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A Conference on the Psychology of Deception and Unethical Behavior

The <a href="http://rady.ucsd.edu/dib-symposium/">Deception, Incentives and Behavior Conference</a> at the Rady School of Management, University of California - San Diego, was attended by <a href="http://rady.ucsd.edu/dib-symposium/participants/">over 100 people</a>, including me, indicating that there is real interest in studying deception and unethical behavior in the real world.  Several presentations had implications for health care, summarized below by theme (titles of presentations follow entries in parentheses). Context Several presentations discussed how context affects peoples' inclination to be honest or dishonest.  Alexander Cappelan,  Norwegian School of Economics, showed evoking a market context, that is, asking people to think about buying or selling something, increased dishonesty, while a personal or intuitive context decreased dishonesty (When do people tell white lies?). John List, University of Chicago, USA, gave the first plenary talk, suggesting that simply reminding charity fund raisers about the mission of their organization decreased their likelihood of stealing contributions. Shahar Ayal, Interdisciplinary Center Herzliya, Israel, suggested that when people can present themselves as ethical, sometimes extremely, maybe harshly ethical in one context, they may then act unethically in another context. (Moral cleansing strategies for ethical dissonance.) Erin Krupka, University of Michigan, suggested that the availability of voluntary regulation may increase cheating: those who do not cheat may volunteer for regulation, while those who do cheat may point to the availability of regulation. (License to cheat: voluntary regulation and ethical behavior.) Chen-Bo Zhong, University of Toronto, Canada suggested that being able to delegate increases the likelihood of deception (Deception: an unintended consequence of delegation.) Keith Murningham, Kellogg School of Management, suggested that priming people by asking them to perform mathematical calculations increases lying, while priming them by reminders about social awareness or family values does not. (The social and ethical consequences of a calculative mindset.) Incentives Several  presentations suggested various ways in which incentives may affect honesty. David Cooper, Florida State University, USA, suggested that the need for long-term credibility may decrease lying.  (Managing credibility: an experiment in leadership and coordination.) Jan Potters, Tilburg University, Netherlands, suggested that increasing size of incentives to advisors increases the likelihood of their dishonesty when giving advice. (Disclosing advisors' interests neither helps nor hurts.) Anastasia Danilov, University of Cologne, Germany, suggested that people who get incentives as part of a team who identify most strongly with the team are more likely to lie.  (The dark side of team identity: expermiental evidence from financial service professionals.) Bill Nielson, University of Tennessee, USA, suggested that people will respond to short-term incentives even at the cost of long-term outcomes. (Temptation, learning and backward induction in sequential decision tasks.) Michael Vlassopoulos, University of Southampton, UK, suggested that people who get random bonuses, that is, whose incentives are not clearly tied to particular outcomes, are more likely to cheat employers.  (The impact of bonuses on effort provision and cheating.)  Lisa Ordonez, University of Arizona, USA, suggested that basing incentives on achievement of short-term goals (pay for performance) increases lying about performance. (The impact of goals on ethical behavior.) Conflicts of Interest Two presenations discussed conflicts of interest and its effects. Jan Potters (see above) also found that disclosure of payments to advisors did not not lead them to give more honest advice. Miriam Mezger, University of Cologne, Germany, presented a poster that suggested that when people must make decisions based on a mixture of advice from unbiased lay-people and conflicted individuals who do not disclose their conflicts, addition of advice from unbiased experts leads to better decisions.(Can experts reduce the impact of deceptive ratings on the internet? - an experiment on product choice with recommendations by managers and experts.) Summary The enthusiasm and level of intellectual engagement at the meeting suggested the importance of this field.  However, it was disappointing, but not surprising that the attendance at this meeting did not suggest this topic is yet of concern in health care.  Although the opening remarks by the Dean of the Rady School included a call for participation by people from health care, and other fields such as environmental science, I may have been the only person attending with a health care affiliation.  Health care could benefit from increased attention to deception, dishonesty and unethical conduct in the field, how it happens, and what can be done to prevent it.  However, as we have often suggested, discussion of such topics is often anechoic because its capacity to offend or threaten those who most benefit from the status quo in health care.  It was striking that presentations suggested that many practices in our current US commercialized, business-focused health care system may be leading to increased dishonesty and other unethical behavior.  These include thinking about health care in business and quantitative contexts, not in the context of the health care mission to help patients and the public, focus and incentives based on short-term goals, often revenue, and acceptance of conflicts of interest as inevitable and necessary to increase innovation. Of course, these particular ideas may not make many of our current health care leaders happy. They do suggest that we could improve honesty and ethics in health care by reminding peole with decision-making authority of the centrality of the health care mission, and the need to improve patients' and the public's health, and to de-emphasize focus and incentives on short-term goals, particularly financial ones.  We also ought to try to minimize, not just tolerate and "manage" conflicts of interest.

A Conference on the Psychology of Deception and Unethical Behavior

The Deception, Incentives and Behavior Conference at the Rady School of Management, University of California - San Diego, was attended by o...

