HONEST MEDICINE: My Dream for the Future

SiCKO "Hitman" Lee Einer Shares More Insurance Industry Secrets With HonestMedicine

Faux Health Insurance for the Self-Employed:
The Sham, The Scam, The Shame of It

By Lee Einer – SiCKO “Hitman”

NOTE: When I interviewed Lee Einer for Honest Medicine, I was so impressed by his directness, and his willingness to share with us the less-than-honorable things he was forced to do (to keep his jobs) on behalf of the insurance and healthcare companies he worked for for 20 years. After our interview, I asked Lee if he would be willing to write a series of columns for HonestMedicine.

He said he would.

This is the first in what will be an ongoing series. In order not to confuse readers, I will share the title of his next column after this one.

One of the great failures of our current American healthcare system is that it does not -- and cannot -- provide true health insurance to most self-employed Americans.

Why not?

The core concept of health insurance is shared risk, and this is what we have with employer group insurance. With employer groups, the insurance company is insuring not an individual, but rather, a group of individuals. The larger the group, the more predictable the risk the company is taking – with “risk” referring to the likely future healthcare costs of this particular group.

It is all a matter of statistics. So, if you have a pool of, say, 500 employees, you can reference the statistics that exist in actuarial tables on heart attacks, cancer, and other illnesses and conditions, and you can make certain predictions about the cost of insuring a particular employee group. For example, if statistics show that 3 people out of a hundred typically have heart attacks in any given year, you can project that, say, 15 individuals in your employee pool will have heart attacks this year. This number has a margin of error and the degree of certainty attached to it, as do all statistics. The larger the pool, the lower the margin of error and the higher the degree of certainty. Since larger groups have more predictable risk and lower margins of error, they are less expensive to insure.

If you are self-employed, however, you don't have access to employer group coverage. Instead, you will likely get individual coverage, and this means you are not sharing your risk with anybody. Consequently, if you stay healthy, you are a cash cow for your insurer: You pay them money and they pay out on nothing but routine physicals. (However, because most of these individual policies are so expensive, self-employed people will often choose a high deductible plan in order to save money. So, in this case, your physicals won’t really be covered either. They will be “applied to your deductible.”)

You won’t find out that your insurer doesn't pay out, until you submit a claim for  a potentially costly condition.  And if you become ill, 100 percent of your “risk pool of one” is ill and therefore a money-pit for your insurer.

The insurer, therefore, has limited options, if they are to maintain profitability on your policy. They can jack your rates through the ceiling when it comes time to renew your policy (typically either every six months or every year). Or, they can deny your claims as treatment of a pre-existing condition. Or they can find an inconsistency on your application for coverage, and use it as a pretext to either increase your rates retroactive to the beginning of your coverage, issue a rider excluding coverage for the health condition you have, or rescind your policy retroactive to the date of issuance.

The first tactic, substantial rate increases at renewal time, is automatic. Every time you renew your policy, your future risk is re-assessed based on your “experience,” i.e., your reported health history during the past coverage period. So if you developed a serious health condition and your policy is up for renewal, your premiums could increase several-fold, forcing you to drop your coverage.

Problem solved, from the insurance company's perspective.

The remaining tactics – which I described very briefly in SiCKO -- all flow from a practice known as retroactive underwriting, or underwriting on the back end.

When you apply for individual, non-group coverage, the application typically asks a number of questions about your health experience over the five years prior.

• Did you have medical advice, diagnosis, care or treatment for any condition of the digestive system?

• Did you have medical advice, diagnosis, care or treatment for any condition of the respiratory or cardiovascular systems?

• Did you have medical advice, diagnosis, care or treatment for any conditions of the breast?

• Did you have medical advice, diagnosis, care or treatment for any mental or emotional issue or condition?

And so on.

Based on your answers, and on the physical exam which accompanied your application, insurance underwriters assess your risk, and determine whether they will cover you, what rate they will charge you and whether any conditions will be excluded with a rider.

When your insurer gets a bill, either for a monetary amount exceeding a certain threshold, or for treatment of a condition which could conceivably have existed before you became insured – even if you didn’t know you had the condition -- your file is “pended” for medical investigation. While it is pended, nothing is paid out for the condition under investigation.

