Eric Dishman gave an impassioned presentation at TEDMED in November 2009 but the video has just been released. He focuses on the need to bring much of healthcare out of the hospital and into the home by illustrating the research that Intel has been doing for the past 10 years. The video is an informative - and possibly inspiring - 16 minutes, after which you might want to go to the TEDMED site and scroll down to read the comments. Some are pertinent, some miss the point and at least one is decidedly cranky. They are a useful reminder of what we are up against.

By closing for 21 days it will allow the hospital to do the training and other matters needed.  This could happen anywhere in any city but since it is a chronic care facility they couldn’t answer whether or not chronic care patients who have to be re-admitted could return.   BD

(NECN: Scot Yount, Stoughton, Mass.) - Massachusetts state health inspectors have been on site at New England Sinai Hospital for seven days and found a number of specific concerns that have led the 83 year old institution to stop admitting new patients.
Inspectors identified concerns about skin and wound care, documentation and patient safety.
State officials suggested the 212 bed hospital close its doors to new patients and the hospital agreed after some patients were improperly restrained or had wounds not properly cared for.  One man nearly lost his foot after an improperly placed iv interrupted blood flow.

Concerns prompt hospital to stop taking new admissions

Payors Algorithms other Dubious Deals with the MedicalQuack - Blog Talk Radio 3-16-2010

Payment and compensation all revolved around the numbers and there’s a lot of gray in some of these areas too as we don’t have sufficient laws to cover a lot of this since we are fighting the battle with swords and the health insurers for the most part with their high investments with technology and business intelligence systems have machine guns. 

Health Fraud Scores Could Be a Contributing Factor to Medical Claims Being Denied

When you read further in here the CEO justified the rescission process being necessary to hold down the cost of premiums, wait a minute, hold down, we don’t see that today.  This testimony was just done by the CEO of the health insurance company in June of 2009.  He also went on to say that those who had been cut off had omitted information and/or were not truthful with what was provided and those “bad” patients who needed care were at fault.  Nice guy, right?

Little Progress on Fighting Healthcare Fraud – Look At Who’s Getting the Anti-Fraud Contracts

By the way, this patient in 2001 was 17 years old and did what he was supposed to do, went out and bought insurance, the big market today that insurers are looking for with our youth finding it not something they want to spend money on.  On top of all of this, the insurance company audit trail showed records of deleted phone calls and other pertinent items.  So basically, once it showed he had HIV, it’s was a “fraud” case investigation.  I didn’t know that contracting HIV was fraud and see it as a huge misfortune and an individual who needs care.  

Would Someone Explain Data Aggregation and “High Frequency Healthcare” to the US Congress

What is also strange in this entire story too is that the CEO testified that Congress should pass a law that would prevent this type of rescission activity.  With this one comment alone, I say another useless CEO that wants to just take home a big fat paycheck.  I guess they need laws and lack human morals here to make the right decisions it appears.  This just goes to show how powerful those decision making “algorithms” really are – nobody will go against what is shown on the screen when presented.  To this I say we need a Department of Algorithms so we know up front how they are going to analyze all of this, we do it for electronic medical records to make sure they function properly.

“Department of Algorithms – Do We Need One of These to Regulate Upcoming Laws?

Here’s a case of fraud “algorithms” in San Diego which I understand is still tied up in court and it pitting patients against doctors, and vice versa. 

Skins game With Dermatology Offices in California – All Insurance Carriers Quit Paying For Treatment Within a 5 Day Period

It’s no wonder that Virginia and Idaho are revolting about forcing citizens to have health insurance from companies who do business like this, and they all do it.  California and Blue Cross was all over the news not too long ago in regards to rescission. 

Virginia The First State to Pass Legislation to Protect Citizens From Being Forced to Purchase Health Insurance – If the Insurance Companies Were Non Profit It Might Make A World of Difference

When you go back to re-enroll, which is what happened to me, I had to prove that I had not seen a doctor for 6 months and pay a 25% premium, now is that the preventive healthcare they talk about – NOT.  The movie “Sicko” brought all of this to our attention, but needs a sequel on how to “fight the algorithms” and get consumers some new items to do battle with besides the swords. 

Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!

Here’s what can happen with the MIB records below.  One may never get items correct either that prevent individuals from securing health insurance. 

Remember all those old 10-20 claim files are around and available to insurance companies through sites like the MIB (medical insurance bureau) and if they can use that information to rescind, they probably will.  On the other hand we have this big gaping hole with Medicare that all the crooks dip into so the infrastructure and enforcement efforts definitely need to be equal and and improved.  The post below adds some information on how to fight denied claims and coverage. 

How to Fight Algorithmically “Scored” Health Care Claim Denials – Line Up and Deliver Your Own Data

After we get through with all of this on the other side of the coin we have hospitals telling doctors they are not meeting quotas, in other words there are not enough people being admitted so they can meet their costs.  Here’s a video on what happened in Texas with a contracted ER group of doctors.

