As a patient with chronic illness, including an autoimmune disorder, I have seen facets of the insurance/medical sectors I hope the average medical consumer never has to witness.
To my medical experiences, I have brought formal training and an entire career managing teams in the best businesses.
What that means is, I have seen these things through the eyes of someone who understands how big businesses operate.
Furthermore, I can help you because I understand how to harness teams to get great results that we, as individuals, could never get on our own.
I hope you will use the following information to have a better experience, feel well, and spend less time and money in “the system”.
If you take the opportunity to do so, I’ll feel my experiences have been worthwhile.
Be a Smart Medical Consumer for Your Chronic Illness
Incentives in the medical sector affect how and why services and products are offered to patients.
They fundamentally shape your experience as a medical consumer.
If you are aware of these incentives, you may be able to better understand some of the reasons why recommendations are made to you.
I intend this understanding will empower you to ask better questions and understand whether the resulting recommendations are best for you.
Here are tips you can use to be a smarter medical consumer, improve your experience, feel well, and get great results.
Smart Medical Consumers Manage Their Own Health
1. Be Organized. No Matter What, it is Your Life: You Own the Results, Chronic Illness or not.
Be Organized to Understand Your Health History
- Write a list of your diagnoses.
- Understand your diagnoses as a collection of symptoms, and understand the symptoms you have that resulted in you receiving each of your diagnoses.
- Capture a collection of the written documentation reflecting your diagnoses, from the doctors who wrote it.
- Create a list of your prescriptions.
- Create a list of your lifestyle and dietary practices that may not be supporting your best health status.
Be Organized for Great Results in Your Future
- Write down your health goals and a plan to meet each one.
- Make a list of the lifestyle choices, supplements, and dietary practices you’ve chosen to positively influence your health and well-being.
- Develop a plan to keep or get the health you want.
- Share your lists and your plan with your doctors. They can use them to quickly see what you’re up to and what you want. They rarely read paperwork they ask you to fill out in the office lobby. You are your only advocate and health manager in the doctor’s office and exam room. Be ready to make your case quickly and powerfully.
- Become a project manager committed to delivering your own health outcomes and quality of life. You must generate great results, because no one else can know or deliver what you really want, until you tell them.
2. Find Purpose: Don’t Let Someone Else Dictate the Quality of Your Life or Fight.
Love him or hate him, Lance Armstrong popularized for many the idea of Livestrong: don’t die weak. You get a say about how you live, and often even how (or whether) you die. I’ve seen an unwelcome future for myself on three separate occasions. In those cases, I took steps to create a totally new future for myself. Doctors often quote statistics or say with authority there’s only one probable outcome.
There is no rule or law that says you have to live or die that way.
Also see items 3, 7, 8, 9, 12, 14, 15, 16, 17, and 18.
If not you, who? If not now, when?
3. Don’t Accept Population Statistics as a Statement of Your Individual Diagnosis or Probable Health Outcome.
Read this article about the distinction between population statistics and personal health information.
4. Avoid the Doctor Entirely.
More people in the US die from chronic illnesses than any other cause, and most chronic illnesses can be prevented.
For proof that the medical sector is not your best friend, twice in one month in 2013 I heard medical doctors proclaim that modern medicine is an ‘epic failure’. One was talking about treatment and management of running injuries; the other was talking about treatment and management of chronic illnesses and autoimmune disorders.
I’m not suggesting doctors and the medical sector intentionally go out of their way to hurt you.
However, I am suggesting they are not as all-powerful as we sometimes believe, and consumers definitely have more power than they realize.
Key contributors to chronic illness include:
- Diet: eat right for you.
- Insufficient Physical Activity: move more.
Your location, lifestyle, and habits are a choice about whether, or how much, you need the services of the medical/pharmaceutical/insurance sector. Our social trend toward unhealthy diets, obesity and chronic illness plays right into the medical sectors’ best interests (see #11 and 13 below). Have you noticed doctors and the people who own medical and related business often drive better cars than their clients? You can choose how much you spend on medical products and services, above and beyond the cost of health insurance. Make the right choices for you.
5. Food is the Best Medicine and Will Prevent or Reverse Many Chronic Illnesses.
The right food is the best medicine. Alternatively, the wrong food can make you sick and may eventually kill you.
Over several decades, the medical sector has trained us there’s a miracle cure for everything, and we just need to make an appointment, then take a pill or have a procedure. As a result, we’ve become dependent, under-informed, and sometimes lazy medical consumers, to our own detriment. Even worse, many modern “medicines” don’t even address the root of the problem. They just mask the symptom.
