The Devil (You Think) You Know / Part IV

In March of 2000, in a New York State court, a class action suit was brought against the United Health Group, the second largest health insurer in the nation. It was brought on behalf of the American Medical Association (AMA), the Medical Society of the State of New York, the Missouri State Medical Association, and other interested parties. The suit charged United Health with systematic under-reimbursement of out- of-network charges. AMA trustee, Dr. Donald Palmissano, remarked at the time that, "...the case calls into question the entire payment mechanism that the insurance companies have used for years in paying physicians."

But it was not only the physicians who were being shortchanged. Many of the parties in the suit included the direct insured, who found themselves saddled with the difference between what they were being charged and what United was willing to pay as "usual, customary, and reasonable" (UCR) charges.

In New York, complaints to the attorney general's office became so numerous and egregious that in 2008 the Attorney General launched an investigation into insurance industry practices. The investigation would be ongoing and would focus on Ingenix, Inc., the nation's largest provider of healthcare billing information. As sixteen subpoenas were going out to the nation's largest health insurers, the Attorney General also announced he would seek to file suit against Ingenix and United Health.

And so begins our story.
Who's Minding the Store ?

Over the past few decades, health insurers have developed a practice for reimbursing out-of-network claims based on customary, usual, and reasonable charges for services. And to provide the needed data, a separate industry was born. These companies would compile the data, do the analysis, and for a fee, provide insurers with UCR rates based on individual procedures, and classified by regions.

The two largest providers of healthcare billing information were the Prevailing Healthcare Charges System (PHCS), and the Medical Data Resource (MDR) database. The PHCS database was created in 1973 by the Health Insurance Association of America (HIAA), which at that time was the industry's trade association. MDR was its next largest competitor. But in the late 1990s, the two would essentially become one, ending any semblance of competition in the field. But wait, it gets worse.
In 1997, the MDR database was purchased by Ingenix, Inc.. The following year HIAA sold its database as well, also to Ingenix. And who is Ingenix? They are the information technology business unit of United Healthcare (to repeat, the second largest health insurer in the nation). So, to summarize, the two main sources of UCR data, which insurers use to calculate how much they will reimburse for out-of-network charges, were suddenly owned by the second largest health insurer in the country. Wouldn't that be the equivalent of putting the kid with the fastest car in charge of setting the speed limits for school zones? And yet, it raised no red flags. Especially in the healthcare industry.
Which brings us back to the 2000 suit filed by the AMA and others, and the 2008 investigation by the New York attorney general's office. (The insurers may not have been paying much attention, but everyone else surely was.) After a yearlong investigation, New York Attorney General, Andrew M. Cuomo, concluded that there was a clear conflict of interest, which resulted in the under-reimbursement of New York consumers. After comparing the Ingenix "customary, usual, and reasonable" rates with claims actually filed in New York, they'd found that consumers were systematically under-reimbursed by 28-30%, due to faulty Ingenix data.

On January 13, 2009, the same day the attorney general's office released it's report, United Health publicly stated for the first time there was an "inherent conflict of interest" in its business relationship with Ingenix. They signed an agreement with the attorney general to shut down the PHCS and MCR databases, and promised to contribute $50 million towards the start of a new, non-profit entity that would create and administer an independent medical claims database. It would be housed in a New York academic institution and would make its price data available to the public through a website.

Two days later (and nearly nine years after filing their original suit), the AMA reached a tentative settlement, with United Health agreeing to pay $350 million for reimbursing patients and providers.

A good end result? You tell me. There is little transparency in the healthcare industry as it is. Even less when corporations settle out of court, as they nearly always do. So we rarely know the actual amounts misappropriated. Only the amounts of their fines. Considering United Health reported earnings for the second quarter of 2009 of $859 million (that's net earnings), it makes one wonder. Have fines simply become a win/win cost of doing business, with companies profiting generously, even if they get caught? And still more if they don't?

Here's a clue. On May 7, 2009, the Federal judge presiding over the class action lawsuit refused to approve the $350 million settlement. The judge expressed concerns over the sufficiency of the settlement amount, and the quality of the data provided to the plaintiffs in reaching that amount. In other words, even in the process of attempting to reach a settlement, the company could not be depended upon to, in good faith, provide anything but faulty data. They'd cheated consumers; they'd cheated taxpayers; they'd cheated healthcare providers and physicians ..... and in reaching a settlement to avoid going to court, they were still cheating.

Business Ethics is an Oxymoron
The U.S. Health and Human Services Department and its investigators this year found that 80% of companies participating in the Medicare prescription drug benefit program overcharged subscribers and taxpayers by an estimated $4.4 billion.

Just thought I'd throw that in there.

The investigation by the New York attorney general's office, and similar state investigations and resulting legal suits across the nation, were beginning to shine a fair amount of light on Ingenix, United Health, and "standard" industry practices. And with government run healthcare programs being affected as well, the federal government was obligated to do some investigating of its own.

In March of this year the Senate Commerce Committee held two hearings to look at the way Ingenix data was being used to reimburse consumers for out-of-network charges. The Committee Chairman, Sen. John D. Rockefeller IV (W.Va.), also sent information requests to 18 of the largest health insurers not involved in the New York attorney general's investigation. Based on those hearings and the information he'd requested, as well as prior investigations, the Committee issued its report on June 24. And what they found could easily be considered a template for the entire healthcare industry, much to its disgrace.

To begin, they determined the use of the Ingenix database to be pervasive throughout the health insurance industry, with most insurers subscribing to its service. It was so pervasive that one healthcare executive told the Committee, "We know of no alternative sources of national healthcare charge databases."

That is a disturbing discovery, considering the same insurers subscribing to the UCR database were also submitting the data. And, as if there weren't incentives enough to supply that data, the insurers were also offered large discounts on Ingenix database products for participating in the "Data Contribution Program". By submitting medical claims data they could receive "Data Credits", which could easily add up to discounts of 50% or more.

According to United Health Group CEO, Stephen Hemsley, nearly 100 different parties contributed data. These parties agreed to submit "non-manipulated, complete, usable data for all covered members for all submitted claims". Ingenix's data submission rules stated:

Customer shall include all data fields that Customer currently collects that are required in the data contribution format, and Customer shall not manipulate or present the data so as to provide only a particular subset of its data. Customer will submit its full claims experience for the number of total contracted covered lives.

