Scandals seem to follow Larry B Anderson (Video and comments)
See all posts for Larry Anderson.
See all posts in SDER blog re Tri-City Healthcare.
Larry B Anderson is now CEO of Tri-City Medical in Oceanside, which is funded by the taxpayers of Oceanside, Carlsbad, and Vista CA, a Tri-City Heathcare District.
(Video) Tina Jillings calls out Tri City Medical Center Board of Director Rose Marie Reno
http://www.youtube.com/watch?v=axPknhw3oH4
http://bit.ly/gBKr26
...Judge Mills denied all restraining orders against the outspoken hospital director. (See second story below.)
OCEANSIDE: Tri-City again sanctions embattled director
By PAUL SISSON
North County Times - The Californian
March 31, 2011
Tri-City Healthcare District directors again sanctioned one of their own Thursday, deciding not to wait for a Superior Court judge's ruling on six pending restraining orders against the woman.
On a 5-1 vote, board members approved a seventh sanction against hospital director Kathleen Sterling for her alleged role in two pushing incidents that occurred at a hospital board meeting Feb. 24.
The board's censure accuses Sterling of pushing and injuring hospital security guards at the meeting in two attempts to enter the board's meeting room at Tri-City Medical Center, even though the board's previous sanctions required her to stay out.
The facts cited are the same as those in six pending requests for permanent restraining orders against Sterling. Judge Richard E. Mills is deliberating whether to grant the orders after a four-day hearing that ended Thursday.
At the hearing's conclusion, Mills expressed reservations about whether the incidents truly constituted battery or an escalating pattern of violent behavior by Sterling, and said he would rule on the orders Monday.
Sterling has said all along that she had a right to enter the room before the meeting started in order to visit with her constituents. She said a second incident, which occurred between the board's open and closed sessions, was her attempt to notify board Chairwoman RoseMarie Reno that teleconferencing and video equipment, which she relies upon to participate in the meetings from a different room at the hospital, was not working.
Several community members who sat through all four days of the restraining-order hearing spoke in support of Sterling at Thursday's meeting.
Tina Jillings of Vista noted that Mills had expressed doubts in court about whether the incidents are battery, and she berated the board for proceeding even though Mills has not yet ruled.
"None of the allegations that you are making today ... have been proven in court," Jillings said.
Sterling attended Thursday's meeting from a separate room in the hospital's facilities building because of a temporary restraining order approved March 4, where again there were problems with the communications system. Sterling also said that she was missing one page of the proposed censure that the board approved.
Scott McMillan, Sterling's attorney, said Wednesday that he will help her challenge all of the board's censures in court.
He said he intends to work pro bono on a belief that Sterling is the victim of a board that wants to stifle her regular, and often loud, criticism of hospital policy.
Except to read the censure as written, hospital directors did not discuss the latest censure before voting Thursday. Director Randall Horton voted against the sanction. It was unclear whether Sterling voted no or abstained.
OCEANSIDE: Judge rejects restraining order against Sterling
By Paul Sisson
North County Times - The Californian
April 4, 2011
A judge refused Monday to grant permanent restraining orders against Tri-City Healthcare District Director Kathleen Sterling, saying there was no clear and convincing evidence that Sterling posed a risk to the safety of board members or employees at the Oceanside medical center.
A seventh censure against Sterling, 60, passed by the hospital board on March 31, requires her to continue attending meetings from a location outside the main hospital building.
Walking out of the courtroom Monday morning, Sterling didn't pause to celebrate, saying other legal battles remain.
"We have a long road ahead of us to ensure that my constituents have representation," she said.
The hospital director still faces a felony charge of vote trading and a $100,000 civil lawsuit brought by the hospital and one security guard regarding the events that occurred during a Feb. 24 hospital board meeting.
The requests for restraining orders ---- made by three Tri-City directors and three employees ---- centered on two allegations of violence that some witnesses said took place before and after that meeting.
The witnesses said Sterling injured hospital security guards while trying to push her way into the board room, from which she had been barred after being censured six times by her colleagues in the past several months.
Sterling has always insisted that the censures pertained to the meeting itself and not to her ability to enter the room and chat with constituents before and after.
In making his ruling, Judge Richard E. Mills agreed, saying that his reading of the censures indicates Sterling was barred only during the meetings themselves.
"It was not proved by clear and convincing evidence, to me, that Ms. Sterling did not have a right to enter the board room before the meeting," Mills said.
The judge added that he was also not convinced that Sterling intended to injure anyone on Feb. 24.
"This court cannot find, by preponderance of the evidence, that Ms. Sterling committed an assault or battery. Her intention was clearly to get around the guards before the meeting, not to come into contact with them," Mills said.
