I’m on a brief vacation mountain biking in Moab, Utah. A gorgeous place, great people, great riding. And upon return from a long and tiring but very fun ride this am, I open up the latest from Fierce Healthcare to read reports about not one, but two reimbursement scams and one piece on docs who don’t disclose when they make mistakes.
That just crushed the hard-earned buzz.
The physician mistake issue is particularly disheartening. An overwhelming majority of doctors surveyed said they’d report a “major mistake”, yet only 5% actually had done so.
While I’d love to believe only one out of twenty docs has screwed up big-time, that is just not credible. Everyone makes mistakes, and the vast majority of us make at least a few that, looking back, we would consider to be “major”.
The other two items are your run-of-the-mill stuff; providers defrauding Medicare and an imaging company accused of illegaly bribing docs to use their MRI facility.
I’d have to say that the docs were involved in the MRI scam should report their involvement – after all, it sure seems like a “major mistake”.
I’m thinking I’ll stay off the internet until I’m back in the office Wednesday…
Joe, admittedly, we’re very subjective when talking about our great state of UTAH! My family and I live in Salt Lake City. Welcome to Utah and the mountain biking capital of the world, Moab, Utah!
Regards,
Bryan Condie
Director of National Sales
Healthesystems
801-943-3757
In Florida, where as a newspaper reporter I’ve been covering health fraud for most of the past 30 years, I’ve seen many Justice Dept. press conferences and mass arrests like the one this week. But it’s like whack-a-mole– nothing ever changes. Is it something in the water in South FL? What will it take?
Greed is excessive or uncontrolled desire for or pursuit of money, wealth, food, or other possessions, especially when this denies the same goods to others.
It is generally considered a vice, and is one of the seven deadly sins in Catholicism. (People who do not view unconstrained acquisitiveness as a vice will generally use a word other than greed, which has strong negative connotations.)
Some desire to increase one’s wealth is nearly universal and acceptable in any culture, but this simple want is not considered greed.
Greed is the extreme form of this desire, especially where one desires things simply for the sake of owning them.
Greed may entail acquiring material possessions at the expense of another person’s welfare (for example, a father buying himself a new car rather than fix the roof of his family’s home) or otherwise reflect flawed priorities.
( Or, as in the following tale, an HMO CEO paying himself many millions of dollars while denying basic healthcare services to an insured person)
“Health Maintenance” and Other Fictions
The following are some accounts of “Health Maintenance Organization” Behavior, recounted to capture your attention….Ready??
First, let me make a statement:
Healthcare, as conceived by my father and all practicing physicians in preceding generations, was mostly a charitable enterprise, done on a semi-entrepreneurial basis by practitioners who had been very carefully selected by Medical Schools out of a large pool of applicants.
Selection was first by intellectual skills, and then by attitude and temperament, so that medical Schools controlled, in a very large sense, the community behavior of physicians, first by selecting the best and the brightest, and then by working them to death treating the poor, during their training, so that most of them understood that their job was to do good in the community, take care of all comers, and remain answerable to themselves and to their peers on an ethical basis.
Any physician could make a decent living by simply charging those who could pay a retail price for services, and scaling down from there for those who could not afford the retail scale.
Doctors prided themselves on their charities.
All of my father’s colleagues groused a lot about poor patients who drove them nuts, but they never refused to see them or treat them.
Anyone who was seen to be selecting out the poor, at least in a primary care setting, was ostracized, castigated, for not playing by the rules.
Hospitals were mostly run by physicians, themselves, and so the ethic of the Hospital reflected the combined community ethic of the doctors on the staff.
Finally, physicians in training, although poorly paid, were not allowed to become overly indebted during their education , so there were not the huge debts of $200,000 or more that we see encumbering current medical graduates.
To indebt someone, whom you wish to maintain as an altruist in the community, is an oxymoron, especially if you transfer the debt from the Medical School to a Bank, whose interest is not in community care, but in profit.
In the 20th Century, Medicine went from a Charitable enterprise, run by physicians, who shared a background and an ethic, to a business, run by businessmen, for whom “Profitability” has always been the issue.
Hospital Corporation of America came on the scene, introducing the concept of “profitable” Hospital Management.
(the emergence of HCA also led to complaints, for the first time, of wholesale refusal to treat, and/or direct transfer of patients to non profit hospitals, some of them in extremis, because they were unable to pay for services)
Shortly after HCA was founded, the first HEALTH Maintenance/Management Organizations were founded.