"..... total contracted covered lives." That's creepy enough. But, hey ... okay. Sounds like they laid down the law. No cheating ..... okay, guys? Wait. What was that? Was that a wink? Did I just see a wink?

Me? I Thought YOU Checked

Although Ingenix CEO, Andy Slavitt, had claimed before the Committee, "we run a number of analyses to check and make sure" the data is accurate and complete, Ingenix's Manager of Research and Development for both database products, Ms. Carla Gee, had responded in recent court proceedings quite differently.

She had stated that, although Ingenix did perform occasional audits of the data, they were ultimately "at the mercy" of insurers to submit accurate and complete data. And even more compelling, "Ingenix has never tested its results to determine if its statistical conclusions bear any relationship to the actual high, low, median, or 80th percentile" of service rates charged by health care providers in any given area.

Excuse me? You mean you've never tested to see if you were even in the ballpark. Is that what you're saying? Wouldn't Ingenix, as virtually the only source for insurers to determine what is customary, usual, and reasonable, bear some responsibility to make sure its data is accurate? Apparently not.

In a paragraph contained in Ingenix materials labeled "Information Tool", they essentially went so far as to disclaim any responsibility for their data:

The data is provided for informational purposes only .... Any reliance on, interpretation of and/or use of the Data by Customer is solely and exclusively at the discretion of Customer. Customer's determination or establishment of an appropriate reimbursement level or fee is solely within Customer's discretion, regardless of whether Customer uses Data.
And yet, they clearly anticipated legal challenges, promising to provide customers with technical and legal assistance in "database challenges", and legal support to defend attacks on its data integrity. Not that they thought any attacks would be forthcoming.

Proprietary Misinformation
During Committee hearings, Chairman Rockefeller discussed the case of Jill Faddis. In 2001, her husband was billed $140 for a visit to a periodontist. Their carrier, Aetna, would only pay the "customary and usual" fee of $65. Thinking the figure low, Jill called every periodontist in the area to compare rates. She found the usual charges to fall between $110 and $163 for the same service. But having no way to challenge her insurer, she paid the difference.

The case files of attorneys general all across the country are full of similar testimonies. When insurers are questioned about their methods for determining UCR rates, they often reply with vague answers, claim proprietary information, or simply lie. And the recourse is no different for doctors and providers. AMA President, Dr. Nancy Nielsen, testified that when doctors asked insurers how they had calculated their "usual and customary" rates, they were told the information was "proprietary". Which, actually, was true. Ingenix contracts forbid any subscribers from divulging their "secrets".

So here's where we are:

Insurers need someone to determine what's usual and customary so they can say with authority this is the normal fee.

The service they subscribe to is the only game in town ..... and it's owned by one of their own.

The data used to determine those rates that insurers will have to pay out is furnished by the same people who will be doing the paying. Sort of a "closed loop", if you will.

And .... the company that determines the rates never checks to see how accurate they are. And no one has to tell anybody where in the hell they get their numbers!

I think that about covers it. Now ... any guesses on how our story ends? You got it!

Aye, There's the Scrub
In an expert report submitted to the New Jersey federal court in 2006, a statistical expert testified that insurance companies did not submit complete sets of data, and some preferred "scrubs" that skewed the data downward. They testified that Aetna, Ingenix's largest data contributor, eliminated the highest 20% of valid medical charges before sending the data to Ingenix. And Ingenix employed essentially the same procedure once it received the data. The effect was to make the charges appear to be lower than they actually were.

In addition to Aetna, the Committee found that CIGNA contributed data from only four of its nine claims systems. While another unnamed company that contributes more than 5 million claims a month to Ingenix, admitted to providing Ingenix with its own average charges for each procedure, rather than the unadulterated "full claims experience" that were required in the contracts. The company stated it had been submitting its data this way for many years, and had received discounts, certifying Ingenix had accepted its data as valid. But then, no one was checking, were they?

The Committee also found that the insurance industry, either through misinformation or false information, routinely failed to provide consumers with accurate information in disclosure statements. Linda Lacewell, a senior attorney from the New York Attorney General's Office, stated that some insurers affirmatively misstated the source of their numbers, claiming they came from "independent" sources. That's a nice way of saying they lied.

Nor was it unusual for large insurers to attribute their UCR rates to the Health Insurance Association of America, even though Ingenix had purchased the database from them more than a decade ago, and the association had been out of existence since 2003.

In the end, a series of private lawsuits and an investigation by the New York Attorney General's office was the only way American consumers and health care providers could discover why reimbursement payments were consistently lower than what really was usual and customary.

I'm Sorry and It Won't Happen Again?
On March 31, 2009, United Health's CEO, Stephen Hemsley, testified before the Committee:

We have a number of regrets related to this. We regret we did not recognize the appearance of this conflict sooner. We regret we were not more forceful in our broad disclosures with respect to the relationship of this database relative to other aspects of our company. And we regret that there has been any breach in terms of the perception of trust, in terms of the consumers' participation in this.

Also before the Committee, the CEO of Ingenix, Andy Slavitt:

There is no denying that Mr. Hemsley's company owns my company and another company that uses our product. And it is clear that we were myopic and perhaps so analytical about defending our integrity that we missed the bigger picture.


To which I can only reply ...... What? Are you kidding me?


Committee member, Claire McCaskill, the Democratic Senator from Missouri, stated that the way Ingenix was marketed to insurers was as a way to "get out of paying" the correct reimbursement rate, a charge Slavitt outright denied. She said neither Slavitt nor Hemsley was willing to take responsibility for the problem, yet "it is my understanding that cases get settled because you are afraid you'll get nailed in court". "This is why there is such a lack of confidence in health care.", she said. "The way you did this, putting the wrong information, put consumers on the short end of the stick. I think this committee needs to stay on you like white on rice."

I couldn't agree more.

I've attempted to provide you with a look into one company within the healthcare complex. And shown you how greedy, uncaring, and arrogant an industry can become. The sad, but necessary truth is that the entire industry is infected with the same virus. Millions of lives are at stake every day. And yet, to think that my life or the life of someone I love might be less of a consideration than shareholder dividends or executive bonuses is chilling, if not an outrage.

