My View • Physicians worry as bumbling bureaucrats, firms get in the way
by: Christopher Onstott, Several recent reports show that the recession has hurt Portland more than other parts of the nation. Evidence of a lagging economy can be seen in the emerging South Waterfront area, where retail spaces are vacant.

Several years ago, a front-page daily newspaper article described a man who had schizophrenia and was very stable at his group home. His medication costs were approximately $3,000 annually.

Some bureaucrat at the Oregon Health Plan decided that the state could save money by denying coverage for certain more expensive medications. This man's medication was terminated, and within two weeks he had a full psychotic episode resulting in a $20,000 inpatient hospitalization to reestablish his previous baseline condition.

Sadly, this penny-wise and pound-foolish attitude continues to be a part of the stated agenda for many health care plans.

It is no secret that the public has a perception that insurance companies are only slightly more 'honest and trustworthy' than oil companies and tobacco companies, according to a Harris poll in late 2009.

As a board-certified family physician, I have a front-row seat watching the various schemes that insurers foist on the people they have supposedly promised to serve. Research shows that my practice is no different than other primary care offices in that the average physician office requires three weeks of physician/provider time, 23 weeks of nursing staff time, and 44 weeks of clerical staff time figuring out formularies and prior authorization procedures to get our patients the medications that I deem to be the most beneficial for a particular condition.

This time-wasting and health-jeopardizing intrusion into the doctor-patient relationship continues to undermine the essential foundation of our health care system. It seems to me that if insurance carriers were to calculate the costs of hiring staff to deny care for their enrollees and instead, use the money to pay for the prescribed medical care by physicians, it might actually save money.

'Fail-first' policy?

Several recent developments devised by insurance carriers enhance the companies' bottom line at the expense and the health of you, the patient. For example, insurance companies give employee bonuses based on finding ways to cancel policies of people who have gotten sick or injured and incurred expenses beyond a certain limit. Insurers call this 'risk' or refusing to accept patient with pre-existing medical conditions.

Insurance companies now institute a 'fail first' policy, which means that they will not pay for the doctor-prescribed medication unless a less expensive alternative has been tried and failed numerous times, resulting in a delay of a possible cure and potential adverse consequences for the patient.

Insurers have also started making deals with generic companies where they receive kickbacks or rebates from the generic pharmaceutical company making less expensive medication, again putting the financial bottom line ahead of the patient's interests.

Some large integrated HMOs are instituting a 'six-month moratorium' on all new medications under the guise of 'wanting to make sure that these new medications are safe' when the real agenda is withholding the newest medication for their own financial benefit.

Also, some physicians whose practices are owned by large integrated HMOs have been forced to take a 5 percent pay withhold, which they can only earn back, plus a bonus, depending on their percentage of prescribing generic drugs. Generics are older medications that can be a cost saver, but in several cases are not as effective or pure as the brand name medication. Therefore a physician's compensation is linked to saving the insurance company money rather than keeping his or her patient healthy or providing the optimal care.

What can you do as a consumer? You may want to call your insurance company and ask if they engage in some of these practices, and if the chief executive officer of the organization continues to take larger bonuses every year.

The American Medical Association is in the process of trying to develop a 'National Health Insurer Code of Conduct Petition' that you can review and sign at This describes the restrictive coverage policies, payment practices and limits to a patient's access to care that undermine the integrity of the physician-patient relationship.

Dr. Gregory Knopf practices family medicine at the Gresham Troutdale Family Medical Center.

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