The fact that none of your healthcare providers are being paid during this time often solves the insurer's problems by itself: Since your file may be pended for months, your medical caregivers will send you to collections, and unless you are financially well-off, you will not have sufficient funds to both pay your caregivers and your premiums.

The goal of the medical investigation is to find evidence that something was not fully disclosed on your application for insurance, so the insurer may claim that had they known, they would not have insured you, or would have insured you at a much higher rate, or would have excluded coverage for the condition for which you are now being treated.

As I described in SICKO, this is the point at which the insurer will go after you “like it’s a murder case.” They will contact every medical provider they believe treated you, and will request medical records. They will contact every pharmacy which you are believed to have used, and request their records. They will go into your health history as far back as five years before you applied for coverage.

If they find anything -- ANYTHING -- which they determine that you did not fully disclose, and which could conceivably have been captured by the questions on your application, they have you.

Example: Did you have rectal itch, constipation, a belly-ache or heartburn four years ago? Did you tell your doctor?  If so, did you remember to disclose this seemingly trivial and forgettable fact fully on your application under “conditions affecting the digestive tract”? If not, the insurer could use this as a pretext to dump you, jack your rates beyond that which you are able to pay or exclude coverage for your present problem.

You will, at that point, have been screwed. Mission accomplished.

The American system of individual insurance for the self-employed is, in short, a cynical scam -- a way to sell people the illusion of health coverage, knowing that when they need it most, the illusion will evaporate and they will be left with nothing.

Isn't it time for a change?

♣ ♣ Be sure to read Lee's second article, "The Truth About Self-Funded Plans." You will be surprised to learn the truth about these plans, which are provided by some employers -- especially the fact that they are NOT really insurance!

Dr. Ronald Hoffman Talks With Honest Medicine

Dr. Ronald Hoffman is one of this country’s foremost integrative physicians. By this I mean that he uses the best treatments from both conventional and alternative medicine to provide truly integrative (or “intelligent”) care. He is Medical Director of the Hoffman Center in New York, and is also the author of several books, including: “Intelligent Medicine” (1997); “The Natural Approach to ADD” (1999); and his 2006 book, which he wrote with my friend Sidney Stevens, entitled “How to Talk With Your Doctor: The Guide for Patients And Their Physicians Who Want to Reconcile And Use the Best of Conventional And Alternative Medicine.” His most recent book, written with Barry Fox for Rodale Press, is “Alternative Cures that Really Work.”

Dr. Hoffman speaks with Honest Medicine on several topics including how so-called scientific “studies” present holistic therapies in the worst possible light –- and how this is sometimes done on purpose.

DOWNLOAD HONEST MEDICINE’S INTERVIEW WITH DR. HOFFMAN.

SHOW NOTES

00:00 to 2:36 -– Introduction. Dr. Hoffman’s background. As a medical student in the 1970s, he was the “perfect stealth medical student, studious by day, while quietly pursuing my holistic interests after hours.” Today, in addition to being Medical Director of the Hoffman Center, and the author of several books, Dr. Hoffman is Past President of ACAM (American College for Advancement in Medicine), and the host of “Health Talk,” the longest-running MD-hosted health show on syndicated radio. Read more about Dr. Hoffman’s biography here.

2:36 to 4:00 –- Defining terms: Alternative Medicine, Complementary Medicine, Integrative Medicine, “Intelligent Medicine”

4:00 to 5:00 -- A discussion of how alternative medicine is too often misused as “the last resort of the desperate” -- or put another way, as an “almost magical, eleventh hour treatment when conventional options have failed.” Used this way, it is bound to fail. A much better way to use alternative medicine is in conjunction with conventional medicine –- either under the care of a doctor who understands how to combine the two; or of two doctors who communicate closely with each other.

5:00 to 8:36 –- A discussion of the Mayo Clinic’s Dr. Charles Moertel’s study of Vitamin C, the results of which were published in 1979. In this trial, extremely sick colon cancer patients, who had already failed to respond to chemotherapy, radiation and surgery, were given very small doses of oral Vitamin C.  Read more about this flawed "study" in the book, "Vitamin C and Cancer: Medicine or Politics." Now, 20-30 years later, we’re looking again at the use of Vitamin C to treat cancer. But now, it is intravenous Vitamin C –- which is what Linus Pauling (pioneer in the use of Vitamin C for the treatment of cancer) always said should be used.