In short, this is the mechanics of how the system operates today.  If you take time to check out the links there’s even more information revealed here.  I’m trying to just put this out in plain English with facts all brought together here on what really goes on behind the scenes and how you are viewed in the eyes of the algorithms that do the computations that are read by humans for profitable decision making processes, not necessarily better care and these are the current rules that patients, doctors and hospitals have been dealt.  

This is truly a sad legal story here, but it is the truth on how greed corrupts healthcare and if you become ill, it is viewed as all “your” fault.  BD 

(Reuters) - In May, 2002, Jerome Mitchell, a 17-year old college freshman from rural South Carolina, learned he had contracted HIV. The news, of course, was devastating, but Mitchell believed that he had one thing going for him: On his own initiative, in anticipation of his first year in college, he had purchased his own health insurance.

Shortly after his diagnosis, however, his insurance company, Fortis, revoked his policy. Mitchell was told that without further treatment his HIV would become full-blown AIDS within a year or two and he would most likely die within two years after that.

So he hired an attorney -- not because he wanted to sue anyone; on the contrary, the shy African-American teenager expected his insurance was canceled by mistake and would be reinstated once he set the company straight.

But Fortis, now known as Assurant Health, ignored his attorney's letters, as they had earlier inquiries from a case worker at a local clinic who was helping him. So Mitchell sued.

In 2004, a jury in Florence County, South Carolina, ordered Assurant Health, part of Assurant Inc, to pay Mitchell $15 million for wrongly revoking his heath insurance policy.

Previously undisclosed records from Mitchell's case reveal that Fortis had a company policy of targeting policyholders with HIV. A computer program and algorithm targeted every policyholder recently diagnosed with HIV for an automatic fraud investigation, as the company searched for any pretext to revoke their policy. As was the case with Mitchell, their insurance policies often were canceled on erroneous information, the flimsiest of evidence, or for no good reason at all, according to the court documents and interviews with state and federal investigators.

Much of the trial record of the Mitchell case is bound by a confidentiality order and not available to the public. But two orders written by the presiding judge, Michael G. Nettles, a state circuit judge for the 12th Judicial District of South Carolina, of Florence County, describe the case in detail. Judge Nettles wrote the orders in response to motions by Assurant that the jury's verdict be set aside or reduced.

In the motions, Nettles not only strongly denied Fortis' claims but condemned the corporation's conduct.

"There was evidence that Fortis' general counsel insisted years ago that members of the rescission committee not record the identity of the persons present and involved in the process of making a decision to rescind a Fortis health insurance policy," Nettles wrote.

Elsewhere in his order, Nettles noted that there were no "minutes of actions, votes, or any business conducted during the rescission committee's meeting."

"In addition to these acts toward (Mitchell) there was evidence that Fortis has for some time been making recommendations for rescission, and acting on those recommendations, without good-faith investigation conducted fairly and objectively ... Fortis pre-programmed its computer to recognize the billing codes for expensive health conditions, which triggers an automatic fraud investigation by its "Cost Containment" division whenever such a code is recognized."

Insurer targeted HIV patients to drop coverage | Reuters

Related Reading:

Are We Ever Going to Get Some Algorithm Centric Laws Passed for Healthcare!

AARP Is Just Caught in the Middle of the Debate – Its the Algorithms That Call the Shots, Not Memberships in Senior Organizations

Brave New Films – “United Wealth Care” – It’s In the Algorithms

How Wall Street Lied to Its Computers – Software and Programming

Health Care Insurers Suggest Algorithms and Business Intelligence solutions to provide health insurance solution

Is This a Case for a New Law – Illegal Algorithms? How Do You Sleep at Night Rockefeller asked the CEO of United Health Care

Somebody Stole Goldman’s Algorithms – Code that Makes Their Money Just Like Health Insurers Use

Goldman Sachs – Healthcare Reform Bets, Hedges, and Analysis, Not About Healthcare But All About Money

Traders Profit With High Speed Computers and Servers…Health Insurers Use Them Too

The University of Pittsburgh is finding out how complicated this is becoming.  SNOMED is international, so it fits with having the same diagnosis all over the world.  This is somewhat amusing when looking at how some of the data they worked with from 3 different EHR systems worked, men that smoked while pregnant, so we all know this is an error. 

As mentioned below, we have the new ICD-10 Codes coming that need to be mapped too, so this is one more growing area of HIE that needs to integrate to ensure accuracy and in the long run, getting paid.  SNOMED codes are far more specific and numerous as well.  BD 

If you think getting standard medical terminology hardwired into EHR systems is simple, just ask the hundreds of Pennsylvania men whose patient records indicated they smoked while pregnant.

Those patients, served by the University of Pittsburgh Medical Center (UPMC), got caught in a quandary of words because of the vagaries of insurance coding and the different vocabularies used in five separate EHR installations (three from Cerner Corp., one from Allscripts-Misys Healthcare Solutions Inc. and one from Epic Systems Corp.).

