For the last two years, Mr. Potter has been revealing everything he knows about the Black Arts of corporate spin, hoping to wake Americans up to the ways that corporate interests manipulate health care policy to the detriment of patients and practitioners alike.
His book, Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR is Killing Health Care and Deceiving Americans (Bloomsbury Press), is as fascinating as it is disturbing. Potter lays out the playbook by which insurers derailed the Clinton reform plan, de-fanged the Patient Bill of Rights and—once it became clear they could not deter it--remade the Obama plan to more or less guarantee steady profits with minimal regulation, little consumer protection, and few advantages for clinicians.
Potter himself was a key player in many CIGNA efforts to defuse and confuse. He helped design programs whereby insurers fund bogus "grass-roots" citizens groups to oppose legislation not to their liking---a practice called "astroturfing." He crafted misleading, oft-repeated anti-reform catch phrases like "government takeover" and "death panels."
He created "intentionally-provocative and xenophobic talking points" like the ideas that reform "redistributes wealth" from hardworking Americans to lazy illegal immigrants and irresponsible bums; that egregious physician fees are a prime driver of healthcare costs; and that patient protection rules would raise costs by creating a tidal wave of "frivolous lawsuits."
"If you were persuaded that the health care reform bill President Barack Obama signed into law was a "government takeover of the healthcare system," my former colleagues and I earned every penny of our handsome salaries," he writes.
Born to poor, hardworking parents in North Carolina, and raised with Southern Baptist values in the Blue Ridge Mountains of Tennessee, Mr. Potter began his career as a journalist but quickly found his calling in corporate communications, running PR for Humana before ultimately landing at CIGNA.
It was a visit home to the hill country a few years ago that brought him to a crisis of conscience. There, he witnessed thousands of uninsured people standing in the rain at an outdoor "health fair," waiting to be treated by volunteer doctors, nurses and dentists in animal stalls. This was their only access to care, and many drove long distances only to be turned away, untreated, at the day's end.
He decided to leave CIGNA and go public after the company denied a liver transplant to a 17 year old California girl, then reversed the decision under intense public pressure, but not soon enough to save her.
Deadly Spin is a must-read for anyone trying to understand US health care. Along with a fascinating history of corporate propaganda, it offers a primer on little-known tactics like "recission," whereby insurers retroactively cancel policies by claiming that people with big bills intentionally withheld info about preexisting conditions (a 2006 Congressional investigation found 3 large insurers retroactively nixed nearly 20,000 policies over a 5-year period).
"The health insurance industry today is dominated by a cartel of large, for-profit corporations. By necessity and by law, the top priority of the officers of these companies is to "enhance shareholder value," he notes. To save money, insurers try to get rid of small businesses by hitting them with egregious, unaffordable rate hikes if a single employee suddenly becomes ill and expensive.
In this conversation, Mr. Potter spoke with Holistic Primary Care about the long history of collusion between organized medicine and Big Insurance---an uneasy alliance that has ultimately been detrimental to patients and physicians alike.
HPC: Ask physicians what they most dislike about their practices, and "managed care hassles" will be among the top responses. Yet, as you note in your book, organized medicine had a key role in creating and defending the existing system.
WP: Throughout history, the American Medical Association, its membership, and many other physicians' groups have feared government involvement in health care more they have feared corporate involvement. The AMA has played a lead role in killing any sort of health care reform in this country. The AMA and other physicians' organizations unwittingly aligned with health insurers to defeat the Clinton plan.
This past time around, they (AMA) ultimately came around to endorse the plan that was finally passed by Congress last year, which put them at odds with the insurance industry and other special interests. I think doctors are coming to realize that their worst enemies are the corporations that now control the health care system, and that have largely made doctors into indentured servants.
HPC: It seems the insurance industry has done a very good job of spinning that, because many practitioners view HMOs, managed care and basically any type of health care bureaucracy as "Government Healthcare." They blame government, and fail to make the distinction between the for-profit corporate bureaucracies and the government-funded programs.