Dr. Hoffman discusses how other studies are designed in such a way as to fail, by putting the (natural) agent being studied at a disadvantage, so it will more than likely fail the test. For instance, one study of St. John’s Wort was conducted on people with moderate to severe depression. This was not a fair test for an herb that has a mild to moderate effect! In addition, this study was partly funded by the pharmaceutical company that manufactures Zoloft. But it was not publicized that the study also showed no statistical advantage to using Zoloft with depression of that severity! Of course, the headlines read: “St. John’s Wort worthless in the treatment of depression.” They might also have read, “Zoloft worthless in the treatment of depression.” The message in the press was therefore skewed, thus depriving people of a possible treatment for mild to moderate mood disorders.

8:36 to 11:00 –- So how can we know how to interpret these studies? This is difficult, because -- in addition to the fact that many of these studies are skewed -- we’re now getting what Dr. Hoffman calls “reporting by press release.” Often, science and health reporters are simply “quick studies,” without the background and understanding necessary to get the story right. In order to pick apart and analyze a study correctly, you must know if the study meets the proper criteria “in terms of objectivity and statistical strength.” Understanding how to analyze these studies is even difficult for doctors who read the medical journals all the time, and are bombarded with conflicting studies about various drugs. For instance, doctors will read studies hailing a drug as a “miracle drug,” and they’ll prescribe it widely. Then a few years later, it may turn out that the drug has DIRE side effects. On his radio show, Dr. Hoffman tries to do “spin control” on the headlines from the popular press to help people interpret the news and be better arbiters.

11:00 to 13:00 –- Why TV, which is where most people get their news, is not as good for in-depth reporting about supplements (and other complex topics) as is radio. Also, so many TV shows are bracketed by pharmaceutical ads and, even if there is not direct pressure, the station is probably subtly pressured NOT to lash out violently at the pharmaceutical companies that pay the bills. A discussion of video news releases (VNRs – or “fake news”), which look like news, and stations play them as if they were actual news. But they are really written and paid for by pharmaceutical companies, and produced by big PR firms. According to Dr. Hoffman, this kind of thing is also happening with natural products.

Dr. Hoffman knows that he is riding the crest of a wave of acceptance of natural products, but many players in this arena are also unscrupulous and they take advantage of the credibility that has been created for natural supplements.

13:00 to 15:21 -– Lot of the really reputable, excellent supplement companies are small companies that don’t have the big advertising budgets, so they are not known by the general public. They are mainly known by some holistic doctors and savvy patients.

Dr. Hoffman’s belief that there is a “populist revolution” going on, with some good websites, publications and radio shows disseminating information that would otherwise not reach the public. There is also a proliferation of outlandish junk. But people need to know how to access and understand the reputable information, and how to separate the bad information from the good. He sees his role as that of an “air traffic controller” for all claims (including natural claims) that need a “reality check.” People who are interested in this topic will read publications and listen to radio shows. But what is on TV is what most of the public is looking at. And what is in the medical journals is what most doctors are reading. Both versions are too often skewed. So this “populist revolution” is going on within a small part of the population.

15:21 to 16:43 -– Dr. Hoffman talks about the “bifurcation” in health styles of Americans, with the aggregate health of Americans deteriorating, since the average is dragged down by fatter, more sedentary, junk-food-fed people. But there is a smaller minority who are healthier than ever -– eating organic food and exercising.  He remembers that the supermarkets of the 1950s had terrible food -– vegetables in cellophane -– horrible produce. Now, there are more options for folks who want to eat well. So we have a split between the least and the most healthy.