Those who testified in favor of the restraining order during the four-day trial said they feared that Sterling's behavior at that meeting was a sign that her often vocal and sometimes in-your-face behavior was escalating and becoming more dangerous.
After the judge's decision Monday, Tri-City attorney Allison Borkenheim said the requests for the restraining order were always about safety.
"We're obviously disappointed, but this was always about protecting the employees of Tri-City," Borkenheim said. "There was a very high burden (of proof), as (Judge Mills) mentioned, and unfortunately the conduct did not rise to the level of that burden, but we believe we were right in bringing the case forward, because it was about the safety of the employees."
Sterling's attorney, Scott McMillan, said he plans to pursue attorney fees against the hospital and challenge the censures that prevent Sterling from attending board meetings in person.
McMillan said he will also ask Tri-City to dismiss the $100,000 lawsuit it has filed against Sterling.
The suit alleges that Sterling injured a hospital security guard and has damaged the hospital's reputation.
Borkenheim declined Monday to discuss the hospital's legal strategy on any pending cases.
CORRECTION: Sterling must still attend meetings from adjacent building
Tri-City Medical Center director Kathleen Sterling will continue to attend board meetings from a building adjacent to the hospital, despite a judge's recent denial of six restraining order requests against her. The original version of this story incorrectly said that denial of the restraining orders allowed Sterling to return to the main hospital building, but a seventh censure, passed by the hospital board on March 31, requires her to "be excluded from the main hospital building" for the remainder of her term. We apologize.
Friday, April 22, 2011
Saturday, April 16, 2011
The two-tiered justice system: an illustration
The two-tiered justice system: an illustration
By Glenn Greenwald
Apr 14, 2011
Of all the topics on which I've focused, I've likely written most about America's two-tiered justice system -- the way in which political and financial elites now enjoy virtually full-scale legal immunity for even the most egregious lawbreaking, while ordinary Americans, especially the poor and racial and ethnic minorities, are subjected to exactly the opposite treatment: the world's largest prison state and most merciless justice system. That full-scale destruction of the rule of law is also the topic of my forthcoming book.
But The New York Times this morning has a long article so perfectly illustrating what I mean by "two-tiered justice system" -- and the way in which it obliterates the core covenant of the American Founding: equality before the law -- that it's impossible for me not to highlight it.
The article's headline tells most of the story: "In Financial Crisis, No Prosecutions of Top Figures." It asks: "why, in the aftermath of a financial mess that generated hundreds of billions in losses, have no high-profile participants in the disaster been prosecuted?" And it recounts that not only have no high-level culprits been indicted (or even subjected to meaningful criminal investigations), but few have suffered any financial repercussions in the form of civil enforcements or other lawsuits. The evidence of rampant criminality that led to the 2008 financial crisis is overwhelming, but perhaps the clearest and most compelling such evidence comes from long-time Wall-Street-servant Alan Greenspan; even he was forced to acknowledge that much of the precipitating conduct was "certainly illegal and... clearly criminal" and that "a lot of that stuff was just plain fraud."
By Glenn Greenwald
Apr 14, 2011
Of all the topics on which I've focused, I've likely written most about America's two-tiered justice system -- the way in which political and financial elites now enjoy virtually full-scale legal immunity for even the most egregious lawbreaking, while ordinary Americans, especially the poor and racial and ethnic minorities, are subjected to exactly the opposite treatment: the world's largest prison state and most merciless justice system. That full-scale destruction of the rule of law is also the topic of my forthcoming book.
But The New York Times this morning has a long article so perfectly illustrating what I mean by "two-tiered justice system" -- and the way in which it obliterates the core covenant of the American Founding: equality before the law -- that it's impossible for me not to highlight it.
The article's headline tells most of the story: "In Financial Crisis, No Prosecutions of Top Figures." It asks: "why, in the aftermath of a financial mess that generated hundreds of billions in losses, have no high-profile participants in the disaster been prosecuted?" And it recounts that not only have no high-level culprits been indicted (or even subjected to meaningful criminal investigations), but few have suffered any financial repercussions in the form of civil enforcements or other lawsuits. The evidence of rampant criminality that led to the 2008 financial crisis is overwhelming, but perhaps the clearest and most compelling such evidence comes from long-time Wall-Street-servant Alan Greenspan; even he was forced to acknowledge that much of the precipitating conduct was "certainly illegal and... clearly criminal" and that "a lot of that stuff was just plain fraud."
A long way to go on health reform
A long way to go on health reform
By Umang Malhotra
San Diego Union-Tribune
April 15, 2011
The American health care system has been leaking like an old car for decades. Congress, in the search for a universal solution, is using a piecemeal or duct tape approach to stop the leaks. Our lawmakers bemoan the expense, while using the most cost-ineffective solution.
