An NPR program on Friday 7/29/2010, which excited listener call-in interest, dealt with patients' rights to their own medical records. Neither the moderator nor the program's physician consultants mentioned highly relevant federal law on this subject and this blog won't deal with that issue today. The program was short on significant statistics and long on testimonials of questionable value.
The program focused on an experimental New England medical teaching institution-based project to post patients' medical records on a secure internet site for them to review. The proposed benefits included better patient information about what the doctor was thinking, the availability of records for patients to download and then provide to other doctors, and increased patient trust in physicians because of knowledge of what was in the record. No downside to this process was discussed.
For years, my practice habit was to always dictate my "progress notes"while the patient was sitting two feet away from me. The process took no more than 3 minutes and informed patients about my understanding of their relevant medical histories, physical findings, interpretation of laboratory data and the diagnosis I had formulated, and my treatment plan and other issues which pertained to that visit. Unlike the process of later posting the clinician's notes on the internet, my system allowed (the patient was invited to) patient correction of any errors and for me to make the correction or explain why I chose not to. I had made it my habit to encourage patients (and often accompanying family members) to ask for clarification and for more information about the subjects I had discussed immediately after I signaled that my dictation had ended. When patients left my office, they were secure in their knowledge of what was (and was not) in their charts and additional requests by patients for copies of their records was unusual unless they needed records for medical care elsewhere.
The New England experimental program involving electronic health records has several downsides. Patients may self-censor the information provided to physicians and physicians may self-censor what they include in medical records. Patients' reviews of the their records is deferred which may leave them with significant delay and unnecessary anxiety about what doctors thought. There is no timely patient-physician give and take with a chance for others (i.e., family members brought in by patients) involved in patients' care to participate in the discussion process. And, it takes strong physician training and discipline to provide a complete internet-posted electronic health record which even touches on serious issues such as interpersonal family relationships, the consideration of the possibility or presence of serious social diseases (such as HIV, syphilis, gonorrhea), or situations, conditions or diseases which may result in deleterious insurer action, employer action, government action or adverse legal consequences.
Maybe we should slow down the use of technology, and bring smart social scientists into the process, so that we do no wrong.
Showing posts with label Insurer. Show all posts
Showing posts with label Insurer. Show all posts
Saturday, July 31, 2010
Tuesday, January 12, 2010
A Free Market Approach To Parental Refusal To Vaccinate
In a recent study reported to physicians by Medscape (the original article appeared in the January issue of the Archives of Pediatrics & Adolescent Medicine), approximately 5% of the children who were studied did not have varicella vaccination because of parental refusal. The study found that the children whose parents refused to have their children immunized were at "high risk" of varicella infection compared to children who were vaccinated.
Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.
A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities. Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases.
Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents. The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease". It's a "win-win".
Today, a parent's refusal to vaccinate with a medically proved effective and safe vaccine has no societal consequences for the parent other than the guilt which he or she may shoulder from severe complications of varicella infection in his or her child. Other parents, and their children who become infected as a consequence of each refuser's decision (such as children with immune disorders or leukemia who cannot be vaccinated) unfairly bear all of the financial and personal liability flowing from the original refuser's decision, a decision in which they did not participate.
A straightforward marketplace approach to the parents' vaccination decision making could be relatively simple. After being provided with relevant information, a parent who denies his or her child the protection of vaccination (or does not present the child for vaccination) becomes liable for all economic and "pain and suffering" consequences of all downstream infections which can be traced back to that child by public health authorities. Guaranteed freedom of choice, the refuser could insure against such liability, or could post a bond which he or she purchases.
Adoption of this approach would reduce the cost of health care because it would prevent the refusing parent from shifting the cost of the decision to payers and other parents. The refusing parent could reduce his or her exposure to liability through insurance, bringing the opportunity for new business to insurers. Attorneys actuaries, public health officials could be engaged in the "fight against preventable disease". It's a "win-win".
Sunday, August 9, 2009
America's Paradox
In the days of my medical practice, I would find people in my office who had been through one romantic relationship after the other, all ending unsatisfactorily. These patients eventually recognized that they had developed relationships again and again with partners who were virtually identical in terms of looks, behavior, abusiveness, handling of money and unfulfilled promises to do better. They were with virtually the same person over and over, with the same unsatisfactory result, and rarely learned from their experiences.
For years, Americans have had relationships with insurers who act like my patients' lovers. The insurers promise a new world of health care in slick brochures, television commercials and sales presentations, provide no real health services themselves, engage in abusive business practices - such as policy cancellation or denial of services, tests, and prescription - to patients who need care, pocket large portions of the premium money entrusted to them for inflated administrative overhead, and then promise to reform. But never do . . . .
