Very Hush-Hush And On The QT ... FBIC Reports
As U.S. Drug makers, MCOs And 2003 Medicare Rx Act All Play Out
FBIC Reports On The Good And Bad Companies Activities In
Managed Care And Medicare In Search Of Fraud And The Best Insurers
First, a few brief simple explanations for you to be able to understand
how the managed healthcare system works. The managed healthcare system is one intentionally designed to be as
complicated as possible just like everything the insurance industry does so the public does not understand how it works
(don't feel inept as most if not all of our elected officials don't understand either how the system works).
Simply put, most managed healthcare companies, are commonly referred to as MCOs, short for managed care
organizations. Many if not most of the American public has some form of private sector third party insurance MCO coverage
or public sector Medicare or Medicaid insurance coverage. They are what is referred to as "third parties"
for reasons that are obvious when you purchase or get drugs directly from pharmacies or hospitals.
When many users of prescription drugs with insurance
coverage buy their prescription drugs, they have to pay a "co-pay", an amount that is charged by the insurer. This amount, although collected by the pharmacy, is an amount that unfortunately the pharmacy does not get to keep but rather it goes back to the insurer, that is minus a miniscule predatory "reimbursement fee" generally somewhere between $0-$3 that is paid by the insurer to the pharmacy for the actual filling process in dispensing the prescription ... hardly enough for the pharmacy to stay
in business. In addition, most users of prescription drugs have seen their co-pays on medications increased
upwards of 400% in the past 2-4 years.
For example, many drugs which may have had a $10 co-pay two years ago in 2002 have grown to have a $40-50 co-pay and more
today in 2004. This is due to the implementation of a three-tiered co-pay system, i.e. $10-$20-$40, which is expected to
go to four or more tiers. This multi-tiered co-pay system is one of managed care's newest of schemes in their arsenal
which changes as they do their business. The tier that you, the customer pays, depends upon the tier that the drug is
classified under which is determined mostly by the drug's
PBMs (Pharmacy Benefit Manager or Pharmacy Benefit Management
Companies) are middlemen between the drug companies on one side and on the other side include: pharmacies, hospitals,
public Medicare and Medicaid government public health plans and managed care private plans. Attorney Generals offices
from no less than 20 states are investigating PBMs (and starting to prosecute) them for their secretive rebate programs
or kickback schemes (the PBMs strongly prefer the use of the word "rebate" as opposed to the word
"kickback" which is how the attorney generals allegedly see it in reality) between drug manufacturers and
the major PBMs which have increased and inflated prescription drugs prices in a number of cases above the standard
prices set by the drug's manufacturer. These rebates paid by the drug company
manufacturers run into the billions of dollars which they have paid out to have their drugs be
on the PBMs formularies and for the PBM to actively promote the drug. ... It's really just that simple,
well maybe not quite that simple but enough hopefully to be able to understand for now how the basic system works and
how FBIC comes into play when the system works against you.
Now that you have a minimum basic understanding as to some of the players and basics as to how they work in managed care, we would like to begin by reporting and exposing to the Public for the very first time (other than on this web site),
an allegation investigated by FBIC and known to be true but at this point is very much inside only information that is unknown to the Public and "Very Hush, Hush and On The QT". In fact to our knowledge with the exception of one state
AG office, it is relatively unknown to the rest of the states and federal authorities which we know are very busy
and receive an overwhelming number of various personal complaints each day covering many different areas. Our hope is that the authorities can save time and be able to examine and investigate the following charges and alleged illegal practices committed by PBMs and/or
MCOs while they are already investigating them on other charges and take appropriate legal action as soon as possible:
- Through investigation, FBIC has learned of an illegal scam and unknown practice being done by MCOs, PBMs and
health insurers to secretly overcharge many of their prescription drug customers. FBIC has termed the practice,
the "100 PERCENT PLUS CO-PAY". Let us explain the alleged scam and deceptive practice which started several years ago
when prescription drugs were less expensive and there was no multi-tier co-pay scheme such as there has been for the past few years. In the earlier days of managed
care and PBMs, it was common if not the norm for "co-pays" to be $0 (zero), an odd figure (i.e. $2.67, $4.31, etc.), $5
or as high as $10. On a few occasions, a pharmacist may have filled a prescription where the cost of the
drug was less than $1.00. As is usual and customary, the PBM would apply the pharmacy reimbursement
rate, the $ amount allowed the pharmacy for the actual process of filling the prescription, and add it on to the actual cost of the
drug. So, for example, lets say the pharmacy's reimbursement rate amount was $3.00 and the cost of the inexpensive
drug was $1.00, the combined total cost for the drug and for filling would be $1.00 + $3.00 = $4.00. However, occasionally
it was noticed that the online information sent back by the PBM's computer which included the $ co-pay amount set
by the PBM to charge the customer, indicated a total charge to the customer of a $10 "co-pay" amount. In this case the MCO and PBM got away with over-charging
the customer a very profitable usurious and excessive amount ... rather than the insurance paying for their
standard or usual and customary part of the customer's cost for the prescription drug, instead they made
a 150% or $6.00 profit for themselves.
