Newspaper Postings From Around the Country

(The following are summaries, with editorial commentary, of some recent articles from newspapers around the country. Most newspapers now have web sites and the articles in question can be accessed, although often for a fee.   Editor.)

This article is especially notable since the lead off quote is from our new president, Deborah Peel: “It’s shocking that the Clinton administration would sell out privacy to business interests in this way…It’s a travesty. Video rentals now officially have greater privacy protections than medical records.” Keep in mind that the article was written during the ancient regime and as the man said, “you ain’t seen nothin’ yet,” as President Bush proceeds to gut even the modest reforms Deborah critiques in this article. This report was one of many published earlier this year as health care advocates noted that the privacy regulations proposed by the outgoing administration closed some loopholes but left a glaring gap, sanctioning use of private health care data for purposes of marketing. Now to hear the feds tell it, the exception is hedged with many protections and qualifications and the intent is to allow doctors and hospitals “to send out individualized health care information and promotions.” This all sounds very laudable until you think about how that will work in practice. In addition to receiving information in the “privacy” of your own home, so that your spouse, children, parents and postman may get information about you that you would rather keep quiet, what about the  inevitable mistakes so that a woman learns she has breast cancer from a tasteful ad for special bras before her physician has a chance to tell her directly?

The article alludes to practices that undermine the presumably laudable goal of providing patients with information and choice of services and products since we are no longer operating in a health care environment in which the folksy family physician or corner pharmacy druggist dispenses advice. The HMOs, drug companies, and even less visible billing and service companies are going to use this loophole to continue to forge direct marketing links with consumers, regardless of the sensitivities involved and the wishes of patients. The article goes on to describe one remedy, which is that the federal rules only represent a “floor” for privacy protections and states are free to enact stricter privacy provisions.

February 16, 2001
Creator of term ‘HMO’ says consumers have lost choices
By Dena Bunis for The Orange County Register

This article provides some background to the managed care debacle through an interview with one of the founders of the movement, Paul Ellwood, a Minnesota physician who was instrumental in the formation of the Jackson Hole Group that influenced the Nixon administration in supporting formation of health maintenance organizations.  The report is based upon an interview with Dr. Ellwood reviewing the evolution of his views. According to the article, “Ellwood and these other health-care pioneers wanted to create a system in which costs were kept reasonable, quality was improved and the veil of secrecy that surrounded so many medical decisions and procedures was lifted. But now he sees a system where, instead of the consumer being in the driver’s seat, large health-insurance companies run the show. And while costs went down at first, they’ve started to creep up.”

The article goes on to report Ellwood’s increasing disenchantment with his own creation, criticizing himself for not recognizing the power of corporate interests.

“We were unsuccessful in getting beyond these powerful interest groups to reach individual consumers,” said Ellwood. “In the original notion of managed competition, we wanted to focus the ultimate power on individual consumers and patients, and we wanted them to have three kinds of power: choice; information about, and an interest in, cost; and, of equal importance, information about quality.”

Ellwood goes on to fault many others for the failure of managed care, including employers and government, especially the Clinton administration. He goes on to critique the Gore and Bush campaign proposals during the last year’s campaigns as lackluster and trivial, appealing only to powerful voting blocs, e.g. the elderly, without coming up with an overall strategy for genuine health care for all.

So what is his current position? Ellwood now believes that universal health coverage is vital and that the government has an important role in assuring this can come about by requiring that consumers have access and choice:  I think the main thing is moving toward universal coverage through tax credits and tax exclusions, and making health insurance mandatory.