Take the best care of yourself you can. Avoid the many chronic illnesses that have become the de facto condition of modern life on North America.
“We can manage our own health and fitness best by improving the lifestyle factors we control — food, physical activity, and stress — while using a variety of healthcare specialists as needed.”–Dr. Phil Maffetone
Smart Medical Consumers Build Team and a Support Network
Everyone involved has a stake and a team to help them win. You as the patient and customer need one too.
- The doctor takes too little time and orders too few tests to authentically have a good chance of properly choosing the correct one of 10,000 possible diagnoses. Furthermore, nurses and staff may fear for their jobs if they second-guess or question a doctor, so you can’t rely on that happening to your benefit.
- Pharmaceutical companies want to sell drugs. Almost always, a visit to the doctor results in one or more prescriptions, so pharma is happy.
- Insurance companies are happy any time they receive premiums, then don’t have to spend money. The doctor, and still diagnosed and prescribed? No problem! The patient didn’t bother to go to the doctor, despite not feeling well? Not a problem! Next, insurers may pressure physicians to limit procedures. Finally, if the patient is suffering and doesn’t want to wait for treatment authorizations, they may be forced to pay for tests out of pocket.
- All the suppliers to the clinic, the pharmacy, the drug companies, and the insurer will make sales of their related pieces and parts of the process, regardless of the health outcomes of the patients to their customers’ businesses.
Take every opportunity to build a team of people you know and trust, who don’t have a stake in the game except to see you win.
6. Find a Non-Medical Support Group Related to Your Chronic Illness, and Participate.
Consider Livestrong for cancer, Weight Watchers for diet and weight, 12 step programs for addictions and even some psychiatric diagnoses.
There are organizations, web sites, and Facebook groups for almost every chronic illness and autoimmune disorder. Use a search engine to find appropriate ones for you.
7. Get a Non-Medical Patient Advocate on Your Side.
Have someone with whom you can take the time to fully discuss your situation and your options. This person should be able and willing to:
- help you explore and understand the pros and cons of your current path,
- help you think through, assess, and narrow your options to the ones best for you.
It could be a helpful friend or family member, a health coach, or any other non-medical person you know and trust. See what you can find on Patients Like Me.
In all of healthcare, there’s rarely a patient advocate, except in the case of terminal conditions. Almost never is anyone taking the time to ask open-ended questions of the patient or their family, understand their situation fully, and help them represent their best interests, free of conflicts of interest.
Even the “advocate” assigned for terminal conditions is a risk management professional who works for the insurance company, not the patient.
Without your own advocate, on your side, unaffiliated with some other participant in the medical sector, you as the patient are on your own. Lone patients are floating, helpless, in an ocean of bigger, better-funded, more experienced, and more sophisticated predators.
8. Find a General Practitioner or Family Medicine Doctor You Trust.
They will take the time to understand your situation, care what you say, and offer options and treatment protocols you understand and are comfortable with. They or their staff will take the time to make sure you know what’s going on and why it matters.
9. Find the Best Specialist, Get a Referral to Them if Your Insurance Requires it, then Make the Appointment Yourself.
Doctors and clinics have established business practices that maximize and sustain their revenues and personal incomes. They are sophisticated business people in an established business and industry that has been optimized to take your money.
Your doctor, or the business s/he works for, has an incentive to avoid referring to competition, and to keep your revenues all “in the family”.
Do your own due diligence.
Ensure “the family” is the one best qualified to take care of you.
In my experience, private practice doctors rarely refer to other doctors.
When they do, it’s always to other private practice single-specialty doctors who don’t compete with them.
HMO’s and large, diversified clinics will generally only refer to doctors inside their system (“network”). As much as they may claim it’s to manage costs, it’s also a revenue protection scheme.
Smart Medical Consumers Build Team to Manage Change in Chronic Illness
10. Build Team for Your Chronic Illness by Asking Your Doctor (and Others) Questions Until You Understand:
- the diagnosis is correct.
- alternative diagnoses, and why they were ruled out.
- alternative courses of treatment, and why they weren’t selected.
- side effects, advantages, disadvantages, and costs to you, of the chosen treatment plan.
11. Build Team to Manage Change in Your Chronic Illness. Ask Your Doctor (and Others) About Alternative Treatment Options, and Ask Why They’re Not Recommended.
Doctors only know what they know, and like the rest of us, they have blind spots.
