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Behind the Curtain: Wendell Potter on the Industry’s Management of Care and Reform

Stop what you're doing and take out a half-hour to watch this week's superb Bill Moyers' 3-part show, especially the extended interview with Wendell Potter, former CIGNA VP Corporate Communications, for a frank, insider's discussion of how major health plans have worked over the last decade.

Also be sure to watch Moyer's very brief final commentary, describing a dinner that was planned by the Washington Post to connect lobbyists with high-ranking officials working on the health care reform process. His conclusion: we won't get anywhere with health care or any other national problem until "the money-lenders are tossed out of the temple and we tear down the sign they've placed on government, the one that reads 'For Sale.'"

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  1. There is a treatment for diabetes which is highly effective in treating all complications of diabetes with a single treatment. The treatment basically mimics in diabetic patients the insulin secretion/liver stimulation of healty patients. This technology has been used safely and effectively for more than 20 years, yet the insurance industry steadfastly refuses to reimburse for the treatment.
    If insurance companies provided their sickest diabetic patients with this new treatment, it would be a reason for those patients not to enter kidney dialysis and disability from work. Hence by refusing to reimburse for this outstanding new treatment, insurance companies are able to move very sick diabetes patients from their list of insured patients to becoming the responsibility of Medicare. The Supreme Court of California has supported a lower court decision that this new technology is safe and effective. Even so the insurance companies in California refuse to reimburse.
    There are 10’s of billions of dollars to be saved if this new technology is reimbursed. The insurance companies say that the technology is no good because no doctors use it. Can you imagine a doctor using a new technology which is not reimbursed by the insurance industry?
    At least the public should be aware of what is happening. No one is aware that this is happening except the few desperate diabetes patients who hang on to this new technology as their way to return to a normal existance.

  2. The Moyers segment further crystallized for me why market-based solutions to healthcare financing and reform are simply wrong-headed. Potter made clear the irreconcilable conflict between the ‘medical loss ratio’ of for-profit insurers and the improvements in efficiency and quality that we need so desperately.
    Those who want to dig further into these issues should read ‘A Second Opinion’ by Arnold Relman,a former editor of the New England Journal. Relman, whose thesis is also echoed by Gawande’s New Yorker article, describes in detail how the corporatization of health care over the past 30 years is at the root of the perverse incentives that have landed us in this mess.

  3. Nate,
    Since we’ve all been so forthcoming about what we do on a daily basis, I’d urge you to share with us the following information about you and your business interests, particularly since you’ve boasted about how strong a business you run.
    Please tell us all:
    1) Your full name
    2) The names and locations of your 3 TPAs
    3) How many total lives are covered through your employer clients’ health plans.
    4) The average annual cost per employee of an enrollee in your health plans.
    We’re looking forward to learning more.

  4. The problem with the “thirst for unlimited care” is that patients can’t afford the mundane treatments they need in order to manage their chronic illnesses because insurance throws them off the rolls, knowing that they won’t be responsible for the consequences of denying modest preventative care which costs $10,000 to 30,000 per year or so. They get worse, inevitably ending up as seriously ill patients. Then the systemic desire to make up for the decision to spend the $10,000, or $30,000 in the first place leads us to spend $900,000 on extreme measures to put off the ultimate consequence of denying people access to maintenance care: fatalities.
    See:
    http://www.post-gazette.com/pg/06339/743713-84.stm
    http://www.upi.com/Health_News/2009/06/19/Many-MS-patients-not-filling-prescriptions/UPI-31731245388651/
    Doctors don’t really help this situation because too few of them have spoken out against the absolute insanity of denying modestly priced care that is proven and effective while supplying unlimited expensive care which is unproven and experimental. I think a large part of that stems from the fact that doctors thrive off of the most difficult cases from an intellectual point of view. But part of it is that doctors and nursing homes do get reimbursed for the most egregious examples of unnecessary treatment (feeding tubes in Alzheimer’s patients who have lost the ability to swallow, cataract surgeries in these same patients, chemo and surgery in the stage V cancer patient, small bowel transplants in the Crohn’s patient on tpn, and the list goes on and on and on.)

