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'Enough Is Enough'
CSMS head Norbeck says it's time to redress the balance of power between doctors and insurers
Timothy B. Norbeck of North Haven is executive director of the Connecticut State Medical Society, which in late September launched a statewide ad blitz attacking Aetna U.S. Healthcare over terms of its proposed new contract with physicians in its managed-care network.
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Business New Haven
10/18/1999
By: Michael C. Bingham
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How did you get here from there?
For the past 33 years I have worked with and for doctors. I started with the AMA [American Medical Association] in 1967; I opened an office for them in St. Louis and came back to Chicago, then went to Rhode Island as executive director of the Rhode Island Medical Society in 1973. I came to Connecticut in 1977 as executive director of the CSMS. Before all that I was in the steel business in Detroit, Milwaukee and Chicago.
What is the mission of the CSMS?
The mission of CSMS is to promote public health. To further that we work with the legislature, the [state's] Department of Public Health, the [American] Cancer Society, the heart and lung association and other groups.
What was the thinking behind the decision to go public in this campaign against Aetna U.S. Healthcare?
We got to point where. literally, enough was enough. That's the mood of the physicians and of those of us who work with and for them. It has gotten so incredibly one-sided, and physicians have absolutely no leverage for themselves in their contractual dealing with insurance plans, and they don't have any leverage for patients. And of course the patients have absolutely no say, although something [is taking place] in Washington this week that may address that. But Aetna is considered to be the most egregious health insurer not only in Connecticut, but around the rest of the country. Their all-products clause [under which physicians agree to accept not only present Aetna products and policies, but those that may arise in the future] is really a pernicious policy that forces physicians, if they participate in one Aetna policy or plan, then they must participate in all of them, [including] plans that haven't even been developed [where doctors] don't know the conditions. It is incredibly coercive, and we felt that we had to make a stand.
Do patients understand or care about this?
There are two important facets to this: Patients are beginning to understand the limits placed on their coverage. But not understood yet at all - and I'm sure that's partly our fault - is that employers and the public need to know the limits placed on their physicians by insurers [through] coercive and unfair contracts. The old saying, 'What the large print giveth, the small print taketh away' certainly applies to health-insurer contracts. It has been entirely one-sided. No businessman or –woman would sign such a contract' their lawyers would say it's so one-sided and unfair…But physicians are placed in a position unlike businessmen and –women where they have to if they want to continue seeing their patients. Another incredibly pernicious side of Aetna's policy, and [that of] some other insurers, is that they allocate liability arising out of patient-care decisions to the physician - even though the contract also requires the physician to comply with the health plan's utilization-management decisions as determined by a definition of 'medical necessity' that requires the least costly alternative. The public is just beginning to understand those limits, and our campaign has focused on that and helped a lot more people and legislators and those in the media to understand some of those limits, ridiculous limits that affect everybody.
Can you amplify what this means for employers?
I often go to Rotary meetings, and invariably the subject turns to health care. [Businessmen and –women] are very concerned about the health care that they're paying for and that their employees receive. I think employers would be upset if they really recognized what physicians are forced to do.
What's to keep all the physicians in Connecticut from simply saying 'No dice' to Aetna on this new contract?
First of all, if they all got together and decided that, that's a violation of antitrust [laws]. If they came to that conclusion individually - and I think they all have - and some physicians have dropped out. But the feeling is, number one, that you're losing patients that you have seen for years. All the surveys show that patients stay healthier when they have a long-established relationship with their physician. So there's pressure on physicians to keep those patients, and also to keep the practice going. If someone is supplying your business with wood or steel, obviously if [terms of the contract] are unfair or the product isn't any good, there are so many other alternatives. There aren't in health care.
The liability issue you mentioned may be made moot by legislation now in Congress, right?
That would certainly address it. However, there will be great resistance in the [U.S.] Senate. I doubt very much if they will be able to address it [this session]. But when it does, certainly the Senate, which passed very tepid, mild reform, is not interested in real managed-care reform such as the Dingle-Norwood bill. Another huge issue for patients and physicians is the [Thomas] Campbell [R-Calif.] bill, the Quality Health Care Coalition Act of 1999, H.R. 1304.
What does it say?
The basic premise is that the antitrust laws have been interpreted to allow health plans such a high degree of leverage that an appropriate balance of interests no longer exists in the market for health-care delivery and finance. In the last five years the 18 leading health insurers have combined down to six, and there will be only five or four in the next year. The Campbell bill would allow independent physicians to negotiate with health plans. That will be a huge issue next year, and I hope patients and employers will unite behind physicians for this.
How did all this evolve?
I've been working with and for physicians for 33 years. I remember back in 1967, in my early years with the AMA, business and medicine were such good friends. But then rising health-care costs started to cause a little split between business and medicine, and then managed care finished it off. [It's a split] that really should be repaired because they belong together. Physicians are small-business men and women. We need to talk more with employers and make them understand medicine's position and be sympathetic so that we can work together far better than we have in the past.
What exactly is the CSMS position on the Campbell bill?
We certainly support it wholeheartedly, and [support] its intention to level the playing field and allow independent physicians [to negotiate with health plans]. Right now only employed physicians can join unions; [but] unions cannot represent independent practicing physicians. They have no leverage. The Dingle-Norwood bill that passed on October 7 is one of the greatest and most important pieces of health-care legislation since Medicare.
Why did the CSMS fight to prevent optometrists from performing laser surgery in Connecticut?
We opposed that because the feeling was that optometrists did not have the professional expertise to do that, and that that was a public-health issue.
How would you address the charge that physicians are merely trying to reclaim financial autonomy that was stripped away from them by managed care?
That's kind of ridiculous. Right now physicians are in a struggle for their professional lives and for their ability to represent and do the best they can for their patients. Any businessman or –woman who looked at these contracts would understand that there is no leverage [for doctors] and there are such incredible constraints, limits and controls on physicians' ability to treat their patients the way they've spent one-third of their lives studying how to do. Enough is enough.
Would you encourage your son or daughter to enter the medical profession today?
I would. I'm an optimist. I recognize that there are many physicians who are so discouraged that they might not, but I believe the system will right itself. I think it will take tremendous upheaval for that to happen, but we are beginning that process. The key here is employers. When they understand this, and the Campbell bill passes - which is going to be an incredibly difficult task, because the insurers will fight that with everything they have. It's a David and Goliath thing. But I keep saying to myself, 'Remember who won that one.'
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