The system is undeniably broken. By reputable measurements, America ranks first in obesity, 27th in life expectancy, 37th in infant mortality and 54th in access to health care (tied with Fiji). CIA World Factbook figures are even worse. Despite the U.S. spending twice what the next affluent country spends per person, all international comparisons show that America lies near the bottom on health care. According to AARP data, it also lags far behind other countries in long-term care for seniors. Nearly 50 million people in the U.S. are uninsured; millions are underinsured, and more than half the personal bankruptcies – over 1 million a year – are caused by medical bills, something unheard of elsewhere.
America is the only affluent nation unable to provide universal health care for its residents – astonishing for the richest country in the world.
The reason is a money-driven system – riddled with interest groups selfishly fighting to protect their own constituencies. With the cost of health care rising at more than twice the rate of inflation, it is already a huge problem for businesses and governments. If it continues, it will be disastrous.
The health care bill signed by President Barack Obama is neither universal nor is it likely to ever be cost-effective. It is nearly 2,700 pages, and with the addition of all the enabling regulations, becomes a minefield open to interpretations in the hands of insurance companies and lawyers – a bureaucratic nightmare. The cost of premiums and payments from your pockets will keep on rising.
Sadly, many legislators turn the issue into an ideological controversy, rather than a search for common good. They bury their heads in a sand of partisanship, power and hypocrisy; accepting government health care plans for their families while denying the same to the rest of the population.
Other issues, uniquely American, are lobbying by insurance and drug companies, and the involvement of vast armies of lawyers. The same drug costs much more in America than in other countries, while frivolous malpractice lawsuits escalate the costly practice of defensive medicine...
By Umang Malhotra
San Diego Union-Tribune
April 15, 2011
The American health care system has been leaking like an old car for decades. Congress, in the search for a universal solution, is using a piecemeal or duct tape approach to stop the leaks. Our lawmakers bemoan the expense, while using the most cost-ineffective solution.
The system is undeniably broken. By reputable measurements, America ranks first in obesity, 27th in life expectancy, 37th in infant mortality and 54th in access to health care (tied with Fiji). CIA World Factbook figures are even worse. Despite the U.S. spending twice what the next affluent country spends per person, all international comparisons show that America lies near the bottom on health care. According to AARP data, it also lags far behind other countries in long-term care for seniors. Nearly 50 million people in the U.S. are uninsured; millions are underinsured, and more than half the personal bankruptcies – over 1 million a year – are caused by medical bills, something unheard of elsewhere.
America is the only affluent nation unable to provide universal health care for its residents – astonishing for the richest country in the world.
The reason is a money-driven system – riddled with interest groups selfishly fighting to protect their own constituencies. With the cost of health care rising at more than twice the rate of inflation, it is already a huge problem for businesses and governments. If it continues, it will be disastrous.
The health care bill signed by President Barack Obama is neither universal nor is it likely to ever be cost-effective. It is nearly 2,700 pages, and with the addition of all the enabling regulations, becomes a minefield open to interpretations in the hands of insurance companies and lawyers – a bureaucratic nightmare. The cost of premiums and payments from your pockets will keep on rising.
Sadly, many legislators turn the issue into an ideological controversy, rather than a search for common good. They bury their heads in a sand of partisanship, power and hypocrisy; accepting government health care plans for their families while denying the same to the rest of the population.
Other issues, uniquely American, are lobbying by insurance and drug companies, and the involvement of vast armies of lawyers. The same drug costs much more in America than in other countries, while frivolous malpractice lawsuits escalate the costly practice of defensive medicine...
Inside George Soros’s “Monstrous Monkey House”
April 12, 2011
Inside George Soros’s “Monstrous Monkey House”
Posted by John Cassidy
The New Yorker
Snow-capped peaks; nightcaps with Larry Summers; discussions of complexity theory over breakfast; Tennyson quotations from Gordon Brown at lunch. No it’s not Davos—it’s Bretton Woods, New Hampshire, where over the weekend the Institute for New Economic Thinking (INET), which George Soros set up in the wake of the financial crisis, held its second annual conference. Last year’s inaugural get-together was held at King’s College, Cambridge, the home of Keynes. This year’s location also had a strong link to J.M.K. It was the grand old Mount Washington Hotel, which in the summer of 1944 played host to a famous international conference about the post-war monetary system.
Soros launched INET in 2009 with the intention of fostering fresh ways of thinking to replace an economic orthodoxy that manifestly had failed. Two years on, it’s not clear how far he’s succeeding in that enterprise, but Rob Johnson, a former Capitol Hill staffer and employee of Soros Fund Management, who heads up INET, has certainly put its annual meeting on the map. This year’s conference attracted more than two hundred economists, policy makers, and journalists from around the world. The subjects covered ranged from “Too Big to Fail” to the European debt crisis to “New New Trade Theory.”...
