Unmanaged Care

Pharma Income

2008-03-16T15:28:00.000-07:00

I just came across an Associated Press article with the title: "US Prescription Drug Sales Growth Slows." (Key work: Growth)

Gee! I was wondering why I saw so many FULL PAGE ads for Lipitor in my local newspaper.

Not to mention the Wall Street Journal article (2/22/08) about the increases in drug prices, specifically stated: "Pharmaceutical companies increased wholesale prices for the 50 top-selling branded drugs by an average of 7.82% in 2007 after an increase of 6.73 percent and 6.22 percent in the previous two years."

Don't ever think that Big Pharma will ever lose.

I guess that with the revenue newspapers receive from Pharma ads we won't see much scrutiny in the print media anytime in the near future.

And - I wonder what Universal Health Care will do to lower those prices?

Where's the outrage?

2008-03-09T16:53:00.000-07:00

Going through a pile of paperwork, I came across a class action settlement advisory covering foreign purchases on VISA, MasterCard and/or Diners Club.

Why the outrage?

The settlement was for an estimated $313,000,000 and the lawyers requested a 27.5% fee - after deducting costs for administering the settlement and notice, PLUS interest. And they also requested reimbursement of their expenses not to exceed $5,000,000.

Where is the outrage?

Just think of what would be said if this altruistic group was representing the victims of Katrina, Andrew or Charley?

As Earl Pitts (WFLA RADIO 970 Tampa) would say " WAKE UP AMERICA!"

And, Yes - this is a major part of our health care problems.

Just drive through Lakeland, Florida and look at the visual pollution on the billboards!

Why aren't the doctors outraged?

2008-03-06T16:21:00.000-08:00

In the last week or so I've seen numerous FULL PAGE ads for Lipitor in at least two different newspapers.

If anyone needs an explanation why, please shoot me!

Therefore, the question - once again - is: Who is treating the patient?

Is it the patient requesting a certain medical diagnostic test, intervention, drug or therapy?

Is it the drug company, medical device maker or ancillary service provider influencing the physician?

Or is it the optimal clinical, economical treatment and outcome for the patient?

(A very good state police investigator once told me to follow the money.)

If I went to a good physician and requested a particular treatment, there is a good chance that that good physician would properly put me in my place. (And, YES, it has happened to me!)

Why then do physicians sit back and let their vast clinical training and experience be diminished, adulterated, prostituted, bastardized and/or mitigated?

Why don't the good physicians stand up and be heard?

Big Pharma Strikes Again

2008-03-04T18:39:00.000-08:00

It appears that this should be the title of my next book - yesterday.

An article in USA Today talks about increases in drug sales as the number of ads surge.

Not to mention an AP report today that mentions the growth in the prices for brand name drugs.

The question that should be asked is, what about the docs? Who makes the clinical decision about what treatment is needed for the patient - the physician, the patient, the drug rep or the perks provided to the doc by the drug company?

There are enough reports to substantiate the relationship between pay-offs and increased drug utilization/prescribing by physicians. The euphemisms used in the health care industry to denote pay-offs include, but are not limited to: medical director, clinical educator, coordinator of this or that drug trial/study or simply "You are the physician, here is you money.).

The big question is... Why don't the other physicians "narc" or whistle blow on their nefarious colleagues? It is not one iota different from the 60 Minutes program a while back that focused on inner-city kids and why the won't cooperate with the police when their friends and family are murdered, shot or preyed upon by drug dealers - and those drug dealers don't even have a team of lobbyists.

Physician heal thyself!

Health Care Costs - Not addressed!

2008-03-03T18:00:00.000-08:00

We're back!!!!!!!!!!!!!!!!!

The problem with the pundits of health care reform is that COST seems to get lost in the rhetoric.

Universal health care will do nothing to decrease the actual cost of care. It may reduce the cost to those who are presently enrolled in an insurance program as well as some (employers and individual buyers) who may purchase insurance coverage in the future.

However, it will not reduce the actual cost. Why?

The true amount that we pay for medical services will not be impacted. The industry will continue to abuse the system by over-billing, self-referral abuse, overuse of technology (Physician ATM = MRI), pharmaceutical agents that are not able to justify their cost to outcome ratios - driven by Big Pharma's ability to market and pay off a sufficient number of physicians, payoffs to physicians by product suppliers such as hip and knee implant manufacturers, individual and corporate greed and a system that lacks realistic supervision and control.

COST must be THE issue, not theoretical issues that look so good on paper - such as managed care and universal health care.

More to come.

More Physician Kickbacks

2007-10-08T11:13:00.000-07:00

Big pharma and medical director schemes move over, you now have a sidekick.

