As an athlete and a patient with chronic conditions, I have seen facets of the insurance/medical establishment I hope the average medical consumer never has to learn. I bring formal training and an entire career in managing businesses. As a result of these experiences, I’m a smarter medical consumer than ever before. If I can help you have a better experience and spend less time and money in “the system”, I hope you’ll take the opportunity to do so.
Be A Smarter Medical Consumer
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. Awareness of these incentives may enable you to better understand some of the reasons why some recommendations are made to you. I hope 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, increase the value you receive, and get faster results.
Manage Your Health
1. Avoid the doctor entirely.
Key contributors to chronic disease 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 #8 and 10 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.
2. Food is the best medicine.
The right food is the best medicine. The wrong food can make you sick and may eventually kill you.
Over several decades, the system 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, most 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 complaints that have become the de facto condition of modern life on North America.
Build a team and support network for your medical life
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 often 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 they’re happy.
- Insurance companies are happy the doctor didn’t order tests because tests are just additional costs. The doctor can and often will diagnosis and prescribe, with or without tests. The insurance company saves money and experiences higher margins when doctors don’t order them. Physicians are also pressured by insurers to limit diagnostic tests, so they’re even less likely to order tests.
- 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.
3. Find a good general practitioner or family medicine doctor.
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.
4. Find the best specialist, then get a referral to them if your insurance requires it. If possible, make the appointment yourself.
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. Doctors and clinics are sophisticated business people in an established business and industry: they have established business practices that maximize and sustain their revenues and personal incomes.
5. 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. In all of this, there’s rarely a patient advocate, except in the case of terminal conditions. Even that “advocate” is a risk management professional who works for the insurance company, not the patient. Without them, you as the patient are on your own.
6. Find a non-medical support group related to your area of concern, and participate.
Consider Livestrong for cancer, Weight Watchers for diet and weight, 12 step programs for addiction. There are organizations for almost every condition or class of conditions. Share others below, and I’ll add them or write another post.
Be Aware Of The Incentives At Play
7. Insurance companies’ business model is to grab every dollar and limit what they pay out.
Insurers receive nearly every dollar of medical and pharmaceutical revenues in the United States, before it’s spent by consumers. Once they have the money, private insurers want to limit how much they pay out. They want to 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. Cost cutting actions on their part are designed to improve their profit or budget position, not your costs as the consumer.
8. Insurers have little incentive to keep prices low or buy you the best care available.
Despite what they may tell you, insurers don’t really have an 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, but ultimately you (or the pool) pay 100% of the cost of your (or the pool’s) medical expenses, so it really makes no difference to them 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. You’ve noticed how that works, right?
The game is designed so the insurer never loses money in any year. That’s why they need you to commit your annual coverage and spending in FSA’s and deductibles up front. 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, they expect to always be profitable on your annual insurance premiums and spending. The only time they’ll likely 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. They don’t even have an incentive to keep you healthy.
9. Ultimately you pay your own way. Get the best value you can.
On the insurer’s financial statements, you or your employer pay insurance premiums, some of those premiums pay for goods and services, and the rest pay for salaries, bonuses, benefits, rents, selling costs, other operating expenses, and profits of the insurance company. The uninsured part of your medical expenses is also borne by you, in the form of a copayment or co-insurance. Eventually they’ll probably invent another word for this. Regardless what they call it, this extra portion paid by you is used as a test of your commitment to receive medical care. 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.
10. 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. Just search “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.
Lead Your Team To Your Best Health
11. Organize yourself, and own the results.
- Write down your health goals and a plan to achieve each one.
- Write a list 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.
- Write a list of your lifestyle choices, supplements, and dietary practices you’ve chosen to positively influence your health and well-being.
- Create a list of your lifestyle and dietary practices that may not be supporting your best health status.
- 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. If you don’t generate it, no one else can deliver what you really want.
12. Keep asking the doctor questions until you understand:
- the diagnosis is correct.
- possible alternative diagnoses and why they were ruled out.
- why the recommended course of treatment and prescriptions were selected.
- alternative courses of treatment and why they weren’t selected.
- alternative prescription options, their side effects, advantages, and costs to you with your insurance plan.
13. Always ask the doctor what alternative drug and procedural options exist, compared to the one initially recommended.
Doctors only know what they know, and like the rest of us, they have blind spots. Sometimes they don’t know all alternatives. They have few incentives to offer all alternatives, even if they know them. There may be four ways to perform a surgery, but if the doctor is only trained in one of those 4 procedures, he’ll use only that one in yours, regardless which one has the highest probable rates of resolution and recovery.
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, and 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 number 5 above, they have just as much incentive to keep costs high in the long run as they do to manage their annual spending.
Information disparity in the medical sector is huge, and it works against the patient. 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.
When the doctor assesses and diagnoses on this poor information from the patient, and often with no objective data about the source of the problem (like a blood test or a biopsy or a specimen), it’s little more than a guess, and 10% of the time the diagnosis is wrong. Practicing doctors are rarely supervised and patients aren’t qualified to reconsider the diagnosis before treatment begins. As a result, the patient is often relying on a barely educated guess to recover their health.
Even more worryingly, my insurance company just sent me a letter stating I can consult with a doctor over the phone and receive prescriptions, without ever being seen by a doctor. 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 an accurate diagnosis.
15. 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 4, 5, 6, 9, 13, and 14 above.
16. Don’t Accept Population Statistics As A Statement Of Your Individual Diagnosis Or Probable Health Outcome.
17. Share And Connect.
- Share your story in the comments below and with others. We are in this together as consumers, in an environment that is continuously being designed to favor the suppliers. Join me in having our best lives possible!
- Contact me directly.
- Read my journey to autoimmune diagnosis and beyond.
- Read more about Me And This Blog
- Share key things medical consumers can do to have better results and more desirable health outcomes at potentially lower cost.
- Inform the reader the environment they’re operating in when purchasing and using medical services.
- 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.
Also published on Medium.