Walgreen Settles

Here is the next story in what seems like an endless succession of prominent health care companies settling lawsuits alleging improper behavior, via the Minneapolis Star-Tribune:

Walgreens has paid the United States and Minnesota and three other states nearly $10 million to resolve allegations of falsely billing Medicaid, the U.S. Justice Department announced Monday, with some of that money going to two Twin Cities pharmacists who turned in the industry giant.

Illinois-based Walgreens charged Minnesota, Florida, Michigan and Massachusetts as if some Medicaid recipients were uninsured, the Justice Department said, when those members were actually covered by Medicaid and by private insurance. The department said Walgreen was entitled to a copay, but instead, charged the difference between what the insurance companies paid for the drugs and what the Medicaid programs would have paid if the recipients were uninsured.

As a result of this improper billing, Walgreens received reimbursement amounts from the states' Medicaid programs that were higher than it was entitled to receive.

Walgreens spokesman Michael Polzin blamed the problem on 'inadvertent billing errors' because of a 'unique requirement for Medicaid billing when Medicaid is a secondary insurer.'

This is the second settlement of this kind we have discussed this week. Its immediate predecessor was the Cephalon settlement. Earlier this year we discussed settlements by Staten Island University Hospital, Amerigroup, UnitedHealth, Anthem Blue Cross and Blue Shield, and HealthMarkets, Express Scripts, Kyphon (Medtronic subsidiary) and Merck. Of course, to these could be added various other ethical lapses, including some involving guilty pleas to criminal charges (e.g., Biovail, and at UMDNJ)

Juxtaposing these events in a procession suggests there are serious systemic ethical problems in the leadership of health care organizations. Moreover, these problems likely have cumulative adverse effects on heath care costs, access and quality, and on the morale of health care professionals. However, outside of Health Care Renewal, there seems to be almost no discussion that so juxtaposes them. In particular, try to find any mention of them in the health services research, health care research and health care policy literature.

Furthermore, while these settlements serve to mark the unethical behavior of the organizations and individuals involved, they never seem to have a large enough monetary value to actually discourage such behavior. As long as health care leaders can shrug off the consequences of unethical behavior merely as acceptable costs of doing business, absent any serious attempts to get health care organizations to enforce internal codes of ethical behavior or to avoid hiring ethically challenged leaders, the procession will likely continue. The effects will be continually rising costs, declining quality, shrinking access, and rising numbers of demoralized health professionals.

Maybe at a time when many people see arrogant, greedy, and unethical executives as the main reason our financial system seems to be in incipient collapse, they will also realize that the same sorts of executives may be a major cause of our ongoing health care crisis.

Post Title → Walgreen Settles

BLOGSCAN - More on Prescription Data Mining

On the Carlat Psychiatry Blog, this post reviews how "pharmacy information companies" get data about which physicians prescribed what drugs from pharmacies, combine it with data on physicians from the American Medical Association (AMA), and package the result, which identifies how many prescriptions each doctor wrote for each drug, to pharmaceutical companies. The post features some delightful sarcasm on how the "pharmacy information companies" defend their lucrative work, as increasing "transparency."

Post Title → BLOGSCAN - More on Prescription Data Mining

Quick In-Store Health Care Clinics: "You're Sick. We're Quick!" but Will You Really Get Better?

There has been a lot in the media lately about quick in-store health care clinics, an issue which we blogged about previously here and here. In Illinois, as reported by the Chicago Tribune, the state medical society is pushing for more regulation, which is predictably not making clinic operators happy.

The Illinois State Medical Society, which represents more than 13,000 doctors, is pushing a proposed law to more closely monitor hundreds of in-store clinics being opened by retail giants Wal-Mart Stores Inc., Walgreen Co. and CVS/Caremark Corp.

The doctors claim the clinics, staffed by advanced-degree nurses and physicians' assistants, are largely unregulated and therefore put patients' health at risk.

The potential loss of business for doctors is great because most health insurance companies are beginning to cover retail clinic procedures.

Doctors say they are concerned about the quality of care if the clinics uphold their promise to treat patients in less than 15 minutes. The doctors said that is not enough time for consultation, and that follow-up may not be adequate.

Facing off against the doctors' powerful lobbying organization are the powerful pharmacy and retail industry lobbyists, who are trying to block the proposed legislation. Retailers say the clinics are staffed by licensed health professionals who track their patients' health in medical records and make referrals.

'Increased regulation has the potential to restrict access to these health-care services and create more costs to patients,' Walgreens spokesman Michael Polzin said. 'That would work against the growing concern over affordable, quality health care that our Health Corner Clinics are directly addressing.'

There is a paean to quick in-store clinics in a today's Wall Street Journal by free market health care booster Grace-Marie Turner.

