My ninth-grader was reading  Mary Shelley’s “Frankenstein.” Having missed it in my high school career, I decided to follow along. It is a story of a noble scientist who, despite lofty and egalitarian motives, unwittingly creates a monster. Coincidentally, at about this same time, I received the newest contract from one of the local managed care health insurance companies sporting a fat rate cut and a whole new set of rules. And it struck me that the theme of this novel in so many ways describes our current dilemma.

The social experimenters of the ‘70s and ‘80s — the captains of industry, the policy wonks and the politicians — desired to create a better health care system by facilitating more and easier access to physicians. This would logically encourage increased disease screening and early diagnoses leading to reduced costs for everyone, they said. Unfortunately what we see at the national level is an estimated $1.8 trillion price tag for health care in 2004. That’s $6,400 for every American! Health insurance premiums are now unaffordable and certainly we cannot argue that Americans are healthier.

In the past, the health care insurance industry gloriously trumpeted prescription drug coverage, low co-pays, and disease management. It’s hideous progeny now spew terms like exclusions, deductibles and coinsurance at patients, and at us phrases such as contractual mandates, carve-outs and maximum allowables. The havoc these companies have created is breathtaking and frightening. We are awash in paper — EOBs, letters of denials, referral authorizations — all requiring more and more office staff to manage. Most patients don’t understand their coverage and it falls to us to interpret and administer as best we can the litany of rules and restrictions, all on our dollar of course.

Our options are few. Dealing with insurance companies and their contracts is an all-or-nothing phenomenon. Either you agree to the latest contract, which undoubtedly pays less than last year, or you refuse. Both responses are losing propositions. To agree to a contract that is one-sided and non-negotiable fuels the fire of the insurance companies’ influence and success in the marketplace, thereby making them stronger enemies next year. To refuse a contract may well create severe financial strain on a practice as patients faced with using out-of-network benefits and higher costs quickly move on to the next guy. Our only strength is in numbers, yet we are loathe to organize.

Certainly since we have been forced to accept less, we must give away less. Many of us now charge for medical records copies, form completion and triplicate prescriptions. Next up will be fees for mail-order prescriptions and faxing services and perhaps even those late night phone calls. As our society invariably becomes more computer savvy, we will be pressured to dispense medical advice online. Let’s resolve not to give away such service for free. Also, the margin in medicine is still quite favorable for our proceduralist colleagues. Is there an ethical difference in receiving from them a bottle of wine at Christmas rather than sharing directly in those margins?

Perhaps computer systems, with their ability to decipher multiple confounding variables typical with most insurance claims, will allow us to successfully survive this attack. But they are expensive, and many of us find it terrifying to let go of our cheap and dependable paper and pens. Ultimately the public will be the winners when we are all computerized, yet it is we who must fund the implementation, something unlikely to happen on a wide scale as long as insurance companies have carte blanche to cut our fees and then delay, or even deny, payments. They have no fear.

Yet before we support killing the insurance beast, let’s reflect on what we need from insurance not only as doctors, but also as potential patients. We all need an established, trusting relationship with a physician whose judgment we trust, and who we know is adequately trained. And, we need protection from financial catastrophe. The result of attempting to cover for every medical eventuality, however, is sky-high premiums and onerous and complex policies, which is what we have now. Rather than passively allowing those same social experimenters to give another try at fixing the system, why don’t we insist on a market-driven approach. Let the consumer decide how much doctoring he wants, and what he is willing to pay. And while some fellow citizens undoubtedly need public assistance to obtain the care they need, everyone ought to pay something, if only a dime, because that which is free often loses it’s value. In return we in the medical community must be more willing to let the public have a close look at us, including our fees.  Our credentials and performance must be available for inspection. We must insist on effective policing of our profession by the Texas State Board of Medical Examiners, and not leave that duty to plaintiff attorneys. Learning a new paradigm of competition is much preferable than continuing the ominous death spiral foisted on us by these huge, unresponsive health insurance companies.

In the end, both Dr. Frankenstein and his monstrous creation were found to be too dangerous to be allowed to survive. At the risk of sounding self-serving, nobody can do what we do as well as we do it, and our health care system is truly in danger if we face extinction. So, if our current health insurance industry neither saves money nor improves health outcomes, then it is time for it to be killed. But beware — it will be incumbent upon us to prove that we can provide those same benefits when unencumbered by the beast. 

Dr. John Kurt Frederick is a family physician in Austin, Texas. You may reach him at jfrederick@pol.net.