Before closing, Summers took a well-aimed shot at policymakers across the Atlantic. Wolf asked him whether the embrace of austerity policies in Europe, and particularly in Britain, wasn’t “basically nuts.” Summers replied: “I’m too soon out of government to use a word like nuts. But I find the idea of expansionary fiscal contraction, in the context of the world in which we live, to be every bit as oxymoronic as it sounds. And I think the consequences are likely to be severe for the countries involved.”...
Inside George Soros’s “Monstrous Monkey House”
Posted by John Cassidy
The New Yorker
Snow-capped peaks; nightcaps with Larry Summers; discussions of complexity theory over breakfast; Tennyson quotations from Gordon Brown at lunch. No it’s not Davos—it’s Bretton Woods, New Hampshire, where over the weekend the Institute for New Economic Thinking (INET), which George Soros set up in the wake of the financial crisis, held its second annual conference. Last year’s inaugural get-together was held at King’s College, Cambridge, the home of Keynes. This year’s location also had a strong link to J.M.K. It was the grand old Mount Washington Hotel, which in the summer of 1944 played host to a famous international conference about the post-war monetary system.
Soros launched INET in 2009 with the intention of fostering fresh ways of thinking to replace an economic orthodoxy that manifestly had failed. Two years on, it’s not clear how far he’s succeeding in that enterprise, but Rob Johnson, a former Capitol Hill staffer and employee of Soros Fund Management, who heads up INET, has certainly put its annual meeting on the map. This year’s conference attracted more than two hundred economists, policy makers, and journalists from around the world. The subjects covered ranged from “Too Big to Fail” to the European debt crisis to “New New Trade Theory.”...
Before closing, Summers took a well-aimed shot at policymakers across the Atlantic. Wolf asked him whether the embrace of austerity policies in Europe, and particularly in Britain, wasn’t “basically nuts.” Summers replied: “I’m too soon out of government to use a word like nuts. But I find the idea of expansionary fiscal contraction, in the context of the world in which we live, to be every bit as oxymoronic as it sounds. And I think the consequences are likely to be severe for the countries involved.”...
Friday, April 15, 2011
Insurer denied needed medical tests, Senate finds
Insurer denied needed medical tests, Senate finds
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
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Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
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Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
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Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
In 10 to 15 percent of cases, crucial heart test was rejected by firm hired to screen requests
By Lisa Myers, Rich Gardella and Azriel Relph
NBC News
2011-04-16
“I gotta tell you Kathy, I can’t keep living like this,” said Michael Fields, 46, who was experiencing tightness in his chest, numbness in an arm and light-headedness as he begged the voice at the other end of the line for help. “It’s been going on for weeks. I don’t know what else to do. I mean you know, I’m trapped here.”
“Alright, let me put you back on hold,” came the reply.
Fields, who lives with his wife and son in Elkton, Md., was not speaking with a 911 operator. He was calling a representative from his insurance provider, Blue Cross/ Blue Shield of Delaware, and he was about to find out that for the third time he was being denied a crucial test to determine if he had coronary artery disease — a nuclear cardiac stress test.
A Senate investigation released Friday found a pattern of inappropriate denials for tests like the one Fields’ doctors say he should have received from the start.
The investigation looked at 1,600 cases over a six-month period from 2009 to 2010 involving requests for nuclear cardiac stress tests in the state of Delaware. All of the cases studied were handled by MedSolutions, a company that screens test requests in the state for Blue Cross/Blue Shield of Delaware and other insurers.
According to the report, “10 to 15 (percent) of requested tests appear to have been denied inappropriately. MedSolutions and the Delaware insurers denied a significant number of medically necessary nuclear stress tests.”
“It is a huge number,” Sen. John D. Rockefeller, chairman of the Senate Commerce Committee told NBC News. “I don't care if it is 5 to 2 percent, it is a huge percent. It follows a pattern that never stops with health insurance companies. It is always the bottom line. The more they say no, the more money they make.”
Advertise | AdChoices
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Michael Fields was one of those found to have been wrongly denied.
Request for test denied repeatedly
When Fields first complained about his symptoms over a year ago, his physician sent him to get a stress test. The request was denied by Blue Cross Blue Shield, and denied again after two appeals by the physician. Finally, his doctor sent him to the hospital, where cardiologists found that a key blood vessel to his heart was almost completely blocked.
Phone calls edited to remove personal info, holds
The next day Fields had an emergency quadruple heart bypass.
“This is as serious as you can get,” said Dr. Andrew Doorey, the cardiologist who saw Fields at the hospital. “There’s no second chance with this.”
