Hot stock tip: Meet Pacificare's Doctor Ho

Here we go again. What is it, about one per quarter now? If this one goes as well as the first did - maybe buried in election hysteria instead of Christmas (the distraction that worked so well last time) - maybe they can squeeze in two or three more before Christmas '08. What a quarter that will be! :: Nyceve wrote [another] very important diary at dkos today.

Pacificare denies 17-year-old cancer patient lifesaving treatment by nyceve Mon Mar 24, 2008 at 08:50:39 AM PDT Remember Nataline Sarkisyan? Well here we go again. We're facing an eerily similar situation. A phone call from you may help save another child's life from the depraved indifference of Pacificare. Who owns Pacificare? Who else? UnitedHealth. ... Today I'm going to tell you about Nick Columbo. Nick is only 17 years old and has Ewing’s Sarcoma (bone cancer). His insurer, Pacifi care death, is denying him a treatment which doctors think may save his life. The family and the nurses are urgently appealing to the public to call PacifiCare at 714-828-1821 or Tyler Mason, the UnitedHealth/Pacificare spokesperson at 714-226-3530 and demand they provide the care Nick needs.

I urge everyone to read Eve's article and to call or contact Pacificare. This isn't some anomaly, it's policy. It's a new direction. Ask them. They'll defend it. These things are just an unfortunate part of having to do business with people that get too sick. Part of a story I wrote about Cigna:

Yes, Cigna knew and took it into account as they calculated their official spin on the girl's death. Read between the lines. It's bold. After the obligatory token apology opening, they are firmly unapologetic about their decision and the policy behind it. From Cigna Official Response, Christmas Eve 2007:

What is often misunderstood is that most health benefit plans, whether public or private, do not cover unproven and experimental treatment related to transplants or other treatments. Coverage decisions under these plans are based on the best scientific and clinical evidence available, often utilizing external experts, without consideration of cost. At CIGNA, we facilitate payment formore than 90% of all requested transplants and specifically more than 90% of the liver transplant requests made to us.

In other words: We stand by our policy because it's just like everyone else's. It's unfortunate the poor girl died, but our decisions are based on the best scientific evidence we can buy. Our experts are smarter than the ones at UCLA and besides, 9 outta 10 ain't bad. More from Cigna CMO, Dr. Jeffrey Kang:

CIGNA HealthCare recently announced that Dr. Jeffrey Kang, CIGNA's chief medical officer, has been appointed to the Board of Directors of the National Quality Forum (NQF), which is a private, not-for-profit, public benefit corporation focused on standardizing healthcare quality measurement and reporting. Kang is responsible for medical strategy and policy at CIGNA HealthCare, including evidence-based coverage decisions and quality measurement and improvement.

I'm sorry. For those of you who don't speak Bullshit, let me translate:

CIGNA announced that Dr. Jeffrey Kang, CIGNA's chief medical officer, has been deployed to head up a false flag op in the not-for-profit sector. He'll focus on standardizing criteria for denying authorization of services. Kang is responsible for strategic policy at CIGNA, including profit-driven coverage decisions to nudge that transplant approval rate closer to 8 out of 10.

It rings true again. Pacificare is following suit. :: Meet Dr. Sam Ho:

As PacifiCare Health Systems' senior vice president and chief medical officer, Dr. Sam Ho is responsible for developing and implementing strategies and programs to improve the quality and cost-effectiveness of healthcare services throughout the company. Dr. Ho is responsible for all initiatives related to quality assessment and improvement, medical management, disease management, informatics, report cards, clinical product development, e-health, and healthcare liaison with public policy, government affairs, industry relations, media relations, provider network management, and sales and marketing.

Dr. Ho is responsible for: 1. medical management 2. disease management 3. informatics 4. report cards 5. clinical product development (what the hell is that? is that shorthand for "care"? But okay, as the head doc, I'll give him that one) 6. e-health 7. healthcare liason with public policy including: government affairs, industry relations, provider network management, and...

9. sales and marketing.

