Princess Health and State Senator Indicted for "Influence Peddling" to Health Care Organizations. Princessiccia

Princess Health and State Senator Indicted for "Influence Peddling" to Health Care Organizations. Princessiccia

bribery CVS Rhode Island Blue Cross Roger Williams Medical Center

Gusty 11:37 Add Comment

A follow-up of a complex local story in the Providence Journal: John Celona, a former Rhode Island State Senator, was just indicted by a state grand jury for using his public office for private gain (or, as the headline said, "influence peddling.")
He was charged with having three financial relationships with one for-profit and two not-for-profit corporations "while he was in a position to influence legislation of interest to these companies."
Relevant to this blog is that all three organizations are in health care. They are the CVS pharmacy chain, Rhode Island Blue Cross and Blue Shield, a not-for-profit health insurance and managed care organization (and by far the dominant such organization in the state), and Roger Williams Medical Center, a not-for-profit university affiliated medical center. Two counts of the indictment "alleged that Celona violated the state's Code of Ethics by accepting employment with Roger Williams Medical Center and CVS ... which 'did impair his independence of judgment'...." One count alleged that he "uses his public office 'to obtain financial gain' for himself and a TV production company... from Blue Cross."
Kim Keough, a Blue Cross spokesperson, said "obviously, the indictment surrounding Mr. Celona's actions are not allegations against Blue Cross whatsoever." CVS' written statement simply stated that the company "will continue to cooperate with any and all inquiries into this matter." Roger Williams declined comment.
The investigation is not yet over, and some matters may well be referred to a federal grand jury.
H. Philip West Jr, Executive Director of Common Cause of Rhode Island, said "Hopefully, this indictment and the trial will demonstrate to the public some of the ways that some lobbying groups have sought to compromise public officials. Until now, CVS and others who paid Celona have come through unscathed."
A brief Providence Journal editorial added, "Mr. Celona's trial might illuminate how special-interest groups use legislators to promote their interest. Meanwhile, people wonder what will happen to those who 'hired' Messrs. Celona and Irons [another State Senator who resigned under fire for accepting "broker commissions from Blue Cross]."
Providence Journal columnist M. Charles Bakst opined, "What about CVS, Blue Cross, and the Roger Williams Medical Center? These are the entities with which Celona is charged with striking private financial deals. If something smelly happened, isn't it reasonable to think they were as much a part of it as this prominent Democrate who chaired a top Senate committee? The public will find it hard to take if Celona lands in the slammer, but the folks he served, or who allowed themselves to be exploited, skate."
As we have noted before, Blue Cross in Rhode Island was known for its rapid premium increases, stingy payments to doctors, and recent lack of interest in maintaining a dialogue with health care professionals. Last year, its CEO resigned after his huge financial compensation package was revealed by the Providence Journal. It is gratifying that the civil authorities are now starting to address dubious relationships between large health care organizations and politicians. But where are the watchdogs within health care who could address how concentration and abuse of power damages patients and health care professionals?

Princess Health and State Senator Indicted for "Influence Peddling" to Health Care Organizations.Princessiccia

Princess Health and State Senator Indicted for "Influence Peddling" to Health Care Organizations.Princessiccia