Dr. Ellwood should consider joining the National Coalition/

March 14, 2001
State shuts health-care manager over patient treatment: The Health Department also fines the company, which it says blurred the lines between those managing care for suicidal patients and those providing it.
By Felice J. Freyer for Providence Journal

This article documents a small victory in preserving patient’s rights and choice in accessing mental health care. The Rhode Island Health Department shut down and fined Continuum Behavioral Care (CBC) after investigating its practice of sending out its employees to emergency rooms to interview suicidal patients and assume direction of level of care and treatment with the result that many patients were sent home from the emergency room, in many cases without even informing the attending emergency room staff. There will be further investigations of the MHC, Providence Center, and its staff for participating in this ethically dubious enterprise, the hospitals and ER staff who did not prevent the interferences, and the corporate perps, especially BC/BS of Rhode Island.

The article also demonstrates the conflict of interest inherent in managed care approach. CBC was under contract with BlueCHiP, the HMO owned by BC/BS of Rhode Island to manage behavioral health services. CBC, in turn, was formed as a partnership between Providence Center and Magellan Behavioral Health. So, the employees of Providence Center were both treating clinicians and case reviewers determining appropriate level of care. So much for dual relationships! The CBC set up “emergency assessment teams” to troll the emergency rooms and spirit patients out of the hands of greedy practitioners and thereby avert a costly hospitalization. The technique relied upon was “contract for safety” and once patients agreed to this verbal contract the CBC reviewer would direct the patient to lower level of care, usually home, with appointments for the Center’s partial hospitalization program. This was done despite the fact that there is little evidence that these so-called contracts are valid predictors of behavior. In the interest of balance, here is the Magellan defense:

Barbara Leadholm, an official with Magellan Behavioral Health, the part owner of CBC, said that BlueCHiP members got good care from CBC. The in-person evaluations are done commonly around the country, she said. “You bring in a clinician who really works with you to gather more clinical information to make sure the member is getting access to needed services,” Leadholm said. “It’s usually seen as very helpful to a provider rather than as being an impediment to a member getting good care.”

The Magellan shill also insisted that proper procedures were followed but were simply not well documented.  Or perhaps, she conceded, the clinicians needed further training. If this were not so vile it would be laughable.  Imagine making a similar claim when seeking payment from same managed care company, insisting that you delivered quality care but did not document this care to Magellan’s satisfaction. And surely Magellan’s credentialing process should assure qualified clinicians.

Shutting down a managed care company would seem to be a powerful statement that its practices were unethical and harmful. According to Health Department spokesman, Donald Williams: “We were not confident at all that this entity could correct itself and that patients would not continue to be harmed.”

PacifiCare to Pay Penalties for Late Claims Payments to Doctors, Hospitals: Santa Ana HMO reaches agreement with state regulators for undisclosed sum.
By Marc Ballon for Los Angeles Times

This article illustrates the “house of cards” that is managed care as the focus repeatedly shifts back to the profitability, or perception of profitability, of managed care companies. The point of the article is that one managed care entity, PacifiCare, finally was caught in a practice that everyone knows is really a business strategy of all managed care companies: denial and delay of payments. The threat of state action was sufficient only after stock market analysts issued warnings that PacifiCare’s failure to make payments to hospitals and physicians suggested that the company might not be able to meet its profit targets. That set PacifiCare’s stock tumbling on the Nasdaq and prompted a settlement with the state.  According to Merrill-Lynch analyst Roberta Goodman, “It raises questions about costs, and it also raises questions about how well they can underwrite and price their business if they haven’t been paying their claims.”

This newfound concern about proper payments might seem curious to those of us in health care. According to California Healthcare Inc., a Sacramento-based advocacy group, late payments have stretched hospitals to the breaking point. Thirty-four hospitals have closed in the last six years, and 85 (out of 450) hospitals in the state are owed over $1 billion from various managed care companies.

Humility not being a strong suit for MC, it will not astonish you to learn that the ever present company spokesperson dismissed all the fuss over the settlement stating that the payments, and penalty of $3 million, are “immaterial to our business this year.” And, of course, there was the ever-ready excuse that the “system” was to blame as they were changing over their claims handling system “from a fixed-payment model to so-called shared risk contracts.”

