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Policy: The LA Times on Kaiser Permanente By John Irvine

• 13

The smoke appears to be clearing around Kaiser Permanente’s headquarters, where the management is no doubt wondering if the worst is over after this week’s decision
  to close the HMO’s Northern California kidney
  transplant center. Patients enrolled in the program have been transferred
  to UCSF and to UC Davis. Embarrasingly for Kaiser, there were a few Medicare Part D style snafus with the transition (apparently nobody was picking up at the toll-free number set up for patients.) But all in all, the consensus
  seems to be that Kaiser did the right thing by moving quickly to shut down the
  operation once the extent of the problems became clear.

What happens next? The answer to that question is probably best known by the
  reporters at the Los Angeles Times, who may or may not have something else up
  their sleeves, after the first wave of stories uncovering the scandal. Historically,
  the Times has been tenacious when it comes to pieces like this (For a good example see: the transplant story at UCI
  Medical Center). The paper won a Pulitzer for
  outstanding public service journalism in 2005 for its series on King/Drew and might well have won another last year if it hadn’t been
  for the Times-Picayune’s
  brilliant coverage of Hurricane Katrina.

The problem for Kaiser is that once a story like this one breaks, a chain reaction
  starts. People get mad. People come forward. E-mails start flying. For reporters,
  the threads begin to unravel. It should go without saying that for a large health
  management organization with a long and varied history, this is not exactly
  an ideal scenario …

The whole emerging Kaiser story of course, has been the topic of lively debate  in the THCB comments section, where the company is far from as unpopular as  one might assume. (Matthew, you’ll note from earlier posts in this thread, is
  a fairly sympathetic observer.) Up from the comments to make life more interesting
  comes a former Kaiser transplant patient who did not particularly care for the
  detached and academic tone of the discussion between some of the posters. Sarah 
  had this to say:

I hate 70% of you. You have no CLUE what you are saying. I am one of those
  patients in the Kaiser Nor/Cal Transplant Program, having had a kidney transplant
  17 years ago. What is coming out about this program is utterly horrifying, and
  how any of you can defend Kaiser or debate the merits of transplants makes me
  ILL. You should be ashamed of yourselves. And I know none of this is coming
  from UCSF or Davis. And I know Dr. Inokuchi personally (she was one of my docs
  at CPMC). And I know the program has been crap since it started (good luck getting
  a call back for a simple question about dental pre-meds).This scandal is far bigger than y’all seem to realize. A lot of people died 
for no reason.

And for my surgery, Kaiser saved a fortune. $40k a year for 17
  years plus health care costs related to dialysis would have been far more than
  the transplant cost plus rejection meds."

POLICY: Do No Evil, Part II.

• 11

Here’s my editorial in today’s issue of FH.

This week saw more controversy regarding some of the bad boys of healthcare past
and strong hints that some of the healthcare market stars of the present may
have adopted their bad habits. Criminal investigations into United HealthGroup
and ACS are now following The Wall Street Journal story about their
stock option pricing and Bill McGuire’s huge fortune. Now Caremark has been
subpoenaed, too. Those of you with very long memories may remember Caremark in a
previous life getting into legal trouble as a home infusion operation in the
1980s and being a financial disaster as a physician group roll-up in the
1990s.

Meanwhile, Tenet accepts a death penalty on one hospital and is still
struggling to get out from the malfeasance and its appalling, if not outright
criminal behavior, in Redding, CA, and probably elsewhere. Not that this is the
first time that appalling criminal behavior has been seen from that company,
although it was called NME back when it was kidnapping children into its
psychiatric hospitals.

We won’t do more than mention the name HealthSouth. While they’ve been off
the news lately, it’s worth remembering that the other big hospital chain, HCA,
has paid two of the biggest fines ever for defrauding Medicare, and that the
Senate majority leader’s brother, who happened to be the chairman, had an SEC
investigation mysteriously end in 2002.

So it’s worth asking the question again. Is it just a few bad apples? Or is
the pressure for stock growth from Wall Street incompatible with running a
responsible healthcare company?

Continue reading…

HEALTH PLANS/PBMs: Don’t be evil?