This "100 PERCENT PLUS CO-PAY" practice started occurring more and more as the lower co-pay amounts of the early days of
managed care started to disappear and as co-pays increased along with the more current and evolving multi-tiered co-pay structures being implemented.
Obviously this same hidden profit-making scheme (or scam) can easily be applied without the consumer's direct knowledge and unknowingly is easily done with the multi-tiered co-pay structure scheme where
the $ amount of the co-pay charged the customer can easily be manipulated and/or changed at will to approach or exceed the
combined total cost of the drug and the pharmacy's reimbursement filling rate. Having knowledge of this practice for some
time, we must admit that this practice is a unique concept for PBMs, MCOs and health insurers to now be able to profit on their
customers' claims. Isn't this the reason why the employer companies and their employee insureds pay premiums each month
to their MCO? ... Clearly this hidden, growing mainstream "100 PERCENT PLUS CO-PAY" scheme practice by PBMs,
MCOs and health insurers in addition to collecting premiums must be very very profitable when you consider that not only does the insurer not
pay anything towards the cost of the customer's prescription, but in addition the insurer makes a nice profit for themselves at the customer's expense while the customer thinks that the insurer is saving them money on any out-of-pocket costs all at the same time.
In addition, now that you have a minimum basic understanding as to the basics of how managed care works, and you now
know about one alleged illegal unknown growing healthcare insurer practice that if you take prescription drugs is costing
you out-of-pocket money, we would also like to take this opportunity to clarify a few misconceptions that will better
help you to further understand managed health care and better reflect on those that you deal with as to who are the
good guys and the bad guys when you are having a problem getting your prescriptions filled for your Doctor prescribed drug which hopefully is the best drug:
- When all 55,000 or so retail pharmacies across the U.S. fill any or all managed care prescriptions, upon prior
instructions from your MCO, it is the PBM that sets the $ amount of the co-pay (not your MCO) with few or no exceptions.
The pharmacy and pharmacist has no say. (On the other hand, if you have no prescription drug insurance coverage, it is
the pharmacy that sets the price).
- Furthermore, with managed care prescriptions, the $ amount of the co-pay set by the PBM is the same in every
retail pharmacy across the country.
- The egregious practices of the PBMs and MCOs have caused retail pharmacies along with pharmacy departments in retail
stores across the U.S. to operate at best on a break-even but more so as a money loser. If the MCOs and PBMs are allowed
to continue to dictate all aspects of the managed healthcare system, retail pharmacies existence and ability to stay in
business will continue to erode if not disappear in favor of the PBM-owned mail-order pharmacies.
- Doctors working with HMOs are provided an incentive plan in working with patients which leads in many cases to
under treating patients. Doctors are basically provided with a certain budget. If they spend less than the allowed budget,
they get to keep the balance.
- Doctors are now being aggressively compensated with checks from Drug Companies for writing prescriptions for
their company's drugs. In many cases the amount of the check is reportedly based on the number of prescriptions
written for the Drug Company's drugs. One could easily question the potential conflicts of interest and/or the significance
of the rebate check as it could relate to being a kickback. FBIC's non-legal opinion on the matter is that in many
managed care cases this check may very well be responsible for the Doctor keeping his private practice going and
keeping his doors open.
Amongst The Major PBMs are Merck-Medco, having allegedly been tarnished legally and no longer owned by Merck the Drug
Company, they are now called Medco Health Solutions or for short just Medco (2002 sales $33 billion, 65 million
"members), which allegedly has its hands full with Justice Department charges and other investigations of
alleged extensive fraud and other problem cases in an estimated 20 states probe, where they are allegedly cooperating
helping to shed light on the secretive alleged unlawful activities by themselves and the other major PBMs, namely Express
Scripts ($13 billion in sales, 50 million members), Caremark ($6.8 billion in sales, 20 million members) and AdvancePCS
($14 billion in sales, 75 million "members) which has recently been purchased by Caremark. All are national companies.
The New York Attorney General's Office is amongst the first to bring fraud charges in August 2004 against Express Scripts
while also including Cigna Healthcare as an additional defendant in the lawsuit ... and many, many more are expected
to fall not only in New York but in many more other states stemming from alleged overcharging and other related fraudulent
schemes. You don't think that it was just Cigna and Express Scripts that engaged in these alleged unlawful and fraudulent
activities just in New York against The Empire Plan, New York's largest health insurance plan, and that it was only Cigna
and Express Scripts that did these alone in the giant industry?
