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HEALTH PLANS: And just in case the pro-Kaiser bias is getting out of hand

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Now that we’ve let Pat Salber be so nice to Kaiser, Gadlfy reminds me about a couple of things.

First a lost laptop apparently filched out of Oakland HQ with a mere 160,000 patients’ details on it. They were fined $200K by Dept of Managed Care for putting 150 names on the Internet, so proportionally this one should come in around the gross national product of Belgium!

And then much more dirt about the kidney transplant disaster–including the reason that the story broke. The whistleblower went to the press and the authorities including the LA Times. It was the LA Times series on Kaiser’s kidney transplant program that made the brown stuff hit the whirling metal thing. And what’s worse is that they still have not have had the no-holds barred public enquiry that they ought to allow and that I called for when it happened—mostly (according to Chris Rauber in the SF Business Times) apparently out of fear that it’ll upset the Permanente Group.

I half expect several commenters to (again) question how Robbie Pearl’s father really died. But the point is that the EMR KP is introducing is capable of massively improving care quality. But it’s a necessary but not sufficient condition.

Meanwhile, there are also allegations that the non-profit guys (Blue Shield and Kaiser) are joining the real schlockmeister behavior of retroactively cancelling patient policies—the ones that Wellpoint’s Blue Cross unit is in hot water for doing. No examples about KP, although there is one for Blue Shield, who’s underwriting is pretty tough these days.

So as everything in health care, there are two sides to the story. It would be very nice if KP made more of an effort to be open about this–I still think a full external inquiry into the Kidney transplant fiasco would be much better for them (and for health care as a whole) than us all having to read the tea-leaves via the unfair dismisall case….but the politics of KP as a whole are very delicate and I understand why they won’t do it. I don’t agree with that policy but I understand its genesis

HEALTH PLANS/PHYSICIANS/TECH:Health care, the way it should be (or How to stop worrying and learn to love the bomb), by Pat Salber

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Pat Salber writes The Doctor Weighs In. She is a doc, an ex-med director at California blue shield, and a Kaiser Permanente member. And she loves them. This is why, and it’s quite an advertorial for Kaiser and an indictment of how everyone else does it. So if this becomes the standard, and people find out about it (and with $80m of advertising budget a year behind it, they will find out) can the rest of the US system compete?

Health care, the way it should be or  (How to stop worrying and learn to love the bomb)

By PAT SALBER

I have to tell you again about what great health care I get from Kaiser Permanente Northern Cal. Drhealth (Yeah, I know, they screwed up on the transplant service).  But, they are doing a lot of the things we, the wonks, have been hollering about for years.  Read this.

Sunday night I noticed new “floaters” in the right visual field of my right eye.  They were different from the run of the mill floaters – those little dark circles — most of us have.  These were like long lines and they only moved on the right side of the visual field.  The next day, I started having sparkling lights, again in the right visual field.  Now, even an emergency physician knows this could indicate a retinal detachment (serious indeed).  So mid-afternoon, when I had convinced myself it would be stupid to miss my own diagnosis, I called KP.  The woman on the phone in the opthalmology department clearly had been trained.  When I talked about the sparkles, she put me on hold and got a nurse. 

The nurse tried her best to get me in the same day.  She had an appointment available, but being rush hour, there was no way I could make it. She carefully went over the symptoms of retinal detachment and compared them to what I was experiencing.  Together we decided it was OK to wait until the next am for an appointment.  She carefully explained that if certain symptoms occurred (e.g., a sensation of a curtain coming down over the eye), that I needed to go to the emergency department right away as that could indicate a retinal detachment.

The next day (today) I showed up at the opthalmology department.  The receipt I was given for my $15 co-pay listed the dates I had had all of my age/gender specific  preventive services and the dates the next ones were due.

There was no wait to see the doctor.  I was put in an eye exam room and saw a nurse right away.  She explained everything she was going to do.  She anesthetized my corneas,  she tested my vision (with glasses and with pinholes), she used the slit lamp to look at the corneal surface, and then she put in drops to dilate my eyes.

