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Trapped in Family Medicine Can this Marriage Be Saved? Act V–The Unhealthy Triangle: Patient, Doctor and Insurance.

Introduction: Here’s a recap of the scenario to date: Mrs. Doctor, a primary care physician is in marriage counseling to determine the fate of her marriage with Mr. Insurance. While she loves her career (medicine), dealing with Mr. Insurance’s increasingly abusive financial and administrative demands are crushing her soul. Yet leaving preferred provider protection guaranteed through the marriage would be devastating too. And Mrs. Doctor doesn’t want to lose her kids (the patients); decades of historical indicators show that 95% of kids (patients) stay with Mr. Insurance and refuse to see Mrs. Doctor ever again.

Last time, the therapist performed a therapeutic technique on Mrs. Doctor akin to psychological judo. When she claimed she was helpless under the power of Mr. Insurance’ ability to pay the bills, the therapist pointed out that Mrs. Doctor has many more powers than he does, including education and training as a doctor, the ability to order labs and meds, and the understanding and trust of each patient. Why, then, would she abandon the kids without a battle? Mr. Insurance wants nothing to do with the kids, and creates hundreds of games to reduce or eliminate his financial obligation to them.

Mrs. Doctor drives home from her most recent appointment, pondering the conundrum with new lenses: What keeps the kids running like lemmings towards Mr Insurance?  The cost of following this Pied Piper has doubled every decade for 60 years, with prices charged to patients doubling in the last eight years alone.  The worse things become, the more desperate the kids seemed to cling to Mr. Insurance.

Home at last, Mrs. Doctor stoops to pick up her newspaper on the driveway. The front page headline screams: “WellPoint Announces 39% Rate Increase in California.” Shocked by Mr. Insurance’s audacity, she wonders: “Were the kids going to stand with him on this one too?”

Do the kids (patients)  are more about the predictability of their co-pay over other key components of their personal healthcare like convenience, access, control, quality, competence, or trust? Was it the lack of transparency in pricing or  the fear of huge unknown costs that trapped the patients with Mr. Insurances even with a 39% rate hike?

Mrs. Doctor then tried a technique suggested to her by the therapist: she stepped back and took a look at the Patients’ experience with neutral eyes. What she saw stunned her.

First off, anytime the kids wanted her attention, they needed to make an office appointment. Never could they reach her without going first through her entire staff (receptionist, scheduler, in window and nurse). They’d then sit and wait for their scheduled day to meet “the queen” to plead their case. One modus operandi existed: a required office visit no matter how trivial the question or obvious the diagnosis.

Next, Mrs. Doctor recalled that she’d ask her patients back for follow up appointments so she could keep track of what was happening. She’d never avail herself by phone, cell, email, or text messaging, claiming: “You must see me face to face; it’s so much better for our relationship.”  Of course this is NOT the way the kids saw it.

The kids consistently said they felt disrespected, angry about long delays, frustrated with staff blocking access, and that every interaction was rushed and a hassle.  They pleaded for longer visits, claimed that delays had compromised their health and stalled healing.

Mrs. Doctor now realized that the entire charade of her required visits for every problem, as well as the need for excessive office staff, were a game to feed Mr. Insurance’s demands since he wanted to supervise and oversee his children.

She now understood that she’d complied, handing all of her kids’ confidential information to Mr. Insurance in an act of surrender and co-dependency, maintaining: “You pay me and I’ll do whatever you want even if it’s not right, costs much, or delays medical care, or disrespects the kids. As long as I, Mrs. Doctor, am paid by Mr. Insurance I’ll keep doing it (even if I have to fight for every penny he gives me).”

She saw that this unhealthy codependency between Mrs. Doctor and Mr. Insurance left the children in the middle as pawns between the warring parents. Mr. Insurance’s secret agenda was, “If I can avoid paying for something, I can keep the money. When you give me their information, I can charge them a lot more and also police your behavior.”

On the other hand, her unspoken agenda was to tell her kids, “Don’t worry the costs, I’m sending the bill to Mr. Insurance. We’ll find a way to make him pay for whatever your heart desires.”
She sadly saw that she was a part of a triangulation between Mr. Insurance and the Patients, all of whom were enmeshed in a predictable legacy of self-serving agendas).

Mrs. Doctor glanced again at the newspaper at her feet. A 39% rate increase had just been delivered to the kids, a symbol of the prolonged storm of doubling premiums nearly every decade and easily an American economy completely fettered by one dollar in four being diverted to health care.

What needs to be done?

Hopefully, the family therapist can help.

Until next week, I remain yours in primary care,

Alan Dappen, MD



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