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Legal Issues

Follow Up: Madigan Commander Reinstated After Army Investigates PTSD diagnoses

Photo Credit: Sgt. Christopher M. Gaylord
Colonel Dallas Homas (far right), commander of Madigan Army Healthcare System at Joint Base Lewis-McChord, Wash., spoke during a press conference addressing the Army’s recent decision to discontinue the use of forensic psychiatry as part of its disability evaluation system.

After two weeks of following the Madigan Army Medical Center investigation, commander Col. Dallas Homas has been reinstated to his position. The investigation started mid-July after soldiers believed their Post Traumatic Stress Disorder (PTSD) diagnoses had been unfairly overturned by Madigan’s team of forensic psychiatrists and psychologists.

At an August 2nd press conference, the Army Vice Chief of Staff Gen. Lloyd Austin announced that forensic teams would no longer screen PTSD patients and reinstated Col. Dallas Homas to his position as commander, stating “he had not exerted any undue influence on the diagnostic process.”

In relation to our previous blog post “Military Psychiatrists Under Fire for Doing Their Jobs,” written by MCN’s Medical Director Brian Grant, MD, the Seattle Times featured him in an article last week. Here is an excerpt from the Seattle Times article “Reinstated Madigan Chief Happy to Be Back”:

Homas spoke to reporters along with Maj Gen. Richard Thomas, commander of the Western Regional Medical Command and Lt. Gen. Robert Brown, I Corps commander.

In his remarks, Homas confirmed before his removal he met with an ombudsman to discuss the forensic-screening team. At the time, Homas said he thought the forensic team was executing the accepted standard of care. “Now we have been given a new policy, and we’re going to execute that,” he said.

The Army’s decision to abandon the use of forensic screening has raised concerns among some doctors who practice forensic psychiatry. “I am baffled as to why making a psychiatric diagnosis in a military context should have different criteria from the civilian sector,” said Dr. Brian Grant, a Seattle-based forensic psychiatrist. “The matter deserves further study, hopefully including input from medical experts outside the military system.”

Read More…

Medical Payment Collection Gone Wild

By Brian L. Grant, MD

Emergency rooms sit of the front lines of the health care payment crisis as they must provide care to all who come though many can’t afford to pay. Photo by Adam Gault / Digital Vision / Getty Images.

Emergency rooms  sit on the front lines of the health care payment crisis. On the one hand, they must provide care to all who come – by law, custom and ethics. On the other hand, the care is expensive and many can’t afford to pay. Many of the uninsured use ER’s as their care sources rather when they lack access to clinics and physicians. Creative companies have found ways to profit and help pay for the care provided. In this case, one such company crossed the line of decency and legality. Our fee for service health care system assumes that personal responsibility and solvency can be relied upon. Is society served by financial triage for essential or urgent medical needs?

One day not too far off, stories such as the one featured in the New York Times article “Medical Debt Collector to Settle Suit for $2.5 Million” will be looked at with the same shame we feel towards the discrimination practiced in our country based upon race and other factors in past decades. We would regard it as abhorrent to deny access to K-12 education for the poor. Why do we believe that different standards ought to apply to access to health care? Why should employers have the burden and responsibility of providing health care for their employees, rather than this be a basic part of the social contract as members of society?

Do we as citizens and particularly those of us who have chosen to enter the field of health care have obligations beyond caring for our patients – to address systemic shortcomings and abuses the adversely impact the public health? Or is medicine just a job, and our goals to maximize profit?
Read more here: “Medical Debt Collector to Settle Suit for $2.5 Million”

What Are They Thinking!

By Brian L. Grant, MD

The article “Silicon Valley’s Surgeons of Fortune” from Business Week should amaze and enrage our readers. It is a compelling read and it certainly got my attention. It describes a chain of surgical centers operated by Bay Area Surgical Management of Saratoga, California that have successfully extracted massive profits for owners and investors, at the expense of insurance carriers and those who pay the premiums – typically employers.

The article is a must read for those wishing to understand one of the many ways that money is made in medicine and how a system, where there is nobody minding the store or watching costs, can be exploited by smart entrepreneurs.

After reading the article, consider where the fault lies, if you agree that something is deeply wrong. Is it the entrepreneur founders who devised a system to entice doctors into their facilities, select patients with rich insurance carefully, and charge multiples of in-network facility charges? Is it the doctors who have lost their ethical compasses by their decisions to sign up and at times, invest? These doctors have been given very low risk investment opportunities that are returning gains stated to be 805% per year! They are referring into facilities that they have a financial interest in, which many consider questionable, especially if they are in essence receiving kickbacks by below-market rent and other enticements. These returns come with strings attached; that one will refer high pay patients into the facilities. And the returns are paid for by the employers who buy the policies.