When Doorey learned that Fields had been repeatedly denied a stress test by Blue Cross/Blue Shield and MedSolutions, he fired off a complaint to the Delaware Insurance Commission.
Coronary artery disease occurs when arteries supplying oxygen-rich blood to the heart become blocked. It causes one out of every six adult deaths in the United States, according to the American Heart Association. Nuclear stress tests are a way of taking a three-dimensional picture of the heart and diagnosing the disease. Radioactive “tracers” are injected into the bloodstream and an X-ray camera takes multiple pictures of the heart from different angles.
Experts say the nuclear stress tests have a diagnostic accuracy in the 90 percent range. A basic stress test, in which a patient exercises on a treadmill while connected to electrocardiogram (or ECG) equipment, is accurate 70 percent of the time. According to data from the American Medical Association, nuclear stress tests can cost up to five times as much as an ECG test.
Concerns over increasing costs
Over the past decade, there have been concerns about the rapidly increasing cost of imaging tests, as well as accusations that physicians — some of whom own and operate the expensive equipment used — were overutilizing the tests.
In response, in 2005 the American College of Cardiology published guidelines for the appropriate use of nuclear stress tests. In 2009 after one in five heart scans performed were found to be unnecessary, those guidelines were updated. Meanwhile, insurers began using third-party “radiation benefit management” companies, like MedSolutions, to conduct prior authorization reviews of test requests.
MedSolutions claims on its website that it can deliver insurers savings of 25 to 30 percent, stating that it “rewards the clinically accurate providers while protecting patients from unnecessary utilization and associated risks.” But, according to a report from the Delaware Insurance Commission, the company had a financial incentive to deny tests. The report says a provision of MedSolutions’ contract with Blue Cross Blue Shield of Delaware required it to return 10 percent of its administrative fee if the annual costs associated with the services it managed did not fall by 20 percent.
According to Delaware law, it is illegal for an administrator’s fees to be “contingent upon savings effected in the adjustment, settlement and payment of losses covered by the insurer’s obligations.” MedSolutions and Blue Cross Blue Shield say they dropped the provision last year — after the investigation had begun and before any annual cost savings had been calculated.
Karen Weldin Stewart, Delaware’s Insurance Commissioner, was mildly critical of Blue Cross Blue Shield’s overall handling of nuclear stress tests. She complained that, in some cases, tests were denied by medical personnel not fully qualified to make the decision. She said that the company used guidelines less likely to result in approval of the tests than those adopted by the American College of Cardiologists.
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Insurer asked to change guidelines
“Overall, we did not find a lot of problems,” said Stewart. “What troubled us most was that the criteria they were using was more stringent than the American College of Cardiologists uses.” The state is asking Blue Cross to change to the less restrictive guidelines.
In the ACC guidelines, patients with intermediate and high risk to coronary artery disease should be considered for a nuclear stress test. But according to MedSolutions’ guidelines, even a high-risk patient — like Michael Fields, who was a diabetic and a smoker with a family history of heart disease — must first take the cheaper and less accurate ECG treadmill test.
“A stress test, had it been carried out when it was first ordered almost a month earlier, would have definitely picked this up,” said Doorey. “This is someone who was a perfect candidate by broad consensus and the only reason to deny him would be to cut your expenses.”
Neither MedSolutions or Blue Cross Blue Shield would comment on Fields’ case, citing privacy laws.
In a statement to NBC News, MedSolutions' chief medical officer, Dr. Gregg Allen, disputed the Senate's findings and argued that cardiologists overuse these tests, often because they have a financial interest.
MedSolutions has developed guidelines to "ensure that patients receive the right tests at the right time," it said. "At no point, ever, is any criteria considered that doesn’t put quality and safety patient care first."
1.
Only on msnbc.com
1. Ryan budget plan passes House; only 4 GOP no votes
2. 'Creepy' new software is a stalker's dream
3. Cosmic Log: Is this the age of megaquakes?
4. Why watching 'The Office' makes us cringe
5. 10 deadly do-it-yourself gadgets
6. Americans moving near nuclear reactors
7. Wacky minds behind Taiwan's viral videos
Blue Cross/Blue Shield of Delaware said in a statement that it has since changed its procedures, provided staff with additional education, and no longer requires pre-approval of nuclear stress tests. (Manufacturers of machines for these tests include Phillips, Siemens and General Electric — a part owner of NBC Universal, a partner with Microsoft in msnbc.com.)
Michael Fields still has not gotten over the desperation he felt last year. He considers himself lucky to be alive and treasures time with his son even more.
“They're playing God,” Fields said of his insurance company and its subcontractor. “I'm probably cheaper dead than alive to them.”
