Hippocrates Under Contract

Psychiatric TimesPsychiatric Times Vol 28 No 11
Volume 28
Issue 11

Insurance often pushes pills rather than talk therapy, believing drugs are less expensive (although there is a fair amount of evidence to the contrary).

We could take you to court for those coding errors!” the medical director of ICIC (the Iron Curtain Insurance Company) shouted at me.

I run a tiny outpatient psychiatry office and this kind of phone inquisition by an insurance company representative is becoming a large part of the job. My notes had too much history for him, too little homework for the patient, and did not push medication sufficiently. I aim to combine both pharmacology and empathy, as needed-no small feat. He wanted the forms and a quicker cure. The patient and I had gone for an outside review and the medical director was angry at me for not falling into line. I didn’t think his threat would hold up, or that he would bother to do it, but I heard how angry he was. I felt a shiver and was briefly tempted to drop the patient. “If I told other companies, no one would want to deal with you!” threatened the ICIC director.

These reviews and legalistic wrangles are becoming an oft-repeated hassle in the commercial medicine of 21st-century America. The Affordable Health Care Act of 2010 has put a huge frosted cake on the table-50 million new patients. The corporate interests (insurance, pharmaceutical companies, HMOs, clinics, and doctors) are angling to grab the best pieces by ads showing resorts with beautiful people (actually hospitals)-and trying to find a way to dump the tough cases. Companies dole out benefits with tight fists. PBMs (pharmacy benefit managers) subcontract with insurance companies and may cut off the supply of medication a patient has used for years. It is up to the doctor to preauthorize or appeal-or deal with a distressed patient. Insurance often pushes pills rather than talk therapy, believing drugs are less expensive (although there is a fair amount of evidence to the contrary).

To make ends meet, many doctors, especially in primary care and psychiatry, are forced to comply. They may spend 30% or more of their time doing paperwork and talking with the likes of the medical director from the Iron Curtain company. It looks bad for the preservation of privacy, patient choice, and personal trust in the doctor-patient relationship. I am not optimistic, but here is my theory, based on mammalian evolution, of one force that may work against the corporate takeover of medicine.

The structure of society-people who stay local, those who concentrate on personal relations, businesses small and large, government-mirrors the way all humans grow up. We learn first to control, then to share, love, be open, or the reverse, keeping secret and not sharing. Some stay home and count their money. Others give dinner parties or go to a church or pub.

The earliest form of human development is face time-that period when you are in someone’s presence, in the same room, and directing your thoughts to him or her. (Watch an infant scan faces, work the room.) The other person expresses himself to you in real time, and you volley back. That’s the only kind of signaling that provides human meaning and and helps us work together. Anything else is more or less unreal. Basically, I am counting on our simian reflexes to work against business, in the long run. We’re more ape than computer.

Of course, thinking about some other individual is hard work and can cause pain or boredom. Most of us don’t do it very well. It hurts the brain to stop and listen. You can be with someone but mainly space out, dream of something else. (You might even dream of starting a large company and making millions.)

How are corporations born? If it is hard to deal with someone one-to-one, it is even harder with a group of people. Remember the first day of kindergarten, when you walked in by yourself, unprotected? Even worse is high school-any one of those faces could go after you, put you down, and who could you count on? You needed a “gang” to stand by you and make you feel safe. You picked up some knowledge and coolness and a band of allies, developed a social persona (or mask), and then it started all over again, as you moved on to college and corporate life.

The grown-up world isn’t that much different, actually, except that we’ve made a thicket of laws, hired attorneys, and invented a number of tools that keep us away from face time. That is when the value of collecting information about others, building a company, and taking power comes into its own.

Information can be gathered in printed texts, detailed contracts, e-mails, corporate structure, electronic health records (the big hope for handling millions of patients), and people who function as automatons (they take no responsibility themselves but simply follow the procedure laid down by their manager). Of course, it is the same thing in industry and banking, but do you want to put your body on an assembly line?

The medical director at ICIC is a decent fellow doing his job; he means no harm, he simply reviews the treatment of patients by a formula, and nudges me as his boss directs him. He is the mouthpiece for a company policy, and whoever decides that remains invisible.

The corporate interests favor the efficient processing of information to handle large numbers of people, and as the pioneer of information theory, Claude Shannon,1 said, “Information is numbers without meaning.” More information equals more money (and less meaning).

It used to be you went to your family doctor and had your face time, and it was a safe enough encounter, even if you took your skivvies down. Now you see an assistant first, he or she asks about your symptoms and tells you what will happen, and you see the doctor for 10 minutes. The doctor orders tests and the assistant calls with the results. A modern doctor is programmed to place the emphasis on tests, not your story, and the diagnosis must be arrived at quickly, to put it on the insurance form for reimbursement. The doctor can’t waste time considering too many diagnoses and is not supposed to spend much of his limited time explaining (which is a “cognitive service” and poorly reimbursed). (Cognitive service is pretty much like face time, and what some psychiatrists like me still do.)

The business schools have persuaded many parts of our society that the most efficient way to make a product, provide a service, and make a profit, is by using their business methods. Unfortunately, increasing numbers of hospitals, clinics, and doctors have signed on.

The patient under review and I went to the office of the Commissioner of Insurance and appealed both in and out of the ICIC. They all said the company was acting within its legal power. (Human meaning doesn’t matter.)

Once I saw the tsunami coming, I was scared but saw I could accept it out of necessity. To the lords of information, a psychiatrist is regarded as a kind of nanny to the unruly and the underprivileged. We are a small number and not much trouble. Still, I count that ancient, low-tech, and meaning-making method of face time as too valuable to throw out. I will keep looking for it in my doctors and will try to give it to my patients

I tell all my patients, both within the ICIC and those who are under another company, “She’s not your mother.” If patients want to appeal (protest), I’m game. They know where I’m coming from.




Shannon CE. A mathematical theory of communication.

Bell System Tech J.

1948;27:379-423, 623-656.

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