level Reviewer:
They sent everything we requested; I didn't think we'd get the
bricks. I'm going to lose big in the office pool on that one.
What are we going to do with the bricks? We already have a stone
wall.
Second Level Reviewer:
Have the patient come fetch them tomorrow after we discharge
him.
First Level Reviewer:
This case could cost us a lot of money. Probably our Christmas
bonuses for the next two years!
Second Level Reviewer:
Not to worry; We still have two excellent reasons to deny care.
Clearly the underlying cause of the accident was stupidity. We
don't cover mental illness or other mental defect. Secondly, the
stupidity must have been a pre-existing condition--he signed on
with us three years ago!
Back to Top of Page
TRUMP ON HMOs
April 1, 2001
Health care 2001: gambling with
health care finally pays off
By Gerald Klee, MD
The health care crisis is finally
over. It ended when Donald Trump and the gambling industry took
over from the insurance industry, Health care is now available
to anyone who wants it, and it's free as long as you play For
those who have not kept up with the rapid changes in health
care' a short review of developments over the past few years may
be helpful.
It turns out that the crisis was
not really due to a shortage of health services or that it
cost too much. It
was mostly over the amount of money that could be made and about
who was going to get it. Nearly everyone agreed that doctors did
not understand money and did not deserve to have it or even
handle it. The public understood money even less and needed
someone to manage it for them.
Politicians fought
with the insurance industry for control and insurance companies
battled with each other for market shares. It was like a bunch
of dogs fighting over a bone. Some observers believed that a
genuine health care crisis was actually created as the health
care system was torn apart by the struggle. Everyone agreed that
health care would never be the same
Insurance
executives say they did a lot of good. Others aren't so sure lt
is true that discipline was imposed on the system. Health care
rationing was made palatable to the public by giving it
different names. such as managed care health maintenance,
capitation and free choice. Other names were changed. too. There
were no more doctors or patients. They were relabeled providers
and consumers. Doctors. nurses. social workers, technicians. and
all other health care workers were lumped together as
'-providers.'' This made them interchangeable and saved a lot of
money that could go into profits for the insurance companies. As
consumers, patients were empowered to make choices between
health care packages without understanding the contents.
Health insurance
companies profits skyrocketed' while doctors' incomes plummeted.
Doctors burned out, patients burned up. and hospitals dosed
down. If patients were displeased with empty packages they took
out their anger on doctors for lack of more accessible targets
Patient dissatisfaction
gave the insurance
companies an excuse to further reduce doctors' fees, which
resulted in still more profits for the insurance companies.
Biological
evolution did not end with Tyrannosaurus rex and health care
evolution did not end with health insurance companies and HMOs.
These organizations dominated the landscape for a while. but
they made some fundamental blunders' which set the stage for
their demise. Their biggest mistake was in. ignoring' or not
knowing, Trump's Rules, which are as follows
1. Don't tell
people what they need, give 'em what they want.
2, Make everyone
feel like a winner.
The insurance
companies and HMOs gave no one what they wanted and made
everyone feel like losers.
Trump saw his
chance and moved in. His thinking on the subject is described in
his recent best-selling book. You bet Your Life. Trump reminds
us that everything in life is a gamble' starting with which
sperm will reach the egg. Taking chances is unavoidable, and we
take them with every move we make. The best we can do is play
the odds. Humans have adapted to this uncertainty in life in
various ways and have even learned to enjoy it by making bets.
People like excitement and thrills---even to flirt with danger—
but they also want security.
As Trump's
argument goes: Although insurance is advertised as a way of
buying security, it is in fact a form of gambling that may offer
a sense of security. In insurance. as in casinos the player bets
against the house, In life insurance, policy holders bet they
``ill expire before the policy does, while the company (the
"house") bets they won't. In health insurance, policy holders
bet they will need medical care costing more than the premium;
the insurance company bets they won't need it, or at least that
the company can avoid paying for it. The insurance industry is,
in effect, a large gambling enterprise that represents itself as
a quasi-public utility. The industry has been successful because
of a combination of actuarial, financial, marketing, and
political skills.