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Why non-medical amateurs need to be kept away from authority roles in health IT ... lest their ignorance kill people

This example of a disaster waiting to happen, in the form of an error-promoting CPOE, is a poster example of why the net of litigation needs to be cast far wider than just clinicians when EHR-related errors result in injury or death: <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErcAOGFgPHwF2RhkSw7AgRGtg9SRiSYR38-RwttcRs36NMMjonVFNJRoXgN887gCIJmThItvDT3Z3yBkir_ApP62Hq71gnlmW9Eqsbqsh3Vp85q-CpGPL31o4FIWtisxSAlYfzCeOVn9j/s1600/warfarin.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="216" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhErcAOGFgPHwF2RhkSw7AgRGtg9SRiSYR38-RwttcRs36NMMjonVFNJRoXgN887gCIJmThItvDT3Z3yBkir_ApP62Hq71gnlmW9Eqsbqsh3Vp85q-CpGPL31o4FIWtisxSAlYfzCeOVn9j/s400/warfarin.jpg" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;">CPOE selection screen for crucial blood thinner, coumadin (Warfarin).  Click to enlarge.</div> This order entry screen, from a production system (of a vendor whose stock price has recently <a href="http://hcrenewal.blogspot.com/2012/04/allscripts-shares-plunge-on-weak.html" target="_blank">taken a dive</a>) shows the following.  In all fairness, I do note it's unclear if the vendor or the customer's configuration "experts" were responsible for this: <div style="text-align: center;">COUMADIN (warfarin) tablet 2 mg Oral daily once. CAUTION: Potential look-Alike or Sound-Alike medication - this product is COUMADIN</div><div style="text-align: center;"> </div><div style="text-align: left;">with similar entries for other doses. Below and not indented as is the selection, where the clinician is liable not to look very carefully, is the helpful interpretation:  "warfarin (COUMADIN) Tablet 2 milligram Oral daily for 1 Times." "Oral daily for 1 Times?"</div><div style="text-align: left;"> </div><div style="text-align: left;">This drug needs to be given daily, generally for a very long term.  Its effect on blood clotting varies for numerous reasons in an individual over time, and needs to be checked frequently via a blood test (International Normalized Ratio or INR) to ensure the level of effect is neither too little (which could result in clots) or too much (which could result in serious or fatal bleeding).</div><div style="text-align: left;"> </div><div style="text-align: left;">In this case, the clinician wanted Coumadin to be administered "daily", as in "each and every day", but this was the default - daily, but only once.  "Oral daily for 1 Times." Brilliant!  </div><div style="text-align: left;"> </div><div style="text-align: left;">Daily Coumadin (i.e., daily EVERY DAY), the clinician related, could be ordered only with "painstaking difficulty."</div><div style="text-align: left;"> </div><div style="text-align: left;">"X mg Oral daily once" is an unimaginably absurd and bizarre dosing selection to have on a CPOE system for such a critical drug - or any drug.  "Daily - once?"  </div><div style="text-align: left;"> </div><div style="color: red; text-align: left;">It should not, and does not, take a rocket scientist to realize this selection could quite easily lull the busy clinician into believing they have selected a dose to be continued every day - i.e., "once daily" - as per the standard usage of this drug.</div><div style="text-align: left;"> To order this drug for (true) daily administration, a user must find a "repeat" icon and click the number of days the drug is to be administered.  The "repeat" icon is not readily apparent amidst screen clutter. For other drugs, the order choices are "## mg oral daily" or similar.  This semantic and human-computer interaction ineptitude is truly a disaster waiting to happen, especially with the medical/nursing/trainee staff turnaround that goes on in hospitals, and with the reality that clinicians are working at various hospitals with different CPOE/EHR systems. Is this some sort scheme to prevent endless-administration Coumadin errors when the drug is actually deliberately discontinued, I ask?  If so, it's ill-conceived and dangerous at best. By way of further information, this drug is a common anticoagulant whose use is often protective of injurious or fatal blood clots that can cause strokes or death in people with common conditions such as atrial fibrillation or prosthetic heart valves:</div><blockquote class="tr_bq"><div style="text-align: left;"> </div><div style="text-align: left;"><a href="http://en.wikipedia.org/wiki/Warfarin" target="_blank">Warfarin</a> is used to decrease the tendency for thrombosis or as secondary prophylaxis (prevention of further episodes) in those individuals that have already formed a blood clot (thrombus). Warfarin treatment can help prevent formation of future blood clots and help reduce the risk of embolism (migration of a thrombus to a spot where it blocks blood supply to a vital organ). The type of anticoagulation (clot formation inhibition) for which warfarin is best suited, is that in areas of slowly-running blood, such as in veins and the pooled blood behind artificial and natural valves, and pooled in dysfunctional cardiac atria. Thus, common clinical indications for warfarin use are atrial fibrillation, the presence of artificial heart valves, deep venous thrombosis, and pulmonary embolism (where the embolized clots first form in veins).