And if you're still willing to stay with the devil you know ... Perhaps now you know him just a little bit better.

The Devil (You Think) You Know/ Part 3

A few facts.

In 2007 the U.S. spent nearly $2.4 trillion on healthcare. That's over $7,500 per person, almost double that of any other industrialized nation.

From 2003 to 2007 the combined profits of the nation's major health insurance companies increased by 170%.

The top executives at the seven largest health insurers average $14.2 million a year in compensation.

That's astounding, considering many Americans are struggling to simply break even and keep their heads above water. With wages stagnant for more than a decade, and costs for everything consistently rising, it's been a difficult generation for most of the American public. And yet, even with two ongoing wars (occupations) and an economic meltdown, the healthcare industry continues to prosper. While, for many households, the monthly health insurance premium is more than the mortgage, and often the largest single monthly expense.

Recently, United Health, the second largest health insurer in the nation, announced its second quarter net earnings of $859 million, up 155% from a year ago. That's just in one year. (And in the midst of an economic crisis for the majority of America.) They also projected their yearly revenue for 2009 at $87 billion. That's an astonishing amount for a company that does not provide any type of actual care within the health care equation. Still, they serve a vital function for most Americans. And even though the cost of healthcare continually rises, it's indicative of the high quality we've come to expect in the U.S. and are willing to pay for. Right? Not so fast.

The Devil In the Details


Though Americans pay more for their healthcare than any industrialized nation, the truth is we have been in a downward spiral for years in nearly every category. In rankings of all countries of the world the U.S. is not in the top ten, nor the top twenty. It's not even in the top thirty. Whether you are measuring infant mortality (here), life expectancy (here), or health systems in general (here and here), the results are more than just humiliating. They're shameful.

So, if we're paying so much and getting so little, where is all the money going? Well, for starters, profits of corporations, executive salaries, shareholder dividends, marketing, administrative costs, acquiring other companies, to name a few. That's on top of actual services rendered, research and development, doctors and nurses, hospitals and equipment, and caring for the patients. Such is the price we pay for private, "for profit" healthcare. But maybe that's not all we're paying for.

In 1999 Hoffman-LaRoche paid a $500 million criminal fine for leading a worldwide price-fixing scheme on certain vitamins. (here)

In 2000 the Hospital Corporation of America agreed to pay $745 million to settle civil charges that it systematically defrauded Medicare, Medicaid, and other federally funded health programs. (here)

In 2003 Glaxo Smith Kline paid $88 million in civil fines for overcharging Medicaid for its anti-depressant Paxil. As well as $41 million in 2006 paid to forty states for inflating prices (here). And $80 million in 2008 to the State of Alabama for more Medicaid price fraud (here).

In 2004 Warner-Lambert, a division of Pfizer, Inc., pled guilty to two felonies and agreed to pay $430 million for fraudulently promoting the drug Neurontin (here).

Nothin' Personal, Just Business

This is just a representative sample of what goes on year after year. (But if you're a glutton for just how much goes on, look here and here.) What becomes readily apparent with even a casual glance is the gross amount of corruption that affects America's healthcare. A simple search on the internet leads to long lists of fines, lawsuits, and settlements involving pharmaceutical companies, health insurers, hospitals and large corporate healthcare conglomerates. Many of the same companies are shelling out millions in settlements, over and over again.

It begs the question: If these companies are paying out hundreds of millions of dollars in fines regularly, how is it they continue to make so much money? How indeed. Obviously the fines are not in any way a deterrent. In most cases the companies settle out of court, likely for much less than they actually gained. (Otherwise they would allow the case to proceed.) And even in cases which bring felony convictions, the perpetrators are allowed to continue business as usual.

For example, a 1996 federal law prohibits any company with felony convictions resulting from their business dealings with Medicare from participating or having any dealings with that program. Yet, one company created a shell subsidiary that could be convicted, while the parent company continued as though nothing had happened. Another simply claimed it stopped selling its pharmaceutical illegally to Medicare on August 20, 1996. The law went into effect August 21.

When I began this series, it was in response to President Obama's comment that many Americans are afraid of change, settling instead for "the devil they know". But if they were truly aware of the enormous level of corruption and what it's costing them, perhaps they wouldn't be so averse to that desperately needed reform. With the amount of corruption and fraud in our current system, maybe it's just a matter of opening one's eyes. As my grandpa used to say, "If it was a snake, it would've bit ya'."I think snakebit is how most Americans are feeling.

In my next post I'll examine one particular corporation, United Health Group, the second largest health insurer in the nation. I don't single them out, but present them as an example of thousands of private corporations who are all riding this gravy train right off the tracks. And just one more devil you think you know.

The Devil (You Think) You Know / Part 2

When the Democratic party recaptured the House and Senate after the 2006 elections, there was much hope and anticipation that an era of "giving the store away", business-friendly administration would be coming to an end. In a February 28, 2007 article in Smart Money Magazine, Peter Keating's opening paragraph illustrates those expectations:

It won't be long before congressional Democrats authorize the federal government to negotiate the prices Medicare pays for prescription drugs - something the 2003 law creating the Part D program notoriously prohibited. Uncle Sam will crack some heads at Merck and Pfizer, and Washington will save so much money that it might even close the much-loathed "doughnut-hole", a flaw in the law that currently denies coverage to Medicare recipients who have at least $2,400 in prescription costs, but less than $3,850 in total out-of-pocket expenses.

It is now August of 2009. And very few heads (if any) have been cracked at Merck or Pfizer, or at any of the other big drug makers. Even worse, in a report last week in the L.A. Times, we are told that the Obama administration has made promises to the pharmaceutical industry that he would not pursue Medicare drug price negotiations, or lift restrictions on the importation of cheaper drugs from Canada or abroad. These assurances were given to Billy Tauzin, President of the Pharmaceutical Research and Manufacturers Association (PhRMA), through a series of meetings in the White House.

The N.Y. Times later confirmed the story, as White House officials assured pharmaceutical companies they stood behind their closed-door deal to block any Congressional efforts to gain more savings from the drug makers. The drug makers had offered up $80 billion over ten years during those behind the scenes discussions. The administration is now trying to back track amidst public uproar and fellow Democrats who are voicing their resistance to any such deals.