WP: They don't, and that's certainly something the insurance industry is very happy about. The industry has been engaging in a lot of behind-the-scenes fear-mongering campaigns to get people—including doctors—to think that very way.
At the core of all these different efforts to defeat reform is fear-mongering. The insurance industry was very much behind the effort to try to persuade people that reform as envisioned by the president and Democratic leaders, would represent a "government takeover of medicine." Those were words that were carefully selected to scare people away from reform, and it was very successful.
Among those people scared away were many doctors who just did not stop to give any real thought to what's really going on. There was not a lot of critical thinking and analysis going on, even among doctors. Many continue to believe that their worst enemy is government, when in reality it is the for-profit sector. Wall Street is dictating how doctors practice medicine far more than they realize.
HPC: You mention in the book that the AMA recently started calling for greater enforcement of antitrust regulations. That's quite a switch, for an organization that many view as a "trust" itself. Where's that coming from? I don't really believe the AMA suddenly has a heartfelt concern for the 'little guy.'
WP: Well, they don't. What they're really worried about is the actions of the health insurance industry. They (AMA & other physicians' groups) are realizing that consolidation in the health care insurance industry has not been very good for doctors, nor have some of the business practices of the insurance companies. These behaviors are pretty much legal because of lax anti-trust laws. These things simply have not been good for many practitioners.
People really don't grasp that our health care system is largely in the control of for-profit insurance companies. They pretty much set the rules not only for how health care is financed but also for how it is delivered.
Health insurers and pharmaceutical makers are among the most influential lobbyists in Washington, and---in the case of the insurers---the state capitals as well. They're much more influential these days than the physicians groups, even the AMA. In years past, the AMA had been exceedingly influential, but I think it is far less so today, partly because it's lost a lot of membership, but also because it's been more or less outgunned by the insurers and other special interests.
Other doctors' organizations just don't have the clout. Doctors who embrace holistic care simply don't have an effective lobby. Doctors' groups don't have the financial resources that the big insurers do.
HPC: How would you characterize the relationship between Big Insurance & Big Pharma?
WP: Well, it's a love-hate relationship. They are often on opposite sides of the bargaining table when the insurers are trying to cut deals to save money on medications. But they are mutually dependent on each other. There's a symbiotic relationship. They need each other, and they often are aligned on the same side of policy. They were aligned very closely to defeat the Clinton plan, and they've been on the same side to try to defeat other health reform measures in the past.
So they share common interests. One in particular is a dislike of any kind of government regulation. It's the one thing they truly share in common, and they can usually find enough common ground on that to help defeat any reform legislation, even if their business objectives are often very different.
HPC: Have you seen them working together directly?
WP: Oh, yeah! I was a representative for one of the insurers I worked for to an organization in Washington called the Healthcare Leadership Council. And the pharmaceutical companies have membership in that group, as do many of the large insurers. And that group played a big role in killing the reform plan as proposed by the Clintons, and also in the effort to kill the Patient's Bill of Rights proposals back in the late 90s and early 2000s.
HPC: The insurance industry has shown a remarkable ability to stand united when confronted with policy challenges. How is it that the companies are able to overcome their competitive imperatives and work so closely together when push comes to shove?
WP: They know it is important for them to speak with one voice and that that voice be consistent. They are disciplined. America's Health Insurance Plans (AHIP), their national trade association, is the enforcer of that discipline and the place where all the messaging originates.
HPC: Why haven't physicians and other health care professionals been able to unite in the same way?
WP: There is no single association that speaks for physicians the same way that AHIP and the Blue Cross Blue Shield Association speak for insurers. AHIP is the most important trade association. Most if not all Blues that are members of BCBSA are also members of AHIP. AHIP has a lot of power & influence.
HPC: Many Americans believe the US has, "the greatest health care in the world," despite evidence to the contrary. They also believe reform will diminish this greatness and stifle innovation. Is this an example of industry spin?