Four companies that supply most hip and knee replacements in the United States have agreed to pay $310 million to SETTLE concerns over doctor kickbacks.

Gotta guess who's in charge. They AGREED to SETTLE. Other big question is, who's going to jail? Criminal charges will be dropped if if they adhere the requirements of the SETTLEMENT for eighteen months.

According to an article in the Baltimore Sun from the Associated Press, the companies paid orthopedic surgeons "exorbitant" amounts to be consultants and use their products exclusively.

Patients and hospitals were unaware of the deals, WHICH RANGED FROM TENS TO HUNDREDS OF THOUSANDS OF DOLLARS. Does the word greed fit in here?

Unfortunately, this is just the tip of the iceberg of physician kickbacks and self-referral issues..

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Big Bucks Big Pharma

2007-09-22T12:03:00.000-07:00

This is a great documentary on the pharmaceutical industry. Go to the address listed below and take a look.

http://www.youtube.com/ep.swf?id=A840A6C583F0ED9C&eurl=

Corporate Health Care Double Standard

2007-09-17T16:47:00.000-07:00

I saw a piece in our local paper about a large health insurance company that had to pay $12 million in fines to 36 states and the District of Columbia to settle complaints about its past claims practices.

The first issue is that it seems every time corporate America has to lay off employees, cut employee benefits, send jobs abroad, cut customer service, or decrease quality it’s for the shareholders and investors. They never fail to remind us that this is a mainstay of our economy. That is, of course, unless you are one of the millions of employees and retirees whose lives have been affected or the millions of Americans who are sick and tired of customer no-service. (The term coined by the great Clark Howard.)

Yet, the bigger issue has to be the double standard exercised by the bastions of our corporate culture and the spin they offer as validation - clearly epitomized in our health care industry. Were is the responsibility of the health care CEO, COO, CFO and all of the other C something O executives when they have to pay the government millions of shareholder and investor dollars for their misdeeds? What about the (+/-) $7.5 BILLION paid out in nineteen of the top twenty False Claims Act cases since 2000? That top nineteen of twenty were in the health care industry. And who knows how much more has been paid out by the remaining hundreds (so who's counting?) of cases?

It’s not about profit and executive salaries, it’s about responsibility and accountability.

And, why is no one going to jail?

At least that's one thing the Chinese do right!

Stay tuned

2007-09-16T15:27:00.000-07:00

Hardware and technical difficulties have been ironed out and blogs will resume this week.

Healing The American Health Care System

2007-08-14T14:20:00.000-07:00

This is the first draft of "healing". Updates to follow.

We have to start somewhere, somehow to develop a long term rational approach to revolutionize our health care industry. And, it’s not going to be easy. But, it can and has to be done – sooner than later. Listed below is a brief, yet comprehensive list of actions directed at healing our critically injured system. Some are obvious. Some are questionable. Some are idealistic and some are pragmatic. Either way change is inevitable.

Put Health Care In the Hands of Physicians. Our health care should be managed by physicians and other clinicians. It should not be under the thumb of insurance companies, pharmaceutical companies, lawyers, bean counters, the government and bureaucrats.

Restructure Medical Reimbursement To Increase Payment For Primary Care. The most important person in someone’s life – especially with an aging population – may very well be their primary care physician. There is a dire need to shift reimbursement from the excessive payments for specialty physician and other similar services to primary care physicians and practitioners. The changes will not have to affect the lifestyle of any specialty physician.

Curb the Overuse Of Expensive Technology. What is a physician’s ATM? It’s called an MRI. Why do physicians go to medical school, residency, specialty and fellowship programs if all they are going to do is order MRIs and other expensive tests?

Challenge the American Patient/Consumer For Accountability. Americans must participate in health care change. Too many of us want it “for nothing” – or actually believe we are not paying outrageous amounts for medical care. “My insurance paid for it.” Look at your pay stub. How much does your employer pay in addition to your contribution? How much are your co-pays and out-of-pocket expenses, especially compared to five years ago?

Health Care Consumerism. Empower and educate the American health care consumer. Education and information are power. For example, a first step should be to standardize medical billing statements and EOBs (Explanations of Benefits) to make them intelligible. We must also learn to separate emotion from financial considerations when evaluating our clinical care decisions.

Emphasize Prevention vs. Treatment. More than sufficient data exist to support the medical benefits and cost saving of wellness and preventive programs. These programs must be available to every American along with a reasonable level of individual accountability to participate. Attack chronic disease upfront.