  5. Brian
    I was disappointed in the piece. Moyers continues to demonize the for profit MCOs (and they deserve it), but at the expense of distracting the public from where the real bloat is. He did not discuss our thirst for limitless care, supplier induced demand, waste, etc. This kind of journalism is no better than those who espouse the Luntz-oid sound bites from outlets on the right. Using Sicko clips and citing MLRs is not the path to enlightenment in this debate. Unfortunately, he did the same with his piece on single payer a few weeks back.
    I will say that Potter is a compelling character and brings needed attention to this broken piece of the puzzle. He strikes me as a decent guy, albeit a reformed one, who had no vindictive motives other than to “do good.”
    Additionally, not to replay the Nataline Sarkisyan imbroglio, as tragic as it was, but using her case as a poster child for what is wrong with managed care is plain misguided. This was a high risk transplant, bordering on futile, and I would say the same for my own relative. For the gobs of sins CIGNA probably has committed, that was not one of them.
    We need better, and so does Obama if we are going to get reform done right.
    Brad

  6. Nate,
    I don’t think scaling down of for-profit health insurance will destroy healthcare as long as providers will be compensated for their work. Yes, Europeans and Canadians pay higher taxes, but, apart from universal healthcare, they also enjoy much better social services and public transportation system. We, Americans, spend far more on healthcare alone without getting better results. You may want to check my blogs http://betterhc.blogspot.com/2009/05/are-we-ready-for-healthcare-to-go.html and http://betterhc.blogspot.com/2009/04/taming-healthcare-costs.html . From my point of view, healthcare is a special kind of services, which relate to our very basic needs as human beings, and sometimes, to our biological existence, to be considered just another industry.
    I am afraid many discussions on healthcare reform become ideological way too soon. Instead of focusing on numbers – costs and gains – opponents are talking about “slippery slope to socialism” and “government bureaucrats”, stirring emotions around the issues.

  7. Nate:
    Doesn’t your TPA ever require your attention?
    Rather than attempt to demean and minimize the on-point insights of a former CIGNA executive, who is disclosing well established truths about publically traded health plans, you opt for hollow, yet mind numbing and childish slams.
    Give it a rest; and please spare us your knee jerk health insurance industry apologist diatribes.

  8. The AMA may support Obama on single-payer health insurance if he sees the connection between malpractice insurance and healthcare insurance.
    Controlling malpractice insurance is just as important as controlling healthcare insurance. Insurance companies and attorneys do not need to take so much money from us for mistakes or malice on the part of physicians. Single-payer healthcare will reduce fraud and put money back into healthcare instead of attorneys and insurance company’s hands.
    Also, patients do need to be compensated for iatrogenic pain and suffering, but not all in dollars, rather in care and opportunities. We have to think outside the box for the future. We have a housing glut, maybe provide a house. Detroit needs to sell cars; patients could be compensated with a car or SUV, whatever is appropriate for the patient. Money is scarce; so home assistance, education, food, medication, etc., may be more appropriate. This could provide less incentive to sue for money. Thus fraud can be reduced by limits or change in malpractice insurance and by single-payer insurance.

  9. Would a janitor at CIGNA HQ be called an insider?
    1:52 The clown can’t even get basic lingo like deductible, co-pay, and responsibility right yet we are to believe he is an insider with an opinion worth listening to? He doesn’t even grasp how hi deductible health plans are being used in the market.
    3:00 If he is troubled by the uninsured then why doesn’t he go after Congress for shifting cost from public plans to private? Why doesn’t he campaign for lower state premium tax? Why doesn’t he advocate for fewer state mandates so people can buy affordable plans? Government requires insurers sell gold plated plans this fools like Potter complain the common man can’t afford gold plated plans.
    9:00 love the no one pays quote, no billing how great, ignoring the fact their taxes are considerably higher. Highlighting good stories by Moore OK Highlighting the other side is misleading and dishonest? Moore does the same thing, just in reverse, he trashes the US system by pointing out the rare horror story and that apparently is ok.
    12:00 radicalized Moore? LOL ya that’s what insurers did Moore was such the moderate before. Moore is a hack who always played loose with facts, see crediting Nixon with HMOs instead of giving credit to Kennedy who himself claims credit for HMOs.
    13:30 millions of Americans CHOOSE not to have insurance so that means our system is worse then Canada and Britain.
    14:30 again butchers what a HDHP is and how they are used.
    That’s all I could watch. What exactly is the public suppose to take from two clueless propagandist who advocate for more taxes and destroying our healthcare system? Neither of them have any knowledge of insurance and what things are the way they are. The public would be better off asking their grade school kids for their opinion then these two shills.

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