WP: I don't know the exact origins of that idea, although it is oft-cited by opponents of reform who want to perpetuate the myth that we have the best system in the world. We do have some of the best doctors and other caregivers, and some of the best facilities and technologies. But we also have one of the most inequitable systems in the world, behind Bangladesh in fairness, as I note in the book. As far as medical innovation, the truth is that much of the innovation comes from government entities such as NIH and other places. For-profit companies profit from their work.
HPC: Your book sheds much light on the ways insurers use and manipulate ideas and words to achieve their aims. What's the history of the word "provider?" Years ago, doctors actively resisted that term. Now, it seems most are resigned to it. That word certainly sounds like "plan-speak!"
WP: Well, it is. The insurance industry decided to go with a term like that to be able to refer to all health care practitioners and facilities with one word, because it embraces hospitals and a full spectrum of clinicians. The word "physician" was not encompassing enough, so they went with "provider." Another reason is that insurers know that doctors are held in higher esteem than insurance companies, and they are loathe to use the word "doctor" or "physician" if they can avoid doing it. So that's another reason why "provider" was useful. It lets them avoid the use of the word "doctor" or "physician."
HPC: Years ago, we used to hear the term, "rationing" quite often. But this word seldom came up during the recent reform debates. Isn't that exactly what our system is based on? Aren't health insurance companies simply rationing care?
WP: Oh, absolutely. People are not fully aware of how it works, but the insurance industry rations care in a much less equitable way than any other system that I know of. The industry's business practices in and of themselves result in rationing. We have 52 million people in the US who don't have coverage, largely because of the practices of insurance industry. The benefit plans are just not affordable for so many Americans.
If your employer doesn't cover you, and you can't afford to buy it, and you're not eligible for a public program like Medicare or Medicaid, you're pretty much out of luck. If you don't have coverage and you don't have a significant income, you're going to forego care. That is de facto rationing! It's happening every single day in this country.
The other thing is that even for those who do have insurance, there are executives and managers in the insurance companies that make rationing decisions every day, when they make decisions to deny coverage for one thing or another. Even the 'not for profit' insurers like the Blue Cross/Blue Shield plans play this way.
So, rationing is done in this country. But in many cases, it is done by a manager at a for-profit corporation, who knows he or she has a job to do, which is to make sure the company he or she works for meets Wall Street's profit expectations.
HPC: In Deadly Spin, you describe how you gradually became aware of the conflicting incentives ingrained in American health care. For example, the insurance plans have financial incentive to keep people out of hospitals and to deny care, while hospitals have incentive to pull people in and do as much as possible. Didn't that tip you off early on in your career that something's not right about the games your employers were playing?
WP: Well, not necessarily. It took me a while to fully grasp what was going on. When I joined Humana, the company had hospitals as well as managed care plans. I thought that was a good model, because it seemed to represent, more or less, integrated care. It seemed that insurers would be interested in working with hospitals and making sure that hospitals were providing good, appropriate care for the people enrolled in the plans.
It was only later that it became clear to me just how significantly different are the interests of the two sides. The fact is, though, that hospitals now are also pretty subservient to the insurers. They will certainly not allow anyone to stay in the hospital any longer than they will get reimbursement for.
HPC: In the book, you make reference to what you call a "sharp divide between doctors and the rest of society." What specifically do you mean by that?
WP: I think what I'm trying to say there relates to economic self-interest. Doctors, or at least organized medicine has historically looked after the best interests of doctors and their incomes. That's been goal number one, more so—in my view---than giving the best care and the best deals for average Americans.
Most trade groups—and I would put the AMA in the category of trade groups—represent their membership and their special interests, not necessarily the interests of the public at large. In that respect, the AMA is hardly different than America's Health Insurance Plans (AHIP) or any other group that represents professionals or companies.
That's one reason why reform is so hard to enact. Reform will inevitably affect someone's income, and someone's profits. One of the reasons health care has become so expensive is that historically there have not been any government interventions to control costs. It has been allowed to explode because of the profit motive, and the greed motive.