He pointed to a picture of his 10-year-old son: “I almost left him without a father. It’s crazy.”
Thursday, April 14, 2011
Goldman Sachs Charges Up to Justice Department, Levin Says
Goldman Sachs Charges Up to Justice Department, Levin Says
By Clea Benson
Apr 14, 2011
Bloomberg
Goldman Sachs CEO Lloyd Blankfein...testified at a Senate Homeland Security and Governmental Affairs subcommittee hearing on Wall Street and the financial crisis, in Washington, April 27, 2010.
Senator Carl Levin, a Democrat from Michigan, talks about Goldman Sachs Group Inc.'s communication to clients and Congress about the firm's bets on securities tied to the housing market...
The U.S. Justice Department and regulators will have to determine whether employees and executives of Goldman Sachs Group Inc. (GS) violated any laws when they traded securities tied to the housing market and testified to Congress about the transactions, Senator Carl Levin said.
The Michigan Democrat, who released the findings of a two- year inquiry into the 2008 financial crisis yesterday, said today in an interview with Bloomberg Television’s “Street Smart with Carol Massar and Matt Miller” that he wanted to send the report to federal prosecutors and the Securities and Exchange Commission. Lawmakers don’t have the authority to declare whether the activities were illegal, he said.
“That is not for Congress to determine whether or not a crime was committed or whether or not he violated the security laws,” Levin said, referring to Goldman Sachs Chief Executive Officer Lloyd Blankfein. “That is for the Justice Department and that is for the SEC to make those determinations.”
Levin, who is chairman of the Permanent Subcommittee on Investigations, said he also wants to forward all of the testimony that Goldman Sachs executives gave before his panel so the Justice Department can determine whether any statements constitute perjury...
By Clea Benson
Apr 14, 2011
Bloomberg
Goldman Sachs CEO Lloyd Blankfein...testified at a Senate Homeland Security and Governmental Affairs subcommittee hearing on Wall Street and the financial crisis, in Washington, April 27, 2010.
Senator Carl Levin, a Democrat from Michigan, talks about Goldman Sachs Group Inc.'s communication to clients and Congress about the firm's bets on securities tied to the housing market...
The U.S. Justice Department and regulators will have to determine whether employees and executives of Goldman Sachs Group Inc. (GS) violated any laws when they traded securities tied to the housing market and testified to Congress about the transactions, Senator Carl Levin said.
The Michigan Democrat, who released the findings of a two- year inquiry into the 2008 financial crisis yesterday, said today in an interview with Bloomberg Television’s “Street Smart with Carol Massar and Matt Miller” that he wanted to send the report to federal prosecutors and the Securities and Exchange Commission. Lawmakers don’t have the authority to declare whether the activities were illegal, he said.
“That is not for Congress to determine whether or not a crime was committed or whether or not he violated the security laws,” Levin said, referring to Goldman Sachs Chief Executive Officer Lloyd Blankfein. “That is for the Justice Department and that is for the SEC to make those determinations.”
Levin, who is chairman of the Permanent Subcommittee on Investigations, said he also wants to forward all of the testimony that Goldman Sachs executives gave before his panel so the Justice Department can determine whether any statements constitute perjury...
Tuesday, April 5, 2011
Hospitals and insurers may be illegally blocking competitors.
Health-care sector facing increased antitrust scrutiny
By Julie Appleby
Washington Post
April 4, 2011
Amid growing concern about rising health-care costs, the Justice Department is stepping up efforts against hospitals and insurers that it suspects are illegally blocking competitors.
Department officials are not talking, but a recent settlement the government reached with a Texas hospital system has antitrust experts buzzing.
In the first case of its kind since 1999, the department sued United Regional Health System in Wichita Falls for allegedly giving health insurers strong incentives not to do business with rival hospitals. That practice allowed United Regional to keep its monopoly, according to the lawsuit, while also becoming one of the most expensive hospitals in the state.
The hospital disputes some of the findings of the case but agreed late last month to a settlement requiring it to change how it contracts with private insurers.
Antitrust lawyer Matthew Cantor of the New York law firm Constantine Cannon, who was not connected with the case, said the court challenge shows that the Justice Department is “looking at ways in which dominant hospitals or conglomerations of medical practices are conspiring to increase medical costs.”
In the past two years, the department also has settled with a group of Idaho orthopedists over allegations that they conspired to drive up prices and stopped the two biggest Lansing, Mich., insurers from merging, citing “a likelihood of unilateral price increases.”
The Texas settlement comes on the heels of a department lawsuit filed in October against Blue Cross Blue Shield of Michigan over contracts that require hospitals to guarantee the lowest prices to the Blues plan. The department contends that the contracts improperly raise costs for other insurers and their customers. Blues plan administrators say the lawsuit is without merit and are fighting it.