But it's leaving a familiar aftertaste in the mouths of Americans, who are increasingly beginning to view campaign promises as being no more dependable than their health care premiums. And it leaves them wondering why a government has to negotiate with an industry it needs to regulate. And how an industry association such as PhRMA has such power that it can be a guest at the White House, repeatedly, for back-room negotiations (which are far from the transparency that President Obama had promised on the campaign trail). And just who is this Billy Tauzin?


I'M GLAD YOU ASKED

Perhaps more important, and more telling, than who Billy Tauzin is, would be who Billy Tauzin was. Beginning his political career at the age of 29, he was elected to the Louisiana House of Representatives as a Democrat, where he served four terms. In 1980, Tauzin moved to Washington when he was voted to the U.S. House of Representatives. As one of the more conservative Democrats, he served fifteen years and even rose within the ranks to become an assistant majority whip. But Tauzin felt he and other "moderate" Dems were being shut out by more liberal members of the party. And when the Democrats lost control of the House in 1994, Tauzin helped found the House Blue Dog Coalition within the Democratic party. Interestingly enough, by 1995 he had switched to the Republican party.

Billy Tauzin went on to serve on the Energy and Commerce Commission and was its chairman from 2001 until February of 2004, when he announced he would not seek another term as Louisiana's representative. On January 3, 2005, the day he left Congress, Tauzin began working for PhRMA, and representing an industry that spent more on lobbying from 1993-2006 than any other industry in America. That would seem to be a good fit, considering all that Billy Tauzin had already done for the drug industry.

Only two months before taking the PhRMA job, he had helped push the Medicare Prescription Drug Bill through Congress (a bill which would be criticized for being overly generous to the pharmaceutical industry). The passage of that bill occurred under extraordinary and highly questionable circumstances, as the vote in the House remained open well beyond acceptable limits while arms were twisted and deals were being made. It would be the longest roll call vote in the history of the House of Representatives. But at 3 a.m., while much of America lay sleeping, the bill was passed. And many of those who worked on the bill, which some lawmakers claimed "the pharmaceutical lobbyists wrote", indeed now work as lobbyists for the same drug makers.

Even Medicare boss Thomas Scully (who had actually threatened Medicare's Chief Actuary, Richard Foster, with firing if he released numbers showing how much the bill would cost Medicare) was working a deal to become a pharmaceutical lobbyist while the bill was still working its way through Congress.

Yet, even as their representatives were passing the bill, very few Americans knew at the time, or know now, what was in the bill. And unless you were directly affected by it, you probably didn't care. But what it created was essentially a windfall for big pharma, in the guise of looking out for the interests of ordinary Americans.

THE SELL OUT

Known officially as the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, the bill which was ushered through Congress in the wee hours of the morning enacted Medicare Part D. Under that bill, Medicare was explicitly barred from negotiating drug prices for seniors. This meant that, although they represented the largest block of the prescription buying public, Medicare could not use that leverage to benefit from volume discounts to make drug prices cheaper for its recipients, or for taxpayers. So, even as Wal Mart is allowed to put its competitors out of business by negotiating these volume discounts with its suppliers, taxpayers and Medicare would not be afforded the same luxury.

The Veterans Administration, by comparison, is allowed to negotiate with the drug companies and pays 58% less for drugs, on average. The VA is also allowed to establish a formulary while, under Part D, Medicare can not. (Formularies are lists of prescription drugs which are covered by a particular plan. They are typically based on the efficacy, safety, and cost-effectiveness of the drugs.) This is a seemingly minor detail, but one which is of major importance in holding down a plan's costs. Compiling a formulary should be done by the end users, and not the distributors, for obvious reasons.

Also included in the bill was the stipulation that placed the processing and payment of Medicare's prescription drug claims under the care of 3rd party administrators known as Pharmacy Benefit Managers (PBMs). In other words, the handling of Medicare's prescriptions was being privatized. Contracted out. Or if you prefer, brought into the for-profit world.

In summary, though Medicare was created as a public program, and a protection for our senior population and the most vulnerable in our society, the passage of the 2003 drug bill essentially took the responsibility for their prescription drugs out of the hands of the government and dropped it in the hands of private, for-profit companies. And with predictable results.

PBMs (Predictably Bad Mojo?)

Pharmacy Benefit Managers, or PBMs, emerged onto the health care scene in the 1990s. Responding to HMOs desires to cut their prescription drug expenses, PBMs became intermediaries between drug companies and many health care plans. The HMOs had already begun to trim their lists of drugs they would cover, and it was thought that the PBMs, representing the purchasing power of the many plans they contracted with, could negotiate lower prices and discounts than the health plans could attain individually. Looked good on paper. But, as with most "good ideas" which involve big business, the profit motive is somehow always left out of the equation.


Initially, PBMs began negotiating prices and discounts with the drug makers as intended. All was right in the world. But it wasn't long before they had begun to pressure pharmacies and doctors to steer patients towards particular prescriptions and medications. And as their leverage as middlemen between drug makers and health plans began to grow, so did the power to dictate to the health plans they had contracted with. For example, which drugs should or should not be included in health plan formularies. Giving a for-profit entity this much influence and control is essentially the equivalent of handing them a signed blank check. So, it's no surprise that they have grown to become very powerful and extremely profitable. Which brings us to the great sell out of Medicare Part D, and the difference between public and private health care administration.

PBMs, like all contractors, are considered to have a fiduciary duty in the relationships with those they contract with. Essentially, that means they have contracted to take actions for and on behalf of someone in a relationship of trust and confidence. In the case of PBMs, they were contracted to negotiate drug prices and discounts on behalf of the health plans who pay them. But the Supreme Court has also ruled that CEOs have a corporate and fiduciary duty to maximize shareholder values (not to mention CEO bonuses and salaries). Is there a clearly defined line which separates the two, or gives one precedence over the other? Evidently, there is.