After about 15 minutes (waiting for the eyes to dilate), Dr. Prusiner, chief of the department came in to see me (he is the brother of Stan Prusiner, the Nobel Prize winner who discovered prions).  He did a very thorough exam of both retinas using a variety of techniques.  He explained that I had a vitreous detachment (annoying, but otherwise, no big deal).  He showed me a color picture of an eye with a vitreous detachment.  He answered all of my questions.  He did  not seem rushed (because the nurse had done a lot of the early work for him).

We were finished, he gave me a  4 x 6 piece of paper with his name, his photo and the URL of his home page.  Here’s the link  so you can see how nice it is.  This is, I think, the new KP Connect.  It also showed all of the stuff (by major categories) that he had on his home page.  He wrote down the diagnosis “vitreous detachment” on the paper and drew an arrow from it to name of the link where I would find the information he had chosen for his patients to read about this condition. He urged me to read it.  I went on the site, found the condition, and, lo and behold, everything he told me was what was on the site.

He then told me, in detail, what symptoms would require me to call or go to the ER right away.  But he assured me that the symptoms represented complications highly unlikely to occur.

By the way, he said as I was leaving.  Be sure to make an appointment with the optometrist.  I think we can improve the correction of your left eye.

I challenge you to find one single thing you would want that I didn’t get.  This is the way health care should be.

HEALTH PLANS: You sleep with scumbags, you expect to catch nasty diseases

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More on the incredible United Healthcare/Golden Rule story that Joe Paduda’s been following. Joe’s latest is called Who is UHC’s customer?

Essentially United’ high deductible subsidiary Golden Rule is advertising that it’s selling a HDHP with agreed procedure rates for customers—just like the vast majority of PPOs out there. But when the time comes, they are contractually allowing their providers to balance bill the customer over and above the rates they’ve agreed. The real kicker is that are keeping that fact secret from their customers because—absolutely incredibly—they claim it’s a trade secret between plan and provider. So they tell the customer that they’re buying into a network with pre-negotiated rates, but it’s not true. This is pretty much straight fraud.

Sadly, Golden Rule has been a scumbag organization since day 1. It was started by Patrick “looney” Rooney and its goal has been to change the law so that it can sell more of its highly underwritten, high margin HDHP policies. After numerous contributions to certain Republicans, who lets face it couldn’t give a rat’s arse about the poor consumer despite all their high fallutin rhetoric about 21st century health care, the HSA is now the law of the land and plans like Golden Rule (as well as one hopes somewhat more ethical ones) are very hot.

So hot that managed care companies decided (as I’ve said before) that acquisition rather than imitation is the sincerest form of flattery.  UnitedHealth Corporation bought Golden Rule for $500m in 2003 when the HSA law was passed. Rooney meanwhile moved onto better things like buying basically reverse racist anti-Kerry commercials on black radio stations in the run-up to the 2004 election.

In a Businessweek article last year United said that it had cleaned up Golden Rule’s scummier practices: 

Soaring demand is one reason why UnitedHealth paid $500 million in 2003 for Golden Rule, of Lawrenceville, Ill., problems and all. Since 1995, Golden Rule has faced 15 investigations by insurance officials for aggressive sales tactics and questionable marketing. That compares with just nine investigations at UnitedHealth, though Golden Rule’s revenues barely equaled 3% of UnitedHealth’s 2003 revenues. At its low point, in 2002, Golden Rule settled for $660,000 a nine-state investigation that found its small-group policies required employees to submit "proof of good health," a violation of federal health-care rules. In addition to the payment, Golden Rule agreed to make "substantive" changes in the way it does business in those states.Since taking over Golden Rule, UnitedHealth has made further strides. Complaints against the outfit have dropped by more than half. And as UnitedHealth expands Golden Rule, it is encouraging consumers to check health-care costs via its online "treatment cost estimator" so they aren’t surprised by big out-of-pocket bills. "When we acquire a company, we take responsibility for all their past conduct," says Mark F. Lindsay, UnitedHealth’s vice-president for communications and strategy.

Apparently you have to now actually have the double secret “treatment cost estimator” which tells you what your balance billing exposure is on top of the secret negotiated rate

All of which goes to show that you can take these trash plans out of the trailer park — into the big respectable corporation — but you can’t take the trailer park trash out of the plan. (With apologies to THCB readers who live in trailers). And of course the problems they bring with them may just spread over to the rest of the organization—which since 2004 seems to be back-sliding on its “be nice to providers” mantra with nasty little episodes in Arizona and New York.

