"Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever does." Margaret Mead
She began as an idealistic, dedicated student. She worked hard against tremendous odds, driven by the desire to learn the mysteries of humanity and apply her knowledge in a noble profession, to heal the ills of her fellows.
He struggled. First in the classroom, for six years or more, as he fought to learn the basic science and to survive the sometimes practical, sometimes arbitrary barriers erected in his path.
For two more years, he labored insane hours in hospitals and clinics unpaid -- indeed, amassing huge debt -- while he discovered the art of healing that went far beyond the science of medicine.
Then three, four, five, perhaps even six more years were spent in further training. Working for less than minimum wage, sometimes for thirty or forty continuous hours at a stretch, often for sixty, eighty, or one hundred hours a week, still in pursuit of the knowledge that would enable her to heal. And there, she learned that the path to health is often blocked not by microbes, not by genes, not by environmental toxins or poor nutrition, not by unhealthy lifestyles or chronic stress or trauma or disease or age or bad luck. No, all too often she and her patients find their way barred by those with a blind dedication to profit.
At first, she doesn't really notice. It's temporary, an aberration. People are working to make it better. She has struggled maybe thirteen years for the privilege of healing her sisters and brothers, and won't let some annoying bureaucrats get in her way.
But then, he watches as a patient suffers uncontrolled pain while accountants second guess his medical management plan. Another dies needlessly while forms are being processed to approve life-saving treatment. He finds that, more and more, the demands of insurance and administration deprive him of opportunities to help patients.
She hopes for an end. Hopes the reformers will finally come through and restore sanity to her world. She feels trapped -- if she doesn't play by the rules, Big Insurance makes sure that it's her patients that pay the price. If she prescribes non-formulary medications, her patients are denied care at the pharmacy and must suffer their illness until she either completes a lengthy and demanding approval process or capitulates and substitutes a riskier or less effective alternative. If, out of concern or compassion, she offers needed services that cannot wait for a bean counter to second-guess her medical judgement, it is her patient who will face financial ruin. She watches as friends who have paid top-dollar for premium health plans are denied basic services because they are too ill. Reform is promised, again. She waits, but instead of getting better, things get worse. The subcommittees and task forces seem to be focused more on their own interests than her patients'.
Another patient suffers and dies. Needlessly. Horribly. And the very monsters who thwarted his efforts to help his friend now point their fingers at him. "We didn't make the medical decisions! We didn't cause this patient's death! We were just trying to be effective managers! If only the doctor had let us know how serious things were, we would gladly have approved the treatment!"
Her belief in the system is crushed. Her faith in reform is in ruins. Her hope that all the players in the health care field have her patients' interests at heart gives way to the daunting reality that only she represents her patients' interests in an otherwise uncaring, profit-driven system.
He feels lost. He must turn his back on a decade and a half of toil, sell out to a comfortable job in a managed-care clinic where he might pay back his extensive loans, insulated from the troubles his patients face when they're really sick. He could walk away from his ideals, face the reality of a system that doesn't seem able to fix itself.
She hates herself for the thought. Then her hatred turns to anger, and her anger finds its target. She won't abandon those whom she set out to help fifteen years earlier. They are her friends, her family, her neighbors, her community. They might never know what she does for them, but she will do battle in their name none the less. She has become a guerilla physician.
When did healing become health care delivery? When did doctors become provider resources? When did patients become capitated lives?
It's about money, pure and simple. Big Insurance got into the health care delivery business to make a profit. In the fee-for-service era, doctors were their unwitting accomplices. Higher costs justified higher premiums, and Big Insurance made millions as health care costs began to escalate to the point where health insurance was no longer a luxury. But Big Insurance wanted a bigger share of the pie, so they began to squawk about the costs which they had earlier helped to drive up. They demanded the authority to control what services their patients got, while insisting that all responsibility remain with the doctors. To the mantra of "controlling costs" (read "insuring profits"), managed care was born.
Tomes have been written about how to manage health care costs. Any system, when it denies treatment to the sick while refusing to take responsibility for the consequences, is wrong. Manage the money any way you want, but leave the care decisions to patients.
Big Insurance is in a bind. They are required by law to consider their quarterly profits above all other considerations. Given the choice of losing some "capitated lives" or losing money, they can be sued by their shareholders unless they opt for the former. Can any of them, then, be entrusted with your patients' well-being?
Big Insurance calls what it does "risk management." But just what is at risk? Insurance customers trust their lives to these managed care organizations: their health, their happiness, their very being is at risk. But the risk that Big Insurance manages isn't life or health, it's profits -- and they even try to shirk that responsibility by forcing doctors into capitated contracts which often move the financial responsibility from a well-endowed mega-corporation to small groups of physicians.