It's Friday evening and you suspect that your child might have strep throat or a worsening ear infection. Do you bundle him up and wait half the night in an emergency room? Or do you suffer through the weekend and hope that you can get an appointment with your pediatrician on Monday -- taking time off your job to drive across town for another wait in the doctor's office?

Every parent has faced this dilemma. But now there are new options, courtesy of the competitive marketplace. You might instead be able to take a quick trip on Friday night to a RediClinic in the nearby Wal-Mart or a MinuteClinic at CVS, where you will be seen by a nurse practitioner within 15 minutes, most likely getting a prescription that you can have filled right there. Cost of the visit? Generally between $40 and $60.

These new retail health clinics are opening in big box stores and local pharmacies around the country to treat common maladies at prices lower than a typical doctor's visit and much lower than the emergency room. No appointment necessary. Open daytime, evenings and weekends. Most take insurance.

Much like the response to Hurricane Katrina, private companies are far ahead of the government in answering Americans' needs, this time for more accessible and more affordable health care. Political leaders across the country seeking to expand government's role in health care should take note.

This industry is in its infancy and will hardly register in our nation's $2 trillion-plus health care bill. But just as Nucor overturned the steelmaking industry with a faster-better-cheaper way of making low-end rebar, these limited service clinics could be the disruptive innovator in our health-care system. Package pricing for more complex treatments, like knee replacement surgery, may not be far behind.

Government can get in the way, of course, with protectionist policies that throw up more regulatory barriers to entry. But retail clinics could be just the beginning of consumer-friendly innovations....

What bothers me about all this? It seems to me that in-store clinics (of this type) could embody what goes wrong when the business managers and bureaucrats who are now in charge of health care treat health care as a commodity, a standardized service that can be provided quickly in a formulaic way by "mid-level providers." But won't the service be quick, cheap and to the point?

My concern is that health care is rarely as simple as it seems, especially to people whose health care training was reading financial statements from health care companies. Let's look at an example. One of the maladies which the quick clinics advertise they can treat is the common sore throat. I have actually done some research on this problem, and what I have learned from reading the clinical literature, and my own clinical and research experience is that even this seemingly simple health care problem isn't.

Sure, most, maybe the majority of people with sore throats just have self-limited viral illness, and only need symptomatic treatment (aspirin or the like, maybe throat lozenges, maybe cough syrup, maybe an anti-histamine, fluids and rest). Such people do not even need to visit a clinic. The first problem is that neither the patient nor the practitioner can reliably determine from the patient's symptoms and physical exam whether the patient just has a viral sore throat, or streptococcal pharyngitis (strep throat).

Strep throat can at times lead to serious complications if not treated with antibiotics. Yet the antibiotics used in treating it can have side effects. So even for the "routine" sore throat, the health care professional needs to look at the probabilistic balance of benefits of treatment and harms of treatment. The relevant probabilities, and the importance and value of the particular benefits and harms will vary for different patients. To some extent, this balancing can be rendered formulaic (although the formula may not be simple.) But a failure to understand that the problem is actually somewhat complex and probabilistic could lead to trouble: a patient with a viral sore throat getting a needless antibiotic complication, a patient with strep throat not getting an antibiotic and getting a complication of the disease.

Things get even more complex for a patient with another condition which may affect the likelihood of complications of strep, or of antibiotics. Some common examples of such conditions are asthma, diabetes, chronic obstructive lung disease, and heart valve problems. There are other, less frequent problems on the list. If a health care professional fails to appreciate that the patient with a sore throat has one of these problems (and patients with these problems are not always fully aware of them), then the potential for something major going wrong is even higher. It becomes much harder to set up a formulaic approach that would efficiently screen for such problems, especially because not every patient with them knows he or she has them.

And then there is the issue of rare causes of sore throats....

Other "simple" problems, like urinary tract infections and ear infections, may not always be simple either. And we physicians feel we really earn our money by figuring out when an apparently simple patient isn't.

My real concern about the "quality of care" delivered by quick health care clinics is that the "mid-level providers," good, well-intentioned people with substantial training, but still years less of training than that given to physicians, operating in isolation with corporate pressure to do things quickly and cheaply may miss some of these not so simple patients. And that would be quite bad for the patients. (And when the lawyers figure it out, it would be quite bad for everybody involved.)

Again, those concerned with decreasing costs and improving access might better first focus on the really expensive parts of health care (look at Health Care Renewal and the blogs on our blogroll for some examples). But of course those costs will be heavily defended by vested interests. And the relatively poor, beleaguered primary care docs probably won't make such a fuss about quick quick health clinics, that is, until there own patients end up having bad experiences resulting from such clinics' care.