Or is it the insurance carriers, who accede to paying massively higher rates to such facilities than in-network options, rather than just capping what they are willing to pay by way of benefits and just saying no? Is it the employers who buy such policies that do not police their payouts in out-of-network scenarios?

Patients deserve to make choices, but these choices should be accompanied by fiscal responsibility to pay a significant portion of the differential between available options in-network and their out of network options. One person’s rights stop at the next person’s wallet, or should. In this story, the facilities further abuse the system by writing off the higher co-pays that patients would owe, that might serve as a disincentive towards going out of network because they might feel the pain and consider using in-network doctors and facilities. In a similar move, many drug companies provide coupons to patients taking expensive brand name drugs, to neutralize the higher co-pay they would pay at the pharmacy, while charging the carrier a much higher rate than the available generic or formulary options.

Those who pay for coverage should maintain the right to set reasonable parameters as to how much they will pay, and hold the line when a patient elects to obtain more expensive care. Patients deserve to be educated on the different fee structures well in advance of receiving care, and bear the responsibility themselves when they make more expensive choices. Would these clinics be able to carry on if insurers were not ultimately footing the bills for their charges? It is doubtful that there are enough patients who are indifferent to price. The facilities, if they lost the deep and willing pockets of the carriers, would have to come down to earth in their fees or be empty. Likewise the doctors, whose own charges if out-of-network, have not been described in the article relative to their network peers.

The article describes current litigation by Aetna and other. We will follow it with interest.

Abusive charges by outpatient surgical centers are hardly unique to Silicon Valley but remain a national issue. A side issue is the fact that facility charges have become common in less egregious but similarly irrational and usurious manners. One writer recalls bringing a child to a dermatologist clinic at a well-respected Seattle hospital. He was dismayed to find that he was being charged a facility fee in excess of $100.00 for a basic office visit merely because the office was located in a hospital-owned building connected to the main hospital. No value was obtained by such proximity. A subtle disclosure was made but the implications of this only set in when the non-covered expense was presented. It was the last visit to that doctor and clinic.

Below are two articles that provide additional examples of this issue:

Virginia Mason Agree to Refund “Facility” Charge

When Hospital Fees Catch You Off Guard

Military Psychiatrists Under Fire for Doing Their Jobs

by Brian L. Grant, MD

In recent months, forensic psychiatrists in Washington State have been pummeled in the media for taking on the task of reviewing PTSD diagnoses. Based upon media accounts rather than any specific knowledge of individual cases, purported statements implying bias by psychiatrists as well as reversal of some prior PTSD diagnoses, have landed some clinicians and the work of the unit in political hot water. The alleged statements were a common sense remark that claims of PTSD cost money and should be evaluated carefully. This is obvious and acknowledging the cost of such claims does not imply bias against proper diagnoses, but merely places it in a social context by the person making the comment. Diagnoses should be evidence based and any clinician who has familiarity with PTSD may be quite aware that the diagnosis can be made in a sloppy and inaccurate manner by those who lack expertise or possess strong biases. Washington’s Senator Patty Murray has perhaps been the loudest in her criticism of the forensic unit. We attach two articles from the Tacoma News Tribune that address the controversy. The long investigative piece does a nice job of laying out the many issues. We look forward to learning more about the outcome of the investigation and the outcome of the careers of the clinicians under fire. Those who dare to challenge popular wisdom do so at their peril.

Madigan Psychiatrists Who Made PTSD Calls Had National Renown
Senator Murray Begins Investigation into Hospitals’ PTSD Designations

Blue Cross Blue Shield of North Carolina fights hospitals and providers for overcharging patients

Blue Cross Blue Shield seems to be on the forefront of health news lately and it seems they are especially  interested in reducing waste in the health industry. Last week BCBS of North Carolina entered into a high-stakes battle with the state’s hospitals, doctors and medical professionals saying “providers were overcharging patients and their insurers by $16 million dollars.”

Blue Cross is claiming that providers are “unbundling” procedures like radiology imaging and blood and urine test procedures and charging an identical fee for every image taken or for multiple tests done to the blood/urine even though there was only one procedure conducted.

In the article, “Blue Cross battles NC hospitals, health care providers over ‘wasteful’ radiology charges,” Gerard Anderson, director of the Johns Hopkins Center for Hospital Finance, called the radiology billing method a classic example of “unbundling,” a widespread practice in which hospitals and other medical providers bill multiple times for a service that in reality is provided only once.