Then again given the charges filed against Brocade’s CEO for backdating stock options and the virtual certainty that after their screwing around with the dating of option awards they are next on the SEC/DOJ hit list, it may just be that instead of sorting out this mess United’s senior management has got, ahem, other things on its mind.

HEALTH PLANS/POLICY: eHealthinsurance still skipping stats 101

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eHealthinsurance is out with its annual report of what premiums are in different cities and they’re still comparing the price of rotten month old apples with sweet juicy, juicy mangoes. And amazingly enough they’re different. Basically some states ban underwriting and therefore have insurance which is more expensive. So what I said last year when they said that prices were going down still applies—

On further review there are more questions than answers. Who got insurance? Was this group more underwritten (i.e. healthier) than the previous year? And what benefits were they getting compared to last year?  And were there changes in deductibles, co-pays and out of pocket maximums?

Just saying that the premium went down is a bit like saying the average price of a BMW 3 series is less this year on average because more people are buying them without the fully loaded options. And if it’s really true that apples for apples the premiums went down why didn’t eHealthinsurance.com put that information in the report?

Although last year apparently “prices went down” and this year they didn’t say that, so it’s pretty damn likely that if you compared apples to apples of the stripped-down underwritten plans they’re looking at, prices went up.

Of course in practical terms this report is useless. I’m a great example in that I applied for two identical policies from different carriers on eHealthinsurance—both quotes about $100 a month for a $2500 deductible plan. But when the underwriting was done, one was still $100 a month and the other wouldn’t take me at all and suggested I went in the guaranteed issue pool at $400 a month for a $4000 deductible. So quoting price without knowing what the individuals concerned need to go through to get the insurance and therefore knowing the actual price is useless.

I do note one little thing in their report. They say that St Louis Missouri has the cheapest children’s insurance premiums ($29 a month) and yet there are 119,000 uninsured kids in Missouri. In other words very cheap—or even free given the numbers who don’t sign up for the SCHIP programs—isn’t cheap enough to get kids (and adults) insured. eHealthinsurance seems to be surprised about this.

The only logical conclusion is that health insurance needs to be compulsory and automatic (although not of course free to those who can afford it). And in fact even eHealthinsurance could do OK in such a system, although the logical ramifications of it would be horrendous for many of the plans they broker for.

TECH: PHR has opportunity to go mainstream

Wellpoint is going to roll out the WebMD PHR based system which has been working at Empire Blues (Wellchoice) for about a year to the rest of its plans to the rest of its plans. So theoretically up to 34 million people will have access to a PHR. I wrote about the WebMD solution before, so I won’t go into it much, but there are two quick points beyond the fact that (at last!) PHRs have the opportunity to go mainstream.

1) This is a vindication of the ASP model—these records live on WebMD’s servers rather than on Wellpoint’s. I never thought that the big insurers would allow another company to take their consumers’ data for fear that they would also take their consumers as well. That was certainly a concern of the plans that we were trying to sell PHRs to at i-Beacon which was why we sold enterprise software rather than an ASP service. WellMed (the company who’s PHR is the core of WebMD’s current service) was always an ASP model. And the answer is, the lowered costs of the ASP model outweigh the fear that WebMD will make it easy for another plan to assume the members data. One WebMD insider told me that they will be introducing a way to move data between plans. So the member will find “data lock” is NOT a reason to avoid moving plans, and technically they may not even have to take it off the server, assuming that WebMD is the back end for both plans. And of course potentially WebMD can start offering other health plan services and even start competing with its clients. But that’s another story.

2) Just as the private sector starts to sort this out with providers using Epic’s MyHealth to give access to the records, and WebMD starting to make real strides, CMS is starting experimentation, and Foundations are getting into the mix too with grants to help figure out what applications are needed. Are they not a bit late to the party?

And finally—it’s about bloody time!!