Of course, it may be possible that quick in-store clinics are just a symptom of larger social ills, and hence may be hard to stop. Let me conclude with quotes from a recent column by Brian McGrory in the Boston Globe:

Oh, I know, I know, every harried mother and overwrought father within Route 495 is undoubtedly thinking that these fast-serve clinics are a going to be a godsend in their mile-a-minute lives. The kid has a rash -- head out to see the nurse practitioner at the CVS, and hey, pick up some Tide while you're at it.

Because that's all we have time for these days, impersonal drive-through treatment centers offering medicine by slogan. As the chief executive officer of MinuteClinic said, 'You're sick. We're quick!'

What's next in their ad campaign? How about 'You've got ills. We've got pills!' And conveniently, you can fill the prescription written by the nice CVS nurse practitioner with the equally nice CVS pharmacist.

It wasn't all that long ago when the average Jane and Joe would take the time to establish relationships with their doctors, who would get to know them inside and out, and doctors would take the time to nurture relationships with patients.

But now look what's happened. Modern technology was supposed to free people up, to give everyone more time.

We can have all the information in the world, but rather than creating the luxury of time, it's causing a constant frenzy. Technology hasn't allowed people to leave their responsibilities behind; it's made people bring their obligations every single place they go.

And thus, the MinuteClinics, guaranteed to be as popular as they are impersonal. So back to my first question: They are merely a symptom, not a cause.

Post Title → Quick In-Store Health Care Clinics: "You're Sick. We're Quick!" but Will You Really Get Better?

Top Pharmacy Chain Executives Indicted for Conspiracy, Fraud and Bribery

Late last week, the Providence Journal reported the indictment of two top executives of CVS, one of the largest US pharmacy chains:

[Carlos] Ortiz and another prominent CVS executive, John R. 'Jack' Kramer, were accused in a 23-count indictment of conspiracy, fraud and bribery for allegedly hiring [former Rhode Island State Senator John] Celona as a $1,000-a-month consultant from early 2000 to the fall of 2003, paying him a total of about $45,000 and also lavishing him with golf outings, trips to Florida and California and tickets to professional sporting events.

Although Celona was ostensibly paid to improve CVS’ image among consumers, U.S. Attorney Robert Clark Corrente charged that Kramer and Ortiz put Celona on the payroll 'to advance the company’s legislative agenda…through illicit payments to Senator Celona.'

In return, the indictment said, Celona used his political clout to kill controversial 'pharmacy choice' legislation that would have expanded the Rhode Island network of pharmacies that accepted Blue Cross reimbursements. CVS, which dominated the restricted network, opposed the bill so strongly that the company tied Kramer’s and Ortiz’s performance reviews to defeating the legislation.

Killing the legislation, Ortiz wrote in one review, had 'helped to protect millions of dollars of sales.'

The indictment says that Celona also opposed the licensing of Canadian pharmacies in Rhode Island, pushed legislation to allow the electronic filing of prescriptions and promoted the creation of a state-backed loan program for pharmacy students.

Celona pleaded guilty in 2005 to selling his office to CVS, Blue Cross & Blue Shield of Rhode Island and Roger Williams Medical Center, and is due to be sentenced Jan. 31. He testified last fall in the corruption trial leading to the conviction of former Roger Williams executives Robert Urciuoli and Frances Driscoll.

Yesterday’s indictment left one major question unanswered: Will the investigation reach Tom Ryan, the chief executive of the nation’s largest drugstore chain...?

The indictment refers cryptically to a 1999 memo that Ortiz sent to a number of CVS officials, including 'Executive #1,' in which he discussed pharmacy choice and wrote, that he was 'hopeful that we will be able to kill it in the Senate Corporations Committee.' However, the indictment also charges that Kramer and Ortiz failed to have Celona’s consulting agreement reviewed and approved by CVS’ chief financial officer; and others, as required under company policy governing consultants.

Ryan has declined to comment on whether he knew of the arrangement. The indictment mentions Celona’s attendance at a social function at the home of 'CVS Executive #1,' but doesn’t elaborate on that person’s possible knowledge of the relationship.

'No charges were filed against the company, which has fully cooperated with the government in connection with its investigation of this matter since its inception,' CVS said in a statement yesterday.

Of course, an indictment does not prove guilt. But this is just the latest example of allegations of criminal behavior made against the leadership of health care organizations of every type.

It seems that for far too many executives and managers of US health care organizations, conspiracy, fraud, and bribery are just part of another day at the office. It is likely that such criminal conduct, plus the probably much more common conflicts of interest, and just plain mismanagement that seem everywhere in the leadership of US (and global) health care are important, maybe the most important explanations of why we seem unable to address rising costs, declining access, stagnant quality, and demoralization of health care professionals.

Post Title → Top Pharmacy Chain Executives Indicted for Conspiracy, Fraud and Bribery