Truth in Health Care Information. We must have reliable, objective knowledge concerning the flow of the money that we pay into the system - where it goes, who gets it, how it is used and who is making the profit and how much. And, equally important, how effective are the relative costs? Where else but in health care is there no financial accountability for outcomes? Enlist our institutions of higher learning. Universities with programs in public health and health care economics would hopefully be able to provide us with the data we need.

Reduce Fraud And Abuse. The system is epidemic with fraud and abuse. No government agency is able to keep up with it. This is arguably the major cause of higher costs. Establishing, for lack of better terms, a task force with accountability, absolutely necessary and will easily pay for itself.

Place Strict Controls on Lobbyists and Campaign Donations - With Severe Penalties. If any American doesn’t know that this is a national embarrassment, they should be ashamed of themselves. Limiting lunches and dinners is not the answer.

Break Down The Bureaucracy. Bureaucratic waste is absurd - bureaucrats creating jobs for bureaucrats and extra work for health care workers, costing us less clinical care and more money out of our pockets. Case in point: Ask any health care provider what HIPAA has done other than cost billions of dollars. This is the poster child for “bureaucracy gone wild”.

Restrain Malpractice/Personal Injury Litigation. The issue is more than contemptible awards with 30% or 40% of the patient’s money going to the attorney. The costs involved in the large number of physician and hospital cases that are “settled” – by design, at the onset – are more costly than the big awards.

Enact “Any Willing Provider” Laws in All States. This may begin to erase control of the insurance industry over health care providers and allow all of us full choice of our medical providers.

Innovative Corporations Should Consider Entering Into The Health Insurance Business. We need some innovative, employee oriented corporations to administer their own insurance companies. If the insurance companies can make a profit, why can’t a consortium of corporations form their own and pass the profit/savings on to their employees and their own bottom line.

Say No To Universal Health Care, Yes To Insurance Coverage for All. Managed care looked good on paper, so does universal health care. However, in no way will we be able to break up our present health care industry. The pharmaceutical, health insurance, physician and other health care lobbies, lawyers and the economy they created are too strong. Let the government work on Medicare - it needs serious work. If the government is able to make Medicare a clinically and cost effective program, then we can use it as a model for expanded programs. Insurance coverage for all Americans is a necessary goal. Change is inevitable, but to put everything in the hands of our government is a dangerous solution. We are not Canada, England or France. Americans could not handle it – for all the bad reasons. And, for you health care providers, physicians, hospitals, insurance companies and pharmaceutical companies now is the time for you to participate in change or change will eventually be made for you. Sooner or later!

It's about time

2007-08-05T17:07:00.000-07:00

In response to the New York Times article by Gardiner Harris (8/4/07) about US Senator Grassley calling for a registry of payments to physicians from pharmaceutical companies – although years overdue, it is warmly welcomed and will hopefully be supported by all of colleagues in the House and Senate.

The American health care industry is wrought with fraud and abuse, with the pharmaceutical industry arguably being the poster-child. Taking a quick look at the major fraud cases pursuant to the 1986 False Claims Act, of the top 20 since 2000, 19 have been in health care – twelve in the pharmaceutical industry. The total amount of settlements for the nineteen was approximately $7,500,000,000. That’s billion! The sad note here is word “settlement”. Is going to jail? The makers of Oxycontin just settled for something in the range of $634,000,0000 with the CEO, attorney and former medical director receiving probation and community service. (Google Oyxcontin deaths for additional information.) And, who negotiated the settlement? Rudy Giuliani.

Pharmaceutical companies, insurance companies, hospitals, physicians and other providers making clinical decisions based on income as opposed to sound medical care is all too prevalent. Senator Grassley’s proposal is the tip of the iceberg of where this country must go to reduce the billions of dollars (Who knows the real number?) in health care fraud and abuse and the deleterious impact on the safety of the American health care consumer.

If it looks like it

2007-07-30T12:49:00.000-07:00

Remember the old adage:

If it looks like it, smells like it, feels like it and tastes likes it, don't step in it!

If we apply it to contemporary American health care, we are rolling in it.

Our apathy owns much of the problem.

Big Pharma Strikes Again

2007-07-28T08:16:00.000-07:00

This time it's AstraZenca, Bristol-Myers-Squib and Schering-Plough.

According to the article in Bloomberg News, all three were found liable by a federal judge and have to pay damages for overcharging on certain drugs paid for by Medicare, pension funds, insurers and patients.

The plaintiffs in this nationwide class-action suit argued that the pharmaceutical companies sold medications to doctors at steep discounts to the "average wholesale price" that Medicare and pension funds paid, while secretly encouraging them to claim full reimbursement from insurers.

Again, is anyone going to jail? And what is the "liability" of the physicians.

More justice for the pharmaceutical industry - NOT!

