James Dobson’s New Role: Candidate Screener
Again I say, This organization should lose its tax-exempt status or remove Dobson as its head. He is either in ministry or in politics, but he can’t do both and we shouldn’t be financing his campaign.
“Everyone knows he’s conservative and has come out strongly for the things that the pro-family movement stands for,” Dobson said of Thompson. “[But] I don’t think he’s a Christian; at least that’s my impression,” Dobson added, saying that such an impression would make it difficult for Thompson to connect with the Republican Party’s conservative Christian base and win the GOP nomination.
- James Dobson, in an interview for US News & World Report
Just for fun, here’s an extra tidbit from the article. Really – Focus on the Family should not be a non-profit organization.
While making it clear he was not endorsing any Republican presidential candidate, Dobson, who is considered the most politically powerful evangelical figure in the country, also said that [Newt] Gingrich was the “brightest guy out there” and “the most articulate politician on the scene today.”
Technorati Tags: James Dobson, Focus on the Family, politics, religion, taxes
Healthcare: Doctors Denying Benefits
Part II of a series on healthcare reforms
Adam J. Wolfberg wrote an excellent commentary for the Boston Globe today on “Hippocritical Doctors”. The issues he describes in his column go right to the heart of the issues at the heart of the PBM problem in my previous posts and deeper to the heart of the overall brokenness of our healthcare system.
Dr. Wolfberg’s daughter has cerebral palsy. The best treatment for her condition is physical therapy which was denied by his insurance by two separate doctors paid to review and deny claims. Describing his experience, he notes the following:
While one of these doctors has no expertise with cerebral palsy, the second one does. In his other job, he cares for children with severe physical disabilities and is a proponent of therapy for disabled children. As he wrote to me in an e-mail, “my personal view is that children with [cerebral palsy] benefit from therapy services.” However, in his review of my appeal, he wrote a careful explanation justifying why the health plan should not pay for the therapy.
So two doctors, one with NO expertise in the area of treating children with cerebral palsy, and one with extensive experience in the field and who holds the personal opinion that children benefit from physical therapy, are charged with saving the insurance company the cost of covering the therapy. Dr. Wolfberg definitely has an opinion about this:
This doctor and others like him are making money denying care – and they might as well hang up their white coats. They may believe that their administrative decisions are medically justifiable. However, it often appears that they are hired because their MD degrees lend a patina of legitimacy to administrative decisions that are based on interpretation of a health plan’s policies, not a chart, lab test, or CT scan.
This is the dark side of our healthcare system: There is only incentive to deny claims, not to evaluate them fairly and approve or deny based upon facts, expertise and the best interest of the patient. The ones who are harmed are the patients, with real conditions, some life-threatening, others not. Dr. Wolfberg concludes with this:
Individuals are harmed when medical care is withheld. Many of these health plan doctors, whose job it is to reject claims, end up being paid to violate the Hippocratic oath they took when they graduated from medical school – to “first, do no harm.”
That is the heart of the matter: There is an irreconcilable conflict when insurance companies place physicians, bound by oath to do no harm, in a position where their decisions are driven by the bottom line instead of the patient’s needs. The most qualified individual to determine a patient’s needs is their own PHYSICIAN. What we have here is a system where the decisions of treating physicians are disrespected in favor of an arms-length review and denial by colleagues who sold their white coat for a paycheck.
Anyone seeking a career as a doctor (particularly one in general practice) today would have to be certifiably insane. Assuming they make it through medical school, their internship and residency, they come away with tremendous debt. Then they are injected into a system where their decisions are second-guessed by insurance company physicians, their malpractice insurance costs equal more than they pay for their homes, their rates are dictated by arbitrary price-fixing and they have to navigate a maze of red tape and paperwork to see patients at all.
Contrast this with one person’s recent experience in an emergency room in France:
…there’s no paper needed anywhere, no forms, no signatures. The French have developed what I would call the USERNAME system of medicine. Just like many web sites who just want you as a user and don’t really care about your real identity, the French Emergency Health care system is the same. They would like to know who you are but they do not need to know who you are when you are in a medical emergency.
…there’s absolutely no paperwork. I had never seen anything like that. You tell them your name, they believe you, you tell them your address, they believe you. They don´t ask you for medical insurance nor for any kind of payment and the whole admission takes at most 45 seconds.
… the legal system is mainly absent from French medicine. When it was all done it was shocking for me to leave the hospital without having to sign any release forms. The surgeon herself notified the administrative staff that I was done and she released me simply saying that I could go home without seeing anybody.