AND NERO PLAYED HIS FIDDLE

Increasingly, in recent years, PBMs are facing lawsuits filed by state and federal governments, as well as PBM clients, which charge them with the practice of negotiating discounts and rebates from drug companies, and then not passing them on to consumers and their clients, as they are contractually obligated to do. Instead, they are keeping the discounts and rebates for themselves as company profits.

In 2004 litigation, Medco Health Solutions (the nation's largest PBM) reached a $29.3 million settlement agreement for allegations of violating consumer protection and mail fraud laws, filed by 20 states and the federal government. We can assume that was but a fraction of the actual monies redirected.

They also paid the state of Massachusetts $5.5 million to settle the allegations that the company pocketed millions of dollars in rebates from drug companies that should have been passed down to the state. And, unfortunately, it's never one, single rotten apple.

PBM Express Scripts had a suit filed against it by N.Y. attorney general, Elliot Spitzer, citing breaches of its $600,000 contract and violations of civil law resulting in New York state being defrauded of up to $100 million over 5 years. And Caremark Rx is suffering a similar class action lawsuit in Tennessee.

The causes are obvious and easily pridictable. PBMs and the pharmaceutical companies have formed mutually beneficial relationships. When PBMs have the power to include particular drugs in health plan formularies, they also have the power to increase a drug's market share. Drug makers will often offer discounts if a PBM can get their drug to be accepted by the health plan. And it becomes difficult to make a distinction between discounts, rebates, kickbacks, and outright bribes when those savings are not passed on to the health plans. And PBMs grow fat by making money at both ends, keeping the rebates they've negotiated, as well as the payments for their services(?) to the health plans.

Yet, they are continually contracted for their services. A fact that becomes more confounding considering actual savings as a result of a PBM is rarely disclosed, by a PBM or its clients. You see, contractual arrangements with the drug makers are not subject to disclosure. The states of Maine and South Dakota, and the District of Columbia, do have laws on the books requiring PBM transparency. But the PBMs are fighting even those efforts. The Pharmaceutical Care Management Association (PCMA) filed suit against Maine and D.C. for their laws.

In Maine, although the industry won two preliminary injunctions against the state, they were denied their motion for summary judgement. The judge agreed that financial disclosure was reasonable in controlling costs of prescription drugs. In D.C. it was a different story, with the judge ruling it would be an "illegal taking of private property". Extraordinary, considering the taking which has already occurred.

THE DEVIL (YOU THINK) YOU KNOW

It continues to baffle me that so many Americans are willing to settle for the devil they know, while remaining fearful of a public health care option for all. They claim the government would have bureaucrats deciding whether or not they get care and how much, just like the insurance companies. They claim they are afraid of socialized medicine, even though the VA and Medicare are essentially just that. They even point to the fact that Medicare doesn't work very well and is running out of money. I would say just ask any senior if they want their Medicare taken away. They, and I, happen to believe it works very well, thank you. And to the extent that it doesn't work, or is running out of money, I'll let you ask Billy Tauzin and all of the politicians-turned-lobbyists why that might be.

And for those who argue that private industry is just more efficient and cost effective by nature, it comes down to one question. Is it more efficient at making health care better for us all, or more efficient at making money for private industry? Look in any direction you choose and you'll find the answer to that question. Follow the money.



Much of the information contained in this and all of my posts is the result of the hard work and investigation of many like-minded writers like myself. And it's from many of their writings that I get much of my information. Please honor their commitment to digging through the muck by staying informed. Read. -JW

The Devil (You Think) You Know

Meet Richard L. Scott. He is the multi-millionaire who is leading the assault against health care reform. The non-profit, Conservatives for Patients Rights, which Mr. Scott helped form and now leads, has been launching ads on TV, radio, and the internet in an attempt to derail universal health coverage, or anything which smells remotely like a public option. Scott initially put in $5 million of his own money and claimed the non-profit would spend as much as $20 million on the campaign.

To do this, they hired the PR firm Creative Response Concepts, who are best known for the Swift Boat ads aimed at presidential contender, John Kerry. The new ads feature Richard Scott, who explains all of the usual arguments against the evils of government-sponsored universal health care. This seems a bit unusual, considering Mr. Scott is not, and has never been, a doctor.

So, who is Richard Scott? And why is he so concerned for "patients rights"?

In 1987, Richard L. Scott founded the Columbia Hospital Corporation. Most of his prior experience had been as a merger and acquisitions lawyer, an expertise that was honed working deals for radio stations and fast-food chains. But then along came Richard Rainwater, a Texas financier, who enticed Scott with the large amounts that could be made with hospital acquisitions. Rainwater intended to do for hospitals "...what McDonalds has done in the food business and what Wal Mart has done in the retailing business." In essence, to grow so big that smaller competitors are put out of business and you become the only game in town. And of course, cutting costs. Not profits, mind you. Just costs.

But what began as an initial investment of $125,000 each and two small hospitals in El Paso, became (with the purchase of Hospital Corporation of America) the largest hospital company in the world, in less than a decade. A $20 billion company, with around 550 home health care offices, 350 hospitals, and many more medical-related businesses in 38 states.

As president of Columbia/HCA, Scott pursued an aggressive pattern of cost cutting that often left nurses and health care workers on the short end of efficiency, purchasing cheaper supplies, consolidating operations, and saddling a reduced workforce with increasing workloads and responsibilities. It also became a standard Columbia/HCA practice to purchase several hospitals in close proximity and then close one down, eliminating competition and driving up profits for those that remained. According to a Forbes magazine article in 2000: "Under former Chief Executive Richard Scott, (Columbia/HCA) bought hospitals by the bucketful and promised to squeeze blood from each one."

Scott also made a practice of selling doctors a stake in the hospitals, offering them partnerships in exchange for their referrals to the Columbia/HCA hospitals. Forbes reported: "In addition it gave doctors loans that were never expected to be paid back, free rent, free office furniture, and free drugs from hospital pharmacies."

When Columbia/HCA were preparing to merge with Health Trust Inc. (which owned eight hospitals in close proximity in Utah), Scott considered the advantages of the merger. "We anticipate annual savings of $125 million from cost reductions and improved efficiencies resulting from our consolidation ..." As we've learned from experience, however, "cost reductions" and "improved efficiencies" do not result in savings passed on to consumers. It simply means less quality for more money, and greater profits for shareholders.