2007-07-26T16:05:00.000-07:00

The makers of the drug Oxycontin, and it's head lawyer, president and past medical director pleaded guilty to criminal charges that they misled physicians and patients by claiming that the drug was not as addictive or was less likely to be abused as other narcotic painkillers.

In a settlement/plea agreement with the government, Purdue Pharma agreed to $600 million in fines to resolve the charge of misbranding the product.

In an April report the FDA announced that Oxycontin may have played a role in 464 drug overdose deaths in the last two years.

This month a federal judge sentenced the officials to three years probation and 400 hours each of community service.

And... it was Rudy Giuliani who helped negotiate the plea deal - for Purdue - that allowed the Purdue executives to avoid jail time!

We need Mr. Giuliani to come forward explain his rationale, not the politically correct stuff and certainly not the lawyer response.

More to follow.

Resume tomorrow

2007-07-25T04:24:00.000-07:00

Technical issues have been resolved and Unmanaged Care blog entries will resume tomorrow.

Strike 1 for Universal Health Care?

2007-07-09T16:43:00.000-07:00

An article in MedPage Today addressed the upcoming (2008) 9.9% cut in the Medicare Part B physician fee schedule. So what's wrong with cutting reimbursement rates to save money?

Just like managed care, it sounds good on paper. However, our friends in Congress and at CMS either don't have a clue or are ignoring the history of such moves.

The actual outcome will be physicians, other health care providers who fall under the same fee schedule and consultants rallying to find a way to make up for the shortfall. Some strategies have yet to be developed, some are probably ready to go and we can assume that some are already in place.

What will happen? Basically, physicians and other health care providers will simply increase the number of visits and procedures - see more patients, order more tests, refer more patients to ancillary medical business(es) in which they receive compensation or own and spend less time with the patient. Some will refuse to see Medicare patients altogether and some may even (carefully) pick and choose those who need procedures that pay more.

They will also spend inordinate extra amounts of time away from their families and private lives.

Ask anyone who worked (past tense, that is) in skilled nursing facilities or in home health how the system is manipulated.

Medicare is not a bad product and could serve as a model for access to health insurance coverage for all Americans. However, under the "leadership" of our Congress and the (all-too-many) bureaucrats who run CMS, universal health care will fail as has managed care.

Fix Medicare first and then move on to universal health care insurance coverage for all Americans.

More about physicians getting paid off

2007-06-27T13:57:00.000-07:00

Just when you think you've heard it all, up comes yet another report about physicians being paid by the pharmaceutical companies. Gardiner Harris wrote in the NY Times that Vermont officials reported that pharmaceutical company payments to psychiatrists doubled last year - to an average of $45,692 from $20,835 in 2005. Endocrinologists were second earning an average of $33,730. What does this mean?

Are the docs being paid to prescribe certain drugs? Is it the patients' clinical need or is the prescription (and possibly diagnosis) based on the doc's payment from the drug company? The other disturbing issue is that the drug companies "spent over $2.25 million on marketing payments, fees and travel expenses to Vermont doctors, hospitals and universities." Universities! So much for academic integrity.

A previous Times article looking at reports from Minnesota stated that payments to psychiatrists there ranged form $51 to $689,000 and that those who received the most money from antipsychotic drug makers prescribed those medications to children more often.

It is time for outrage or are have we Americans become too apathetic?

More to come about disclosure.

Physicians paid by pharmeceutical companies?

2007-06-16T13:15:00.000-07:00

Last year I attended a clinical workshop where a local neurologist gave a talk on neuropathy. The first ten minutes were outstanding and the remaining twenty minutes were mostly an infomercial for a new drug used to treat neuropathy. At no time did he mention that he was being paid by the company to represent that drug. Was he?

Last week I heard a radio interview where the physician was talking about one of the new OTC weight loss medications. One of the hosts asked her if she was paid by the pharmaceutical company. He answer was something like "I only get paid for the time I represent them." (Sorry for the lack of an exact quote, but it was very early in the a.m.) She also spoke about treatment effects - what ever euphemism that may be - without actually listing them. I'd think that a treatment effect was weight loss. My guess is that she was referring to adverse side effects.

To these two physicians I say: Stop the spin and be honest. Are you hiding something or are you not "proud" to be representing the drug/drug company? If you are, and you believe in the drug or the company say so.

Is our health care worth the cost?

2007-06-14T06:09:00.000-07:00

A report in today's New Your Times looks at a soon to be released study comparing cost vs quality of heart bypass surgeries in 60 Pennsylvania hospitals. The hospital that received nearly $100,000 per procedure and the hospital that received less than $20,000 had comparable lengths of stay and death rates. And among the twenty hospitals serving metro Philly, two of the highest paid actually had higher-than-expected death rates.