This author concludes:
But what’s wrong with the American health experience is that it is invaded by a lot of elements that are foreign to medicine. The result is a cost so onerous that the percentage of GDP Americans spend on medicine is much higher than in France but the results are very disappointing.
Indeed.
(Hat tip to Kevin, MD for the link to Dr. Wolfberg’s article)
Technorati Tags: medical benefits, claims review, health insurance
Sphere: Related ContentHealthcare: Caremark Profits Rose 15% in 2006
An illustration of why PBMs are such wonderful cash cows for the insurance boys:
For the year ended Dec. 31, Caremark reported that its profit grew 15 percent to $1.07 billion compared with profit of $932 million in 2005. Caremark’s revenue grew 11 percent in 2006 to more than $36.7 billion from revenue of nearly $33 billion in 2005.
Keep in mind that Caremark was being courted by two suitors at the end of 2006: CVS and ExpressScripts. CVS won, just last week.
What those profits mean to the insureds: Denied claims and substandard claims review.
What those profits mean to employers: No reduction in the overall burden of providing pharmacy benefits.
What those profits mean to the healthcare system overall: Erosion of the quality and standard of care available to all insureds, and in particular, insureds who are covered by Medicare or Medicaid.
Did I mention that the CEO of Caremark’s predecessor (AdvancePCS), David Halbert is a good buddy of our esteemed President? Did I also mention that he was one of the key drafters of the current Medicare pharmacy benefit laws? Follow the money.
Technorati Tags: Caremark, AdvancePCS, Medicare, pharmacy benefits, PBM
Sphere: Related ContentHealthcare Reform: PBMs Don’t Save Money
[First in a series on healthcare reform]
Those who read my personal blog know that I have a special place on my hit list for Pharmacy Benefit Managers, or PBMs. This stems from: a) My personal experiences and ongoing struggles to force Caremark to honor their contract and cover prescription ADHD medications which are necessary and which are prescribed by a qualified physician after the proper diagnosis was made, and b) My professional experience as a third-party pension administrator with more than 20 years time in the business and a better-than-average understanding of ERISA and employee benefit plans.
In our current healthcare system, PBMs are viewed as a cost-saving mechanism to deliver prescription medications to insureds under contracting health insurance plans. Let’s be clear: They are an invention of the major insurance companies, who separated themselves from pharmacy benefits in order to continue to realize profits on one of their largest profit centers while becoming non-profit corporations.
In fact, PBMs create an additional layer of administrative costs while serving as a pathway to deny legitimate benefits to insureds while keeping the insurance companies’ involvement at arms-length. They are the unclothed emperor of the health insurance industry, but there are some who are calling them what they are.
Recently, I wrote that Caremark dodged a legal bullet when a Federal Appeals Court ruled that Caremark had no fiduciary liability for denying benefits to covered individuals, defining them as a contract administrator only. I disagree with this ruling for a number of reasons, despite the party line that the Caremark employee-commenters like to leave about how the insurance contract dictates the benefits, Caremark merely carries out the contractual arrangement and so on. The fact is that it is Caremark and Caremark employees, qualified or otherwise, which make the determination as to whether or not to deny access to a “prior authorization required” medication. I have copies of letters proving that, where a gastroenterologist who has not practiced for two years denied my access to ADHD medications.
Now it seems, the courts and state legislators are waking up to that fact. Over on the Health Plan Law blog, they report that PBMs just lost a significant decision, and that there is legislation pending to regulate PBMs in 36 States and the District of Columbia. They report:
Thus, state lawmakers are taking seriously the allegations of fraud and abuse by PBM’s and are doing something about it.
In this particular case, the courts continued to hold that PBMs are not fiduciaries under ERISA. (Note: That determination does not preclude them from being considered fiduciaries under a less restrictive standards. ERISA is one of the most restrictive definitions of fiduciary on the books). This particular aspect of the ruling went to the benefit of the PBM, since it stands to release them from any liability for arbitrary and capricious denial of benefits.
What was good about this particular ruling was the larger issue: State regulation of PBMs. It paves the way for states to force transparency and disclosure, which is definitely a victory for insureds who are subject to their whimsical claims denials, as well as unbridled rebating practices and other methods of lining executives’ pockets.