Sometimes they don’t know all alternatives.
Even worse, ethics aside, they have few incentives and many reasons not to offer all alternatives, even if they know them.
Remember, most chronic illnesses can be prevented by eating well, being physically active, avoiding tobacco and excessive drinking, and getting regular health screenings.
Therefore, before you ever commit to medication or surgery, understand the behavioral and lifestyle interventions that are available.
- Knee pain and overweight? There’s another option besides surgery, at least as a starting point. Furthermore, being a healthy weight improves chance of fast, healthy recovery from surgery.
- Doctor recommended cutting out gluten as an approach to managing your autoimmune condition, but you just love bread? Maybe consider gluten-free bread.
If there are four ways to perform a surgery, and if your doctor is only trained in one of those 4 procedures, he’ll use only that one on you.
He won’t consider an alternative, even if there’s a better one.
He’ll use the approach he knows, even if it’s not the one with the highest rates of resolution and recovery.
While he’ll have an ethical reason to share with you, he won’t have a legal obligation to share with you, so you’ll never know — unless you ask.
Furthermore, if he’s not officially trained in alternative techniques, he can plausibly claim (and his malpractice insurer and attorney will advise him to do so) that he doesn’t know about the alternatives. In fact, he’s not qualified to determine whether they’re appropriate for you, in your case (even though standard treatments are well-documented across the sector).
Finally, and very sad for the state of patient care in the United States, some procedures are patented. In these cases, only doctors who’ve licensed the use of the procedure can use it. Once again, you’ll never know if you don’t ask.
Too bad for the patient whose doctor doesn’t know or isn’t offering the one thing that could help best. Assuredly the doctor will offer an alternative, just maybe not the best thing.
Build team and ask around about the procedure your prospective doctor will use. Understand whether the one he’ll use is best for you.
Before I had my inguinal hernia repair surgery, I did significant research.
I determined I did not want a piece of plastic mesh permanently implanted in my abdomen. My already hyper-reactive immune system doesn’t need any more reasons to be reactive!
When I could only locate 3 doctors in the country who would do no-mesh surgeries, I went all the way to Florida to have the procedure.
I feel good that I stood up for my rights, did my research, protected my health, and avoided further injury.
Pharmaceutical companies drive the advertising that creates demand for their products, by:
- providing free lunches, travel, gifts, training, consulting contracts, and research grants to doctors.
- advertising to consumers in magazines, on the radio, on TV and the internet.
- sending “detailers” to doctors, to communicate the company’s latest research and explain the reasons why their product is better than alternatives. They may leave out reasons why their drug is not preferable. They do this for their newest, still patent-protected chemicals, with massive margins. For these, the insurance company and the patient will pay multiples of the amounts they might pay for alternative options like foods, supplements, or generic drugs. Sometimes insurers will decline to pay those high prices, and they’ll remove the drug from their formulary. Nonetheless, like I wrote in item 11 above, they have just as much incentive to keep costs high in the long run as they do to manage their annual spending.
12. Build Team for Your Chronic Illness by Getting a Second (or Third or Fourth…) Opinion about the diagnosis and the treatment options.
Information asymmetry between businesses and consumers in the medical sector is huge, and it works against patients.
Patients Are Not Well-Informed
The average patient knows next to nothing about their body, biology, medicine, or pharmacology. Sometimes patients even lack the ability to accurately describe the specific symptoms they’re experiencing, or the possible causes of such symptoms.
As a result of their lack of training, patients lack a vocabulary to discuss their concerns effectively.
Furthermore, doctors spend very little time to understand the specific concerns of the patient.
Doctors Spend Very Little Time to Understand the Concerns of Their Patients
When the doctor assesses and diagnoses the patient’s condition based exclusively on this poor information from the patient, it’s little more than a guess.
Furthermore, doctors are rarely supervised, and patients are rarely qualified to assess their diagnosis before treatment begins.
The net effect is the patient often relies on a barely educated guess to manage or restore their health.
10% of the time, doctors get the diagnosis wrong.
Another worrying example:
My insurance company sent me a letter that states I can consult with a doctor over the phone and receive prescriptions, without ever being seen by a doctor. Previously, for my whole life, doctors’ offices have told me I need to see a doctor to receive a prescription (unless it’s a recent renewal). Somewhere there’s an inconsistency, and it seems clear it can’t work in the interest of a correct diagnosis.
13. Build Team to Manage Change in Your Chronic Illness. Share Your Story. Get Connected.
- Share your story and shed light on the problems and related opportunities for improvement across our society. You can start by sharing a comment below via your own social media account.