16:43 to 20:00 –- Dr. Hoffman (and co-author Sidney Stevens’) book, “How to Talk With Your Doctor.” A true story in the book: One of Dr. Hoffman’s patients who had cancer was taking supplements under his direction, while undergoing chemotherapy –- until her oncologist ordered her to stop. She stopped, and started to feel and look sicker. Although Dr. Hoffman doesn't agree with this oncologist –- when patients are taking the supplements under the care of a qualified holistic doctor –- he doesn't want patients to feel conflicted, so he doesn't argue. However, he feels that it is a shame that these patients are being denied these supplements that can protect them from the harmful effects of chemo and radiation, and can also keep their immune systems functioning better.

However, Dr. Hoffman often encourages his patients to take conventional therapies, if he thinks they need them. One example: A patient with AIDS, who wanted to avoid all pharmaceutical treatments. Dr. Hoffman convinced him that he would die without drug treatments. Today, 15 years later, thanks to following a truly integrative approach, the man is doing well, and is taking his meds, as well as weekly intravenous Vitamin C treatments. It is the combination approach that is working for him.

20:30 to 22:35 –- There is not enough dialogue between conventional and holistic doctors. His book is a call for this dialogue. Without this cooperation between doctors, patients are put in a bind. More oncologists are starting to work with him –- and with doctors like him.

22:35 to 24:30 –- How conventional doctors can learn more about alternative treatments through organizations like ACAM (American College for Advancement in Medicine). Dr. Hoffman encourages young doctors and medical students to attend ACAM conferences (for which they can get CME credits), to hear presentations on complementary medicine done in a highly rigorous manner. At these conferences, doctors learn about the serious research being done on supplements. He also invites conventional doctors to whom he refers patients to come to his office for rounds, where they learn that he’s just adding natural medicine to sound medical practice.

24:30 to 26:13 –- Dr. Hoffman wants to teach medical students about integrative medicine. So, over the last 10-15 years, he has had approximately 25 medical students do a 1-month rotation at the Hoffman Center. These young doctors become very excited because what they get in medical school is often not patient-oriented. ACAM encourages doctors around the country to do this.

26:13 to 29:00 -– There are not enough medical school courses in complementary medicine. And those that are taught are often not taught by doctors really knowledgeable in CAM (“Complementary and Alternative Medicine”). Some hospitals in wealthier suburbs offer what they call “CAM,” but it’s really window dressing for conventional medicine. In such hospitals, patients will get chemo and radiation, along with foot massages and music therapy. And these hospitals and doctors think that this is true CAM. They should really be looking at a more intensive use of diet and supplements, for a more cutting-edge, potent version of complementary medicine. But this “CAM-lite” approach lulls people into thinking they're getting complementary medicine, when they're not.

29:00 to 32:00 -– How the yearly physical might be improved upon. The way physicals are currently done in many conventional medical offices doesn't make much sense. For instance, to do yearly EKGs and Chest X-rays for everyone is NOT cost effective, nor does it make sense. AND, it is NOT evidence-based. Dr. Hoffman feels that we should eschew some of the things that have been done routinely, but that we should add other things that really make sense. For instance, the New York City health commissioner recently announced that one-fourth of all New Yorkers have high levels of mercury. Why not do tests for this at the time of the physical? Also, there is an epidemic of pre-diabetes in America. Why not do a 5-hour glucose tolerance test on those people the doctor feels are probably pre-diabetic. Vitamin D levels have been found to be inadequate in 60% of the population in the Northeast. Why not test for this? But conventional doctors aren’t aware of things like mercury and vitamin D levels.

32:00 to 37:00 –- Dr. Hoffman thinks things are changing. For instance, the “New England Journal of Medicine” recently published a review article by Dr. Michael Holick, about the huge role Vitamin D can play in the prevention of many diseases. Not long ago, this researcher was widely criticized for his views on vitamin D. However, it will take a long time before doctors will be actually checking patients’ Vitamin D levels, and prescribing Vitamin D supplements if levels are low. We can be quite sure that drug detail people won’t be giving doctors samples of Vitamin D, and that there won't be TV ads for Vitamin D. However, some good news: fish oil is now prescribed by cardiologists, because one brand of fish oil achieved drug status with the FDA. It is now in the PDR (Physicians’ Desk Reference).

These are moments of vindication.

37:00 to 40:00 –- The difficulty for doctors who practice in both the conventional and alternative medical worlds.