In other litigation involving Caremark and Medicaid, it seems that Caremark was denying claims for Medicaid reimbursement, because the insureds were not presenting a Caremark card and therefore not compliant with the pharmacy benefit plans they administered. But here’s the catch: The insureds in the TennCare plan could not comply with the card presentation requirement because the agency responsible for Medicaid benefits did not have a card. Further, Medicaid is the final payor if there is other coverage present. In other words, all other avenues for payment have to be exhausted before Medicaid will make a claim for benefits. When TennCare would file with Caremark for reimbursement, they were denied on the basis of not presenting a card and not filing a timely claim.
Caremark effectively constructed a Catch-22 that insureds could not navigate their way through: They created compliance requirements that the insureds could not meet.
The court ruled that the requirements were discriminatory against Medicaid; however, Caremark has still weaseled away from any liability by passing it through to the insurance company it serves. If Caremark has the power to deny payment of benefits and is subsequently found to be liable for those benefits, the cost for the benefits pass through to the insurance company.
All of this leads back to this question: What good is the PBM?
The answer: Not much. On the Health Plan Law Blog again, an excellent analysis of the utility (or non-utility) of the current PBM structure.
PBM’s promise to deliver cost savings to health plans through plan design, effective purchases of appropriate pharmaceuticals, disease management and various ancillary services. The PBM’s dictate the formularies that drive traffic toward certain drugs and away from others based on reimbursements that the PBM’s specify. Inasmuch as the big are posed to get even bigger, these current events present an occasion to reflect on the utility and effect of the PBM mechanism in the American health care system.
The entire post should be required reading for anyone interested in our current healthcare delivery system and the corrupt structure of the PBMs. It points out that the use of rebates is rarely passed through to the consumer, though the price for acquisition of prescription medications is increased in the United states by 50-70%, mail order savings are not passed through to the consumer, there is non-transparency of price fixing on generic medications, bloated costs associated with an additional layer of administration, and the liability for claims denial skips the PBM and lands at the feet of the employer and insurer anyway. Those factors say to me that the answer to whether PBMs help or hurt the healthcare system is clearly “NO”.
If we are to have any hope of arriving at meaningful healthcare reform, it’s going to be necessary to shed the idea that there are sacred cows which cannot be sacrificed. There isn’t much dispute that the current system is broken, and rather than putting a bandaid on it, we’d do better to look hard at each piece of the current system and make a decision about whether it should remain in a reformed system. I do not believe there is a place for PBMs in the reformed system. Claims management for pharmaceuticals should follow a standardized procedure that encompasses all claims, with no special carve-out for pharmacy benefits. I would be much more supportive of a system that applied fair and non-discriminatory standards to prescription drug coverage than the arbitrary, capricious, and profit-taking system we have now.
Technorati Tags: Caremark, PBM, ExpressScripts, healthcare reform, pharmacy benefits, courts, legal
Sphere: Related ContentPolicy, Priorities and Management
Margaret Chiara was commended for carrying out Bush policy on firearms prosecutions in one batch of documents used to build the case to fire Carol Lam, yet in the end, it didn’t matter — she was also fired for political expediency. They can’t even come up with a reason for her dismissal that makes sense.
From Moschella’s testimony before US House Judiciary Committee:
In carrying out these responsibilities they serve at the pleasure of the President and report to the Attorney General. If
a judgment is made that they are not executing their responsibilities in a manner that furthers the
management and policy of departmental leadership, then it is appropriate that they be
asked to resign so that they can be replaced by other individuals who will.
– page 20, document 1-8
To be clear, it was for reasons related to policy, priorities and management – what has
been referred to broadly as ‘performance-related” reasons – that these U.S. Attorneys were asked
to resign.
- page 20, document 1-8
Margaret Chiara to Paul McNulty, March 4, 2007
I respectfully request that you reconsider the rationale of poor performance as the basis for my dismissal. It is in our mutual interest to retract this erroneous explanation while there is still time. Please simply state that a presidentially appointed position is not an entitlement. No other explanation is needed.
Margaret Chiara to Paul McNulty, cc: Michael Elston, March 6, 2007
Today’s Congressional events make dear that I am, indeed, among the “USA – 8″. Shortly after his opening statement, but before citing the perceived deficiencies of my former colleagues, Will Moschella stated that the two United States Attorneys not present were dismissed because of management problems. Apparently Kevin Ryan (whom I do not know) and I share the same reason for termination.
Michael Elston told me on more than one occasion, that the rationale for dismissal was on a continuum of sorts and that I am on the de minimus end after Dan Bogden. It Is abundantly clear that this regrettable situation could have been better managed if the reasons for the dismissals were initially communicated to the affected United States Attorneys.
So, l now need to know what is the management problem to which Mr. Moschella referred?