- Get connected to appropriate support groups on the internet and social media. Get advice from others with your condition, and from others who support others with your condition.
- Contact me directly. I am thrilled to hear your story. I would also be happy to see if I can provide you some further information or an unpredictable breakthrough in your current situation.
Smart Medical Consumers Understand the Financial Interest in Managing (or Not Managing) Chronic Illness
Insurance Companies’ Financial Interest
14. Insurance Companies’ Best Business Model Is to Grab Every Dollar and Not Pay Out.
Insurance companies receive nearly every dollar of medical and pharmaceutical revenues in the United States, before it’s ever spent by consumers.
Once they have the money, private insurers want to limit how much they pay out. They do this so they can generate a profit for their shareholders and bonuses for their executives and managers.
Public insurers have budgets to keep, so they too want to restrict their payout to their budget allocation through the funding cycle.
Insurers cut costs to improve their profit or budget position, not to reduce your costs as the consumer.
At the end of every year, the insurance company wins if you or your advocate has been paying insurance premiums but you’ve been quietly taking your medication and not spending beyond the premiums of your policy.
15. Insurers Have Little Incentive to Keep Prices Low or Buy You the Best Care.
Despite what they may tell you, insurers have no economic incentive to cap prices over the long run.
Bigger is better in the financial services industry, and insurers are just a go-between.
They want to be big so they can use their size to negotiate better pricing, some of which may trickle down to you. However, ultimately, you (or the pool) pay 100% of the cost of your (or the pool’s) medical expenses. The net effect is, it really makes no difference to insurers what prices are borne by the overall system.
Next year they’ll just raise rates, deductibles, and out-of-pocket expenses to accommodate price increases in the system.
When they do, they’ll even have agreement from the insurance regulators.
You’ve noticed how that works, right?
The insurance business is designed so the insurer never loses money in any year — ever.
That’s why they need you to commit your annual coverage and spending in FSA’s and deductibles up front. First, they define their spending budget based on revenues commitments during enrollment period. Then, they manage their spending inside that budget for the rest of the year.
Until You Reach Old Age, Insurers Expect to Always Make a Profit On the Difference Between Your Annual Insurance Premiums and Spending.
About the only time they’ll pay more out than you pay them is if you reach old age, when statistics show you’ll likely have your highest medical bills.
If you die unhealthy and early, it actually works to the advantage of insurance companies.
What this means: insurance companies don’t even have an incentive to keep you healthy.
For the thousands of dollars a year in insurance premiums paid to them by most consumers, who use little in the way of insurance, pharmaceuticals, or medical services, the least the insurers can do is pay for an annual check-up.
16. Large Pharmacy Chains Have Insurers Over a Barrel
CVS and Walgreens have such huge distribution that they can essentially dictate their pricing to the insurance companies that depend on them for a large percentage of their revenues.
While some other chains probably could, it appears they don’t. Furthermore, the many, small, local chains and ‘mom and pop’ pharmacies have no economic clout and are forced to accept whatever payments insurers offer them.
Key takeaway: In general, buy your prescriptions anyplace EXCEPT CVS and Walgreens.
17. Ultimately You Pay Your Own Way.
On the insurer’s financial statements, you or your employer (or a government agency) pay:
- insurance premiums, then
- some of those premiums pay for pharmaceuticals, devices and services, and
- the rest of the premium pays for salaries, bonuses, employee benefits and perks, rents and real estate costs, selling costs including agents’ commissions, and other operating expenses (like the marketing budgets that lobby government officials and the HR departments of the companies that buy their services).
- Everything that remains after all those costs, then becomes a profit of the insurance company.
By the way, if you think your insurance payments through your employer or the government are “free”, consider that you dedicate every day of your life to them at work and paying taxes to “earn” those insurance benefits.
You pay dearly for every penny of insurance premiums paid on your behalf.
As regulated businesses, insurance companies are virtually assured a profit by the regulators.
The uninsured portion (copayment or co-insurance) of your medical expenses is also borne by you. Aren’t you glad somebody paid those premiums on your behalf?
Regardless what they call it, the portion of “insured” healthcare costs paid by you (after the insurance premiums) is used as a test of your commitment to receive medical care. The insurance company is figuring there’s no reason they should have to shell out a penny of your premiums unless you’re willing to spend still more of your hard-earned money on the treatment.
Insurers have increased it significantly in the last few years, to deter you from buying more medical treatment, which saves them money.