Their public pronouncements, regarding their raison d’etre, were that the cost of medical care was escalating at about fifteen percent per year, whereas the economy was only inflating at about three percent. The business types who were trying to establish these Health Management Companies claimed that the medical cost inflation was due to unbusinesslike behavior by physicians who were clearly overordering costly treatments, costly medications, and costly Specialist referrals, all of which was causing the 14% per year cost escalation, which was far ahead of the inflation in the rest of the economy.
HMO founders argued that medications, special high tech services and excessive Specialist referrals were the underlying cause of the escalation in costs.
The HMO owners generously offered to step in , manage the “Business of Medicine” and the savings would be sudden, profound , and, most importantly, shared with all of us.
The promise was that the achieved savings would be everyone’s profit, and would be shared, passed back to members, and to third party payors, the US Government included.
Savings, huge savings, were in fact achieved, but there is no evidence that a penny of savings was ever passed back to either members or payors, and no evidence that the ripping out of the body medical of these “Management Fees” ever did anything to slow the inflation of health care costs.
Due to retained and unreturned savings, which were held by the HMO’s, HMO’s became the darlings of Wall Street…because, for a brief moment in time, they were enormously profitable.
Control of access to state of the art services and to prescriptions of the latest wonder drugs were the first items to be “managed”.
Doctors had to plead, to beg, to get their patients seen by specialists, admitted to Hospital, treated with the latest wonder drugs granted access to expensive diagnostic and testing equipment…this was the deal, deny access, pocket the difference, pay the management huge salaries, with stock options added on for “profitable behavior”, and Katy bar the door.
This worked for about ten years.
Then the corner was turned, patients and doctors organized and began complaining to the press about abuses.
There was no use complaining to the Politicians, they had been co-opted already via political contributions, and the complaints got a lot of lip service, but no actual redress, right up to the present, when the “Patient Bill of Rights” died in conference, and was threatened with veto by President Bush, a “poster child” for the effect of money in American politics. (Bush also weighed in on drug prices, denying Medicare the right to negotiate a price reduction with the drug industry)
Even so, even before the Patient Bill of rights went down in flames, the Golden Days were over for the HMOs. Huge profits began to shrink about 5 years ago.
The founders of HMOs who had loaded up their own portfolios with huge blocks of their own stock via complacent Boards of Directors, effectively owned and controlled the HMO organizations, and uniformly sold out to the very companies they had always painted as “The Enemy” , the large Insurance Companies.
In so doing these CEOs disregarded the interests of anyone, any shareholder, any ratepayers, other than themselves, as it became clear that the HMOs they controlled were becoming unprofitable due to a number of factors including the aging of the population served.
No consideration for the interests of the insured was ever exhibited, during the sale of these large HMOs,
This was “Insider selling” of the worst order, because they had squeezed everything and cooked the books so as to look enormously profitable, and destined to remain so, (Sound familiar??) much as Enron WorldCom and Xerox have done a little later, bringing us to the present, where most HMOs are only marginally profitable, and the owners are trying to squeeze profit out of the policy holders via death spiral policies of upward pricing coverage and diminishing services available without special dispensation/preauthorization.
THERE NEVER WAS a good logical, fact based argument for HMOs, ( other than pure greed) and certainly never a logical argument why Billions of dollars should be extracted from the Healthcare Budget and pocketed by a few greedy entrepreneurs, but that is precisely what happened.
Dr Norman Payson, who founded Health Source, New Hampshire’s largest HMO, first succeeded in bamboozling an acquiescent Board of directors into “gifting” him huge amounts of stock in the HMO as a “reward for excellence in Management”, gained controlling interest via these “stock bonuses”, and sold out his shares and control of the HMO to Cigna Insurance Company, pocketing just under One Billion Dollars himself, personally.
Dr Payson is now “reorganizing” Oxford Health Care, a failing HMO based in the New York area, and, if past performance is a model for the future, will probably divert another Billion dollars from the system into his pockets .
Meantime, it is alleged that the THREE private pilots Dr. Payson retains to fly his personal private jet, an additional bonus from HealthSource years, are all maintained as “part time employees” and that Payson has denied them and their Families health care benefits as a result of this sham/scam.
