We have ways of making you comply

If we want to get or keep a job or government benefits, have affordable health insurance, or be able to find a doctor who will care for us, then we are quickly finding our options limited unless we do what the government or our insurer decides is best. Our ability to decide, with our healthcare provider, what is best for our personal wellbeing and for our loved ones, is steadily being eroded. Those who are aging, minority or of marginalized social status, or born with genes predisposing them to certain health problems (real or perceived) may have the most to lose.

With national electronic databases — of our medical records, pharmacy records, laboratory results and lifestyle behaviors that the government and pharmaceutical and insurance industries are vigorously lobbying for — everyone can be identified and targeted for mandated screenings and interventions: those with any number viewed “too high” and in need of treatment, such as body mass index, cholesterol, blood pressure or blood sugar; and those with diets or lifestyles that are judged as unhealthy. This may sound overly dramatic, but it’s becoming a troubling reality.

It’s all in the name of “health,” and for our own good and the good of the country or company, of course. But is it?

Today, we’ll look at just a couple of recent news items from the consumer side of things. An upcoming post will share what doctors are encountering. Seeing them together may give us new insights that we might otherwise miss.

On April 4th, the nation’s largest health insurance company, WellPoint, Inc. with 34 million members, announced that its employees’ compensation would be tied to how well people comply with their wellness program and participate in their health risk assessments and disease management. As the Los Angeles Times reported:

Health insurer ties pay to members’ health

...Health insurers and the federal government have been pushing for ways to tie the compensation of doctors and hospitals to how well patients fare. WellPoint is believed to be the first health plan to apply that standard to its employees. The central component of WellPoint's program is a “member health index" — a complex formula that measures and tracks patients' overall health levels, including how often they ended up in emergency rooms, how often they received preventive care and whether they were taking needed medications, such as cholesterol-lowering drugs.

But some consumer advocates and physician groups are skeptical. They contend that WellPoint's program could be used to identify the sickest patients so that their premiums could be raised or their coverage canceled. They cite a finding by state regulators that Blue Cross of California illegally dumped individual policyholders after they incurred hefty medical bills. WellPoint, which the regulators fined $1 million, has denied the allegations....

Many of these and other efforts have focused on controlling the epidemic of largely preventable chronic diseases, such as hypertension and diabetes, that are closely linked to obesity....

But not everyone was convinced of WellPoint's motivations. WellPoint's member health index can go up if health levels improve but also if sick members drop out, said James Rohack, a cardiologist in Temple, Texas, and member of the American Medical Assn.'s board of trustees. “If a small employer who has sicker-than-average workers were to drop out because WellPoint premiums are too high, guess what? Your index just got better," Rohack said. “And for uninsured people who need healthcare, with this index, WellPoint would have no incentive to sign them up" if they will bring the index down.

How sound is the evidence behind the heath measures being used? We’ve looked at the poor evidence behind one of the most popular employer wellness programs, for example. And concerns have already been reported that older people, and those who are minority, of lower social status, in ill-health, or fat could go the way of smokers and be fired or denied employment or insurance coverage, or penalized with higher premiums.

On April 9th, the Tampa Tribune reported on measures afoot to expand local electronic medical record sharing programs into a single, statewide network. The $51 million project will purportedly reduce healthcare costs and medical errors. As far as privacy of those records, “A public-private partnership would authorize the network’s users and decide how best to secure it,” according to the project chair. [Read that sentence again for reassurance — not.]

Pledges that they will keep records safe from hackers is not what really concerns consumer privacy rights advocates, though, as the Tribune reported:

Insurers, pharmacists, even hospitals have aggregated and sold sensitive patient data over the years, said Peel, who founded the Texas-based Patients Privacy Rights Foundation in 2004. Moving to electronic records, she said, vastly increases the potential for collecting and selling such data....If insurers and employers can access identifiable health data, she said, they can discriminate against the mentally and chronically ill.