Money talks. Patients pay to play.
Get the best value you can.
Doctors‘ Financial Interest
18. Your Doctor’s Fundamental Business Goal Is to Have Steady Revenues that Require Little Marketing Or Selling.
This isn’t unique to doctors — it’s fundamental to driving any successful business.
Have you noticed your doctor nearly always has a ready recommendation for referrals if you push for them? Doctors are business people who refer clients back and forth to other, non-competitive businesses.
The successful ones attend morning leads groups and referral network meetings, just like other business people do.
The successful ones give free talks about their areas of expertise, usually to other medical professionals who might refer them clients.
Some doctors offer training and seminars directly to consumers, as a marketing practice, just like other successfully marketed companies do.
They even take classes and training to market their businesses. Use a search engine and search for “how to market my medical practice” to get a feel for how healthy that part of the medical industry’s expense line item really is.
19. As the Person with the Most Training and the Sole Legal Authority to Diagnose, Prescribe, and Operate, the Doctor has no Checks or Balances on His/Her Authority or Performance.
Any time there is no check on a person’s or group’s authority, abuses are inevitable.
Books and media show that unchecked incompetence and abuse is rampant across the medical sector (one such book is linked below).
I have experienced it myself on several occasions.
For example, I have been:
- Prescribed drugs for conditions I was later proven not to have.
- Prescribed drugs “as a precaution” for conditions the doctor stated I likely didn’t have.
- Misdiagnosed by doctors who could have made the correct diagnosis with very inexpensive tests.
If you think back on your own experiences, you can likely identify similar situations you have also experienced.
After all, 10% of the time, doctors get the diagnosis wrong.
“…preventable medical error is the third-biggest killer in the United States, causing more than 400,000 deaths every year. More people die from mistakes made by doctors and hospitals than from traffic accidents. And most of those mistakes are never made public, because of malpractice settlements with nondisclosure clauses.”Matthew Syed, Black Box Thinking: Why Most People Never Learn from Their Mistakes–But Some Do
Systemic Financial Interest
20. The Medical Sector is Continuously Remodeled for Taking Advantage of Consumers.
As consumers, we are in a fight for our health and even our lives.
Nonetheless, powerful forces have stacked the deck against us, and they work together every day to stack the deck further against us.
As evidence, the Pharma/Healthcare/HMO and Insurance industries spend more money lobbying for governmental regulations than the next 4 industries combined.
In Business School, one of my professors taught me the #1 way the best businesses create opportunities for themselves and ensure an operating environment that is friendly for themselves, is by lobbying government officials.
The best businesses lobby not only to reduce threats to themselves, but also to reduce the friction they encounter in their environment, to restrict competition, and to increase their autonomy.
Pharmaceutical, medical, and insurance companies influence governmental regulations, sometimes taking advantage of consumers.
The most successful businesses (including the Pharma/Healthcare/HMO sector, which now represents nearly 1/5 of the total US economy) have created an environment where they are free to limit and unilaterally influence the information available to consumers, without resistance or consequence.
The manipulation of the market by these highly funded, well-organized and similarly interested business partners is a master class in owning one’s consumers.
The financial and information asymmetries between the suppliers and the consumers in the medical sector are perhaps unprecedented in modern business. A possible exception is the slightly less modern but more completely closed loop company towns.
For more Information
- More about 1 of my chronic illnesses: https://dylancornelius.com/chronic-conditions/.
- Dr. Phil Maffetone quote is from Healthy mouth, healthy body.
- An eye-opening book about the culture of dishonesty in medicine, and the structural forces that perpetuate healthcare professionals’ failure to look at the systemic failures: Black Box Thinking: Why Most People Never Learn from Their Mistkes – But Some Do, by Matthew Syed.
- Read my journey to autoimmune diagnosis and beyond.
- Read more about Me And This Blog.
- Consumer paying medical expense. Photo via iStock. Link.
- High cost of healthcare. Photo via iStock. Link.
- Team doing fist bump around table. Photo by fauxels via pexels. Link.
- Young woman holding money. Photo by Sharon McCutcheon on Unsplash. Link.
Purpose of This Article
- Share key things medical consumers can do to have better results and more desirable health outcomes at potentially lower cost.
- This article informs the reader about the environment they’re operating in when they purchase and use medical services.
Audience for This Article
- People who use medical services.
- Consumers who want to spend less money and get better results in their interactions with the medical sector.
- Anyone who thinks more is possible.
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