bribery CVS Rhode Island Blue Cross Roger Williams Medical Center

Gusty 11:37 Add Comment

A follow-up of a complex local story in the Providence Journal: John Celona, a former Rhode Island State Senator, was just indicted by a state grand jury for using his public office for private gain (or, as the headline said, "influence peddling.")
He was charged with having three financial relationships with one for-profit and two not-for-profit corporations "while he was in a position to influence legislation of interest to these companies."
Relevant to this blog is that all three organizations are in health care. They are the CVS pharmacy chain, Rhode Island Blue Cross and Blue Shield, a not-for-profit health insurance and managed care organization (and by far the dominant such organization in the state), and Roger Williams Medical Center, a not-for-profit university affiliated medical center. Two counts of the indictment "alleged that Celona violated the state's Code of Ethics by accepting employment with Roger Williams Medical Center and CVS ... which 'did impair his independence of judgment'...." One count alleged that he "uses his public office 'to obtain financial gain' for himself and a TV production company... from Blue Cross."
Kim Keough, a Blue Cross spokesperson, said "obviously, the indictment surrounding Mr. Celona's actions are not allegations against Blue Cross whatsoever." CVS' written statement simply stated that the company "will continue to cooperate with any and all inquiries into this matter." Roger Williams declined comment.
The investigation is not yet over, and some matters may well be referred to a federal grand jury.
H. Philip West Jr, Executive Director of Common Cause of Rhode Island, said "Hopefully, this indictment and the trial will demonstrate to the public some of the ways that some lobbying groups have sought to compromise public officials. Until now, CVS and others who paid Celona have come through unscathed."
A brief Providence Journal editorial added, "Mr. Celona's trial might illuminate how special-interest groups use legislators to promote their interest. Meanwhile, people wonder what will happen to those who 'hired' Messrs. Celona and Irons [another State Senator who resigned under fire for accepting "broker commissions from Blue Cross]."
Providence Journal columnist M. Charles Bakst opined, "What about CVS, Blue Cross, and the Roger Williams Medical Center? These are the entities with which Celona is charged with striking private financial deals. If something smelly happened, isn't it reasonable to think they were as much a part of it as this prominent Democrate who chaired a top Senate committee? The public will find it hard to take if Celona lands in the slammer, but the folks he served, or who allowed themselves to be exploited, skate."
As we have noted before, Blue Cross in Rhode Island was known for its rapid premium increases, stingy payments to doctors, and recent lack of interest in maintaining a dialogue with health care professionals. Last year, its CEO resigned after his huge financial compensation package was revealed by the Providence Journal. It is gratifying that the civil authorities are now starting to address dubious relationships between large health care organizations and politicians. But where are the watchdogs within health care who could address how concentration and abuse of power damages patients and health care professionals?

Princess Health and "Crackdowns Can't Keep Pace as Scams Grow More Cunning". Princessiccia

Princess Health and "Crackdowns Can't Keep Pace as Scams Grow More Cunning". Princessiccia

Gusty 11:29 Add Comment

The San Francisco Examiner has published an investigative series on Medicare fraud. (The two articles are here and here.) The second summary article suggests that such fraud may be a far larger problem than has been heretofore documented.
Anecdotally, it cited a physician at a senior health whose patients started reporting incidents of potential fraud involving durable medical equipment. Despite her calls to Medicare and the Federal Bureau of Investigation in 2004, the case still has not been prosecuted.
Patrick Burns of Taxpayers Against Fraud, declared "There is so much fraud in the Medicare system that it is unbelievable. It is a tsunami of fraud. Yet we devote so little resources to it."
Malcolm Sparrow, from Harvard University, and author of License to Steal: How Fraud Bleeds America's Health Care System, said that the Medicare official estimate of fraud and abuse (a mere US $20 billion a year) is very low. Furthermore, he asserted that there are insufficient investigators and prosecutors to handle the problem.
Assistant US Attorney Connie Woodhead asserted, "Tell Congress to give us some help. There is a lot of crime, and relative to the amount of crime, not a lot of people to do the investigations."
My comments are that this just adds to our sense that there is far more mismanagement, unethical behavior, and outright crime in the health care system than many people realize. Such issues up to now have gotten little attention in the medical, health care and health policy literature. The civil authorities can address them, but clearly have insufficient resources. There is not yet any watchdog group within health care that patients, doctors, and other health care professionals can turn for help.

Princess Health and "Crackdowns Can't Keep Pace as Scams Grow More Cunning".Princessiccia

Princess Health and "Crackdowns Can't Keep Pace as Scams Grow More Cunning".Princessiccia