On April 10th, the Washington Post wrote a veritable sales piece for the benefits of national electronic databases, profiling the development of electronic records across the country’s veteran healthcare services. Amidst the possible positives were disturbing peeks at the potentials for abuse and misuse of the information:

Since 1999, the VA's 155 hospitals, 881 clinics, 135 nursing homes and 45 rehabilitation centers have been linked by a universal medical records network. It allows any authorized person to look at 5.3 million patients' records — everything from a nurse's note written during a hospital stay, to the result of a blood test drawn at a clinic visit, to the moving-picture film of a coronary angiogram done in a cardiology lab.

Even though President Bush has set a goal of 2014 for when most Americans should have their medical information stored electronically, the Department of Veterans Affairs is today one of the few health systems — and by far the largest — that is virtually paperless.

A study commissioned by the Department of Health and Human Services last fall reported that one-quarter of American physicians use some sort of electronic record-keeping in their practices. But less than 10 percent have systems that store all necessary data, allow electronic ordering of tests and provide clinical reminders. Only 5 percent of the country's 6,000 hospitals have computerized ordering of drugs and tests, and even fewer have a fully integrated system like the VA's....

The ability to detect trends in physiological variables such as serum chemistry, cell counts, blood pressure and even weight is important to good decision-making. But it is often hard to do. Electronic medical records make it easier....Electronic records are especially helpful in managing prescription drugs, a major source of medical errors....Electronic records can also improve physician performance. They can warn of things that shouldn't be done, provide reminders of what should be done and monitor what is done...

Also on April 10th, the Philadelphia Inquirer wrote of a broad, ambitious new plan to manage “chronic illlness across the state.” The plan will identify and track all those with diabetes first and take comprehensive management of these patients away from their primary-care physicians and to state “primary care teams.” It will develop information organizations to support data exchanges and patient registries, provide reminders and alerts to doctors and patients to adhere to disease management guidelines, educate patients, and “work with insurers to restructure reimbursement system in support of chronic-care management practices.”

“What we are hoping is that by significantly changing the payment structure, we will encourage a really different way of providing chronic care," said Ann S. Torregrossa, senior policy director in the Governor's Office of Health Care Reform. The state could lead the way because it is one of the biggest purchasers of health care — through Medicaid, state employee health plans, and other programs, she said.

Some insurance companies already are prodding doctors to follow medically proven standards for their chronically ill patients. Aetna, for example, increases payments to primary-care physicians who meet certain measures, such as checking diabetics' blood sugar and cholesterol levels at every visit...Electronic medical records can track all of a physician's patients this way.

Today, Human Resources News, a publication of the Society for Human Resource Management, explores how far employers can go to “press workers to participate in ‘not-so-voluntary’ employee wellness initiatives.” Employers are considering how to “leverage their wellness programs even more to make their premium increases leaner. Some payoffs are nothing short of heart-racing,” it said.

Employees at Scotts Miracle-Gro Co., it exampled, are “required to take annual health risk assessments or pay $40 a month more in premiums. Those with moderate to high risk had to be assigned a health coach or pay $67 more a month in premiums.” [Health coaches, by the way, are not licensed healthcare professionals, but are typically low-paid personnel following a script provided by the insurance company.] However, the company is being sued by a worker allegedly fired for failing a drug test — for nicotine use. Currently, company wellness programs can legally penalize people up to 20% of the cost of their insurance. The article concluded:

But [Garry Mathiason, an attorney with Littler Mendelson] predicts that the business need for wellness will lead more employers to go beyond voluntary wellness programs. He expects a new story to emerge, predicting that over the next 20 years courts will write new chapters about how far employers can go.

Also in the news today comes the announcement that AARP has gone into the health insurance business in a big way. As Reuters reports:

AARP has expanded its line of health insurance plans for older Americans in conjunction with UnitedHealth Group Inc. and Aetna Inc. AARP and UnitedHealth, which already offer a number of joint insurance plans, will add a Medicare Advantage managed care plan....The new plan is part of a broader seven-year agreement between the two organizations to provide plans featuring financial incentives and penalties based in part on clients' management of chronic conditions such as diabetes and obesity, AARP said....