DISEASE MANAGEMENT BOSTON JULY 30 – AUG 2At a three day conference in Boston MA, scheduled between July 31 and Aug 2, industry leaders from managed care companies, employer groups purchasing healthcare services, providers, third party administrators, physicians, healthcare technology players, nursing and pharmacy practitioners, disease management experts will meet at the 4th Annual Disease Management Conference. The event is posted online at www.srinstitute.com/ch142.  Learn about advertising on THCB.  

POLITICS/POLICY/HEALTH PLANS: On the Blues’ political giving & CDHP complexity

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Says here that Blues Plans Favor Republicans With Their 2006 Campaign Contributions. But I think what it means is that they’re favoring incumbents. Having said that and reading the polls and the tea leaves, I think the Blues might think about evening up those contributions given that the Congress is as likely to flip over his year as any since 1994, and that the Blue Dog Democrats are the crowd most traditionally aligned with their interests.

Meanwhile, Joe Paduda is showing that the CDHP is even more confusing to consumers than ordinary health plans. Well, when United bought the shysters at Golden Rule, you didn’t actually think that they were going to reform them, did you?

 

POLICY/POLITICS/HEALTH PLANS: HSAs for Medicare? Crazy but apparently true

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So the HSA ideology has wormed its way into CMS, and now Medicare is seeking proposals for its Consumer-Directed Health Plan demonstration. Those taxpayers who can do basic math might wonder why you’d want to to give healthy Medicare beneficiaries cash for health services that they’re not going to use, while taking that cash away from the pot that pays for the sick beneficiaries that do use said services. But we’ve asked that question so many times before and no-one on the free market side dare answer it. And I guess you might say, why not give the taxpayers money straight to the “healthys” instead of laundering it through Medicare Advantage plans as we’re doing it now so that they can hand out free gym memberships to seniors and boost their executives’ stock holdings.

But given that risk adjustment is coming to Medicare Advantage, it may be that that gravy train is ending. Perhaps we’ll get to see if the private plans really can stand on their care management merits—and there’s so much fat in Medicare that they ought to be able to, easily.  Although they failed to do so in the late 1990s.

However, it’s just bizarre to increase the costs of a tax payer funded universal risk pool by allowing people who are not paying into it to withdraw cash from it. So the only real explanation is that CMS and its political masters in the White House are eventually intending to put the entire system into a high-deductible plan and not fund the amount below the deductible.  Just the same as most employers are doing (as I explained in this Spot-on piece about Intel).  That of course makes perfect sense for the government and the taxpayer. Until, that is, the seniors find out! I wouldn’t want to be in charge of Medicare when that happens, remember what those seniors did to Rostenkowski!

CONSUMERS/HEALTH PLANS/HOSPITALS/TECH: Consumer comparison tools, not exactly wowing the world as yet

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There’s a new report from CHCF, written by Katy Hendrickson at Forrester, it’s called  (pdf) Health Care Cost Comparison Tools: A market under construction. I’ve read it and it does suggest that something is slowly happening in the Submio/Health Grades world, but that it’s mostly about a few plans trying to steer consumers around based on quality….we are a long, long way from price transparency. Stll def worth a read if you’re all interested in consumerism, transparency or health care cost and quality. And apparently some of you are

There’s also a companion report out called Consumers in Health Care: Creating Decision-Support Tools That Work . I haven’t read that one yet. Comments please from anyone who does.

 

HEALTH PLANS: Remembering the Halcyon days of yore

I’m sure that all lawyers are crooks, etc, etc and that Milberg Weiss were doing naughty things while they went trawling for plaintiffs. 

In early October 1997, he bought 50 shares of Oxford Health Plans. Three weeks later, the stock nose-dived, and Mr. Vogel lost about $3,000 of his investment.  Still, Mr. Vogel reaped $1.1 million.

Apparently he was paid off to be the first plaintiff in a bunch of cases, which is illegal under a rather obscure law passed in 1995, —a law which the Milberg Weiss guys claim was the reason that the shenanigans in the bubble got so out of control. And somehow despite Ken Lay being the biggest contributor ever to a certain Texas based President, and being convicted of a gazillion counts, the next big indictment is of lawyers who go after fraud. Funny that.

But what I want to know about this NY Times story is how did lead plaintiff Vogel know that Oxford stock was about to collapse? And perhaps next time he could let me know too!

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