The uninsured and underinsured are the patients hurt worst by the practice, Anderson said. “If you don’t have someone negotiating on your behalf, they’re going to unbundle to the maximum extent possible,” he said. This radiology dispute is a small but revealing example of how arcane billing practices can drive up health care costs, which have been rising faster than inflation, even during the Great Recession. In particular, major urban hospitals in North Carolina have made record profits in recent years, raising their prices each year and exerting growing market power to negotiate higher payments from insurance companies. Read More…

American Pain: The Largest U.S. Pill Mill’s Rise and Fall

This article in Bloomberg Businessweek puts a human face on the opioid crisis – an interview with one of the owners of the largest Florida “pill mill” provider of prescription versions of Oxycontin. Now in jail, Christopher George provides some insight into how pill mills work and just how DEA regulations work and don’t work.

It’s a horrendous problem for society (according to the Centers for Disease Control and Prevention, 14,800 Americans died from overdosing on opioids in 2008, the most recent year data is available—more than the number of deaths from heroin or cocaine), as we’ve frequently noted at MCNtalk in the past. There were 335 million prescriptions for painkillers written in 2011. Is it any wonder some of them were from criminals? Read more…

Risky Rise of the Good-Grade Pill

At high schools across the United States, pressure over grades and competition for college admissions are encouraging students to abuse prescription stimulants, as noted in this New York Times article. Pills that have been a staple in some college and graduate school circles are going from rare to routine in many academically competitive high schools, where teenagers say they get them from friends, buy them from student dealers or fake symptoms to their parents and doctors to get prescriptions.

The D.E.A. lists prescription stimulants like Adderall and Vyvanse (amphetamines) and Ritalin and Focalin (methylphenidates) as Class 2 controlled substances — the same as cocaine and morphine — because they rank among the most addictive substances that have a medical use. (By comparison, the long-abused anti-anxiety drug Valium is in the lower Class 4.) So they carry high legal risks, too, as few teenagers appreciate that merely giving a friend an Adderall or Vyvanse pill is the same as selling it and can be prosecuted as a felony. Read more…

Discrepancies on Medical Bills Can Leave a Credit Stain

From a distressing but not unexpected article in The New York Times:

  • According to the American Medical Association’s 2011 National Health Insurer Report Card, commercial health insurers processed 19.3 percent of claims erroneously in 2011, up from 17.3 percent in 2010.
  • In 2010, an estimated 9.2 million people aged 19 to 64 were contacted by a collection agency because of a billing mistake according to the Commonwealth Fund, a nonprofit research group, while 30 million were contacted by a collection agency because of an unpaid medical bill.
  • Medical providers collected no more than 8 percent of their revenue from patients about 10 years ago. Now it is closer to 20 percent, or even 30 percent, in some markets.

Rodney Anderson, a mortgage banker in Plano, Tex., said he started to notice in 2008 that more of his customers were being hurt by these medical delinquencies. So he kept notes on 5,100 loan applicants over 10 months. He found that 2,200 had at least one medical debt that lowered their credit score, and many of them were unaware of the damage.

“It’s the same thing over and over,” said Mr. Anderson, executive director of Supreme Lending. “You just don’t let $100 go to collections to ruin your credit.”

That prompted him to take the issue to Congress. He said he had spent $1.5 million of his own money on consultants and on lobbying to change the rules. And his efforts, along with those of consumer groups and others, have gotten lawmakers’ attention.

A version of the Medical Debt Responsibility Act, which would erase medical debts from credit reports within 45 days of being settled or paid, was approved by the House with bipartisan support in 2010. The bill was reintroduced in the Senate by Jeff Merkley, Democrat of Oregon, in March. Read more…

Disabilities Act Prompts Flood of Suits

As noted in this New York Times article, a small cadre of lawyers, some from out of state, are using New York City’s age and architectural as the foundation for a flood of lawsuits citing violations of the Americans with Disabilities Act (ADA).

Suit by suit, the lawyers are forcing this tough and intensely pedestrian city, so resistant to change, to meet standards for accessibility that are more than 20 years old. In doing so, they are part of a nationwide trend: In the last year, 3,000 similar suits, including more than 300 in New York, were brought under the ADA, more than double the number five years ago.

The lawyers are generally not acting on existing complaints from people with disabilities. Instead, they identify local businesses, like bagel shops and delis, that are not in compliance with the law, and then aggressively recruit plaintiffs from advocacy groups for people with disabilities. Read more…