Dr. Payson’s behavior is not unique, no matter how greedy and unfeeling it may appear.
It is “just business”.
Payson’s behavior, the diversion of Health Care funds out of health care and into a CEO’s pockets has been totally ignored by the government, into whose campaign coffers/election funds millions of dollars of contributions have poured, helping to elect and keep in office people who would never seriously address truly outrageous and antisocial behavior, including refusal to treat, refusal to admit, refusal to serve any but the wealthy, the insured, the “MEMBERSHIP” whose membership fees, not coincidentally, have escalated annually at a faster rate than the previous and much lamented expenses had done, prior to Healthcare Management..
The US Senate, The US Congress have done NOTHING to address any of these outrages.
No laws worthy of the name “laws” have been passed to protect consumers.
Laissez Faire is the rule of the day, the decade, the Millenium, to date.
Dr. Payson is not a unique physician/Robber Baron.
Another altruist, Dr. Leonard Abramson founded US Health Care, another large HMO.
The business plan for US Healthcare was a little more transparent;
First try to select only the very young and very healthy.
Undercharge them slightly, sell a “discount HMO policy”
Then block these healthy patients from getting anything expensive done, NO REFERRALS, NO CAT SCANS, NO SPECIALISTS, NOTHING, pocketing a large number of premiums with out rendering an iota of service.
Once again, as the formula begins to become threadbare, sell out to an Insurance Company, in this case AETNA.
Pocket nearly One Billion dollars of “retained profit”
All of the foregoing may seem a digression, but I wished for the reader to understand the terrain in which I must run, on behalf of my patients, in the 21st Century.
It is a cruel world…unforgiving.
Most of the major HMOs in the USA have followed this business model, this behavioral formula, and most are now being operated by Major Insurance Companies, who are “losing money”, while paying senior executives seven figure salaries, and doing their level best to deny anything other than very basic services to policy holders
This brings me to three actual, current, true tales of HMO behavior,
not pretty, and absolutely not unique:
Case number One:
I have been treating since her childhood, an eighteen year old girl, who is very bright, but who became depressed, attempted suicide, was very nearly successful, was hospitalized for a long time, eventually treated successfully, discharged and is on a prescription antidepressant, Prozac.
This young woman is in her last year of High School, back on the Dean’s List, and is thriving.
I count her a great success, and am delighted.
Into my Fax machine, without courtesy of advance warning nor rationale, arrives a notice, an order, really, not a suggestion, from her HMO that she is to be taken off Prozac and put on a different drug, Paxil, also an antidepressant.
I Fax back “I am unwilling to make this change in a patient who was hospitalized following a nearly successful suicide attempt and who is now doing well on Prozac”.
The HMO Faxes back “You will effect this prescription change”
Several to and fro Faxes ensue:
“You will”, “ I won’t”, etc,
Never the courtesy of a phone call.
Finally I call the 800 number displayed at the bottom of the multiple faxes, and insist on speaking to the human person responsible for this directive.
I can hear the squeaks and squawks as I am patched through and finally a male voice answers the phone.
I ask who is speaking, write down the name, ask where he is physically located, and am told I am speaking to a Pharmacist in Austin Texas.
“You are not a physician.. Why am I speaking to you about the drug therapy for a New Hampshire patient??”
“Because I am the expert person in charge of the Formulary for this HMO”
“OK, so let me tell you why I am unwilling to change medications…and I reiterate the story, suicide attempt, doing well on Prozac, etc, etc”
“I’m sorry, Doctor, you will have to change the medication, so as to be in compliance with the Formulary”.
“You know what?,”
“I refuse, but this is clearly a pricing issue, what are we talking about here, how much more does Prozac cost than Paxil??”
“Twenty cents per capsule”
“Let me see, Twenty cents per capsule, times thirty days, that’s six dollars a month, right?? —–“
“And in order to save $6.00 a month you are suggesting that I should take a chance, on my license, and on my conscience, that a promising eighteen year old will kill herself… for $6.00 per month”
“That’s not what I said”
“Yeah, it is exactly what you said, and I’m going to give you thirty seconds to see this my way, and continue the Prozac, or I’m gonna make you famous…”
“What do you mean famous??”
“I’m sorry, your thirty seconds are up” , and I hang up.
New Hampshire is a small State.
I once ran for the US Senate, and every career News Reporter in the State knows me and vice versa.