March 2, 2001
WebMD Asks Court to Back It In Denying Data to Quintiles
By Ann Carrns for The Wall Street Journal

This article is a good illustration of the complications involved in attempting to ensure privacy in a corporate world that feeds on a constant flow of information concerning every detail of your life, problems and interests. All in the name of marketing, of course. In addition, the interconnectedness of the corporate world further complicates any attempt to control the flow of information, let alone assure privacy.

The dispute emerged from the relationship between WebMD, an online health information company and Quintile Corporation, which repackages information for sale to drug companies and other clients. Quintiles also conducts marketing and clinical research for pharmaceutical companies. The additional wrinkle is that WebMD acquired Quintiles’ Envoy Corporation, a subsidiary of Quintiles, which processes medical and pharmacy claims. Quintiles, in turn, is allowed to access this data in generating information concerning patterns of drug use, medical conditions, etc.

So, the dispute centers around the decision by WebMD to renege on its agreement to share data with Quintiles because of concerns that the information could be used to identify specific individuals despite arrangements to “strip” this information from the data transmitted to Quintiles. In turn, Quintiles is suing WebMD for violation of their agreement, alleging that there is no indication that Quintiles could or would attempt to use the data to identify specific patients.

While not addressed in the article, the dispute clearly points out the difficulty in securing privacy and the conflicts of interest inherent in the corporate world.

Why in God’s name put a rule in place we know is wrong? Let’s just step back and give this new secretary, give us, some time. With these words, Rep. Charles Norwood joined the call of other Republicans on Capitol Hill and the corporate interests to call for the delay of implementation of the HIPAA privacy rules. The article quoted industry insiders worrying that the cost of privacy for the drug companies, hospitals and pharmacy chains will run at $18 billion over the next ten years with an uncited “study” estimating costs of $40 billion. The immediate focus of concern has to do with a consent provision, the requirement that doctors, hospitals and pharmacists obtain consent in order to use patient information. The Healthcare Leadership Council, whoever they are, want the rule “altered” to allow patient information to be “used and disclosed for treatment, payment and health-care operations without consent or authorization.” Pretty breathtaking isn’t it.

Now the article went on to cite all those obsolete crusaders with silly notions such as the fact that the patient’s life, problems and health concerns might just belong to the patient.  Mary Foley of the American Nurses Association warns  “there is a real effort to find reason to delay or derail the [HIPAA] regulations.”  Robert Gellman, lawyer, privacy advocate (and Coalition Report contributor) warns, “They just want this [privacy rules] to go away.”  Finally, Patrick Leahy observed “Make no mistake - that [i.e., reform] is not what the industry giants with money to burn are really trying to do…they are trying to kill the medical privacy rule, and they are trying to get the new administration to pull the trigger.”

Bush addressed the American College of Cardiology (ACC) vowing he will not sign current versions of a patient’s bill of rights. Bush lied his ass off regarding his role in enacting the bill of rights in Texas, praising his wise leadership and support when in fact he stood in the way of reform until it rolled over him - twice. The core issue for Bush administration has to do with damage awards and the bottom line is protecting MC companies from civil suit.                 

Aides clarified after the talk that Bush was referring to all bills before Congress, Republican and Democratic, specifically the Senate version introduced by John McCain, John Edwards and Edward Kennedy and the House version offered by John Dingell and Greg Ganske. The implication is that Bush will throw his backing to a weakened version sponsored by Bill Frist, John Jeffords and John Breaux that will cap damage awards and provide that all lawsuits must be heard in federal court. So much for state’s rights.

According to Bush, he will accept a bill of rights as long as there are “reasonable caps on damage awards…[with] fair and immediate review when care is denied.” Once again, the words do not match the actions and the bill of rights, much as all patient protection measures before Congress, faces hard going with a White House that thinks we need more arsenic in our drinking water and carbon dioxide in our air, and, oh yeah, stop whining about that carpal tunnel thing.

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