The health system is on the vanguard of a national movement, because adoption of SNOMED CT is required of all health care providers by 2015 in order to qualify for meaningful use certification. Currently, most providers use the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), which providers will retire in favor of the next revision, ICD-10-CM, in October 2013.

Fixing the coding for the male patients smoking while pregnant was one of the many problems Hogan and Konicek addressed during the mapping process. They shared their experiences in a presentation on SNOMED CT implementation at the HIMSS10 annual conference earlier this month.

So how are they going to get the lists mapped to ICD-10-CM via SNOMED CT terminology? Watch the National Library of Medicine and the American Health Information Management Association, which are working on mapping projects. Also, some benevolent private health care systems may step up to the plate and share their maps, too.

SNOMED CT will be coming to EHR systems and patient records near you

In the video below the individuals purchased a pharmacy operation that already had a Medicare license and went to work, billing, billing and more billing.  If we could take the criminals that code for fraud and turn these folks into legitimate employees we might have something here.  All claims are processed electronically so the ones who get the data filled in properly and the right boxes checked, get the payout, legally or illegally.

For 2 months, they had “midnight” billing going on.  If you do your paperwork correctly, you get paid.  Meanwhile back at the ranch, hospitals and doctors struggle to keep up, but unlike the criminals they are taking care of patients, the criminals do not and are only billing so thus they focus on billing to get the pay out.  Click on the image below to watch the Nightline story. 

The video also points out how frustrating it can be to get Medicare to investigate as well.   In addition, 60 Minutes had a video talking to an individual who actually did all of this. 

Medicare Paid More than 47 Billion in Questionable Claims

Criminals last year also found a way to use the NPI numbers of “dead doctors” to generate revenue.  Again, this type of fraud should be monitored and checked out and as you can see by the example here, it takes more than technology sometimes to find fraud as filling out the forms and checking the right boxes can be done by criminals very well when nobody is home watching the shop. 

Probe finds dead doctors used in Medicare Scam

What it interesting is watching the FBI policing agents to visit an actual pharmacy that had not filled a prescription at all, they just billed. 

In the example in the video, a quick million was billed in 2 months.  The people covered by Medicare have no clue either.  For $45,000 the existing business was purchased by the criminals along with the existing patient files and data bases. 

A four month "Nightline" investigation into Medicare fraud makes one thing perfectly clear: this is a crime that pays and pays and pays. The federal government admits that a staggering $60 billion is stolen from tax payers through Medicare scams every year. Some experts believe the number is more than twice that.

It looks to be what the agents say is a typical scam: a fraudster buys a pharmacy along with its Medicare license and entire patient database. This one was sold five months ago for just $45,000.

The scheme is relatively low-risk and requires little investment. Investigators allege that one person at a computer terminal could have submitted the million dollars worth of claims this pharmacy sent to Medicare in two months, before shuttering the place and disappearing.

Ogrosky said criminals' forms are often filled out more completely than actual health care providers'.  "Real hospitals and doctors who are struggling every day to keep up with the paperwork sometimes miss things ...whereas if you are a criminal trying to steal, all the forms look perfect every time because the whole goal of the enterprise is to check the right boxes," he said.

Judge Marshall Ader, who sat on the Florida state bench for decades, said he even had trouble getting Medicare to pay attention. When he saw that Medicare was being billed for two prosthetic legs using his Medicare number -- for the record he has both of his legs -- he hit the roof.

According to Piper, Medicare was billed three times a week at this clinic and paid out $10,000 per claim -- more than $30,000 a week for a service that was never provided.

Medicare Fraud Costs Taxpayers More Than $60 Billion Each Year - ABC News

Design firm Priestmangoode has prepared a Health Manifesto to argue for a bigger role for design in health care. They have outlined some interesting principles, culminating in the Priestmangoode Recovery Lounge show in the photo above. Looks pretty good to me.

Here’s their list:

1. Nothing touches the floor –furniture floats above the floor for easy cleaning, like Motel 6
2. Privacy in every space, for every patient –like first class seats on Swiss
3. Cheap doesn’t mean poor quality –like modular, low-cost hotel rooms for ETAP
4. Speed –fast turnaround times like airplanes coming in and out of gates
5. Better information systems to reassure patients and families –like the way-finding system in the new Heathrow Terminal 5
6. Reduce the amount of work for people in the system –like the focus on making things easy for airline cabin crews
7. Smarter, more functional use of space –like hotel/airline central columns that contain electricity, water pipes, Internet/phone cables, desk, mirror, sink
8. At home in hospital –pay as you go entertainment (TV, music, computers)
9. Can’t they just be nicer to look at? –pay attention to aesthetics and good feelings will follow
10. The Priestmangoode Recovery Lounge –pulling all the concepts together into a new concept

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1. How should Sanofi aventis have dealt with their Facebook problem? (submitted by Sam Walmsley; @sammielw)
2. How should a pharmaco "engage" a "disgruntled" patient postings AEs on its social media (eg, Facebook) site? Are Terms of Use adequate? (submitted by me - @pharmaguy)