A great quote came from the chief executive of a California group of employers that provides health care for workers. He said "For most consumers, the fact that there is no connection between quality and cost is one of the dirty secrets of medicine." Unfortunately the emotion of health care distances most of us from truly evaluating the actual quality of our outcomes.

The other issue that is extremely disturbing in this study is why is there such a wide range for similar procedures; $100,000 to less than $20,000. So much for managed care and a feather in the cap for unmanaged care!

How's this for another case of "health care gone wild"? The executive director of the Pennsylvania Health Care Cost Containment Council doesn't understand why one hospital was paid an average of $33,549 for a bypass by private insurers and other hospitals received nearly $80,000 - with poorer track records.

He must have tenure.

And finally the worst revelation is that PENNSYLVANIA IS THE FIRST STATE TO MAKE SUCH INFORMATION , NORMALLY CLOSELY GUARDER BY THE HOSPITALS AND THE INSURANCE COMPANIES, AVAILABLE TO EVERYONE.

And, who's laughing (at YOU and ME) all of the way to the bank?

American Health Care - Out of Control, - Questions

2007-05-26T14:39:00.000-07:00

This is Unmanaged Care's first blog entry. Gotta start somewhere so, here we go!

It's a long one and now the learning curve begins.

Let's begin by asking ourselves some questions.

How many Americans lives are strapped due to immense medical bills?

How many Americans lives are strapped due to immense health insurance premiums?

How many Americans have to claim bankruptcy each year due to medical bills?

How many Americans without health insurance wake up at night worrying about what will happen to them if they or a family member develops a medical problem?

How many Americans have no medical insurance and/or can't afford even basic health care for themselves, their children, their family?

How many of the above Americans put a major strain on our health care system because they are unable to afford insurance and have to access the emergency room for their most basic medical (and sometimes dental) needs?

How many of these hard working Americans get ill because they can't afford the preventive and early detection programs that are standard with many if not most health insurance programs?

How many of these Americans develop costly medical problems that may have been treated early and aggressively, thus saving lives and tremendous cost.

How often do we ask about what we are being charged for our medical services, hospital stays, etc. - before we receive the service?

Do we ever ask how that charge was determined?

Do we know how to read a medical bill?

Do we ever challenge a hospital or medical bill?

Do we know how to challenge a hospital or medical bill and interpret the answers we get from the billing and collection people on the other side of the phone or desk?

Do we ever challenge our insurance company as to how they arrived at the amount we have to pay for a service or why they denied a payment?

How often do we leave a medical office or hospital knowing exactly how much we will have to pay?

Do we know how to evaluate if we are being taken advantage of by a medical provider?

Do we pay deductibles and co-pays without looking at our EOBs (explanation of benefits), asking our medical provider's office/hospital to explain the bill or calling our insurance company to explain the bill?

Do we ever ask our physician if he/she has a financial interest in the ancillary service (therapy, MRI, surgery center, etc.) to which that physician referred us?

Do we ever ask the physician how much money the pharmaceutical company is paying him/her for "services" or the "clinical study" he/she is directing?

Have we ever thought about how much money the malpractice attorney gets from the so-called victim's award or settlement?

Have we ever asked the attorneys to “fess up” about the number of cases they take knowing knowing well and sure that it is easier for the physician or hospital to settle rather than pay his colleague (the attorney's, that is) to defend the physician/hospital?

How often have we said something ludicrous like "They ought to, I would, … sue the doctor; or - for that matter sue anyone? (Without realizing that eventually the cost is passed right back to us!)

Have you ever asked a physician how much he/she gets paid to be a medical director of another medical service company that he refers you to?

Did you wonder why some physicians went to medical school when it seems that all they do is order MRIs?

Did you ask any of your senators and congressmen and women why they will not allow Medicare to negotiate with the pharmaceutical companies?

Or, why some of our elected officials and/or staff members (at the time they voted for and/or were authors of/contributors to that bill) are now consultants or lobbyists for drug companies, insurance companies and other medical providers?

However…

On the other hand, have you ever followed a physician throughout the day, night, early morning, week, weekends… to see how much time they put in; how many serious medical decisions they have to make every day; how many lives they save in a year, how much bureaucratic nonsense they have to put up with or how much a good physician has to pay for malpractice insurance?

Well, so much for a few questions, however, there are many, many more questions to be asked as UMC goes forward.

Please feel free to contribute your anecdotes, experiences and comments. Please refer to actual individuals, corporations, entities, etc. ONLY if you have previously published documentation and please cite the source.