And yet, the insurers demand that we love them. Should we? Don't we ever learn?
For years, Americans have had relationships with insurers who act like my patients' lovers. The insurers promise a new world of health care in slick brochures, television commercials and sales presentations, provide no real health services themselves, engage in abusive business practices - such as policy cancellation or denial of services, tests, and prescription - to patients who need care, pocket large portions of the premium money entrusted to them for inflated administrative overhead, and then promise to reform. But never do . . . .
And yet, the insurers demand that we love them. Should we? Don't we ever learn?
Tuesday, June 30, 2009
Framing The Health Care Reform Debate
When carpenters frame a new building's walls, the building takes a recognizable shape. Passers-by get a sense of structure, a release of anxiety, the assurance that the process is reasonable and guided by established principles of physics, mechanics, truth and responsibility.
Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.
Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.
What does the "frame" look like? How does it compare to the truth?
The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.
Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.
Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?
Unfortunately for his investors, Bernard Madoff's framing process provided his investors with a sense of structure, freedom from anxiety, and assurance - echoed by respected financial experts - that his structure was reasonable, in accordance with the principles of the financial industry of which he was an noted executive, responsible and truthful. A Ponzi scheme is an exercise in framing for deceit.
Framing is not restricted to buildings and financial structures: it is also part of our daily political exposure. Arguments are carefully framed and discussed by health care "experts" representing entrenched vested personal and business financial interests in advocating or opposing health care reform. We hear the expert-of-the day on television proclaiming that he or she has a solution or a reason not to solve, our health care problems and we hear our Congresspeople in high dudgeon about the foolishness of some of the proposals.
What does the "frame" look like? How does it compare to the truth?
The Norman Rockwell painting showing a doctor by the bedside, indelibly etched into our psyche, is a good place to start. It is part of the mythology of American medicine: each person should have his or her own honest and competent personal physician who is completely dedicated to him or her, and can marshall all necessary care without any intervention by an outside force. Unfortunately, the physician that one sees when really sick is not likely to be the physician who might know you; the hospitalist may never have met you before admitting you to the hospital and probably will not know you after discharge. The specialists who undertake your care come and go, often unfamiliar faces appearing at odd hours. Medicine has changed from Rockwell's days when the doctor sat by the bedside, waiting for the patient to die because the doctor had no antibiotics, little technology, and scientific knowledge which was woefully deficient. And today's family practice physicians have the impossible task of being knowledgeable in many complex fields requiring their attention today.
Another myth grew from the non-profit operation of early health insurers such as Blue Cross and Blue Shield and non-profit HMOs, the latter established in response to Richard Nixon's actions supporting a new system of care. Insurers and HMOs have perpetuated an image of providing service and valuable expertise to health care, rather than acknowledging that they are essentially system integrators which primarily contract with networks of providers and themselves provide little or no health care, but lots of resource-draining bureaucratic intervention and political contributions.
Another frame issue is the concept that, as scientifically and technologically advanced Americans, we now provide high-quality and efficient health care to all who need it and that health care reform will exponentially increase health care expense. This is a dubious position: overflowing hospital emergency departments (many roadblocked by the uninsured) are many times more expensive than a doctor's office for providing episodic non-critical care. With health reform, why shouldn't we develop money and life-saving efficiency rather than perpetuating the wasteful system that perpetuates income flow to selected self-serving segments of the health care industry and poor quality inefficient care to many Americans?
Monday, May 11, 2009
Kafka Couldn't Have Done Better
The New York Times, Monday May 11, 2009, page A1: Stephen Labaton's "Administration Will Strengthen Antitrust Rules." Page A11: Robert Pear's "Health Care Industry Is Said to Promise to Hold Down Costs Voluntarily." Page A21: Paul Krugman's "Harry, Louise and Barack."
The administration has made a grandiose threat to enforce antitrust rules "against corporations that use their market dominance to elbow out competitors, or to keep them from gaining market share." And then, with apparent administration encouragement representing a full-blown schizophrenic break, the big financial interests in healthcare ("doctors, hospitals, drug makers and insurance companies") have joined forces, out of the public eye (in Senator Kennedy's offices?), to exert their market dominance on the citizenry without any administrative recognition that this is insane. When the big players put their heads together, will they be more interested in diverting dollars to their corporate treasuries or in saving health care dollars while providing quantitatively higher quality health care? Were these the country club buddies of the bankers and financial people who just wrecked our economy, chanting "greed is good"?
Krugman describes his cynicism about the motives of these big money operatives. I'm not cynical, I just think the whole situation is sick.
