A century ago, National Underwriter -- one of the three print sister publications that help run the LifeHealthPro.com website -- ran many anguished articles by experts wondering if it would ever be possible to write profitable disability insurance.
The experts of the early 1900s wondered how insurance companies could ever make money selling policies that rewarded workers for not working.
In the 1980s and 1990s, insurers tried to get around the "moral hazard" problem -- the risk that an agreement will affect the behavior of one of the parties to the agreement in a negative way -- by focusing on insuring the income of individuals who seemed to be all but immune to malingering: young medical doctors.
Insurers assumed that doctors were healthy enough to get through medical school and internships, aware of the risk of disability more because of professional experiences than personal experiences likely to affect morbidity, and engaged in interesting, lucrative, largely self-managed work.
Why would doctors bother to make up ailments to go out on claim when they could simply choose to cut back to two or three days of work per week if they wanted more leisure time?
In the 1990s, health maintenance organizations tried to take aggressive steps to manage medical costs, and many doctors decided that being a doctor was not as much fun any more. Some doctors may have pretended to have problems they didn't have. Others suddenly made a fuss about serious chronic disorders they'd been trying to ignore for months, or years. Still others may have come down with genuine new cases of depression, crippling anxiety, heart disease or stroke because of the stress they faced.
Similar forces attacked another industry popular with individual disability insurers -- law -- and an increase the number of claims filed by doctors and lawyers hit the individual disability insurance industry like a financial epidemic.
Now, it looks as the doctors who got through the early 1990s with their practices intact are about to go through another round of winnowing.
We as a society want the finest medical care for everyone, and we want it at low prices that will be paid by someone else. Whether rightly or wrongly, we aren't much willing to emulate Europe and provide low-priced education for doctors, protection against medical liability lawsuits for doctors, rich public benefits for patients who are the unlucky victims of the fact that medical treatment sometimes goes wrong, or subsidized housing or other living expense subsidies for doctors.
At this point, our main national health care cost control strategy is to tell doctors and hospitals, "Hey, provide care for 15% more patients for less money, and, buy the way, you've got to shift to the ICD-10 coding system and feed hundreds, maybe thousands of paper files per patient into electronic health record (EHR) systems. Maybe, once you've done all that EHR work, will give you enough cash to buy a nice new car. Live it up, buddy."
In the long run, the shift might be good for the overall efficiency of the U.S. health care system, but, in the short run, the pressure on doctors is likely to be about as intense as the gravity on the surface of a black hole. Some practices may cross the financial event horizon and never been seen again.
In the 1970s, the stereotype was the doctors were all rich.
A few days ago, a reporter at CNNMoney started a story with the lead "Doctors in America are harboring an embarrassing secret: Many of them are going broke."
Even doctors who continue to have high incomes may face new sources of misery.
The push for doctors in small and midsize practices to participate in "accountable care organizations" -- teams of providers that try to treat patients on a whole-patient basis, rather than a fee-for-service basis -- could hit physicians in the gut, by replacing the unpleasant task of doing battle with faceless health insurers with the even more unpleasant task for fighting over money with local doctors and hospital administrators that they play golf with and car pool with.
Insurers have taken a number of steps to protect themselves against a repeat of the problems that occurred during the 1990s, by, for example, imposing limits on coverage for mental and nervous conditions and for subjective conditions.
But it seems reasonable to ask whether, for example, the new pressure to convert to electronic health records will lead to some physicians at small or understaffed practices to develop carpal tunnel syndrome and blurry vision from trying to enter, or at least, check, many of the records themselves. Will sleep deprivation related to an increase in workload cause or aggravate objective conditions, such as lack of exercise, obesity and high blood pressure, that will, in turn, lead to an increase in the number of doctors with disability insurance who suffer heart attacks. strokes and disabling car accidents?
Maybe disability insurers could help conscientious doctors who try to deal with the new requirements the right way -- by doing more, better work for less money, rather than by finding ways to game the system -- by helping policymakers figure out when doctors are just whining and when they are really being crushed by unrealistic expectations.
No one wants to ration care, but, at a certain point, we have to create some mechanism, whether it's cold, pitiless, but imminently rational market forces, or cyborg clones of Kathleen Sebelius standing at the doors to physicians' offices with flaming copies of the Patient Protection and Affordable Care Act, to limit the amount of care and related services physicians provide to the amount they can actually provide without dropping dead from exhaustion.