</div></blockquote> This is an example of the kinds of mission hostility (other equally bizarre examples presented <a href="http://www.tinyurl.com/hostileuserexper" target="_blank">here</a>) that results when amateurs attempt to play doctor. I add that this type of "errorgenicity" is inexcusable.  If patients suffer harm from this type of "feature", the net of liability needs to go further than just the clinician who was caught in a web of cybernetic clinical toxicity. -- SS 5/1/2012 Addendum: More EHR madness and another physician, a cardiologist and electrophysiologist, who also believes these should be considered medical devices. From DrWes blog (excerpts, and emphases mine; see entire post at link below): <blockquote class="tr_bq"><a href="http://drwes.blogspot.com/2012/04/why-electronic-medical-record-needs-to.html" target="_blank">The Electronic Medical Record Should be Viewed as a Medical Device</a>  Apr. 30, 2012 </blockquote><blockquote class="tr_bq"> This week I received a medical record from a large academic medical center somewhere in the United States (the details were are unimportant) that has one of these new pioneering EMR systems manufactured by $13 billion-dollar company, <a href="http://www.cerner.com/" target="_blank">Cerner Corporation</a> ... what I saw was one of the better examples of how EMRs are contributing to misinformation and confusion when health care is delivered. I received a copy of an internal medicine consult that was performed on a patient at this outside hospital. I have extracted the "medications" portion of the internist's note exactly as it was displayed in the note below ... Needless to say, I was terrified at what the system had listed as the patient's medications: In this example, we see multitudes of medications listed more than once. We see drugs of similar classes (antihistamines, beta blockers) on the same list. We see warfarin, one of our most dangerous drugs dispensed, without a dose included. We see what seems to be outpatient meds listed with inpatient meds, I'm not sure. Honestly, we really have no idea what medications are actually being taken from this list. And yet this list of medications is listed by the EMR as the patient's "Active Medications." <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLVg_K31W2k2woo4cxzkEWNEyihdGXVwcOQYD7QWdf9oACrepD14SekHK0sTSlMhvk2GPWFcPERiVcHdpflBjtzZtbQHJFDPdOw_wB9_TLUmhMP69VNLQg8tQKL_Bdc9nZXs_dkD_4e5ss/s1600/Medlist1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiLVg_K31W2k2woo4cxzkEWNEyihdGXVwcOQYD7QWdf9oACrepD14SekHK0sTSlMhvk2GPWFcPERiVcHdpflBjtzZtbQHJFDPdOw_wB9_TLUmhMP69VNLQg8tQKL_Bdc9nZXs_dkD_4e5ss/s320/Medlist1.jpg" width="176" /></a></div>Med list (page 1).  Click to enlarge; see original post for part 2. ... What the heck have we created?  </blockquote><blockquote class="tr_bq">Certainly, any capable physician who cares for patients would describe this medication list as worthless. </blockquote> This "med list" is similar to the list I showed at <a href="http://hcrenewal.blogspot.com/2009/02/are-health-it-designers-testers-and_26.html" target="_blank">part 4 of my multi-part series on the mission hostile user experience</a> of most commercial EHR's, from yet another system, redrawn by me in redacting the vendor ID.  These lists reflect a mercantile computing person's view of a med list as an inventory of pills: <div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfk6_NvuGu6WBIr_QdltCZ-jdeiAxOhYdSGxhovKJWdBkByUuK3QQLblfOgxBLUhHyXiXALUrdOO_L3Mpmo0MVK0uVv9ogJKnjRU5xWhvQJV125qgLBvIipD6pBDOZJ49s3EPjoCe_AL3-/s1600/meds.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgfk6_NvuGu6WBIr_QdltCZ-jdeiAxOhYdSGxhovKJWdBkByUuK3QQLblfOgxBLUhHyXiXALUrdOO_L3Mpmo0MVK0uVv9ogJKnjRU5xWhvQJV125qgLBvIipD6pBDOZJ49s3EPjoCe_AL3-/s320/meds.jpg" width="320" /></a></div><div style="text-align: center;"> Another "what the heck have we created?" EHR med list, on screen. Click to enlarge.</div><div style="text-align: center;"> </div><div style="text-align: left;"> Dr. Wes also asks:</div><div style="text-align: left;"> </div><blockquote class="tr_bq">... So how will we measure problems with EMRs? It seems industry representatives would rather not address these concerns. We should ask ourselves, is anyone thinking about this?</blockquote><div style="text-align: left;"> </div>Yes, they are.  And we are spreading our thinking to one place where action might actually occur sooner rather than later:  to the Plaintiff's Bar. -- SS