AARP's new arrangement with UnitedHealth is expected to bring in an extra $22 million a year in royalties for the group, which said it could not comment on what the deal was worth to the insurer. It also said it aimed to boost current enrollment from 7 million AARP members in the insurer's various plans to 14 million by 2014. AARP has about 38 million members overall.

The mere fact that obesity treatment for seniors is one of the AARP’s key “chronic conditions” it will manage and tie incentives and penalties to, reveals something other than evidence might be at work — because, as we’ve seen, the evidence shows dieting and weight loss among seniors especially endangers their health. It goes beyond insights such as the $4.8 million Robert Wood Johnson Foundation had given the AARP just between 2001 and 2005, and the AARP’s partnership with the American Obesity Association.

The New York Times today adds that this deal will make AARP the largest provider of private insurance to Medicare recipients in the country. It will also continue to provide prescription drug coverage and policies to supplement Medicare, known as Medigap coverage.

William D. Novelli, the chief executive of AARP, said, “In launching these initiatives, we are driven by our mission to create a healthier America.” The group also said it would use its leverage to reshape the health insurance market....

AARP also said it would use $500 million of insurance sales revenue over the next decade to help people navigate the health care system, with a new counseling service. Payments to UnitedHealth and Aetna will be linked to their performance in improving the health of subscribers...AARP will measure how frequently the companies deliver recommended treatments to people with diabetes, hip fractures and other conditions.

And how will AARP juggle appearing to be a consumer lobbying organization while also being a major Medicare insurer? The Times reviewed the various policy issues where conflicts of interest were a concern, and noted:

The role of private insurers in Medicare is one of the most hotly debated issues in American health policy....“AARP will not be perceived as a truly independent advocate on Medicare if it’s making hefty profits by selling insurance products that provide Medicare coverage,” [Judith A. Stein, director of the Center for Medicare Advocacy] said. “AARP’s role in this market could give a big boost to the privatization of Medicare.”...

AARP officials insisted that its financial interests do not affect the positions it takes on Medicare, Medicaid, Social Security and dozens of other issues on which it lobbies and litigates.

Will anyone actually believe that?

Whether or not under any of these mandated government, insurer and employee programs the guidelines for screening and management of chronic diseases are actually based on sound evidence and proven to be beneficial to everyone — let alone if the identification of “disease” is based on actual clinical illness or upon arbitrarily-determined surrogate measures — highlights the potential for abuse and misuse and for harm.

The manipulation of health indices have already reached such extremes that, according to the latest recommendations for blood pressure and cholesterol levels alone, ninety percent of adults are now deemed diseased. [We’ll look at this more soon.] And, two-thirds of us have been labeled fat and in need of weight management. Healthful and realistic lifestyle behaviors will not overcome age and genes to allow most adults to comply with the numbers being targeted, according to the medical literature, meaning we will “need” lifetime prescriptive medications.

As is becoming increasingly evident, many of the thresholds believed to be risk factors are not good predictors of future health risk. Instead, they are easily-manipulated measures burdened by economic and political interests and have been redefined over and over again, each time adding tens of millions of Americans to the rosters of those labeled as diseased or at risk.

More importantly, the benefits of the pharmacological interventions, let alone the screening, wellness and prevention programs, being advocated are often less significant than the public is being led to believe. We and our doctors, however, will not have the choice of weighing the risks and benefits for our individual situations, but could be compelled to comply with what others decide is best. Or else.

The tyranny of health provides the state, working both independently and through the agency of doctors and other health professionals, with a mechanism for extending its authority over the lives of each individual citizen and thereby over the whole of society. — Michael Fitzpatrick, GP (The Tyranny of Health — Doctors and the Regulation of Lifestyle)

© 2007 Sandy Szwarc