It has become, unfortunately, the standard operating procedure for any and all large corporations, as they are beholden to the shareholders (of which CEOs are also substantial stakeholders), above all else. This is bad enough on the surface, and something we are all growing quite tired of. But for Richard Scott, as with many CEOs, shareholders and executives, a lot of money is rarely enough.

In 1997, Scott was fired by the Columbia/HCA board after the company had been found to be ripping off the Feds and state governments in bogus Medicare and Medicaid charges. In what was the largest fraud of its type in history, the company was forced to pay nearly $2 billion. Considering most penalties and fines amount to only a smaller portion of actual fraudulent monies, it leaves one to wonder at what must have been an enormous fraud on the taxpayers.

In government investigations over seven or more years, it was found that the company was not only committing the garden-variety frauds of unnecessary tests and procedures to raise billings. They were also engaged in practices which included such things as billing employee picnics, food for non-employees at company functions, and Christmas gifts as patient care expenditures. In addition, Columbia/HCA routinely shifted administrative costs into categories with higher reimbursement rates, such as capital improvements.

With fraudulent activities on a history making scale, did Richard Scott face any criminal penalties? In addition to his firing and the fines paid by Columbia/HCA, was there anything more? Well, yes.

Upon his departure, Scott was given a 5-year consulting contract with Columbia/HCA at $950,000 a year, plus $5.3 million in severance pay, plus $300 million in stock. (Crickets chirping.) Do you want me to repeat that? For his wrongdoing he received around $10 million in severance and $300 million in stock. Is it any wonder there is no disincentive for company execs to pursue wrongful behavior in their relentless pursuits of profits? The organized crime syndicates of old must be rolling over in their graves at the thought that so much criminal intent could go not only unpunished, but rewarded.

This is why our health care should not be subject to the private sector, whose sole responsibility - even proclaimed by the Supreme Court - is their fiduciary duty to shareholders (i.e.- maximizing shareholder equities). If it's all about the dollar (and it is), your health care and my own will always be no more than a market consideration, and a tool with which to generate the most wealth with little thought given to what is best for the patient.


As I wrote earlier, Richard Scott is now leading the assault on universal healthcare, or any other public option. He, naturally, represents our usual refrain of, "Follow the money!"

Much of this story can be found in Maggie Mahar's book, Money-Driven Medicine: The Real Reason Healthcare Costs So Much.

Additional information on Richard L. Scott and Columbia/HCA can be found at these sites: Healthbeat.org, Business Week (Aug. 4, 1997), Media Matters, and the New York Times (July 26, 1997).



NEXT UP: The Devil (You Think) You Know-Part 2

Is Your Life Cost Effective ?

Where does one start? For that matter, where does one end? I'm referring to health care. More specifically, America's health care. In trying to prepare for this topic, I've pored through hundreds of documents and news articles, attempting to get some sort of grip on where the problems actually begin. To find the root causes which might lead to a fix. And I find it's similar to a physician examining symptoms in order to gain clues as to their cause. As with any patient, if diagnosed correctly and tackled head-on, it could improve the overall health and possibly save their life.

But in this case the patient is the health care system. And what I've found is, though the symptoms are many, the diagnosis is typical and the prognosis fairly predictable. When physicians become businessmen and -women, health care becomes a numbers game. And when profiteers control and run the system, the rewards become a matter of quantity, rather than quality. Rewards that move up the ladder as profits, rather than down to the patient level in the form of care.

The root cause is not very surprising. It can be found throughout our society, busily infesting the heart of most all of our ills, whether at the highest levels of industry, finance or government, or at the lowest levels in our relations within our own communities. Money and greed. No earth-shaking revelation there. But we're beginning to see it become pervasive at every level.

Admittedly, that's what capitalism is all about. But I don't believe that every man for himself was the battle cry shouted on numerous battlefields by American soldiers, under a proud flag which supposedly unites us. It doesn't work on the battlefield. And it doesn't work in our lives, for much the same reasons. And yet, it's become the credo which governs the way we do business, the way we treat our fellow Americans, and the way we manage our health.

Which brings us to the downside of a system based on money, where profits matter more than people. Wherever, whenever there is an opportunity for money to be made in large amounts, it might just as well be blood in the water of a shark tank. The resulting frenzy which occurs causes larger and larger amounts of capital to be injected, creating larger and larger profits. Often, as we see in the typical Ponzi schemes, it becomes the ongoing greed itself which generates the wealth, largely due to its own inertia. This in turn creates irrationally inflated bubbles, as with the dot-coms and the financial derivatives which have put us in our current predicament. But, though we all tend to suffer the consequences when these bubbles burst, it must be noted that it was greed which created them, inflated them, and ultimately caused them to burst.

There is also another type of bubble, differing in that it is not created as simply another vehicle for accumulating wealth. At least, not in the beginning. But once it is discovered that large amounts of money can be made, the blood is in the water and the sharks begin to swarm. The most attractive and notable difference with this bubble is its potential longevity. For this bubble is the health care of the citizens of the United States. And the potential for profits, at least for the short-sighted, is endless. It's not based on consumer wants or the cycles of financial markets. It is a profit machine whose longevity is guaranteed because every man, woman and child has to have it. They have no choice.

A diabetic or a cancer patient is clearly not a consumer. And these are not consumer choices. And yet that is exactly the dialogue you will hear in the private health care industry when they speak of increasing profitability, gaining market share, and marketing their health care products and services. And of course, "increasing efficiency", which means essentially giving less care for more money.

You see, in the for-profit corporate world, executives move freely between diverse industries. There's no need to have any particular expertise in these industries because it's all just a matter of widgets. Knowing how to generate profits. And in the health care industry, we are the widgets. It begs us to ask the question: Do we really want our care, if we are in an accident or suffer a serious illness, to be decided according to whether we are profitable or cost-effective for a provider or an insurer?

Unfortunately, that is exactly where we are. So it seems that to take the profit motive (i.e.-cash cow) out of our health care, or to at least mitigate its influence, would be a no-brainer. For the nearly 72% of Americans in favor of a public option, it is. But for the rest (as well as our representatives and governments) our current system, bad as it is, is enough. As President Obama has elaborated, people tend to be afraid of change. So much so, that they're often willing to stick with "the devil they know". But this isn't some sappy song which declares to know, know, know him, is to love, love, love him.