Why non-medical amateurs need to be kept away from authority roles in health IT ... lest their ignorance kill people

This example of a disaster waiting to happen, in the form of an error-promoting CPOE, is a poster example of why the net of litigation needs...

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The 2011 Best Paid US CEO's Company's Latest Legal Settlement

Yet another legal settlement illustrates the contrast between rewards given to the hired managers of large health organizations and their organizations' performance.  The New Settlement The legal settlement in question was simple, as <a href="http://www.reuters.com/article/2012/04/26/mckesson-settlement-idUSL2E8FQ5KJ20120426">reported</a> by Reuters, <blockquote>McKesson Corp, one of top U.S. drug wholesalers, has agreed to pay more than $190 million to settle claims that it had violated the federal False Claims Act by reporting inflated pricing information for many prescription drugs, causing Medicaid to overpay for them. The settlement was announced Thursday by U.S. Attorney Paul Fishman in New Jersey. According to the government, McKesson reported inflated pricing data to First DataBank, a publisher of drug prices that most state Medicaid programs use to set payment rates for pharmaceutical products. The government accused McKesson of marking up prices on a variety of drugs by 25 percent between Aug. 1, 2001, and March 31, 2005. It said McKesson's conduct had caused the United States and individual states to pay inflated reimbursements on Medicaid claims submitted between Aug. 1, 2001 and Dec. 31, 2009. 'We have no tolerance for those who take advantage of that system to bring in more business by falsely increasing reimbursements to retailers,' Fishman said in a statement.</blockquote> As is typical, the company denied doing anything wrong: <blockquote>McKesson was not immediately available to comment. According to settlement papers, McKesson 'expressly denies' the government's charges, as well as those of a whistleblower, David Morgan, in a related civil lawsuit filed in New Jersey federal court. The San Francisco-based company did not admit liability or wrongdoing in agreeing to settle.</blockquote>It was hardly McKesson's first ethical problem. McKesson's Track Record This is just the latest in a long series of legal problems for this company. The Depression-Era Scandal Way back in 1938, there was the McKesson & Robbins scandal, one of the major scandals of the depression era. The company had been taken over by one Philip Musica, an accused bootlegger, who committed suicide before a trial (see <a href="http://hcrenewal.blogspot.com/2010/10/history-repeats-and-repeats-mckesson.html">this post</a>). In this century, there were: The Securities Fraud Case As we <a href="http://hcrenewal.blogspot.com/2009/11/former-mckesson-ceo-and-board-chairman.html">posted</a> in 2009, five former executives pleaded guilty, the former CEO and Chairman Charles McCall was convicted of fraud in 2009. The company settled investor lawsuits in 2005 for $960 million. The First Pharmaceutical Pricing Case As the Wall Street Journal <a href="http://online.wsj.com/article/SB122731205016649381.html">reported</a> in 2009, <blockquote>McKesson Corp., a giant drug-wholesale and -distribution company, agreed to pay $350 million to settle cases in which it was accused of helping to increase drug prices in 2001 and 2002. The money will go to health plans that pay for drugs and consumers who paid co-pays for their medicines. The San Francisco-based company said the settlement, which is subject to court approval, includes 'an express denial of liability of any kind' but that it decided to settle the cases to avoid the uncertainty of litigation</blockquote> In addition, as we noted <a href="http://hcrenewal.blogspot.com/2010/10/history-repeats-and-repeats-mckesson.html">here</a>, the company settled with the state of Connecticut for "illegal and deceptive" pricing practices for a mere $15 million. These settlements appear to be precursors of the just announced one. The Propofolol Punitive Damages As we noted <a href="http://hcrenewal.blogspot.com/2011/10/another-month-another-series-of-adverse.html">here</a>, McKesson was one of three companies to collectively pay $162 million in punitive damages in a case involving allegations that the companies sold propofolol, an injectable anesthetic, in reusable containers that were susceptible to contamination with the hepatitis C virus. The Best-Paid CEO in America All these legal issues notwithstanding, late in 2011, McKesson leadership made headlines for a different reason. Based on one method of computation, the company's CEO was the best-paid of an exceedingly well-paid 2011 CEO class. An <a href="http://www.thedailybeast.com/articles/2012/01/02/he-s-one-of-the-nation-s-highest-paid-ceos-and-you-ve-never-heard-of-him.html">article</a> in the Daily Beast noted: <blockquote>John Hammergren, [is] the CEO of the McKesson Corp., a giant medical-supply company in California. Hammergren is the $145 million man, top dog on the latest listing of the country’s highest-paid chief executives.