According to
Trump, these capabilities, although impressive, are no match for
those of the gaming industry. The gaming industry has a far
better understanding of human motivations and behavior than the
insurance industry (or the medical profession, for that matter).
Both the insurance industry and the medical profession attempt
to tell people what they need. Trump knows what people want.
Trump knows people want excitement. They want to take chances,
but to feel safe while doing so. He knows that people want to
live recklessly while having the safety net of free health care.
He will give them what they wan. No one should complain if he
enriches himself and his partners while doing so.
Trump's health
care financing plan took the industry by storm. Adding to his
gambling establishment, he opened the Taj Mahal Health and
Gaming Resort with headquarters in Atlantic City. He made health
coverage automatic far anyone who plays, and for as long as they
play. One can play roulette, blackjack, slot machines, craps, or
any other game in the house It's all the same. Win or lose. the
coverage is in proportion to amounts wagered. (A small
percentage of sums wagered goes into the health care account.)
As long as you play. you can never lose your health coverage And
you still have a chance to win the jackpot.
Trump promotes his
painless method of financing health care with slogans such as
"Don't get sick, get lucky!"
After Trump added
his health care package to the Taj Mahal operation, a revolution
in health care financing took place almost overnight. Thousands
of people from surrounding areas dropped their health insurance
and headed for Atlantic City Gambling facilities strained under
the onslaught, but were rapidly expanded.
As other gaming
organizations followed Trump's example, new facilities were
established in Atlantic City and Las Vegas. on riverboats ships
at sea and in states throughout the nation. Whatever your
favorite game of chance, you can now play it. and get free
health coverage. Indian reservations, which already had
legalized gambling have expanded their facilities and now offer
free Native American health care for those who play. Home
shopping networks have joined in by adding gambling channels.
For those who are house-bound or prefer to stay at home for any
reason. it is now easy to play on interactive television, 24
hours a day, 7 days a week, and gain health coverage while doing
so.
Casinos overcame
people's moral objections to gambling by donating some of the
profits to charity or to other good causes. One week would be
"Cancer Week," in which a fraction of each dollar wagered would
go for cancer research: another week would he for AIDS research,
or for the homeless. These charitable contributions are highly
advertised and enable people to feel virtuous as they play.
Doctors rushed to
Join the system. There was no red tape and no paperwork. In
order to be providers, they merely had to play at the gambling
tables. A remark by a well-known medical leader is often quoted:
"Even if
health care these
days is just a crap shoot, now least there's a chance of winning
something.'' Your best chance of finding a doctor now is at a
casino. Medical school courses on managed health care have been
replaced by courses on gambling and health care. They are the
only classes in which students always stay awake.
As the gaming
industry took over health care, the health insurance industry
collapsed. Victims of their own misjudgment of human nature they
quickly lost their
contracts and went into the red. Down but not out, health
insurance companies and HMOs had huge cash reserves gained
during the preceding years. With these resources they bought
into the gaming industry and in the process drove the price of
shares through the ceiling. wall Street went wild with joy.
Trump cites recent
studies conducted by the Taj Mahal Institute for Medical
Research showing clinics and hospitals to be half empty most
doctors and patients would rather spend their time at the gaming
tables. Ever since managed care set the standard by allowing a
maximum of twenty minutes for any type of surgery, from ingrown
toenails to kidney transplants, many people believe that their
chances at the gambling table are better than they are on the
operating table
Every advance in
human society has its opponents. There are some voices from the
medical field and elsewhere that denounce Trump's system as evil
and corrupt. They say we are rapidly going to hell Trump reminds
us that under managed care we were heading for hell anyway.
Under his system, at least we can enjoy the trip.
Perhaps things
could be done in better ways. Perhaps the time will come when
human affairs are governed by benevolence and wisdom rather than
by greed and folly.
Perhaps.
But don't bet on
it.
GERALD D KLEE, M D.
Dr. Klee is a psychiatrist in
private practice in Towson, Maryland, and a lecturer in
psychiatry at The Johns Hopkins University School of Medicine.
Maryland Medical Journal April 1996 p289-291
Reprinted with permission.
Maryland Medical Journal is a publication of the Maryland Med
Chi
Visit the Med Chi Web Site
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