Gusty 11:29 Add Comment

The San Francisco Examiner has published an investigative series on Medicare fraud. (The two articles are here and here.) The second summary article suggests that such fraud may be a far larger problem than has been heretofore documented.
Anecdotally, it cited a physician at a senior health whose patients started reporting incidents of potential fraud involving durable medical equipment. Despite her calls to Medicare and the Federal Bureau of Investigation in 2004, the case still has not been prosecuted.
Patrick Burns of Taxpayers Against Fraud, declared "There is so much fraud in the Medicare system that it is unbelievable. It is a tsunami of fraud. Yet we devote so little resources to it."
Malcolm Sparrow, from Harvard University, and author of License to Steal: How Fraud Bleeds America's Health Care System, said that the Medicare official estimate of fraud and abuse (a mere US $20 billion a year) is very low. Furthermore, he asserted that there are insufficient investigators and prosecutors to handle the problem.
Assistant US Attorney Connie Woodhead asserted, "Tell Congress to give us some help. There is a lot of crime, and relative to the amount of crime, not a lot of people to do the investigations."
My comments are that this just adds to our sense that there is far more mismanagement, unethical behavior, and outright crime in the health care system than many people realize. Such issues up to now have gotten little attention in the medical, health care and health policy literature. The civil authorities can address them, but clearly have insufficient resources. There is not yet any watchdog group within health care that patients, doctors, and other health care professionals can turn for help.

Princess Health and 26-digit patient ID codes and other dumb ideas. Princessiccia

Princess Health and 26-digit patient ID codes and other dumb ideas. Princessiccia

Gusty 07:06 Add Comment

In the "awards for information technology that actually hinders patient care" category, this story takes strong honors.

My automobile has a 17-digit VIN (vehicle identification number). However, to some in managed care, even this is inadequate for patients. One payor has a nearly-unbelievable 26-digit patient identifier required for billing purposes. If this does not violate every precept of common sense human/machine interaction in busy clinical settings, I'm not sure what would.

As reported in "Magellan Health's procedures attacked", Philadelphia Inquirer, Wed, Apr. 20, 2005, The Pennsylvania Psychological Association blasted Magellan Health Services for what it called inefficient rules and bureaucratic roadblocks that it said keep Southeastern Pennsylvania patients from getting psychological care and therapists from getting paid.

Therapists have been dropped temporarily from Magellan's rolls for no apparent reason, and communication with the company is so slow it's sometimes impossible to meet deadlines, the association said in a report released to the public. Magellan assigns each patient a 26-digit code, which is difficult to type properly and has caused many bills to be rejected, psychologists said. Magellan manages mental-health services for the region's two dominant private insurers, Independence Blue Cross and Aetna Inc.

(Note: for the mathematically-minded, a 26-digit number could be used to uniquely identify over 99 septillion individuals - that's 99,999,999,999,999,999,999,999,999 - and many, many more if alphanumerics are allowed!)

The article goes on to state:

Sam Knapp, director of professional affairs for the psychological association, said it was the first time his group had taken this kind of action. "The only reason we did it is because the quality of administrative services just became horrible in the last six months," he said. "It was never that great." The company's procedures, he said, "waste money and they disrupt patient treatment."

Magellan controls mental-health treatment for virtually all of the private HMO market in the region, and also manages care for many employer-operated plans and for Medicaid patients in Bucks, Delaware and Montgomery Counties.

... Rep. Dennis O'Brien (R., Phila.), chairman of the state House Judiciary Committee, said yesterday that he hoped to hold hearings next month on issues raised in the report. "I have some real concerns with Magellan," he said. "I think there's enough questions here that we'll bring people in and we'll let them tell the story."

... The psychological association report focused on problems in four areas: authorization to provide care, which is required before bills will be paid; credentialing or approval of therapists for an insurance company's network, also a billing requirement; billing itself; and appeals of denied care.

The report was based on a random survey responded to by 73 Philadelphia-area psychologists in Magellan networks, plus discussions with psychologists who work with the company ... The psychologists told the association that 30 percent to 35 percent of their budgets go to satisfying insurance company demands.

Tom Whiteman, a psychologist who directs Life Counseling Services, a practice with 100 therapists in Pennsylvania and New Jersey, said Magellan controlled 90 percent of his business. He has one full-time worker who does nothing but pursue denied claims.

Something as benign as a therapist's marriage can upset billing for months, he said in an interview. He tells employees never to change their names. "It can take them six months to change you in the computer," he said. "In the meantime, every claim will be denied."