</blockquote> The details of the compensation package included, <blockquote>Yet last year McKesson contributed more than $13 million just to Hammergren’s pension, according to company documents. Among the other perks he enjoys: a chauffeur to drive his company car, free use of the corporate jet for personal travel, and an extra $17,000 a year to pay for a financial planner because handling all those hundreds of millions is no doubt complicated stuff.</blockquote> Also, <blockquote>Then there are the assorted perks he gets each year at an annual cost of $1 million or so. Choose the perk that makes you the most jealous. Maybe it’s this line found in McKesson’s most recent proxy statement: 'For security, protection, and privacy reasons, the Board has directed our CEO to use the corporate aircraft for both business and private travel.' Or maybe it’s the bounty that awaits Hammergren on the other side of his retirement. The company discontinued its pension program for ordinary employees in 1997 but not for top executives. If Hammergren quit tomorrow, according to company filings, he would receive a pension valued at $125 million. The party won’t stop once the 52-year-old Hammergren retires. Among his lifetime benefits: a personal assistant and office, which the company figures will cost more than $200,000 a year, and the services of a financial counselor—a perk that will eat up $350,000 in profits, according to company estimates. The goodies keep coming even after he dies. If his wife survives him, she will continue receiving his base salary for six months and will also get $2 million in cash. That cash bonus would actually cost the company nearly twice that amount, as it's promised to cover the widow’s cost of paying taxes on that money. And then there’s a provision so outsize it’s drawn the attention of corporate-governance watchdogs like GMI, the research group that put Hammergren in the top spot of its latest survey of CEO salaries. If Hammergren loses his job due to a change in ownership, he receives an immediate $469 million payout, GMI found—giving him perverse incentive to see it happen.</blockquote> Although Mr Hammergren has not been the best paid CEO every year, the Daily Beast article showed how much he has made over the years: <blockquote>Hammergren’s annual total compensation payouts, taken from the company’s public filings with the Securities and Exchange Commission: $46 million in 2011; $55 million in 2010; $37 million in 2009; another $41 million in 2008. Hammergren hadn’t founded the company. Wall Street analysts covering McKesson can tell you of the disappointments and miscues that have marked his tenure. But his haul in the 13 years he has been running McKesson? More than $500 million, according to data provided by Equilar, an executive-compensation data firm.</blockquote> It then contrasted this consistent largess, spiced with the 2011 results, with the company's long-term financial performance. After the scandal that eventually resulted in crimincal convictions for some McKesson executives: <blockquote>'They had to give the CEO job to somebody, and basically he was the last man standing,' said an analyst who has been covering McKesson and its competitors since the 1990s. Many in the industry had never heard of Hammergren when he took over as president and co-CEO in 1999, this analyst said, 'but I guess it’s better to be lucky than good.' Hammergren became sole CEO in 2001. McKesson’s stock had hit a high of just under $95 a share but fell below $20 after the scandal broke. Hammergren deserves credit for stabilizing the company—some might even say he rescued McKesson—but a long-term shareholder could be forgiven for feeling that the company’s board of directors has been overly generous to its chief executive. As of Friday, the stock was trading at $78 a share—still off its 1998 high. Factoring in the regular dividends the company has paid over the years, a shareholder’s investment would be worth slightly more than it was 13 years ago.</blockquote>Summary So Mr Hammergren's corpulent compensation is vastly out of proportion not only to the company's woeful ethical performance, but also to the long-term wealth created for its owners, that is, its shareholders. So McKesson provides just the latest example of how the top hired leaders of health care organizations seem to monumentally prosper no matter how badly their organizations fare in terms of ethical performance, good done for patients and health care, or long-term financial performance. (See recent examples <a href="http://hcrenewal.blogspot.com/2012/04/another-legal-settlement-for-tenet.html">here</a> and <a href="http://hcrenewal.blogspot.com/2012/04/spoils-of-scorched-earth-defense-merck.html">here</a>, and our posts on executive compensation <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">here</a>.)  As we <a href="http://hcrenewal.blogspot.com/2009/12/compensation-madness-insiders-hijacking.html">quoted</a> a McGill economics professor who was writing about the global financial collapse, "all this compensation madness is not about markets or talents or incentives, but rather about insiders hijacking established institutions for their personal benefit." To truly reform health care, we must stop this compensation madness. We must make health care leaders accountable for their organizations' effects on patients' and the public's health, and make sure they get reasonable, not royal compensation reasonably related to their organizations' performance, including ethical performance.