• 3

I’m in Miami to talk to the Blues Association about blogging and new media. I think my theme is that You Shouldn’t Be Evil (or whatever the Googlers say…)

But it looks like Caremark is joining United and ACS in options woes. Given the shenanignas going on at those two places— and unnecessary shenanigans as it turned out—perhaps a bunch of others have been playing that game. And as McGuire himself said "If we can’t find new ways to provide value, we won’t grow". But then again around here THCB fans know that Wall Street hates healthcare services but doesn’t know it.

Of course it’s not the evil liberal blogosphere that’s found out all this dirt. It was real journalists—Charles Forelle and James Bandler. Meanwhile fellow WSJounralista, Barbara Martinez is hot on the trail of the PBMs. So perhaps the answer is not to blame the blog, but to call your PR flacks and ask why the MSM, or SCLM, hasn’t been warned off the way you wanted?

QUALITY/CONSUMER/TECH: Health — On Demand by Pat Salber

• 6

Pat Salber writes The Doctor Weighs In, and she has some pretty interesting thoughts about this consumer health schtick. I cross-posted here but go check out her blog too!

The Internet has changed the way we do so many of life’s routine activities. We shop on-line for clothes, food, birthday presents (thank heavens–no more going to the post office), insurance, dates, and new friends. The list of things we can do and get on the net just goes on and on. PEERtrainer (www.peertrainer.com) has joined many other websites as a convenient, fun way to meet people with common interests and goals. It offers peer support and accountability with 24/7 convenience, and if desired, anonymity. And the Internet is changing the face of health care as well. I belong to Kaiser Permanente, an integrated health care system that makes it easy to make appointments on-line as well as to refill and have my medications mailed to me. I can get my lab results via a secure website and I can communicate with my physician via email.

But I never thought I would be able to get health and wellness services on the web. This weekend, I was at a medical conference and learned about an amazing new website: www.keepyoursight.com. A young ophthalmologist, Sean Ianchulev, described how his company, Peristat Group, has developed a way to screen for glaucoma on-line. Now, I guess I am a little out of date. My first thought was, "How are they going to deliver that little puff of air to my eye via the web?" Of course, that is not the only way to screen for glaucoma anymore. Rather, machines that test your peripheral vision have replaced the air puffs in many health care settings. This type of testing is called perimetry. The Peristat Group has figured out how to mimic what on-site perimetry machines do — on-line. That means, anyone can get screened for glaucoma in the privacy of their home anytime they want. It’s a bit complicated and takes some practice, but the site takes you through some simple instructions and then allows you to practice until you get the hang of it. Dr. Ianchulev tells me they built algorithms into the on-line test that help them weed out tests that are not performed properly. He also tells me they are developing an on-line test for macular degeneration, one of the leading causes of blindness in the US. Imagine, as this technology gets better and better and the test-taking gets easier and easier, glaucoma testing, testing for macular degeneration, and who knows what else, will be available to people “On Demand.”

As we move into an age where consumers are being asked to shoulder more and more of the financial burden of health care, I suspect we will see even more innovation in the delivery of services. The FDA recently turned down the request to have statins, very effective cholesterol-lowering drugs, available over-the-counter (OTC). Opponents of OTC statins worried that consumers would not recognize the rare, but serious side effects of these relatively safe medications. However, such dangerous drugs as aspirin and acetaminophen (e.g., Tylenol) have been available OTC for decades. I can’t tell you how many people I treated for overdoses of these benign drugs during the years I practiced emergency medicine. I think the argument of having to protect the public is one that will not hold up in the long run. Combine the use of home testing electronic devices with great interactive web-based programs, OTC availability of cholesterol-lowering drugs and blood pressure-lowering drugs, and on demand lab testing (available in many states) and you now have a way to get treatment of these common conditions to millions of people who are now untreated or undertreated…and for a fraction of the cost.

I think innovations in health care delivery, such as these, are very exciting, but also threatening to the same folks who have been promoting "Consumer Directed Health Plans" as the way to save the disintegrating American health care "system." But, hey, if I have to pay for it out of my pocket, I am going to get what I want, how I want it and when I want it. If I can get it for free on the net in the middle of the night, I say, bring it on. “Health On Demand,” — now this will usher in the age of real consumer directed health care.