The Wall Street Journal reported that the department has expanded its investigation of such contracts to other insurers, including CareFirst BlueCross BlueShield, which does business in Northern Virginia, Maryland and the District.
Even as they increase enforcement efforts, federal antitrust authorities are planning a more flexible response to select groups of doctors and hospitals that form accountable-care organizations, or ACOs, an experimental model of payment and care authorized by last year’s health law. But, at least initially, ACOs will compose only a tiny fraction of the health-care market; the type of actions that got the Texas hospital in trouble, for example, would remain illegal for ACOs.
Robert Leibenluft, former assistant director for health care in the Federal Trade Commission’s Bureau of Competition under President George W. Bush, sees a pattern in the lawsuits filed in Texas and Michigan: “Increased scrutiny by the DOJ of both health plans and providers who have market power.” He specializes in antitrust law at the D.C. firm Hogan Lovells.
The department’s actions coincide with increasing concern by policy experts over the impact of a decade of consolidation among hospitals, insurers and doctor groups. Some mergers have led to sharp increases in health-care costs, the FTC has found in a number of studies, although not all do.
Justice officials would not comment on the Texas case or others they are working on.
At a conference last May in Arlington, Justice antitrust chief Christine Varney promised an aggressive approach to challenging health-sector mergers and contracts used to keep out new rivals.
The success of the health-care overhaul law approved by Congress, she said, partly depends on “healthy competitive markets free from undue concentration and anti-competitive behavior.”
While watching for those problems, Varney told lawyers at that conference that the department will try not to impede more health-sector partnerships to improve quality and contain costs. Some policy experts say the new emphasis on coordination — encouraged by the health law — could also spur more market consolidation among medical providers in some markets.
“The key,” she said, “is whether we can gain those benefits without sacrificing meaningful competition.”
The Texas case revolved around contracts United Regional offered to insurers starting in 1998, according to the complaint and settlement agreement filed in U.S. District Court on Feb. 25 by the Justice Department and Texas attorney general’s office. The contracts offered insurers steep discounts, but only if they agreed not to contract with other hospitals or outpatient facilities in the area.
At the time, 369-bed United Regional was the only hospital in Wichita Falls, population 100,000. But a group of doctors was working to build a far smaller rival facility, said surgeon Jerry Myers, who led the effort and is now chief executive of the 41-bed Kell West Regional Hospital.
If insurers signed with a rival medical center, the discounts would be dropped and they would have to pay close to full charges.
Such pricing practices aren’t “just about charging higher prices generally, it’s strategically charging prices in a way specifically designed to keep out competition,” said Tim L. Greaney, an antitrust expert and director of the Center for Health Law Studies at St. Louis University.
Within three months of Kell’s opening, United Regional had signed the now-disputed contracts with five health insurers and by 2010 had eight insurers, according to the federal lawsuit. The only insurer in the region that didn’t sign was the largest, Blue Cross Blue Shield of Texas.
Even with the discounts offered to insurers, United Regional became expensive, the complaint alleges. An analysis by a major insurer cited in court documents concluded that payments from insurers for hospital care at United Regional were at least 50 percent higher than average amounts paid in seven other comparable Texas cities. For services offered at both United and Kell, the big hospital’s average per-day rate for care was 70 percent higher.
The hospital disagrees with the way the Justice Department applied the law. “We believe then and now that these contracts were appropriate and legal,” United Regional chief executive Phyllis Cowling said.
Cowling also disputes the department’s cost findings. “We are paid a little bit more by insurers, but I know it’s not 70 percent,” she said. “It’s probably some 10 percent or 15 percent more, based on our numbers.”
The hospital is under orders to remove the exclusionary contract provisions. It will continue to honor the deeper discounts offered to its insurers, even if they sign deals with Kell, Cowling said.
Kaiser Health News (www.kaiserhealthnews.org) is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health-care policy organization that is not affiliated with Kaiser Permanente.
By Julie Appleby
Washington Post
April 4, 2011
Amid growing concern about rising health-care costs, the Justice Department is stepping up efforts against hospitals and insurers that it suspects are illegally blocking competitors.
Department officials are not talking, but a recent settlement the government reached with a Texas hospital system has antitrust experts buzzing.
In the first case of its kind since 1999, the department sued United Regional Health System in Wichita Falls for allegedly giving health insurers strong incentives not to do business with rival hospitals. That practice allowed United Regional to keep its monopoly, according to the lawsuit, while also becoming one of the most expensive hospitals in the state.
The hospital disputes some of the findings of the case but agreed late last month to a settlement requiring it to change how it contracts with private insurers.