The 2011 Best Paid US CEO's Company's Latest Legal Settlement

Yet another legal settlement illustrates the contrast between rewards given to the hired managers of large health organizations and their or...

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Insurers' diversification creating monopoly power and conflict of interest - quoted in the Washington Post

I am quoted in a Washington Post article today on potential conflicts of interest when medical payers/insurers acquire the firms that hospitals and doctors use to challenge medical payment denials: <blockquote class="tr_bq"> <a href="http://www.washingtonpost.com/health-insurance-companies-push-to-diversify-raises-concerns/2012/04/27/gIQAWoSkoT_story.html" target="_blank">"Health insurers’ push to diversify raises ethical concerns" </a> Washington Post Jay Hancock, Sunday, April 29 Like hospitals and doctors everywhere, Banner Health fights a daily battle to get paid by insurance companies and government agencies for the care it delivers.  So the hospital system hired a company called Executive Health Resources to fight back against the likes of Medicare and UnitedHealthcare when they deny claims or pay bills for less than what Banner thinks it is owed.</blockquote> Fair enough. <blockquote class="tr_bq">But Banner executives began to worry about EHR’s independence when the firm was acquired in 2010 by UnitedHealth Group, UnitedHealthcare’s parent. </blockquote> Issues can get a bit sticky under such an arrangement. I put it this way: <blockquote class="tr_bq"> Critics call United’s ownership of EHR a troubling conflict of interest that could give it confidential information about rivals as well as patients and limit EHR’s power to demand payment from its much larger corporate sister. “How is that ownership going to affect the mission of a company whose business is to extract more money from payers?” said Scot Silverstein, a physician and specialist in medical software and patient records at Drexel University. “Imagine going to a plaintiff’s lawyer to take your malpractice case and not knowing that plaintiff’s lawyer actually works for the hospital that you’re suing.”</blockquote> When payers acquire those who would challenge their payment denials, I worry about the consolidation of power being too great for the public good. As we learn, the relationship is somewhat stealthy: <blockquote class="tr_bq">... There is no mention of EHR’s ownership in the “Corporate Overview” section of its Web site or elsewhere on the site. Nor did the American Hospital Association identify EHR as a United subsidiary in September when it renewed its exclusive endorsement of EHR’s denial-fighting services. EHR pays the hospital association a fee for the endorsement. The group declined to disclose the amount.  </blockquote> The plot thickens: <blockquote class="tr_bq">Claims consultants such as EHR typically gain access to millions of patient records and confidential contracts between hospitals and insurers, industry officials say. If UnitedHealthcare, United’s insurance wing, gained access to that data, it would obtain “a huge business advantage” over insurance rivals as well as the hospitals, Kofman said.</blockquote> In today's healthcare business environment, "if" seems to me to be optimistic. Hancock goes further in the article: <blockquote class="tr_bq"> As insurers eager to add revenue streams convert themselves into diversified health-services companies, they often buy traditional business adversaries, including physician groups and hospital consultants such as EHR. They’re also buying technology companies and research firms that serve medical-care providers, raising questions not only about independence but about the privacy of patient information. </blockquote> A Georgetown professor, formerly a state insurance superintendent, gets to the heart of the matter, using United as but one example: <blockquote class="tr_bq"> “I am not convinced that, even with proper disclosure, that an entity owned by United could aggressively advocate against United’s interests,” said Mila Kofman, a Georgetown professor who was Maine’s insurance superintendent.</blockquote> This factoid is eye-opening: <blockquote class="tr_bq"> Appealing claims denials has become a huge, high-tech business, reflected in the more than $1 billion that United reportedly paid for EHR [Executive Health Resources].</blockquote> You might think there were better things to do with $1 billion besides administrative bloat - such as taking care of patients. We probably need new laws to catch up with the flurry of M&A's going on in healthcare between payers, the healthcare delivery sector, and the "referees" that mediate between them when disputes arise. Read the entire article at the WaPo link above.  The examples get even more convoluted. -- SS Addendum: Roy Poses notes: <blockquote class="tr_bq">This appears to be a newly recognized type of conflict of interest that contributes to the concentration of power in the US commercialized health care system.  While many people tout how our health care system is "competitive" and a "free market," it is ever more dominated by a decreasing number of enlarging organizations.  True health care reform would break up health care oligopolies. </blockquote> -- SS

Insurers' diversification creating monopoly power and conflict of interest - quoted in the Washington Post

I am quoted in a Washington Post article today on potential conflicts of interest when medical payers/insurers acquire the firms that hospit...

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Using a computer called “Blue Balls” to track whether ED patients seeking care paid their bills

I could not make this up if I tried regarding hardball tactics to collect money when patients are at their most vulnerable. From Bloomberg News: <blockquote class="tr_bq"><h1> <a href="http://www.bloomberg.com/news/print/2012-04-29/accretive-says-it-s-working-to-address-minnesota-concerns-1-.html" target="_blank">Accretive Says It’s Working to Address Minnesota Concern</a></h1><div id="story_meta"><cite class="byline"> By Dan Hart and Alex Wayne - Apr 29, 2012 </cite> </div> <a class="web_ticker" href="http://www.bloomberg.com/quote/AH:US" title="Get Quote">Accretive Health Inc. (AH)</a>, a hospital billings-collection company, said it’s working with advisers to address concerns raised by the Minnesota attorney general’s office that it puts bedside pressure on patients to pay bills. The claims “grossly distort and mischaracterize” its revenue cycle services, the company said today in a statement. The suggestion Accretive puts bedside pressure on patients to pay their bills out of pocket are a “flagrant distortion of fact,” the company said. ... Accretive shares tumbled by the most ever on April 25, just after Minnesota Attorney General Lori Swanson issued a report alleging Accretive violated U.S. and state patient-privacy and debt-collection laws. She said patients at Fairview Health Services, a Minnesota hospital chain, were pressured for payment before they received care in some cases and that Accretive’s debt collectors didn’t properly disclose their role. Swanson filed a lawsuit on Jan. 19 against Accretive. Chicago-based Accretive said in today’s statement it doesn’t deny access to patient care and the allegation is “flatly untrue.”</blockquote> There appears to be something to the allegations, though... <blockquote class="tr_bq"><h2>  Credit Scores </h2>[Minnesota Attorney General ] Swanson said last week employees at Fairview, a nonprofit chain of seven hospitals based in <a href="http://topics.bloomberg.com/minneapolis/"></a>Minneapolis, were required to use a computer system derisively called “Blue Balls” to track whether patients paid their bills. The payment system began after Fairview hired Accretive in May 2010, Swanson said in her <a href="http://www.ag.state.mn.us/" rel="external" title="Open Web Site">report</a> describing the companies’ relationship. Actions that Accretive used at Fairview included issuing emergency room employees “scripts” for conversations with patients that “can lead a patient or her family to believe the patient will not receive treatment until payment is made,”Swanson said. Employees were instructed to ask for credit card payments, tell patients they’d wait for them to retrieve their checkbooks from their cars, or if the patients said they couldn’t pay, remind them that debt-collection activities “can affect your credit score,” according to the scripts. </blockquote> Considering the setting, that sounds like a technique more suited for a movie about mid-30's Chicago then a 21st century hospital.  It seems a not so subtle form of strong-arming someone when they're down. <blockquote class="tr_bq">Accretive said late on April 27 that Fairview had canceled its contract with them, adding it didn’t know yet how the cancellation would affect its business. Accretive said it would provide an update on its May 9 quarterly financial call. Earlier that same day, Representative Pete Stark, a California Democrat, asked U.S. health officials to investigate Accretive’s practices. Federal law prohibits hospitals from denying emergency care to anyone, regardless of their ability to pay. </blockquote><a class="web_ticker" href="http://www.bloomberg.com/quote/AH:US" title="Get Quote"></a> While no statement is made in this article about care denial, Federal law should prohibit strong-arm tactics and psyops at a time when patients are most vulnerable.  The unpleasantness and added stress are certainly not good for outcomes in the vulnerable. I note a site has appeared related to this issue, at this link:  <a href="http://www.mn-healthcare.com/links">http://www.mn-healthcare.com/links</a> -- SS

