How the Healthcare Industry Fails Patients and Pins the Blame on Physicians: High Deductible Healthcare Plans

This is the beginning of a three-part series detailing the ways in which patients are harmed by the Healthcare Industry and how I was complicit as an employed physician. I was threatened with a lawsuit due to a patient who suffered medical and financial harm from the Health Insurance System. A Medical Board complaint was made against me due to corporate policies designed to increase profitability. Finally, I was the victim of both libel and verbal assault with the threat of bodily harm by the family member of a patient who was struggling with prescription drug dependency and addiction perpetuated by the Healthcare Industry and its campaign of “Pain as the Fifth Vital Sign”. This series also illustrates the moral injuries perpetuated by corporate healthcare upon physicians.

Before I discovered Direct Primary Care, I didn’t understand health insurance at all. I had a very loose understanding of the term “deductible”, and when patients without insurance or ones with a high deductible plan would inquire about the costs of various tests or treatments, I felt as frustrated as they did. I couldn’t even provide an estimate, especially since these costs can vary from hundreds to thousands of dollars depending on where patients go to get them done. At that time, I felt defensive. It wasn’t my job to know the costs. It was my job to recommend the Gold Standard for diagnosis and treatment. Billing and coding for my services was part of my job. I didn’t know the cost of anything in healthcare except for primary care appointments and the minor procedures I performed. I knew these rules backward and forward.

One time, I saw a New Patient with Hypertension, Type 2 Diabetes, Hyperlipidemia, and Morbid Obesity for a Level 4 New Patient Appointment (99204). The patient had bloodwork ordered and drawn at that appointment, and she was scheduled to return for a follow-up appointment in one month to discuss her lab results and make any necessary changes to her treatment plan. Her lab results included well-controlled diabetes and slightly elevated liver enzymes. I suspected non-alcoholic steatohepatitis, which commonly occurs in patients with these types of chronic medical conditions, which is known as metabolic syndrome. I had planned to discuss this with her at her follow-up appointment and order additional testing at that time.

Prior to her follow-up appointment, she was billed for her initial visit. She had expected her insurance to pay for her appointment, but she had a High Deductible Health Plan, and they only covered an annual wellness exam. She called to complain to the office manager to change the billing to a wellness exam, so her insurance would pay for it. However, this change could not be made because she did not have a wellness exam. Preventative screening had not been addressed, and even if insurance fraud had been attempted on her behalf, it would not have been successful, since her insurance company already had documentation of her appointment, which supported the original billing code.

Of course, the patient didn’t come in for her follow-up visit, so her elevated liver enzymes were never addressed. Surprisingly, she returned for another New Patient appointment three years later. Her liver enzymes were normal, but she had pancytopenia (low red and white blood cells and low platelets), so I referred her to a hematologist for additional work-up, which revealed liver cirrhosis. Several years later, after I had started my Direct Primary Care practice, she found me on social media and sent me a message. She was upset that her cirrhosis could have possibly been prevented. She admitted that she had tried to sue me, but multiple lawyers were unable to find any evidence of malpractice. I often think about how the system failed this patient and the role that I played. I think about how even if she had come to her follow-up visit and been diagnosed with fatty liver disease, she probably would have still developed cirrhosis due to the ubiquity of fatty liver disease and lack of insurance reimbursement for counseling on lifestyle changes. 

I think about how the system continues to fail similar patients, including many of my current patients with fatty liver disease. When I refer these patients to a liver specialist for a fibroscan, a special type of ultrasound which is only done by liver specialists, my patients tell me that they are chastised by the nurse practitioner for coming in and wasting his time being seen for a condition without any FDA approved treatments. Along with diet and exercise, GLP-1 agonists show great promise in treating fatty liver disease and preventing development of cirrhosis, but FDA approval is still pending completion of Phase 3 trials. In my DPC practice, I have plenty of time to work with these patients on lifestyle changes and, in some cases, to try off-label use of GLP-1 agonists, and some of them have been able to reverse this process. I think about how much this former patient would have benefitted from Direct Primary Care, both medically and financially and how her cirrhosis could have been prevented.