40:00 to 43:00 –- the unreliability of the Meta-Analysis, which combines the results of lots of studies. Unfortunately, studies are included or excluded in these meta-analyses, according to the biases of those who are putting them together. For example, in 2005, one meta-analysis of Echinacea for use with the common cold led to the headline that this herb showed no benefit. Then, in 2007, the highly respected Lancet published the results of another meta-analysis, that said that Echinacea reduces colds by 60%. How do you reconcile these results?

We know that in studies conducted by pharmaceutical companies, in which their drug is compared with a drug from another company, 85% of the time it is “shown” that their drug is better. Recently, a drug company tried to bury the results of a study that showed that their drug was not superior to another. They had to pay damages because of this scientific dishonesty. The researcher said she was intimidated by the pharmaceutical company.

43:00 to 44:00 –- This is a scary time, because our “news” is influenced and paid for and promoted by  pharmaceutical companies and their publicists. The natural products industry is not exempt from this kind of behavior either.

44:00 to 45:45 -– It is disingenuous for conventional medicine to be writing articles on the perils of natural therapies. The damage ratio is probably 10,000 to 1 -– of damage caused by drugs versus damage caused by natural products. The "New York Times" published an article on the dangers of natural products. They got so many letters objecting to this article that, weeks later, they wrote a retraction –- which was buried in Section D, page 28, in tiny print. So the message that gets out is about the so-called dangers of natural products!

45:45 to 47:00 –- When he was a medical resident, Dr. Hoffman often reported the causes of death in the hospital where he worked. Harried interns and residents filled out the cause of death forms. Many times the cause of death was cardiac arrest -- often the result of drug toxicity. However, the cause of death was most often listed as “cardiac arrest,” rather than drug toxicity.

47:00 to 48:15 –- Dr. Hoffman’s website, www.DrHoffman.com, has lots of great articles, also information about his radio show and his salmon and salad diet.

Michael Moore's SiCKO

Like so many Americans -- especially those of us who have done serious battle with our health care system -- I have eagerly awaited the release of SiCKO. I am happy to report that I loved the movie, but with reservations. I hope that, by addressing my reservations here I, too, will make a difference by bringing these concerns to the attention of those who are working to change our healthcare system.

My reservations have nothing to do with the fact that Moore idealized the universal healthcare systems of England, Canada, France and Cuba. He never said he was making a true documentary. And he never presents both sides equally. That's simply not his modus. I love his films anyway. And I certainly would rather live in a country with universal healthcare -- even with long lines. Heck, let's not kid ourselves: we often have to wait a long time for care in America. That would mean little to me if we were all completely covered medically.

And I really love the fact that Moore, instead of making a film about the horrors of being uninsured in America, took an unexpected turn by exploring the problems suffered by the majority of us who feel (naively) confident because we are insured. If he'd concentrated his film on the uninsured -- as many assumed he would -- most Americans would have distanced themselves emotionally with: "Well, that could never happen to me."

But focusing on the insured -- the majority of us -- and the fact that we are not as safe as we think we are, was brilliant. It puts the fear of God into lots more people.

As well it should.

I wrote a letter to Michael Moore when, in February, 2006, he sent out his request for medical horror stories. In it, I told him how my husband, Tim, also originally from Flint, Michigan, had suffered a cancerous brain tumor in 1990 at the age of 40, and how for the next 15 years until his death in 2005, we battled both our insurance company and the hospitals.

I also told him how sub-standard I thought the care Tim received had been in some of the so-called best hospitals in our country.

I told him that we were insured, with what was supposed to be a "Cadillac" of policies, and that, as Tim's illness progressed, our insurance company kept raising our rates, until we were paying $1700 a month for a policy that left us with thousands and thousands of dollars in uncovered bills.

Just like several of the people featured in Moore's film, from the beginning, our insurance company tried to get out of paying anything for Tim's initial brain tumor surgeries, chemotherapy, radiation and numerous infections. They cited his tumor as a "pre-existing condition."

Why "pre-existing"? Because Tim had had a seizure 5 years earlier, which had been misdiagnosed by our doctor as a "sleep disturbance." Luckily, unlike so many people in Moore's movie, we won that first battle -- but not without the help of many people, and many hours spent by me, as well.

