DENY DEFEND DEPOSE : A call to Action - Are Physicians Complicit ?

The U.S. Healthcare System: Losing the Plot  

On December 4, 2024, Americans awoke to the shocking and tragic news of a highly publicized, cold-blooded murder—an event that has since captured the nation’s attention. While the details are chilling in themselves, one particular aspect has deeply unsettled the medical community: the bullet casings at the crime scene bore the haunting words “Deny, Defend, Depose.”

For physicians, this phrase strikes an unsettlingly familiar chord, evoking the daily battles we face with a healthcare system that often seems indifferent to patient care. It is impossible not to reflect on the countless frustrations tied to a system that places bureaucracy and profit above human lives. Yet, as we navigate the visceral reactions on social media—many expressing anger and even dark justification for this act—it is essential to reaffirm that violence is not the answer. The murder, grotesque in its execution, calls for a collective reckoning with the deeper, systemic issues that brought us here.

This tragedy brings to mind the Ouroboros, the ancient symbol of a snake consuming its own tail—a powerful metaphor for self-destruction. It forces us to ask: has the U.S. healthcare system reached a point where its internal contradictions threaten its very existence? After all, healthcare in America is a business—driven by the same capitalistic pressures as any other industry. Yet, uniquely within this sector, physicians are expected to perpetuate the illusion that we operate on a foundation of compassion and morality, not profit. This dissonance is at the heart of our frustrations and discontent.

A particularly illustrative example lies in the insurance industry's "prior authorization" process—a bureaucratic obstacle that consumes hours of unpaid physician labor, delays care, and often denies patients access to life-altering treatments. As a rheumatologist, I routinely deal with the complexities of securing biologic therapies for patients—medications that are often prohibitively expensive yet critical for conditions like rheumatoid arthritis.

In one recent instance, I recommended a biologic therapy for a patient with poorly controlled rheumatoid arthritis, who was already on a traditional DMARD (disease-modifying anti-rheumatic drug). To clarify for the lay reader, the "standard of care" for rheumatoid arthritis has, for decades, involved the use of traditional DMARDs such as methotrexate, leflunomide, or hydroxychloroquine, often in combination with biologic agents. This dual-therapy approach is well-established in medical literature and practice. Yet, the insurance company’s denial letter revealed a glaring lack of understanding of these clinical standards.

The denial stated: [ this is a REAL scenario and stated verbatim] "Your plan only covers this drug if you will not be taking it with certain other drugs. We have denied your request because you are [will be] taking another biologic. We reviewed the information we had. Your request has been denied. Your doctor can send us any new or missing information for us to review. For this drug, you may have to meet other criteria. You can request the drug policy for more details. You can also request other plan documents for 'your review.' Additional coverage criteria may apply; please review policy or plan documents for full requirements."

This decision was not only factually incorrect—the patient was not on another biologic—but also profoundly frustrating. The denial disregarded the patient's prior unsuccessful attempts with conventional treatments and the potential health risks posed by delaying biologic therapy. Worse, the denial stalled care for months, during which the patient continued to experience painful joint inflammation, a deteriorating quality of life, and the looming risk of permanent disability. 

My appeal to the insurer was a mix of scientific evidence and moral argumentation: "Given the patient's unsuccessful history with conventional treatments and the consequential side effects, the denial of coverage for alternative, potentially more effective treatments is not only detrimental to the patient's health but may also lead to more severe outcomes. Should the patient become disabled due to inadequately managed underlying connective tissue disorder/ arthritis or require hospitalization for flare-ups, the financial responsibility will inevitably fall to the payor/insurer. In the interest of the patient's health and well-being, I strongly urge you to reconsider your decision and approve coverage for the necessary treatment."

Such denials are not anomalies; they are routine. Physicians and their staff spend untold hours curating appeals, adhering to arbitrary timelines, and navigating opaque policies—all unpaid labor that is simply "part of the job." This dynamic creates a stark disparity: physicians are held to the highest ethical standards, yet must operate within a system driven by profit margins and corporate efficiency. The strain is immense, and events like this tragedy serve as an inflection point for the broader conversation about the healthcare system’s sustainability and morality.

As physicians, we must resist the temptation to condone or justify violence, no matter how egregious the system’s failings. Instead, we must channel our frustration into advocacy for systemic change. Let this tragic event be a call to action—not for destruction, but for reimagining a healthcare system that prioritizes patients, respects physicians, and aligns its moral compass with the compassionate ideals it claims to uphold.

Capitalism’s Deadly Legacy  

The tragic events of December 4, 2024, resonate deeply, not just for the life lost but for what they symbolize about the state of our healthcare system. While the murder of one man, even the CEO of one of the largest healthcare corporations, is shocking, it is not a solution. It’s a symptom—of frustration, of systemic dysfunction, and of a profound disconnection between healthcare as a moral right and healthcare as a business.