In an article to be published in the August issue of the American Journal of Medicine, a study by Harvard University researchers found that 62% of all bankruptcies in 2005 were medical-related. That was up from 51% in 2001. And these bankruptcies all occurred before our recent economic downturn (and despite a 2005 law making bankruptcies more difficult). If you're thinking this was obviously due to the 46million uninsured, the study also found that 78% of those medical-related bankruptcies were filed by people who had insurance. One can only imagine what those numbers look like now. (That LA Times story can be found here.)

Another study in July of 2008, by the Commonwealth Fund, found that some 75million are uninsured or under-insured. For instance, you may be paying $800, $1200, $1500 a month for your insurance. But with an accident or serious illness, the out-of-pocket expenses could still total in the $tens-of-thousands. And with deductibles going up, alongside premiums and the cost of care as a whole, who can afford illness?

We are then left with families paying more per month for health insurance than for their homes, yet avoiding care simply because their deductibles are so high. They're basically insuring themselves against some catastrophic illness which might one day take them by surprise. They can't go to a doctor because they can't afford it. And all the while the insurance companies happily accept their payments. Sadly, the surprise often comes when they discover that their coverage is inadequate even for that catastrophic illness they've been insuring against. And if the illness also resulted in a job loss, they are likely to lose everything.

Question: When is insurance not insurance?

Answer: When you need it.

The point is, our health and well-being should not be subject to creating wealth for shareholders, executives, or anyone else. (This includes doctors who are more businessman than physician.)

And if you're relegated to this ongoing and growing trend of every man for himself, then perhaps it's also time for those who benefit the most to pay for our armed services. Let's privatize the military. In fact, let's privatize everything. Let only those who can afford it have their blazing home saved by a for-profit fire department. Police? Let them charge for every time they respond to a call. If your credit doesn't check out, so sorry. And while we're at it, let's get rid of that quaint American flag. Instead, we can sell our nation's banner to corporate sponsors, just as we do with our sports facilities. That'd be great! Good ol' United States of Goldman Sachs ...... this year.


NEXT UP: The Devil You Think You Know

Now Would Be Good

In my previous posts I've talked about what it means to become an informed citizen, and given you some tools to help you reach that goal. I've also discussed the importance of making your voice heard. I'd intended to continue along those same lines, but instead have decided to address an issue that concerns every one of us. Coincidentally, it does fall in line with my previous posts in that it requires you to raise your voice, now more than ever.

For more than sixty years our elected representatives have been attempting, to various degrees, to address the problems of our nation's health care. Time after time, through every new administration, our governments have faced the issue simply because we demanded it. And unfortunately, those efforts have always proved to be meager at best, as we have forever witnessed our supposed representatives simply going through the motions in their attempts to appear to be doing something, while maintaining the status quo. Any fixes have tended to represent the health care industry they protect, and have amounted to applying a band-aid when a tourniquet is required. Medical malpractice of a legislative kind. Or perhaps just treating the symptoms instead of the cause.

Of course, the arguments which have worked so well in the past are being unpacked for another go-round. We hear that we don't want "socialized" medicine, even though Medicare would fall under that definition (as well as the health care coverage of every one of our representatives, paid for by taxpayers, while the same representatives vote to deny those benefits to the rest of us).

We hear that we don't want the government to decide whether we receive care or not, even though our private insurers do the same and worse, actively and routinely seeking to deny coverage, paying for investigators to unearth pre-existing conditions, and raising premiums and deductibles, all in the interests of generating enormous profits for their shareholders and executives. "You won't be able to choose your own doctor. You'll have to wait for treatments. Quality will deteriorate ..... ad infinitum."

All of these arguments have worked in the past, so it's no surprise that they're being used once again by those who benefit the most by leaving things the way they are. But for 43 million Americans, all of these arguments are becoming moot points. And with each bankruptcy caused by crippling health care costs, that message is becoming less effective. Every small business forced to close or drop its benefits due to skyrocketing premiums, every family or individual paying more per month for insurance than for housing, and every opportunity missed for reform leaves the same old arguments appearing dog-eared and worn. And with so many Americans uninsured or underinsured, and more each day, it becomes more difficult to suppress the truth. What is the truth? GREED. You've heard it from me before: Follow the money!

LIFE AS TEACHER

Years ago, I worked for an insurance company. I was employed in one of their large branch offices. At the time the company was owned by American Express, a very well capitalized parent company, indeed. That should give you some idea of the money to be made in insurance. I recall, at the beginning of a particular year, they had announced their income projections for the next twelve months. I also recall, six months later, when it appeared they would not meet their projections, the insurance company was instructed to begin dropping policyholders. That meant anyone who was any kind of risk whatsoever was to have their policy canceled. They would meet their projections, one way or another. It was all about the money. It still is.

That was an early lesson that did not go unnoticed by me. And that is why now, as in the past, when insurers in particular begin to offer cost cutting measures in good faith, when they openly acknowledge the crippling costs of coverage and volunteer to become caring partners in the health and well being of all Americans ..... I hear only dishonesty and desperation .

And I also hear the pleas of an entire industry that has been charged with the health care of all of our citizens, our mothers and fathers, sisters and brothers, our families and friends. I hear a $1 trillion industry that knows full well if Americans are given a choice, the continuing larceny of business as usual will at last come to an end. And the devastating costs of health care, along with their predatory profits, will die. This is why they are willing to do whatever it takes to deny you that choice. It's why, right now, you need to raise your voice and be heard. The industry is spending a lot of money to plug the ears of our representatives, and it will take every one of us in order to get through.

In my next post we'll examine some of the arguments being tossed around, as well as look at the cold hard facts which will inform you so that you can decide for yourself. But many Americans don't need facts and figures to be convinced. Their lives have already been touched and they have suffered the results.

I'll end with just a few noteworthy facts which lead us, as always, to our number one rule: Follow the money!


AMOUNTS SPENT BY HEALTH CARE LOBBYISTS IN THE FIRST QUARTER :

• $6.4 million - 5 largest private insurers and trade group America's Health Insurance Plans

• $1.5 million - United Health Group

• $809,000 - Aetna, Inc.