Become a guerilla physician! There are no forms to fill out. No dues to pay. No mailing lists or pledge drives. Just a rededication to what you went into medicine for: your patients' health.
That said, being a guerilla physician isn't easy. Big Insurance is counting on the fact that you're overworked, not interested in accounting, and anxious to get back to seeing your patients. They'll put barriers in your way -- forms to complete, phone calls to make -- that will make it seem easier to do things their way. Don't give in to the temptation! There are alternatives to playing the game their way, and they don't require that you become a dedicated paper pusher.
Much of the Guerilla Physician website will be dedicated to finding and disseminating information on how to effectively advocate for patients without giving up sleep. Here are some basic strategies:
Perhaps the most important single thing you can do is to make your stand known. Many of your colleagues are probably struggling with the same issues you are. Show them, by word and deed, that Big Insurance needn't be allowed to call all the shots.
We've all seen patients harmed by Big Insurance and managed care. Talk about it! Remaining silent feeds the machine.
Many of us have learned ways to get the care our patients need, while sidestepping the costly and inefficient administrative burden that Big Insurance tells us is the only way to get them to cooperate with a medically necessary patient care plan.
Get the word out! Sharing our successes and failures will give our colleagues a leg up in advocating for their patients. The Guerilla Physician will strive to provide a forum where your stories can be told, both on an anonymous stories page and in an email discussion list.
If you're like most doctors in the Era of Managed Care, you no longer work for yourself. You might be working in a small group that contracts with MCOs. You could be in a large group or locum tenens organization. You could even be a salaried employee of a staff-model HMO. It makes it hard to know where your loyalties should lie, right?
It is the essence of professionalism that your ethical obligations remain within the doctor-patient relationship. That relationship supersedes obligations to your boss, your co-workers, and even
Big Insurance doesn't understand that obligation. It is outside the realm of their experience. It isn't that they're evil; they just don't know any better. They'll even try to tell you that your ethical obligation includes controlling costs, even at the expense of appropriate patient care. That means that it is up to you to preserve the sanctity of the doctor-patient bond. It might mean that you have to go outside the bounds of what the MCOs might provide. The more you rely on your organization, the harder it will be to stay focused on your patients. A little independence can go a long way, however:
At least keep track of what patients you see, when you see them, and what their major issues are. You should be able to provide continuity of care even if your organization's infrastructure collapses (or they decide to no longer support your care of the patient). A PDA is invaluable, as it can help you remain both independent and mobile. You don't have to be into geeky toys, though: just saving a copy of your daily patient care schedule with some quick notes scribbled at day's end can go a long way.
The guerilla physician was surprised what he learned when he began to allow his patients to communicate directly to him. He discovered that Big Insurance often denies care in ways that never comes to the attention of doctors. His own office staff didn't think it was important to "bother" him with this information.
It's nice to offload some patient contact -- vital in most clinics -- but beware who's ultimately controlling the flow of information.
Keep a list of authorization phone numbers for third-party payors you frequently encounter. The guerilla physician has her fax machine programmed with fax numbers for most of the MCOs she's involved with. Whenever she makes a referral or writes a prescription that might be denied, she faxes a form letter to the organization emphasizing the medical necessity of the treatment. Some phone numbers and sample form letters are on the Guerilla Physician Tools page.
Of course, many third-party payors will try to deny care to your patients because you haven't submitted information on their particular form. They might also demand an inappropriate level of detail. The guerilla physician believes that MCOs cannot deny services to their beneficiaries on these grounds -- "failure to have the proper form on file" probably wouldn't sit well with a judge or jury, especially when all relevant information has been provided. (Since MCOs often insist that they never practice medicine, the word of a licensed physician is the only information that could be considered relevant, anyway.)
Do this directly, or enlist the help of a professional organization representing your specialty or locality. Beware some of the organizations, though. Be sure you know what ties they have to Corporate Healthcare.
The Guerilla Physician has an area for patients. You can contribute it by contacting the webmaster.
Most of all, stand up for what you know is right. California law, at least, now recognizes the responsibility of an MCO to provide the health care they contracted for, but some doctors let them off the hook by not fighting back when their patients are being harmed. Once you have the basic materials in place, it takes only seconds to send a fax alerting Big Insurance that they are denying needed care to your patients. It's the least we can do.
The Guerilla Physician website has no advertising. No corporate sponsorships or unrestricted educational grants from managed care or pharmaceutical concerns. So are we asking you for money? No, we're asking for something far more valuable: your time. Send those faxes. Make those phone calls. Talk with colleagues. Go public. Join our roundtable discussion. Share some tips with us here at The Guerilla Physician; we'll pass them on to the other struggling medical guerillas out there. You are our best hope.
Date created: February 7, 1999
Last modified: December 21, 1999
Copyright © 1999, The Guerilla Physician