This tragedy reflects the darker truths of corporatized healthcare and serves as a chilling reminder that health should never be reduced to a profit-driven enterprise. The corporatization of health systems, insurance conglomerates, and the broader industry creates a paradox that western capitalism has yet to reconcile: the fundamental clash between prioritizing profits and serving human lives. Health is a right—not a business. And yet, under capitalism, it often becomes the latter, with devastating consequences.

While it is difficult to attribute deaths directly to capitalism, history is filled with examples where economic systems rooted in profit and exploitation have caused immense suffering. Scholars have even argued that capitalism has been responsible for more deaths than wars in the last century. Consider the following Capitalist Phenomenon of the last century:

Colonial Exploitation:

• Irish Potato Famine (1845–1852): Over 1 million died as British policies prioritized exports over addressing local starvation.
• Bengal Famine (1943): 3 million died in British-controlled India due to economic mismanagement and wartime policies.

Labor Exploitation:

• Unsafe working conditions during the Industrial Revolution caused countless deaths, including child labor leading to stunted lives and early mortality.

Public Health Failures:

• Market-driven healthcare systems prioritize profits, denying millions access to essential care, vaccines, and medicines for diseases like HIV/AIDS and tuberculosis.

Environmental Degradation:

• Industrial pollution and climate change, fueled by unregulated capitalism, cause millions of deaths from respiratory diseases, cancer, and natural disasters.

Structural Violence and Inequality:

• Capitalism often neglects vulnerable populations, perpetuating systemic inequality and preventable deaths.

  • Global Poverty and Hunger: Over 9 million die annually from hunger due to inequitable resource distribution.
  • Unsafe Working Conditions: Events like the Rana Plaza collapse (2013) killed over 1,000 workers, illustrating the prioritization of profit over safety.

  The U.S. Healthcare System: An Absurd Reality

Today, the American healthcare system embodies this dissonance. Both patients and providers lose, while corporations—especially insurance companies—continue to win. Consider the stark realities:

• Insurance Company Profits: Insurers rake in billions while healthcare systems operate on razor-thin margins, with less than three months of savings.
• Out-of-Pocket Costs: Americans spend more on healthcare than any other developed country—around $12,914 per person annually, accounting for nearly 18% of GDP—yet outcomes lag behind those of nations with far less spending.
• Life Expectancy Decline: U.S. life expectancy peaked at 78.9 years in 2014 but dropped to 76.1 years in 2021, the lowest in decades, according to the CDC.

The system is failing everyone except those profiting from its inefficiencies. Consolidated health systems are akin to deforestation: independent practices (akin to rainforests) are replaced by corporate entities (monocultures like palm oil plantations) with closed networks and limited competition. Patients pay more for less, while physicians are reduced to laborers in a corporate machinery that prioritizes revenue over care.

UnitedHealth Group likely leads in negative statistics for prior authorizations and denials, with many physicians agreeing it compensates its providers among the worst in the industry. In contrast, Kaiser Permanente, with its closed-system model, boasts one of the best records for minimizing prior authorization delays. However, it too exemplifies systemic exploitation—albeit through a different approach, consuming the health system in its own way.

Consider This:

In October 2021, a whistleblower lawsuit filed against Kaiser Permanente alleged that the healthcare organization fraudulently obtained billions of dollars from Medicare by manipulating risk adjustment scores. The lawsuit claimed that Kaiser Permanente systematically altered patient medical records to exaggerate the severity of illnesses, thereby increasing payments from Medicare Advantage plans. This practice, known as "upcoding," involves inflating diagnoses to receive higher reimbursements. This is also the reason many Kaiser physicians are unable to take 'vacation' at the start of the year in 'january' when upcoding is a priority system -wide. 

The whistleblower, Dr. James Taylor, a former employee of Kaiser, accused the organization of pressuring physicians to add diagnoses that patients did not have or that were not supported by medical records. The lawsuit alleged that this fraudulent activity spanned several years and involved multiple levels of management.

Kaiser Permanente denied the allegations, stating that they comply with Medicare Advantage program requirements and that their practices are consistent with regulations. The case highlighted broader concerns about potential abuses in the Medicare Advantage system, where insurers may have financial incentives to overstate patient illnesses to receive higher payments.

The outcome of the lawsuit was pending at the time of reporting, and it underscored the need for increased oversight and regulation to prevent fraud in Medicare Advantage programs.

The Ouroboros, the snake eating its tail, is an apt metaphor for what is unfolding. Consolidated health systems, exploitative insurance practices, and the erosion of independent care have created a cycle of self-destruction. Physicians are overburdened, patients are underserved, and health outcomes continue to decline—all while premiums rise and profits soar.

This is not a fight that can be won by targeting individuals. It is a structural problem, one that demands systemic change. The solutions will not come from acts of violence but from collective action to reclaim healthcare as a public good, not a corporate asset.

Until then, we remain trapped in this cycle—feeding the beast and wondering why it devours us. Snake eating its tail indeed.

Farah Salahuddin MD FACP FACR