Yesterday's blog illustrates how the money will be saved. And it bodes poorly for our families' health.
By the way, who is protecting the public?
The administration has made a grandiose threat to enforce antitrust rules "against corporations that use their market dominance to elbow out competitors, or to keep them from gaining market share." And then, with apparent administration encouragement representing a full-blown schizophrenic break, the big financial interests in healthcare ("doctors, hospitals, drug makers and insurance companies") have joined forces, out of the public eye (in Senator Kennedy's offices?), to exert their market dominance on the citizenry without any administrative recognition that this is insane. When the big players put their heads together, will they be more interested in diverting dollars to their corporate treasuries or in saving health care dollars while providing quantitatively higher quality health care? Were these the country club buddies of the bankers and financial people who just wrecked our economy, chanting "greed is good"?
Krugman describes his cynicism about the motives of these big money operatives. I'm not cynical, I just think the whole situation is sick.
Yesterday's blog illustrates how the money will be saved. And it bodes poorly for our families' health.
By the way, who is protecting the public?
Monday, March 2, 2009
Part D Insurer Passive-Aggressive Behavior?
Imagine this. On your way to an important appointment. you drive down a busy 40 mile per hour street behind a car moving no faster than 27 mph. You can't pass. There's no way to get around this driver. And then the light changes and that car drives right through the changing light, giving you the "finger", leaving you late, stopped and angry.
A psychoanalyst friend uses this scenario to illustrate passive aggressive behavior. The driver ahead of you deliberately and consciously roadblocked and provoked you, and then sped through the light.
My wife and I recently encountered a passive-aggressive situation with respect to a Medicare Part D drug. In the late Fall of 2008 we were reminded by our Part D insurer that we didn't have to do anything to renew for 2009. Late in December, just before the time had expired to renew, the insurer sent us its complex revised formulary which tripled our copayment for Zetia by raising the copayment and moving Zetia into a higher tier and threatened to non-renew our Zetia prescriptions. My wife made a number of calls to the "customer service" desks at that insurer, was given different stories by each of the persons she talked with, and was sent numerous differing forms to "appeal" the tripled Zetia copayment and non-renewal threat. Our physician sent a letter to the insurer. The company responded, indicating that it would provide us with Zetia for the next 20 years and then charged us the full augmented copay (which, having no other choice, we paid), as if our appeal had been denied.
More days of calling brought conflicting responses and forms until my wife finally learned that the company had agreed to grandfather us to the extent that it would provide us with Zetia, but had not considered restoring our copayment to what it had been before January 1, 2009 leaving us with the prospect of paying about $2000 a year for this one, of many, prescriptions. However, after almost two months of frequent calling, for the first time the company acknowledged that our physician could submit an appeal letter to roll-back the copayment.
Since I spent years negotiating contracts with HMO, PPO and other insurers, I am familiar with their tactics. The confusing, conflicting and opaque behavior of our Part D insurer was neither the result of incompetence nor accident. It was a calculated stall to block, or at least discourage, customers from getting the drugs they need. The insurer's calculation was for its financial benefit: mislead, block, delay and use secret administrative policies, not clearly disclosed to the Medicare customers brought to it under Part D, for its own profit.
When the driver ahead of you is passive-aggressive, you may become angry, but for the mature driver, there is no lasting injury. When Part D pharmaceutical insurers' policies are passive aggressive, mature Medicare beneficiaries will die.
I hope that the Obama administration will not fill health care reform posts with people (including board members) connected with health/pharmaceutical insurer policies of secret administrative regulations, deliberate misleading of Part D beneficiaries, blocking and stalling the provision of needed drugs, and other obstructive health insurer profit-enhancing behavior. Persistence of these policies will generate public frustration and anger. And people will die.
A psychoanalyst friend uses this scenario to illustrate passive aggressive behavior. The driver ahead of you deliberately and consciously roadblocked and provoked you, and then sped through the light.
My wife and I recently encountered a passive-aggressive situation with respect to a Medicare Part D drug. In the late Fall of 2008 we were reminded by our Part D insurer that we didn't have to do anything to renew for 2009. Late in December, just before the time had expired to renew, the insurer sent us its complex revised formulary which tripled our copayment for Zetia by raising the copayment and moving Zetia into a higher tier and threatened to non-renew our Zetia prescriptions. My wife made a number of calls to the "customer service" desks at that insurer, was given different stories by each of the persons she talked with, and was sent numerous differing forms to "appeal" the tripled Zetia copayment and non-renewal threat. Our physician sent a letter to the insurer. The company responded, indicating that it would provide us with Zetia for the next 20 years and then charged us the full augmented copay (which, having no other choice, we paid), as if our appeal had been denied.