Using a computer called “Blue Balls” to track whether ED patients seeking care paid their bills

I could not make this up if I tried regarding hardball tactics to collect money when patients are at their most vulnerable. From Bloomberg N...

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Don't Worry, Your Records are Safe - Part IV

At past posts "<a href="http://hcrenewal.blogspot.com/2012/03/at-my-oct.html" target="_blank">Don't Worry, Your Electronic Medical Records Are Getting Safer With Every Passing Day</a>", "<a href="http://hcrenewal.blogspot.com/2011/09/another-episode-of-dont-worry-your.html" target="_blank">Another Episode of "But Don't Worry, Your Records are Safe...</a>" and "<a href="http://hcrenewal.blogspot.com/2011/10/still-more-ehr-chaos-pandemonium-bedlam.html">Still More Electronic Medical Data Chaos, Pandemonium, Bedlam, Tumult and Maelstrom: But Don't Worry, Your Data is Secure</a>", I wrote on the issue of medical record security. Security from prying eyes, that is. I didn't include security of data from placement into <a href="http://en.wikipedia.org/wiki//dev/null" target="_blank">/dev/null</a> (that is, destruction). There's this email, received by East coast physicians not long ago from a claims processing company (identities redacted): <blockquote class="tr_bq">Dear Provider, As you may be aware, we experienced a significant problem with our computer system during a software maintenance function on XX/XX/2010. In addition to the network issue, we discovered that the redundant back-up systems were not operating as reported.  ["Reported" when, and by whom, one wonders? - ed.] We had two on-site back-up systems that were monitored daily and which were historically reported as successful.  We have since learned that these internal back-up functions were not operating as reported and the on-site back-ups were not entirely successful. [Meaning, they were not successful, period - ed.] Also, our software vendor, [major EHR vendor], was providing two additional remote back-ups on servers located in [city, state] and [city, state]. [EHR vendor] has informed us that these remote back-ups were not initiated as represented.  [Meaning, they screwed up - ed.]  Therefore, when our computer network system malfunctioned, there was no readily available back-up data on-site or at the remote redundant back-up servers. Please be aware that we have replaced hardware components and were able to recreate the data bases and we are billing.  However, we are still unable to access data that was stored on our servers prior to XX/XX/2010. [EHR vendor] is diligently working to retrieve the data from the hard drives, back-up tapes, and through other means.  Please be assured that all files will be restored, if the files cannot be fully restored electronically, then they will be fully restored manually. At [our claims processing company], we are truly saddened by the fact that we have disappointed clients and we sincerely apologize for any inconvenience experienced by you, your staff, or your patients. We have always appreciated your loyalty as a valued client and will continue to keep you informed of the progress. </blockquote> The levels of information technology and data management incompetence exhibited in this message are stunning.  The confidence it imparts regarding the safety of our critical medical data from destruction, and its availability when truly needed, is less than stellar. A major problem is that the health IT industry has no accountability.  I believe the Food, Drug and Cosmetic Act needs to be amended to become the "Food, Drug, Cosmetic, and Cybernetic" Act. -- SS

Don't Worry, Your Records are Safe - Part IV

At past posts " Don't Worry, Your Electronic Medical Records Are Getting Safer With Every Passing Day ", " Another Episod...

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Another Legal Settlement for Tenet, Another $10 Million Plus for its CEO

