For example, our government in attempting to bring better access to healthcare to inner cities and rural areas, provided hefty grants to medical (and dental) schools to accept minorities into their classes, and as a result, because these minorities were educationally unqualified, for more than 30 years, medical education had to be aimed at the lowest common denominator. Some of my students were one notch above functionally illiteracy. So there was a period (and we are not through it by any means) when hundreds or thousands of physicians are unqualified by the standards of pre 1965 graduates. Oh, I know not all physicians fall into this category because they didn’t stop learning after their internships.

No wonder many physicians find themselves in the middle of legitimate malpractice actions. And those who have not, began over testing to protect themselves. This leads to increased healthcare costs, and the cycle goes on and on. People complain of paying increasing insurance premiums and getting less and less healthcare in return. Those people have no understanding of the reasons for increased costs for healthcare… … all they want is to have all there healthcare costs covered (presumably by their employers!). Every one seems to want entitlements without any notion of who is to pay for it. Well, Russia tried it and their healthcare became one of the worst in the so-called developed countries. Healthcare in Great Britain and the Scandinavian countries has been touted as a model of social progress. But at what costs. The same applies in Canada, today. The answer for these countries is in rationing healthcare. In Sweden if you are above a certain age and have no dependent children you do NOT get dialysis. It is rationed. If you don’t want to pay for it out of pocket, you die! In Canada when the pot with the healthcare dollars runs out, as it does every November, you don’t get that operation until January. That is, unless you want to pay for it out of pocket. And as a result, all the best and brightest of the physicians in these countries leave and come to practice in the United States.

Ha ha, the joke is on us! Why? Because now we have an oversupply of providers (for that is what they have become) and so with fewer patients each, some join HMO and become salaried, and the others who want to stay in the fee-for-service system raise their fees in order to offset the fewer patients.

• Benefits restriction. In one of my plans we had regular meetings to determine what our highest costs were and how we could redesign benefits to control them).
• Exclusions, even those fabricated to justify a trend in denials.
• Pre-existing condition exclusions, to ensure that persons with known conditions would either forgo our plan, or give us the mechanism to avoid payment for services, creating a game of wits to figure out ways to make current needs connect with some prior diagnosis.
• Selective marketing using partial information, e.g., about coverage limits and rules of the health plan.
• Underwriting, or selection of the ‘best’ groups,. (I became a veritable ‘bookie’ for the plan).
• Contract design and implicit restraint of trade; we would exploit a physician’s economic vulnerability by telling them they could either sign or be excluded.
• Maze of rules and hoops for authorizations, referrals and network availability — convoluted procedures set out in a ‘Certificate of Coverage’ that became grounds for denial of payment.
• Claims of authority that exacted a desired economic outcome, again with implied threats to de-selection; and finally
• The “smart bomb” for “cost-containment: “medical necessity” denials that employ non-standard criteria, oftentimes developed without sufficient specialty-specific expertise to be durable’ this is the ultimate weapon for the plan.