... Vince Bellwoar, a psychologist who runs a large group practice based in Delaware County, said it took Magellan six weeks to kick back one report because a therapist had forgotten to write in the patient's birth date. When that was corrected, it took the company three days to reject the claim because it was late. Eventually, Bellwoar's group got some of its money.

This kind of thing wears on therapists, Bellwoar said. "These aren't huge obstacles. These are hurdles, but after a while you just want to stop jumping over the hurdles, and the patients want to stop jumping over the hurdles."

The company defended its practices. "We're very proud of our track record in Pennsylvania and around the country," spokeswoman Erin Somers said. The company has tried to enhance "services and operations" in the last two years, and "the feedback that we've gotten from our stakeholders... has been very positive in a majority of cases."

Such widely-divergent reports leave me skeptical. Considering the implications of implementing a 26-digit identifier as a starting point of the claims and reimbursement processes, I'd tend to find the quoted practitioners' complaints more credible.

In any case, ill-conceived and implemented information technology that requires an easily-corrupted 26-digit patient identifier and six months to change a name of a provider employee for billing purposes, and processes that require practice owners to have full-time employees to work on denials and expend a third of their budgets for insurance paperwork and other administrivia, simply have no place in modern healthcare. This seems a prime example of bureaucrats living parastically off of clinicians, sucking their lifeblood.

-- SS

Princess Health and 26-digit patient ID codes and other dumb ideas.Princessiccia

Princess Health and 26-digit patient ID codes and other dumb ideas.Princessiccia

Gusty 07:06 Add Comment

In the "awards for information technology that actually hinders patient care" category, this story takes strong honors.

My automobile has a 17-digit VIN (vehicle identification number). However, to some in managed care, even this is inadequate for patients. One payor has a nearly-unbelievable 26-digit patient identifier required for billing purposes. If this does not violate every precept of common sense human/machine interaction in busy clinical settings, I'm not sure what would.

As reported in "Magellan Health's procedures attacked", Philadelphia Inquirer, Wed, Apr. 20, 2005, The Pennsylvania Psychological Association blasted Magellan Health Services for what it called inefficient rules and bureaucratic roadblocks that it said keep Southeastern Pennsylvania patients from getting psychological care and therapists from getting paid.

Therapists have been dropped temporarily from Magellan's rolls for no apparent reason, and communication with the company is so slow it's sometimes impossible to meet deadlines, the association said in a report released to the public. Magellan assigns each patient a 26-digit code, which is difficult to type properly and has caused many bills to be rejected, psychologists said. Magellan manages mental-health services for the region's two dominant private insurers, Independence Blue Cross and Aetna Inc.

(Note: for the mathematically-minded, a 26-digit number could be used to uniquely identify over 99 septillion individuals - that's 99,999,999,999,999,999,999,999,999 - and many, many more if alphanumerics are allowed!)

The article goes on to state:

Sam Knapp, director of professional affairs for the psychological association, said it was the first time his group had taken this kind of action. "The only reason we did it is because the quality of administrative services just became horrible in the last six months," he said. "It was never that great." The company's procedures, he said, "waste money and they disrupt patient treatment."

Magellan controls mental-health treatment for virtually all of the private HMO market in the region, and also manages care for many employer-operated plans and for Medicaid patients in Bucks, Delaware and Montgomery Counties.

... Rep. Dennis O'Brien (R., Phila.), chairman of the state House Judiciary Committee, said yesterday that he hoped to hold hearings next month on issues raised in the report. "I have some real concerns with Magellan," he said. "I think there's enough questions here that we'll bring people in and we'll let them tell the story."

... The psychological association report focused on problems in four areas: authorization to provide care, which is required before bills will be paid; credentialing or approval of therapists for an insurance company's network, also a billing requirement; billing itself; and appeals of denied care.

The report was based on a random survey responded to by 73 Philadelphia-area psychologists in Magellan networks, plus discussions with psychologists who work with the company ... The psychologists told the association that 30 percent to 35 percent of their budgets go to satisfying insurance company demands.