Yet another large health care organization has added to its collection of legal settlements.  Reuters briefly <a href="http://www.reuters.com/article/2012/04/10/us-tenet-medicare-idUSBRE8390UZ20120410">noted</a> Tenet Healthcare's latest scuffle with the law: <blockquote>Tenet Healthcare Corp has agreed to pay almost $43 million to settle allegations that it overbilled the federal Medicare healthcare program for treating patients at certain rehabilitation facilities, the Justice Department said on Tuesday. The company was accused of improperly billing Medicare between May 2005 and December 2007 for treating people at inpatient rehabilitation facilities when they did not qualify for such an admission, the Justice Department said. Tenet agreed to $42.75 million to resolve the allegations, which were made under the U.S. False Claims Act. Medicare is the federal healthcare program for the elderly.</blockquote> While this story appeared briefly and without context in a few business news outlet, it really is part of a much bigger picture. National Medical Enterprises Published in 2006, Maggie Mahar's Money Driven Medicine was one of the important early works on health care dysfunction (see post <a href="http://hcrenewal.blogspot.com/2006/08/money-driven-medicine.html">here</a>, the web-site of the documentary film based on it <a href="http://www.moneydrivenmedicine.org/">here</a>).  One of the striking cases it discussed was that of Nartional Medical Enterprises.  NME was charged not only with run of the mill offenses like over-billing, but more exotic ones like kidnapping patients. NME eventually settled with federal authorities in 1994 for $379 million, and pleaded guilty to a variety of charges. The results were similar to many more recent cases. No one went to jail, and the CEO walked away with a golden parachute.  Despite the seriousness of the offenses, NME did not go out of business.  It simply changed its name - to <a href="http://www.tenethealth.com/pages/home.aspx">Tenet Healthcare</a>. Legal Problems in the 21st Century The "new" Tenet continued to have legal issues.  These included a $395 million settlement of the Redding Medical Center unnecessary heart surgery scandal in 2004 (look <a href="http://articles.sfgate.com/2004-12-22/news/17458067_1_redding-medical-center-steven-campanini-unnecessary-heart">here</a>), and a $21 million settlement of US government charges of kickbacks (look <a href="http://www.nytimes.com/2006/05/18/business/18tenet.html">here</a>), a $7 million settlement with the government of Florida of charges of fraudulent billing (look <a href="http://www.bizjournals.com/stlouis/stories/2006/02/20/daily31.html">here</a>), and a $900 million settlement of federal over-billing complaints (look <a href="http://articles.latimes.com/2006/jun/30/business/fi-tenet30">here</a>, and see our post <a href="http://hcrenewal.blogspot.com/2006/07/echos-of-previous-scandals-in-for.html">here</a>), all in 2006.  There was an apparent lull, and then in 2011 the company settled a class action suit brought after the deaths of 34 patients in a Tenet facility in New Orleans after Hurricane Katrina (see Bloomberg story <a href="http://www.bloomberg.com/news/2011-03-23/tenet-healthcare-settles-class-action-lawsuit-over-katrina-hospital-deaths.html">here</a>.) Again, while this substantial string of settlements suggest a pattern of repeated misbehavior, as in many other legal resolutions in health care (look <a href="http://hcrenewal.blogspot.com/search/label/legal%20settlements">here</a>), the cost of financial penalties was diffused across the organization.  No individuals seemed to suffer any negative consequences from any of these episodes. No Consequences for Hired Managers Instead, despite this evidence of repeated misbehavior, now extending over nearly 20 years and across two centuries, the top hired leaders of Tenet continued to flourish.  Earlier this month Becker's Hospital Review <a href="http://www.beckershospitalreview.com/compensation-issues/tenet-ceo-trevor-fetters-total-compensation-exceeds-107m-in-2011.html">announced</a> the compensation received by Tenet's CEO in 2011: <blockquote>Total compensation for Trevor Fetter, president and CEO of Dallas-based Tenet Healthcare, dropped 12 percent from 2010 to $10.74 million in 2011, according to documents from the U.S. Securities and Exchange Commission. Mr. Fetter's base salary in fiscal year 2011 was $1.08 million, the same as the previous two years. He received $4.88 million in stock awards, $2.67 million in non-equity incentive plan compensation and $1.93 million of accumulated benefits under his supplemental executive retirement plan. Mr. Fetter also received more than $142,000 for personal use of Tenet's aircraft.</blockquote> Despite the small dip last year, Mr Fetter's total compensation has generally increased  over the years, from $6.12 million in 2003 (<a href="http://articles.latimes.com/2004/apr/06/business/fi-tenet6">via</a> the LA Times), to $9.7 million in 2008 (AP <a href="http://www.foxnews.com/wires/2009Mar26/0,4670,TenetExecutiveCompensation,00.html">via</a> Fox News). Summary One would think that Tenet's record of legal trouble would have turned it into a pariah, or led to its corporate demise.  However, like many other large health care organizations, the organization has been able to shrug off evidence of a deeply flawed culture, and within such a culture, its leaders have continued to enrich themselves with seeming impunity.  Such cases should raise many questions - Why are repeated offenses by the same well known health care organizations barely considered news?   Why do repeat offenses not generate at least increasing financial penalties?  Why do the organizations' stake-holders, particularly as represented by their boards, not show more concern?  Why has the regulation of health care organizations devolved into Kabuki theater? So, I once again insist, to really deter bad behavior, those who authorized, directed or implemented bad behavior must be held accountable. As long as they are not, expect the bad behavior to continue. Real health care reform needs to make health care leaders accountable, and especially accountable for the bad behavior that helped make them rich.

Another Legal Settlement for Tenet, Another $10 Million Plus for its CEO

Yet another large health care organization has added to its collection of legal settlements. Reuters briefly noted Tenet Healthcare's ...

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