HPC: We certainly hear a lot about what insurers will not cover—all the denials of care and exclusions of services. But it is often surprising what the insurers WILL cover: drugs & procedures with marginal benefits, diagnostic tests of limited value, futile end-of-life care. In your years of work inside the industry, what have you learned about how plans decide what gets covered and what does not?
WP: For the most part, those decisions are made in collaboration with employers, since most of us get our benefit plans through the workplace. It's not necessarily rational, because we're talking about profits and expenses here--financial considerations.
HPC: And these negotiations all go on behind closed doors, correct?
WP: Absolutely. Physicians and patients have no input whatsoever.
HPC: Despite widespread public interest, and growing scientific support, insurance plans have been very slow to embrace holistic medicine, nutrition, supplements & other aspects of preventive medicine, even though it could save money down the road. Why?
WP: For one thing, the insurers don't know or haven't seen sufficient evidence that holistic medicine could help them lower cost. If they can be made to understand that a holistic approach could actually lower their cost, then I think they would embrace it. But they haven't been persuaded of that so far.
The plans won't do anything unless they believe it will have benefit on profitability. They're very focused on short-term profitability, and they know there's a great deal of turnover in plan membership. So they don't want to spend a lot of money providing preventive care to people right now who in one, or five, or 10 years will no longer be enrolled in their plans. They don't see it as a prudent investment.
HPC: The AMA controls the CPT/ICD coding systems, which are the bureaucratic 'grease' enabling the whole reimbursement system to run. What is the relationship between the AMA, the insurance industry, and the Fed in creating the codes that control health care management?
WP: Those codes play a vital role in how insurers pay, and how much doctors get reimbursed. The insurers use those codes, but they also try to manipulate them. This is one reason why a class action lawsuit was brought against insurers back in the early part of the 2000s....it was over manipulation of codes and bundling of codes to avoid paying more than the insurers were wanting to pay. The insurers certainly look for ways to pay as little as possible for each code by doing a variety of things. They've got sophisticated software to try to reduce how much they pay for any particular procedure, for example.
HPC: What's your take on the direct-pay/concierge medicine movement, which has been growing steadily over the last decade? There are now over 5,000 physicians in the US who've stepped completely outside the insurance systems.
WP: Yes, it's happening. But that's not a large percentage. There are doctors who live in places where there are a lot of high-income individuals who can afford that. I know there are some efforts to try and expand that to other folks who are not rich, but it's largely something that only rich folks can finance.
To call it a trend is really more than it is. It's something that's been going on for some time, and I think there's a limitation to it. I don't think that most doctors can afford to avoid dealing with insurance companies. Because the reality is, the bulk of their patient panel comes from people who are enrolled in health plans. If you stop taking those people, your patient panel's going to shrink. So you have to make sure you've got some scheme, and enough people who are well-heeled enough to be able to support you.
HPC: Talk about the idea of transparency. We hear this idea in connected with the so-called "P4P" (pay for performance) plans where doctors are supposed to be "transparent" with all their care protocols and outcomes data, and the plans will preferentially reward the "best-performing" doctors. It seems that the insurers like to off-load "transparency" onto the practitioners, while avoiding transparency themselves!
WP: That's very true. Transparency....it's a good word and they (insurers) like to use it, because just using the word makes people think that they themselves are already transparent. But what they're really trying to do is shift the responsibility to be more transparent away from themselves and toward providers, to a certain extent. Frankly, they don't want providers to be all that transparent. When they are negotiating rates with doctors, both sides have an interest in making sure that that is proprietary information.
HPC: What do you think primary care doctors can expect from the Obama health care reform plan as passed by Congress?
WP: I think primary care could benefit more than other doctors. There are incentives, for example, to expand their numbers, and hopefully for primary care doctors to be better compensated for their care. There's an emphasis on primary care in the legislation. So, I think students who are looking to become doctors really should look at primary care. There are also provisions in the legislation to help pay for medical education for people going into primary care if they will agree to practice for a while in areas that are underserved.
