The Insurance Intelligencer - It's All about the Networks

**Justin** · 10-31-2010, 06:14 PM

I forgot to post this earlier this month...

The Insurance Intelligencer
10/4/10

October 4, 2010 is a very important day in the history of Insurance Warrior-ing. It is the fifth anniversary of the fourteen-hour surgery that saved my life.

In order to get this lifesaving treatment, I had to learn that my local doctors were not telling the truth. They lied to me, and they were dead set against my having this treatment. I had to confront the full bureaucratic might of my insurance company, which had no intention of paying for it. All while fighting a late-stage abdominal cancer. All because the one treatment that would save my life was "out-of-network."

If this month's newsletter sounds like a cry from the heart .... it is.

It's all about the networks

A little history

When treatments are denied, people go first to the insurance company for help, then to their doctor. This demonstrates that insurance companies have been very successful in hiding how this system really works.

Going to the insurance company for help when treatments are denied is like going to the fox for help, when chickens go missing from the henhouse. It is the fox's job to take a chicken for his dinner, and it is the insurer's job not to pay.

There is nothing bad or evil about this, it is just the way of life. An insurance company is a business, and a business is tasked with reducing operating expenses. To your insurer, any money that they spend on medical treatments is considered the "medical loss ratio." It is critical to your insurer to reduce this "loss" as much as possible, every month. If they don't their institutional investors will rush to another insurance company -- one that pays out less for medical treatments.

Doctors and networks

Going to your doctor for help, when treatments are denied? The entire system of "managed care" was designed to take away the power of doctors, so as to limit their ability to order expensive tests and treatments. Before 1970 or so, insurance companies and doctors were two separate entities. If the insurance company denied a treatment, your doctor had the power to go to bat for you.

Health insurers came up with an extraordinarily effective way to control doctors, with a diabolically friendly name: managed care. We manage. We care.

There is very little difference between HMOs and PPOs. PPOs are simply HMOs, hiding behind an illusory "out-of-network" benefit. In the PPO, out-of-network treatments have to be pre-authorized, and are often denied. Further -- and herein lies the biggest deception -- when PPOs do pay for out-of-network treatment, they pay based on a percentage of a secret number which they themselves generate -- the "reasonable and customary" shell game.

The danger of networks and medical care goes far beyond denial of out-of-network treatments. I had a late-stage, metastasized abdominal cancer. The in-network doctors had no curative treatment for it. Their plan was to do more surgeries as my tumors repeatedly filled my abdomen, then to watch me die. There was no scientific proof that these treatments would extend my life, or improve its quality in any way. There was a tried-and-proven treatment for my disease which had been practiced for over thirty years -- cytoreductive surgery and HIPEC -- with hundreds if not thousands of peer-reviewed medical journal articles, consensus statements, and other proof of its safety and effectiveness.

My local in-network doctors were not the slightest bit interested in this treatment. They did all they could to discourage me from getting it. Why? Because it is out-of-network; therefore it does not exist. When physicians have lived with networks for two generations, we have a world where ignoring the one treatment that can save your life -- or your child's life -- is encouraged, rewarded, and exceedingly OK.

Networks also nurture the concept that it is the job of a healthcare delivery system to treat the greatest number of people, with the most common illnesses, and offer the lowest common denominator of treatments.

I was watching the Today show last week. Matt Lauer was interviewing a guest about the latest in health insurance. The guest mentioned that, if you go out of network, the costs can be astronomical. Matt smiles and says, "So, just don't go out of network, right?" Smile and say that again, Matt, when your child has an aggressive, fast-moving brain tumor, and the only surgeon who can remove it is out-of-network.

A PPO is really an HMO

The dark heart of all healthcare plans -- PPO or HMO -- is networks. Doctors can be squeezed, harrassed, disempowered, and underpaid in this "network" system. Insurers are empowered to rob, abuse, injure, mislead, and often kill those who seek effective treatment within this system.

Networks are a vast body of contracts. Insurers have had fifty years to perfect these contracts so as to retain all decision-making power to themselves. Contracts between insurers and doctors, contracts between insurers and patients. Many of these contracts between you and your insurer state: "A treatment is medically necessary if the medical director of Acme Insurance says that it is medically necessary." Because we say so. We who are going to have to pay for it.

Does this not sound like the world's worst conflict of interest to you? Why aren't millions of insured people marching in the streets? Because insurance companies have had fifty years to perfect the managed care system. They have also had fifty years to perfect the publicity machine that makes them look like wise, benevolent, benign social service agencies who are there to help us.

Want to reform the healthcare system? Abolish. All. Networks.

To ignore a treatment because it is out-of-network is wrong.
To deny a lifesaving treatment because it is out-of-network is wrong.
The worst, in my estimation? To lie to a patient to discourage them from going out of network.
In a healthcare system based on networks, it happens every day.

******

And so, we end where we began. On October 4, 2005, I arrived at Washington Hospital Center in Washington, D.C. at the crack of dawn. I underwent a big whomping surgery, a whole lot of intraperitoneal chemotherapy, and forty days of abject misery in the hospital. I won't sugarcoat it.

I have not needed any medical treatment since I returned from Washington, D.C. in December 2005. I have had no recurrence, I remain free of disease. I eat Mexican food. I'm fine.

I just finished writing appeals #64 and #65. I have written and published two books during the past five years, and sold a few thousand copies of them. I have travelled all over the United States, speaking before all manner of groups. I speak to them about how, when life suddenly spins out of control, it is possible to win great victories.

A new career found me, right in the place where I was fighting, learning and living. I became the Insurance Warrior.

The fact that all of this grew from those perilous days amazes me. All that I did was show up, take my lumps, do the important things right, and cultivate an open heart. Had I believed my local doctors -- and the insurance company who denied me -- I would be long gone, and none of this would have happened.

As far as I'm concerned ... it happened just as it needed to, and it is all good.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd
The Insurance Warrior