I follow through, dialing up the patient’s mother, and ask if I have her permission to tell this story to a Newspaper, or even better, would she/could she strike a blow for all of us…
Would she and her daughter be willing to go public, themselves, and talk to the Newspaper, so this abuse will stop.
They agree, and on Monday on the front page of the Manchester Union Leader appears the story.
There is a small furor, letters to the editor, etc, etc
Shortly thereafter our Governor begins talking about a “Patient Bill of Rights”.
Shortly after that, A Political Action Group funded by the HMO industry makes a significant donation to the Governor’s reelection fund.
No HMO Reform Bill, No Patient’s Bill of Right has ever been enacted in New Hampshire.
The Governor is running for the US Senate, where “Patient Bill of Rights Bills have never reached the floor for a vote, presumably also due to large political contributions to re election funds.
Isn’t this fun??
Case number two:
A thirty something young woman, also a patient for awhile comes into my office and tells me a new story, but of long standing..
She has crescendoing headaches, followed by clear fluid running from her right nostril, whereupon the headaches abate.
There is no history of trauma that she can recall, no other historic or medical reason that I can link to this phenomenon, but this is a very worrisome story.
I order an MRI of her head, thinking to find a meningeal defect, with a leak.
Her HMO refuses to authorize the study.
A parade of phone calls begins, dealing with a nonmedical phone answerer whose sole job is to deny services.
My patience is very quickly exhausted.
I tell the nay sayer that “ we are going to have this study done, bank on it”
“You will need to talk to the Medical Director to get authorization for this study”
“ I know your Medical Director, worked with him long ago, and if he knew how to actually practice Medicine, he would not be working for you”…
There is a moment of silence, as she digests just how furious I am…
“I will put you on hold and speak with the Medical Director.”
A few moments pass, and she speaks again…the study is authorized”
The MR is done at our local Hospital, but is not diagnostic,(lousy quality) leading me to worry even more that there is something gravely amiss, and that time is against us.
I call the HMO…same nay sayer..
“We are going to have to send this patient to a consultant Neurologist at the Lahey Clinic, and get a better quality MRI”
There is silence at the other end of the line… , then,
“OK, I will authorize the consult”
A few days later, I get a call from the Neurologist..
“Great call, she had a meningeal cerebrospinal fluid leak, and was waiting to get a fatal or ruinous meningitis, had you not intervened”
“In future, did you know that you can test the fluid with a urine sugar test tape?? If it tests positive for sugar it is cerebrospinal fluid , nasal secretions are sugarless.””
Two surgeries later the leak is stopped, and the patient on with her life.
She and her husband stop in to thank me, having observed me as I confronted the HMO to whom they send a large fee every month.
They understand what has happened, and what I have had to do to get her the care she needed They watched me go to war for them, and know that nobody else would have done so. No battle, no diagnosis. No diagnosis equals dead or ruined, that simple…
What if I were not an aggressive angry man, unbeholden to anyone ??
Case number three is a similar case..
This time the patient is a forty something woman with a 50 pack year smoking history.
“Doctor, I have had horrible headaches for a couple of months.”
“Yesterday my husband found me unconscious in the kitchen, on the floor.”
Jesus!!
I call the HMO, the same HMO as for the last case, Dr. Payson’s old HMO.
“I need a CAT scan done on a young female patient with severe headaches and a loss of consciousness episode, I need it done ASAP, as in now, right away”
“You will need a prior authorization from the Medical Director….”
Then she realizes who it is…
“Oh, OK Doctor, I will authorize the study”
Bad thoughts are going through my head, while I wait,
I am suspecting lung cancer with a cerebral metastasis in this heavy smoker.
Once the CT is done, I am stunned to find an early pituitary adenoma, amenable to medical treatment.
I have had a nose full of this gross interference in my work, which I hold to be important work, much more important than some CEO’s paycheck
I call the HMO and demand to speak with the Medical Director.
(There is no way in hell to call the CEO, he is insulated from the likes of me by 5 or 6 layers of impenetrable bureaucracy)
Once speaking with the Medical Director, I ask him to check my record to see how frequently I order these studies, and what the recovery (positive versus negative study results) rate is on me, and if below normal or normal, to flag my record so that I will be left to practice careful efficient Medicine as I have for nearly forty years, unmolested.
I have heard nothing back.
No new godawfulness has presented….yet
So ends this tale, for now