• $1.2 million - Wellpoint, Inc.

• $ 370,000 - Humana, Inc.

• $ 6.1 million - Pfizer, Inc. ($3.3 million in fourth quarter of 2008)
  

Follow The Money

In our United States of America, we happen to live in a capitalist society. Not such a bad thing, really ..... in good times. In bad times, as we are finding out, capitalism can be ruthless, unjust and uncaring. That should come as no big surprise. After all, by definition a capitalist society is one in which capital and its accumulation has been made a priority. Sometimes that priority gives it precedence over all other considerations. And that is not such a good thing. Especially when one considers capitalism's inbred cannibalistic nature. In short ..... it eats its own.

Luckily, we also live under a democratic form of government. I say luckily with some ambivalence, simply because the idea of majority rule appears to have become no more than a "quaint notion". I can recall when NAFTA (the North American Free Trade Agreement) was first passed. An overwhelming majority of Americans were opposed to it, and lit up the switchboards of their supposed representatives to let them know. NAFTA passed, just the same. Even though most of those representatives could not tell you what the treaty contained. They hadn't read it.

We're seeing much the same " business-as-usual" representation now with the public's demands for healthcare reform. Polls have shown that nearly 70% of Americans favor a single-payer plan for their healthcare coverage. Yet, even though the present costs of healthcare are crippling families, businesses, and the economy ..... our representatives do not seem to be listening. In initial hearings on the topic, single-payer was not even on the table for discussion. No one was invited to speak.

The great promise of democracy, at least on the surface, is that a government will be required to govern according to what is in the best interests of the greatest number of its citizens. Else, through the ballot box, the greatest number of citizens will elect a replacement who is more sympathetic of their needs. At least, that is the promise.

But, capitalism and democracy are not synonymous. And unfortunately, though they can and do coexist at times in a mutually beneficial relationship, they are most often at odds with one another in a powerful tug-of-war for supremacy. Given the choice, I will cast my lot with democracy. Capitalism is fine, so long as it takes a back seat to the will of the people within a nation, a state, or a community. At the moment, it happens to be in the drivers seat.

And yet, there are still those occasions when democracy has been able to push back, to limit capital's excesses which might harm the many, to the benefit of the few. It is still a powerful tool for an informed public armed with the facts. Considering this, what would be to the advantage of a powerful and well connected minority, in the face of an active and well informed public?

In keeping with my habit of including Thomas Jefferson, here are some more of his thoughts, written in a letter to Justice William Johnson , in 1823:

" ... The doctrines of Europe were, that men in numerous associations cannot be restrained within the limits of order and justice, but by forces physical and moral, wielded over them by authorities independent of their will. Hence their organization of kings, hereditary nobles, and priests. Still further to constrain the brute force of the people, they deem it necessary to keep them down by hard labor, poverty and ignorance, and to take from them, as from bees, so much of their earnings, as that unremitting labor shall be necessary to obtain a sufficient surplus barely to sustain a scanty and miserable life. And these earnings they apply to maintain their priveleged orders in splendor and idleness, to fascinate the eyes of the people, and excite in them an humble adoration and submission, as to an order of superior beings."

Nearly two centuries have passed since that letter was written. But one could go back two centuries more, and another two centuries before that. There have always been the extremely wealthy few who have sought to maintain the status quo, insulated from the masses and the will of the people. And as Jefferson observed in the governments of Europe, the best way for the priveleged to maintain "business-as-usual" is to keep the majority ignorant, struggling, and submissive.

This has been a very roundabout way of offering you some tools I had promised, which we can all use in becoming informed citizens:

>Rule #1 Follow the money!

> Rules 2-10 Follow the money! This is the most important filter you can apply when considering anything and everything ... and the who-what- when-where-why and how of all that occurs. (In a capitalist society, in which it's essentially become all about the money, very little occurs that does not lead to someone's financial gain.) Follow the path to the trail's end and you're likely to discover all you need to know.

> Rule #11 Always get a second opinion. Or a third. Good advice whether you're preparing for surgery or searching for the truth. Don't depend on a single source for your news or your facts. No matter which way you lean on the political spectrum, look for opinions and news from all sides. Years ago, during the Iran/Iraq war (as with many wars), both countries inflated the casualty figures of the enemy, while reducing their own counts. One had to consider both sets of numbers and the truth was usually somewhere in between. It's the same with politics and big business. Each side will commonly point to the evils of their opponent's positions. They may both be right. But you'll never know if you only listen to one voice.

> Rule #12 You can't know everything ... and that's OK. Always be on the lookout for new facts and information. It's not a sin to be passionate about the facts as you know them. Likewise, it's no sin to admit your opinion is based on those facts as you know them. If someone offers you new information, hear 'em out ..... and then check 'em out. It's better to find out if it's true, than to simply dismiss it out of hand.

> Rule #13 Resist the "herd mentality". In every issue there are those who may attempt to start the stampede by appealing to your emotions ... first and foremost. Check out the facts for yourself and then decide how you feel about it. If you're outraged by the facts (and nothing but the facts), then by all means ... be outraged! Emotion is a powerful motivator. Unfortunately, there are some who will try to bypass the facts and go straight for the gut. Especially when all else has failed, or if to use facts would be detrimental to their interests.

There are a number of other tools which can be helpful in becoming an informed citizen. But, in essence, don't believe half of what you hear. And always .....ask yourself who benefits. Follow the money!

Lastly, I can't help but return to the healthcare debate. We have an historic opportunity to end this fleecing of the American family and finally provide affordable healthcare for all. The fear-card being played by the corporate sector is that you'll have some bureaucrat in government deciding whether or not you receive care. This is not true. And even if it were, how different can it be from some bureaucrat of an insurance company deciding whether or not you receive care, especially when the number one concern is making profits? Since when has a large corporation truly cared about what was best for the people? Follow the money!

I'll end with a bit more of the writings of Thomas Jefferson:

" I join in your reprobation of our merchants, priests, and lawyers for their adherence to England and monarchy, in preference to their own country and its constitution. But merchants have no country. The mere spot they stand on does not constitute so strong an attachment as that from which they draw their gain. "