Our woes kept escalating. Like Donna and Larry Smith, the hardworking, 50-something couple in Moore's film, who were forced to move into their daughter's basement storage room because of high deductibles and insurance co-pays, Tim's visits to the hospital and the doctors continued, and our uncovered bills kept mounting. In addition, our $1700 per month "Cadillac" insurance policy only minimally covered the cost of Tim's numerous medications, which totaled several hundred dollars a month.

Although I was still working full-time, we were nearly broke.

But, here is a really important point -- and a point that Moore does NOT address in the movie: Our insurance company was not the only one who was rapacious. The hospitals and doctors, too, demanded their full "pound of flesh." Of course, I'm sure that most of them deserved to be paid, but they had already been paid very handsomely by our insurance company. (And remember, this was NOT an HMO.)

The problem was, in many cases, the hospitals and doctors charged more than the "usual and customary" amounts the insurance company was willing to pay. And although they had already received hundreds of thousands of dollars, both the doctors and the hospitals went after us for every last dime.

When there is a serious illness, many, many doctors are involved, most of whom neither Tim nor I had never seen or heard of, even though I was in his room almost all the time.

The prodigious efforts of these doctors' offices and hospitals to collect the many thousands of dollars remind me of Lee Einer, the insurance company "hitman" featured in SiCKO, who said it was his job to get money back from patients, no matter what he had to do to get it. "We go after this like it's a murder case," he said. Tim and I were down to one income (mine), and even though I was making payments the best I could, these folks called me nearly constantly at work; they sent collection notices; they harassed me. I told all of this to Michael Moore in my letter.

Which brings me to my most serious criticism of SiCKO.

To only attack the insurance and pharmaceutical industries -- and they are both pretty greedy -- is, I believe, a huge mistake. They certainly are not the only healthcare villains.

Moore points out in SiCKO that the AMA was behind the early efforts to block Medicare, because it was "socialized medicine." He pointed out that the AMA arranged coffee klatches, in which doctors' wives conducted an anti-Medicare "Operation Coffee Cup" campaign, aided enormously by a promotional recording by Ronald Reagan -- back when he was "just" an actor. It's priceless: Turn your speakers up and listen to it here! (I am indebted to Doug Hammond's Dirty World News blog for turning this recording up!)

Does Michael Moore think that America's doctors won't try to block all serious plans for universal health care now? Indeed, the AMA has already released its official reaction to the film. Read the statement. It's almost laughable, since it seems obvious that Edward L. Langston, MD, "Chair, American Medical Association," the person credited with having written it, most likely didn't actually see SiCKO, before putting pen to paper. (The AMA obviously thought the film was about those who are without insurance. Check it out.)

Moore humorously looks at the fact that there are more healthcare lobbyists in Washington than Congress people, and that many -- including Hillary Clinton -- are financially indebted to them. But he doesn't touch the fact that our doctors, too, are in the thrall of Big Pharma. All you have to do is read the articles about doctors' financial ties to drug companies. For instance, here are just a few of the many articles I was able to dig up on this topic: Dr. Adriane Fugh-Berman's New England Journal of Medicine piece, "Doctors must not be lapdogs to drug firms" ; the Associated Press's "Groups Question Doctors' Ties to Drug Firms"; and my personal favorite, MSNBC's "Cancer docs profit from chemotherapy drugs."

While Moore castigates the pharmaceutical companies for charging huge amounts of money for their drugs, he doesn't at all address the fact that we can't even be sure these drugs are safe, since so many drug companies hire doctors and universities to conduct their so-called "trials," and then to write about how successful these "trials" are. Many have blown this whistle.

Is it possible that Moore didn't know about this highly questionable practice? (See the wonderful 2000 article by Marcia Angell, published in the New England Journal of Medicine, "Is Academic Medicine for Sale?" -- and Slate Magazine's shocking "Rent-a-Researcher: Did a British University Sell Out to Procter & Gamble?" In 2006, the Wall Street Journal's David Armstrong blew the whistle on the American Medical Association (his article is reprinted here) by exposing the fact that the association's own professional journal, JAMA, had published the findings of a study, for which the doctors/researchers involved had a to