More days of calling brought conflicting responses and forms until my wife finally learned that the company had agreed to grandfather us to the extent that it would provide us with Zetia, but had not considered restoring our copayment to what it had been before January 1, 2009 leaving us with the prospect of paying about $2000 a year for this one, of many, prescriptions. However, after almost two months of frequent calling, for the first time the company acknowledged that our physician could submit an appeal letter to roll-back the copayment.
Since I spent years negotiating contracts with HMO, PPO and other insurers, I am familiar with their tactics. The confusing, conflicting and opaque behavior of our Part D insurer was neither the result of incompetence nor accident. It was a calculated stall to block, or at least discourage, customers from getting the drugs they need. The insurer's calculation was for its financial benefit: mislead, block, delay and use secret administrative policies, not clearly disclosed to the Medicare customers brought to it under Part D, for its own profit.
When the driver ahead of you is passive-aggressive, you may become angry, but for the mature driver, there is no lasting injury. When Part D pharmaceutical insurers' policies are passive aggressive, mature Medicare beneficiaries will die.
I hope that the Obama administration will not fill health care reform posts with people (including board members) connected with health/pharmaceutical insurer policies of secret administrative regulations, deliberate misleading of Part D beneficiaries, blocking and stalling the provision of needed drugs, and other obstructive health insurer profit-enhancing behavior. Persistence of these policies will generate public frustration and anger. And people will die.
Saturday, July 5, 2008
The Most Dangerous Addiction
Don't believe that heroin, cocaine, morphine, methamphetamines and oxycodone are the most dangerous addictions in health care.
The most dangerous addiction is cash flow on which health care systems, insurers, HMOs and providers depend. Improving cash flow induces an endorphin glow; a dimishing cash flow causes cash and credit to become unavailable resulting in acute deprivation symptoms. Analysts devalue health-related stocks and bonds, boards berate executives and their administrations, chief financial officers get fired, providers get paid less with the expectation that they will do more, and health system employees lose their jobs, homes, communities, family health insurance, and social connections. All this without ever smoking, snorting, inhaling or taking a "hit".
As our recession worsens, layoffs will cause loss of health insurance with appropriate medical diagnostic, treatment and pharmaceutical services and products (and leave the former employee with no recourse under ERISA). As employment rolls dwindle and with available global options to save money, employers will change health insurance programs which, in turn, will add higher copayments, restrict benefits, insert more difficult administrative barriers to authorizations and contract with insurers and HMOs which may not have the most qualified physicians, hospitals and health care providers. Providers will find that insurers and HMOs become more difficult to satisfy when claims for payment are made. When a recession is coupled with inflation, a few days' delay in payment to providers may means thousands (or millions) in "float" to payers and wreck providers' cash flows.
Systems which are closely linked to specific manufacturing or service industries may be the most vulnerable to a downturn. HMOs and insurers dependent on stable enrollment will experience the shock of lower membership rolls and cash flows. The impact will be directly felt throughout health care.
See Kaiser Network's article on the vulnerability of UnitedHealth Group which announced its lower profit outlook and said that it will undertake some restructuring at http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=53110
The most dangerous addiction is cash flow on which health care systems, insurers, HMOs and providers depend. Improving cash flow induces an endorphin glow; a dimishing cash flow causes cash and credit to become unavailable resulting in acute deprivation symptoms. Analysts devalue health-related stocks and bonds, boards berate executives and their administrations, chief financial officers get fired, providers get paid less with the expectation that they will do more, and health system employees lose their jobs, homes, communities, family health insurance, and social connections. All this without ever smoking, snorting, inhaling or taking a "hit".
As our recession worsens, layoffs will cause loss of health insurance with appropriate medical diagnostic, treatment and pharmaceutical services and products (and leave the former employee with no recourse under ERISA). As employment rolls dwindle and with available global options to save money, employers will change health insurance programs which, in turn, will add higher copayments, restrict benefits, insert more difficult administrative barriers to authorizations and contract with insurers and HMOs which may not have the most qualified physicians, hospitals and health care providers. Providers will find that insurers and HMOs become more difficult to satisfy when claims for payment are made. When a recession is coupled with inflation, a few days' delay in payment to providers may means thousands (or millions) in "float" to payers and wreck providers' cash flows.
Systems which are closely linked to specific manufacturing or service industries may be the most vulnerable to a downturn. HMOs and insurers dependent on stable enrollment will experience the shock of lower membership rolls and cash flows. The impact will be directly felt throughout health care.
See Kaiser Network's article on the vulnerability of UnitedHealth Group which announced its lower profit outlook and said that it will undertake some restructuring at http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=53110
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