Technorati Tags: Margaret Chiara, prosecutorgate, US Attorneys, Scandal
Sphere: Related ContentDavid Iglesias: Fired for being Non-Political
In the NY Times today, David Iglesias gives his side of the story. Iglesias was the US Attorney in New Mexico, and had an exemplary record (he had even participated in the peer oversight committee for all US Attorneys) until someone decided he should be fired. His editorial is reproduced here because of the NY Times insistence on placing content behind the paid content curtain after 7 days.
Why I Was Fired
By DAVID C. IGLESIASAlbuquerque
WITH this week’s release of more than 3,000 Justice Department e-mail messages about the dismissal of eight federal prosecutors, it seems clear that politics played a role in the ousters.
Of course, as one of the eight, I’ve felt this way for some time. But now that the record is out there in black and white for the rest of the country to see, the argument that we were fired for “performance related” reasons (in the words of Deputy Attorney General Paul McNulty) is starting to look more than a little wobbly.
United States attorneys have a long history of being insulated from politics. Although we receive our appointments through the political process (I am a Republican who was recommended by Senator Pete Domenici), we are expected to be apolitical once we are in office. I will never forget John Ashcroft, then the attorney general, telling me during the summer of 2001 that politics should play no role during my tenure. I took that message to heart. Little did I know that I could be fired for not being political.
Politics entered my life with two phone calls that I received last fall, just before the November election. One came from Representative Heather Wilson and the other from Senator Domenici, both Republicans from my state, New Mexico.
Ms. Wilson asked me about sealed indictments pertaining to a politically charged corruption case widely reported in the news media involving local Democrats. Her question instantly put me on guard. Prosecutors may not legally talk about indictments, so I was evasive. Shortly after speaking to Ms. Wilson, I received a call from Senator Domenici at my home. The senator wanted to know whether I was going to file corruption charges — the cases Ms. Wilson had been asking about — before November. When I told him that I didn’t think so, he said, “I am very sorry to hear that,” and the line went dead.
A few weeks after those phone calls, my name was added to a list of United States attorneys who would be asked to resign — even though I had excellent office evaluations, the biggest political corruption prosecutions in New Mexico history, a record number of overall prosecutions and a 95 percent conviction rate. (In one of the documents released this week, I was deemed a “diverse up and comer” in 2004. Two years later I was asked to resign with no reasons given.)
When some of my fired colleagues — Daniel Bogden of Las Vegas; Paul Charlton of Phoenix; H. E. Cummins III of Little Rock, Ark.; Carol Lam of San Diego; and John McKay of Seattle — and I testified before Congress on March 6, a disturbing pattern began to emerge. Not only had we not been insulated from politics, we had apparently been singled out for political reasons. (Among the Justice Department’s released documents is one describing the office of Senator Domenici as being “happy as a clam” that I was fired.)
As this story has unfolded these last few weeks, much has been made of my decision to not prosecute alleged voter fraud in New Mexico. Without the benefit of reviewing evidence gleaned from F.B.I. investigative reports, party officials in my state have said that I should have begun a prosecution. What the critics, who don’t have any experience as prosecutors, have asserted is reprehensible — namely that I should have proceeded without having proof beyond a reasonable doubt. The public has a right to believe that prosecution decisions are made on legal, not political, grounds.
What’s more, their narrative has largely ignored that I was one of just two United States attorneys in the country to create a voter-fraud task force in 2004. Mine was bipartisan, and it included state and local law enforcement and election officials.
After reviewing more than 100 complaints of voter fraud, I felt there was one possible case that should be prosecuted federally. I worked with the F.B.I. and the Justice Department’s public integrity section. As much as I wanted to prosecute the case, I could not overcome evidentiary problems. The Justice Department and the F.B.I. did not disagree with my decision in the end not to prosecute.
Good has already come from this scandal. Yesterday, the Senate voted to overturn a 2006 provision in the Patriot Act that allows the attorney general to appoint indefinite interim United States attorneys. The attorney general’s chief of staff has resigned and been replaced by a respected career federal prosecutor, Chuck Rosenberg. The president and attorney general have admitted that “mistakes were made,” and Mr. Domenici and Ms. Wilson have publicly acknowledged calling me.
President Bush addressed this scandal yesterday. I appreciate his gratitude for my service — this marks the first time I have been thanked. But only a written retraction by the Justice Department setting the record straight regarding my performance would settle the issue for me.
Technorati Tags: David Iglesias, US Attorney, Karl Rove
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