Tom Whiteman, a psychologist who directs Life Counseling Services, a practice with 100 therapists in Pennsylvania and New Jersey, said Magellan controlled 90 percent of his business. He has one full-time worker who does nothing but pursue denied claims.

Something as benign as a therapist's marriage can upset billing for months, he said in an interview. He tells employees never to change their names. "It can take them six months to change you in the computer," he said. "In the meantime, every claim will be denied."

... Vince Bellwoar, a psychologist who runs a large group practice based in Delaware County, said it took Magellan six weeks to kick back one report because a therapist had forgotten to write in the patient's birth date. When that was corrected, it took the company three days to reject the claim because it was late. Eventually, Bellwoar's group got some of its money.

This kind of thing wears on therapists, Bellwoar said. "These aren't huge obstacles. These are hurdles, but after a while you just want to stop jumping over the hurdles, and the patients want to stop jumping over the hurdles."

The company defended its practices. "We're very proud of our track record in Pennsylvania and around the country," spokeswoman Erin Somers said. The company has tried to enhance "services and operations" in the last two years, and "the feedback that we've gotten from our stakeholders... has been very positive in a majority of cases."

Such widely-divergent reports leave me skeptical. Considering the implications of implementing a 26-digit identifier as a starting point of the claims and reimbursement processes, I'd tend to find the quoted practitioners' complaints more credible.

In any case, ill-conceived and implemented information technology that requires an easily-corrupted 26-digit patient identifier and six months to change a name of a provider employee for billing purposes, and processes that require practice owners to have full-time employees to work on denials and expend a third of their budgets for insurance paperwork and other administrivia, simply have no place in modern healthcare. This seems a prime example of bureaucrats living parastically off of clinicians, sucking their lifeblood.

-- SS

Princess Health and "This Pricing is a Joke:" The $1275 Physical Therapy Session. Princessiccia

Princess Health and "This Pricing is a Joke:" The $1275 Physical Therapy Session. Princessiccia

health care prices Tenet

Gusty 10:59 Add Comment

A bizarre story about health care costs from the Miami Herald: A patient required hand physical therapy after a motor vehicle accident. She went to Palmetto General Hospital, owned by Tenet.
Because she was on a UnitedHealthCare policy which included a deductible and a 10% co-pay, she asked the hospital about how much a course of therapy would cost. After talking to at least one uncooperative functionary in the hospital's finance department, another told her the physical therapy would cost about $35 to $55 a session.
She first went for an evaluation and then had 11 additional sessions, the latter lasting around 45 minutes, sometimes one on one with a therapist, sometimes as part of a small group of patients with a therapist. So far, so good.
Then she started getting bills. For her first session, Palmetto General charged a whopping
$2713. With United's discount, this was reduced to a still whopping $1275. For her additional
sessions, charges ranged from $228 to $2454.
Palmetto General refused to respond to the Herald regarding the specifics of the case, but said "We support providing patients with meaningful information about the cost of health care."
UnitedHealthcare spokesman Roger Rollman also refused to respond directly about the case because of "privacy laws," (even though the patient had provided the Herald with her side of the story.) But Rollman did say "UnitedHealthcare strongly believes in transparency of hospital costs to the public."
Teri Bielefeld, the President of the Hand Rehabilitation Section of the American Physical Therapy Association responded to the story by saying, "my heart dropped. That's way out of range. That's incredible." She thought an evaluation session ought to cost around $200 and individual sessions around $50 per half an hour. Thus she thought "This pricing is a joke. Somebody needs to do something about it."
I'm not sure which is more amazing: that the hospital would charge thousands of dollars per
therapy session, or that UnitedHealthcare would be willing to pay these charges after a 50%
discount.
It is arguable that the major rationale for the rise of for-profit managed care organizations
like United was controlling costs. Such managed care organizations often have reputations for
being extremely tough on physician reimbursement, at least for cognitive and especially primary care services. This may be one reason that primary care physicians have an increasingly hard time just staying in businees, and why primary care is having an increasingly hard time attracting new trainees.
So why would a managed care organization with a reputation for fiscal toughness be willing to pay over a thousand dollars for a physical therapy session?