ESCANABA — Our healthcare system is in crisis mode. Millions of Americans go through their daily lives without any form of healthcare insurance. Physicians are calling for strikes and pushing to unionize, proposals once considered heretical. Private, for-profit, privately held insurance companies profit to the tune of billions by denying services, restricting access to care, and delaying payments to millions of Americans.

Every insurance plan seems to have its own rules, varying greatly, making it nearly impossible for anyone to know what services are covered. There is no definitive guide to read or expert to consult. The patient and provider often have no idea which of various treatments or therapies will be considered a reimbursable procedure. Each plan has its own idiosyncrasies. Will some therapy, which the physician has been trained and educated to provide, be paid for? Too often, the people that really need to know, don’t.

The big insurers have taken numerous routes to increasing their profits. They restrict coverage for expensive medications and tests, as well as other services, by declining coverage until some hoop is jumped through, usually some form must be filled out to justify the service. It is no longer enough that the provider has prescribed it and believes it appropriate.

Many U.S. residents still believe the physician has control over the fees that are charged in the provision of health care. Nothing could be further from the truth. The doctor has become just another pawn in the billion dollar game of U.S. health insurance. It has been decades since providers had any say in what is charged for procedures, therapies, or office visits. Healthcare providers, just as much as consumers, are feeling the squeeze of the chaos that is American health care.

A particularly onerous tactic is the dreaded prior authorization in which a physician must get on the phone, in the middle of their workday, during patient care, to argue with an assistant or administrator, sometimes a nurse but often not, as to why some treatment should be covered by the individual’s plan. Ideally, this information should be “cut and dried,” well defined, easily available. A determination on coverage needs to be made quickly: someone’s medical condition is waiting to be treated.

Are prior authorizations truly necessary? Because of the time required to get through these corporate phone answering systems, these calls can take an hour or more. Consequently, a common approach by providers is simply to not utilize the therapy requiring it. But prior authorizations have been a tremendously successful technique for the insurance companies, allowing them to deny or delay payments (and the interest on these adds up).

Another area of great debate are the Advantage plans. The private insurance companies have uncovered a huge profit-generating method with the development of these plans. These are healthcare plans for Medicare-eligible seniors….but it isn’t Medicare (which is health insurance provided to senior citizens paid for by the U.S. government). The marketing efforts promoting these plans have been tremendously successful. Many recipients of these plans have no idea they don’t have Medicare. The private insurers talk a good game about providing the same benefits as Medicare, but the inadequate care provided by these plans has become a matter of public record.

In an ideal world, a physician, as well as the patient, would have certainty, definitive information regarding what is covered by individual plans, allowing the doctor and patient to plan accordingly. Instead, to most healthcare providers, it’s a convoluted game, with rules that are constantly changing. The deck is stacked against them, and only the insurers are going to win.

There can be no question at this point, healthcare in America is inordinately expensive. Yet we’re not getting a good bang for our buck. Too many middlemen, too many administrators and too many shareholders. Too many people pocketing millions at the expense of the health and wellbeing of Americans. All the recent studies have confirmed this: our health outcomes, how well our system is performing, are at the bottom of the list of all the developed countries, including places like Turkiye and Serbia.

The U.S. now spends more than $4 trillion a year on health care. Our high costs, combined with the high number of under- or uninsured, means that many people risk bankruptcy if a serious illness develops. For this and many other reasons, the majority of Americans rate our healthcare quality as poor. Clearly our system is flawed. In many ways, it’s designed to discourage physicians from efficiently providing care, unable to help their patients because of “red tape,” restrictions, limitations, obfuscation. The U.S. healthcare system is expensive and complicated. Is it too broken to be fixed?

It seems odd that every other developed nation has gone to a single payer, government-run system, except the U.S. In essence, these other countries have Medicare for all, not just seniors. Every citizen is provided with health care benefits. What a concept! Medical care as a right and not a privilege.

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Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with offices in Escanaba, Marquette, and L’Anse. McLean has lectured internationally on wound care and surgery, being board certified in surgery, orthotic therapy and wound care. His articles on health and wellness appear in multiple local and national publications. Dr. McLean welcomes subject requests for future articles at drcmclean@outlook.com.