HOSPITALS/TECH: Is the kiddie porn hysteria going too far?

• 8

You would expect Children’s Hospital in San Diego to be very, very nervous about anything to do with porn. After all, this is the place where apparently a nurse and a tech roamed free taking pornographic pictures of children, molesting them, and spreading the pictures on kiddie porn sites.

Wayne Albert Bleyle, 54, who was arrested March 8, has pleaded not guilty to molesting five patients. He also pleaded not guilty to distributing pornographic pictures of patients on the Internet. Christopher Alan Irvin, 32, a nurse who was arrested April 15, has pleaded not guilty to charges of molesting a 4-year-old girl and distributing child pornography.

And speaking from experience I know about second-hand, people do very, very foolish things on their work computers. But it seems that the latest news from San Diego Children’s may be a little over the top. So far three doctors have been suspended because one of them, while logged on to the hospital’s system from home, visited a porn site

Hanscom said using the access code to look at pornography would violate hospital policy whether the images were of adults or children. The access appears to have been on a home computer. Improper use of the code was discovered as a result of more vigorous auditing adopted after the arrests of the two hospital employees.

Now the key issue we don’t know is what type of porn site—and there is a huge legal as well as ethical difference between the secret chat-rooms where paedophiles trade pictures, and the Playboy online type sites. And of course whoever was logged into the hospital’s Internet access was dumb, dumb, dumb not to log out and go off to their own local ISP before looking for smut online. But let’s get real. A huge proportion of Americans look at porn online, and doctors are no different.

Assuming that this is a case of legal behavior at home, that was inappropriately sourced through the wrong ISP, you have to think that handing this over to the “Internet Crimes Against Children Task Force, which includes local and federal agencies” and suspending three physicians and putting it in the newspaper, may be an over-reaction.

Did the hospital management not think to first have a quiet word with the physicians concerned to find out a) which one of the three was the guilty party and then b) have their IT staff and lawyers investigate what they saw, and discover whether their behavior was illegal or just stupid. And if was only the latter, then take some administrative action against them before ruining careers and getting law enforcement involved. Which if it was the former would clearly happen anyway.

Meanwhile, a reminder to all of you out there, make sure that you keep a private Internet connection, email server, et al away from your employer.

TECH/CONSUMERS: It’s care delivery that matters most

• 2

Here’s my FH editorial today….

This week two very different healthcare conferences rolled through San Francisco. One was about Consumer-Directed Health Care and was a cross between a capitalist land-grab and a political pep rally for HSA-backers and Canada-bashers. There are clearly interesting ideas from many start-ups as to how to better serve consumers , and plenty of new initiatives from bankers wanting to get at the new accounts being set up within health care. Google’s announcement of its new “Co-op” service that includes a “Health” component, and Intuit’s deal with Ingenix show that big time consumer companies are viewing this movement seriously.

Later in the week the National Patient Safety Conference saw clinicians discussing the issues of medial errors, nursing and clinical efficiency, and how to use technology to turn around provider performance. That is clearly a much bigger and even more intractable problem than making health care more consumer friendly. It’s also a movement that has been going on for more than twenty years, and we are really only seeing marginal improvements. Health care has many problems, but clearly the care delivery coal-face is where most health care money is spent, and where we have the most to change.

POLICY/PHARMA: Cato calls the Republicans on the Part D deceipt

• 10

I approve of government programs done well. Michael Cannon doesn’t approve of them done much at all. We both disapprove of them being done expensively and then having so-called Conservatives in power lie bold face about their costs and enrollment rates. Yup, I’m sending you over to the Cato Institute blog. That might be a first for TPM Cafe, but it’s a great explanation of what’s wrong with Part D.

(Also posted at TPMcafe)

CODA: I haven’t made it thorugh Kling’s book yet, and I had a real problem with Cannon’s — as it missed the point so badly that I didn’t think it was worth reviewing. But with Radley Balko keeping up on the drug war stuff, Cato remains the thinking man’s right wing think-tank.

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