Sales and Marketing you say? On that long list of responsibilities of the good doctor, sales and marketing is the last thing listed. Any health care related business has clinical elements and business elements. The clinical elements are supposed to keep the business elements in line, especially at the highest levels of policy influence at which Dr. Ho operates. How subject is Dr. Ho to the pressures of his company's sales goals? Is his clinical integrity intact? Are Sales and Merketing his last priorities or his first priorities? PBGH (Pacific Business Group on Health) had a conference: Advancing Physician Performance Measurement Using Administrative Data to Assess Physician Quality and Efficiency (pdf). Dr. Ho attended. From the conference:

Organizations or entities that embark on physician performance measurement and transparency must clearly articulate the goals of the initiative in order to define the performance measures, capture the relevant data and determine which measurement tools to use. This goal-setting should consider: • How will the measurement information be used (physician feedback, physician quality improvement activities, consumer use, benefit design, network design, etc.)? • Which physicians will be measured (primary care or other specialists), and why? • Will physicians be measured individually or through a mechanism that aggregates the care of a practice site or medical group? • What fraction of contracted physicians in each specialty will be sufficient to implement the planned strategy? • What benefits or incentives, if any, will be provided to high performing physicians? • What consequences [!], if any, will be imposed on lower performing physicians? • What opportunities will exist for lower performing physicians to improve or change their performance? • Will physicians be measured on quality, cost efficiency or a combined measure of quality and cost-efficiency? • How often will the measurements be repeated? (emphasis mine)

Consequences. If we are speaking of consequences for low quality of care I understand. But I'm not so sure that's what they mean. I think "lower-performing" physicians are less-efficient in terms of their denial rates, e.g., they try to help a higher percentage of people than some other doctors. In my opinion (and experience as a nurse) those are often the best doctors. I'm proud to know one psychiatrist who is the epitome of this.

"Let them deny it. We'll appeal it. I'm not changing my diagnosis - it is what it is and this is the level of care I'm ordering. Period."

Of course we are way backlogged on appeals. Is Ho going to channel that Sales/Marketing pressure and obligation as SVP/CMO to act in the best interest of Pacificare stockholders onto the doctors who stand in the way if his denials? After all, the lower down the food chain the denial process starts, the more credibility the denial has. If some of these damn doctors would turn some of these obviously too sick people away in the first place before they get all hopeful, maybe they could get away with this more easily.

"What opportunities will exist for lower performing physicians to... improve or change their performance?"

Does that mean what opportunities will exist to bully physicians into increasing their denial rates? I think in their context, it does. And: "Will physicians be measured on quality, cost efficiency or a combined measure of quality and cost-efficiency?" Um.. both are important, right? Right? Dr. Ho was a pioneer of neo- tiered-system care - one of the many things that make appeals, authorizations and every other process vastly more complicated - with his revolutionary Value Network Plan in Southern California:

Pacificare

"This represents an extremely viable approach to addressing concerns of health-care inflation and quality," says Ho.

Perhaps not surprisingly, physicians and hospitals have serious misgivings about such initiatives. "We're in favor of diminishing costs, but we think this is the wrong approach," says Dr. John C. Nelson, a Salt Lake City obstetrician-gynecologist who's president of the American Medical Assn. "There's no way to accurately delineate [quality]." The methodologies by which tiers are set and the data that are used to rank doctors are unreliable, Nelson argues. DELAYS IN CARE? ... Patient population, too, is a major factor that could affect how doctors and physicians are rated. Wealthier patients tend to be healthier, Nelson notes. "That needs to be factored in," he says.

I wonder if Nick is a Value Network Plan member. Is this an extremely viable approach to addressing his needs, Dr. Ho?

Whether tiering is the most proactive and useful method is questionable and controversial in light of results gleaned from quality and outcomes data. Suzanne Delbanco, the CEO of Leapfrog, a coalition of large healthcare buyers, is optimistic about the use of tiers but cautions insurers and employers to be careful about how quality measures are interpreted with the following: “We could be artificially changing where patients seek care in ways that have nothing to do with what benefits them". Advances in Marketing Proceedings of the Annual Meeting of the ASSOCIATION OF COLLEGIATE MARKETING EDUCATORS (warning: long PDF)

It's all about cost containment. I salute the service Dr. Kang and Dr. Ho are providing for their stockholders. For their patients, not so much. They aren't the problem, the system is. As long as health care is for profit, doctors like Kang and Ho will be selling their integrity, damning their oath, and sacrificing our lives to it. :: In my previous diary about Dr. Kang I made the following reference:

I'm sure Kang is less of a lackey and more of a cronie. My guess is that he's not an incompetent, failed doctor who pimps what's left of his license to the highest bidder, but that he's a smart and respected one who does.

I'm just going to stop writing now, lest I go there with Doctor Ho. [Cross-posted from SanchoPress] http://sanchopress.com/showDiary.do?diaryId=455