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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.


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!

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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.


But don't bet on it.

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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Copyright © 2003  Northern County Psychiatric Associates
Last modified: January 29, 2005



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Copyright © 2004  Northern County Psychiatric Associates
Last modified: January 29, 2005