HPC: I've heard mixed things about that. Some experts say that while there may be more emphasis on primary care, there's not a whole lot more money going into it (read Healthcare Reform Makes Primary Care a Prime Focus...But Don't Expect a Raise from our Fall 2010 edition). There's a lot of money going into training nurses. Some doctors worry that it's going to be the nurses who do most of the primary care in the future.
WP: The reality is, if you do bring more people into coverage, you're going to have to have more practitioners in the system who can treat them. And the fact is, a lot of ailments can indeed be treated successfully and appropriately by nurse practitioners. So I think that, once again, it's being looked at from the perspective of fearing 'losing out' and 'losing income'. But I think that the world can stand both more nurses and more primary care doctors!
HPC: The politics around health care reform got really ugly, and remain so. But is there really any big difference in principal between so-called "Obamacare"—a Democratic initiative, and the Massachusetts state-level reform pushed through by Republican governor and possible presidential candidate, Mitt Romney?
WP: Not much! The federal law, in many ways, is based on what was passed in Massachusetts, signed into law by Romney, and embraced by a lot of Republicans, including Romney. The problem, of course, is that when Obama and the Congressional Democrats were proposing it, rather than Republicans, it became something the Republicans opposed because they wanted to politicize the issue. It's just a matter of partisan politics here. The Republicans saw opposition as a way to score political points.
HPC: There's no deeper principle involved?
WP: That's my view of it. Now, I would say that the Republicans in Massachusetts are not necessarily indicative of Republicans all across the country, or those who hold public office elsewhere. I'm not an expert on Massachusetts politics. But I would think there are probably more so-called moderate Republicans in the Massachusetts legislature than in other parts of the country.
What was different in Massachusetts was that there was an agreement that there could be a bipartisan solution. In Congress, that was not even a possibility from the get-go. The Republican leadership had little interest whatsoever in trying to craft a real bipartisan solution. By the time it reached the national stage, bi-partisanship didn't even seem to be a possibility. Even before the first bill was introduced, Republican consultants were advising the Republican leadership to call whatever the Democrats came up with a "government takeover of the health care system."
HPC: We certainly heard that idea go through the media echo-chamber! Now, if you could redesign the system, what would be the role of health insurers?
WP: They facilitate payment to doctors on behalf of people enrolled in the plans. They are the main middle-men. In Canada, there are no insurance companies who play that function. Care is provided by the government as a single payor. In this country, care is largely financed by third parties---that could be employers and/or insurers. We have a uniquely American system; there's really no place quite like this. There's no other country that allows insurance companies to have such control over their health care system.
HPC: So, it comes down to whether "We the People" accept that, or whether we want something fundamentally different?
WP: Yes. Something fundamentally different might be very much in the best interests of many Americans, but the problem is that many Americans don't really have a good understanding of how other systems operate. What they do hear is largely based on propaganda from the insurance companies that want to make sure they remain in control.
HPC: You write in the book that for a long time, you were afraid to speak out (about the ways CIGNA and other insurers manipulate policy) because you were afraid the industry would retaliate. What specifically did you fear? Have you seen such retaliation?
WP: I think anyone is fearful of making any kind of major change in career. That's number one. Number two, is that when you're speaking out against the very industry that you work for, you can expect---at least, I expected an effort to discredit me, to black-ball me from getting a job elsewhere if I wanted to. And as I describe in the book, there was a big effort to discredit Michael Moore as a film-maker. He was certainly a critic of the health insurance system here. I was even a part of the effort to discredit him. So I know that they play to win, the insurers do. And they marshall a lot of resources behind their efforts to discredit people. I know these folks, and I know how resourceful they are, and I was very concerned that I would be a target myself of a campaign like that.
HPC: And have they launched one?
WP: They have not. At least it has not been apparent, or it doesn't seem to have been successful if they have tried such a campaign. I think that what they've done is largely what I would have advised them to do, which is to ignore me and hope that I will go away at some point.
HPC: And I'm guessing you have no plan to go away.
WP: I have no plan to go away!