Antitrust lawyer Matthew Cantor of the New York law firm Constantine Cannon, who was not connected with the case, said the court challenge shows that the Justice Department is “looking at ways in which dominant hospitals or conglomerations of medical practices are conspiring to increase medical costs.”
In the past two years, the department also has settled with a group of Idaho orthopedists over allegations that they conspired to drive up prices and stopped the two biggest Lansing, Mich., insurers from merging, citing “a likelihood of unilateral price increases.”
The Texas settlement comes on the heels of a department lawsuit filed in October against Blue Cross Blue Shield of Michigan over contracts that require hospitals to guarantee the lowest prices to the Blues plan. The department contends that the contracts improperly raise costs for other insurers and their customers. Blues plan administrators say the lawsuit is without merit and are fighting it.
The Wall Street Journal reported that the department has expanded its investigation of such contracts to other insurers, including CareFirst BlueCross BlueShield, which does business in Northern Virginia, Maryland and the District.
Even as they increase enforcement efforts, federal antitrust authorities are planning a more flexible response to select groups of doctors and hospitals that form accountable-care organizations, or ACOs, an experimental model of payment and care authorized by last year’s health law. But, at least initially, ACOs will compose only a tiny fraction of the health-care market; the type of actions that got the Texas hospital in trouble, for example, would remain illegal for ACOs.
Robert Leibenluft, former assistant director for health care in the Federal Trade Commission’s Bureau of Competition under President George W. Bush, sees a pattern in the lawsuits filed in Texas and Michigan: “Increased scrutiny by the DOJ of both health plans and providers who have market power.” He specializes in antitrust law at the D.C. firm Hogan Lovells.
The department’s actions coincide with increasing concern by policy experts over the impact of a decade of consolidation among hospitals, insurers and doctor groups. Some mergers have led to sharp increases in health-care costs, the FTC has found in a number of studies, although not all do.
Justice officials would not comment on the Texas case or others they are working on.
At a conference last May in Arlington, Justice antitrust chief Christine Varney promised an aggressive approach to challenging health-sector mergers and contracts used to keep out new rivals.
The success of the health-care overhaul law approved by Congress, she said, partly depends on “healthy competitive markets free from undue concentration and anti-competitive behavior.”
While watching for those problems, Varney told lawyers at that conference that the department will try not to impede more health-sector partnerships to improve quality and contain costs. Some policy experts say the new emphasis on coordination — encouraged by the health law — could also spur more market consolidation among medical providers in some markets.
“The key,” she said, “is whether we can gain those benefits without sacrificing meaningful competition.”
The Texas case revolved around contracts United Regional offered to insurers starting in 1998, according to the complaint and settlement agreement filed in U.S. District Court on Feb. 25 by the Justice Department and Texas attorney general’s office. The contracts offered insurers steep discounts, but only if they agreed not to contract with other hospitals or outpatient facilities in the area.
At the time, 369-bed United Regional was the only hospital in Wichita Falls, population 100,000. But a group of doctors was working to build a far smaller rival facility, said surgeon Jerry Myers, who led the effort and is now chief executive of the 41-bed Kell West Regional Hospital.
If insurers signed with a rival medical center, the discounts would be dropped and they would have to pay close to full charges.
Such pricing practices aren’t “just about charging higher prices generally, it’s strategically charging prices in a way specifically designed to keep out competition,” said Tim L. Greaney, an antitrust expert and director of the Center for Health Law Studies at St. Louis University.
Within three months of Kell’s opening, United Regional had signed the now-disputed contracts with five health insurers and by 2010 had eight insurers, according to the federal lawsuit. The only insurer in the region that didn’t sign was the largest, Blue Cross Blue Shield of Texas.
Even with the discounts offered to insurers, United Regional became expensive, the complaint alleges. An analysis by a major insurer cited in court documents concluded that payments from insurers for hospital care at United Regional were at least 50 percent higher than average amounts paid in seven other comparable Texas cities. For services offered at both United and Kell, the big hospital’s average per-day rate for care was 70 percent higher.
The hospital disagrees with the way the Justice Department applied the law. “We believe then and now that these contracts were appropriate and legal,” United Regional chief executive Phyllis Cowling said.
Cowling also disputes the department’s cost findings. “We are paid a little bit more by insurers, but I know it’s not 70 percent,” she said. “It’s probably some 10 percent or 15 percent more, based on our numbers.”
The hospital is under orders to remove the exclusionary contract provisions. It will continue to honor the deeper discounts offered to its insurers, even if they sign deals with Kell, Cowling said.
Kaiser Health News (www.kaiserhealthnews.org) is an editorially independent news service of the Kaiser Family Foundation, a nonpartisan health-care policy organization that is not affiliated with Kaiser Permanente.
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