[Just a note: FBIC is supported and funded by contributions from the Public which along with our costs
continue to increase along with the awareness to the widespread insurance and related problems we all share. Please
support FBIC and click here to make a
tax-deductible donation today. To those many and growing number who have made donations that continue to make it
possible for us to do our work and succeed through your kind generosity and understanding that its our country and as
most of us are all in it together we need to do what's necessary to reclaim it for ourselves as no one else will, we
say thank you and thank G-d for your help and support as we succeed.]
FBIC has been researching for sometime some of the alleged extensive frauds and illegal schemes perpetrated by MCOs,
Health Insurers, HMOs and Long Term Care companies. FBIC’s research has not been limited to healthcare, although an area
of greater experience, as it has been exposing alleged extensive frauds and unlawful activities and schemes by bad faith
insurers in the Property & Casualty insurance industry since 1997. Many of these activities have been cited and
referenced on this website for the better part of the last 4 years. In addition the past year's portion of FBIC's research
has extensively focused on the 2003 Medicare Prescription Drug Act which reports indicate that not only did The 2003
Medicare Act cost taxpayers $10 billion dollars plus which was paid out to MCOs (managed healthcare companies), but along
with pressure and financial contributions to our country's legislators by nearly 1000 drug manufacturers and health insurers
lobbyists, shamefully, it is no wonder that such an agreement was forged that had the support of U.S. drug manufacturers
and health insurers as it excluded the right for Medicare (and the 73 approved managed care companies) to have a
single payer system and/or be able to negotiate volume drug discount deals from the U.S. drug makers for Medicare
prescription drug users. This alone will cost and take upwards of $100 billions or more out of the pockets of seniors
directly into the coffers of drug companies and managed healthcare companies, severely limiting the opportunity for
any real savings for the proposed beneficiaries, America’s seniors.
Of surprise, many of the contractors selected for The 2003 Medicare Prescription Drug Act Program have been and/or are
under investigation for previous Managed Healthcare, Medicare and/or Medicaid fraud. Many of them have
already paid substantial fines for fraudulent criminal and civil activities, some repeatedly over the past years. In
addition, the following are but a few of the major fines, penalties and lawsuits that don't even scratch the surface
of the number of fraud charges reported and assessed against Drug Companies which are followed by MCOs and related
companies (each are linked to an article(s) from our "Reference Library" web site page giving more
detail on the specifics and the offense(s) committed against the Federal Government, Medicare, State Governments,
Medicaid and wherever cited any private sector fraudulent misdeeds:
- Schering-Plough pleads guilty to criminal charges and pays $345 million to resolve civil liabilities from its
fraudulent pricing of Claritin (July 30, 2004) ...
- GlaxoSmithKline. The NY Attorney General filed a lawsuit against drug maker GlaxoSmithKline, the maker of the
antidepressant drug, Paxil, accusing the company of concealing important information about the drug's safety and
effectiveness. (June 2004) ... [MORE].
- Pfizer, Inc. and subsidiary Warner-Lambert to resolve state and federal allegations of deceptive marketing, Medicaid
fraud and illegal kickbacks in Warner-Lambert's promotion and sale of drug Neurontin agrees to a $430 million settlement
with CA Attorney General (May 13, 2004) ...
- GlaxoSMithKline. A two year investigation of GlaxoSMithKline by Italy's finance police ended, leading to criminal charges
against the company and 4,440 doctors. It is reported that GSK spent $278 million in bribes whose purpose was to influence
the doctors' prescribing. The practice, according to British analysts, is common in the pharmaceutical industry. The doctors
have been criminally indicted and could face jail sentences. According to the suit Glaxo employees offered incentives including
cash to doctors and other healthcare professionals to encourage them to prescribe Glaxo drugs. (May 2004) ...
- AstraZeneca, a $355 million settlement in civil and criminal charges for reporting to the government the average
wholesale price for a prostate cancer drug was about $300 for a month's dose, but doctors who dispensed the drug in
their office, were charged about $170 for that same dose resulting in a $130 profit (i.e.. kickback) to the doctor.
(June 2003) ... [MORE],
- The New York Times reports about the lawsuits brought against Bayer (re: Baycol), Bristol Myers Squibb (re: Serzone),
GlaxoSmithKline (re: Paxil), Johnson and Johnson (re: Propulsid), Pfizer (Rezulin), and Wyeth (re: Redux & Pondimin).
It appears that trial lawyers will produce the results that government oversight agencies--in particular, the FDA--have
failed to do. Namely, to protect the public against an increasing number of unsafe drugs. The lawsuits were brought on
behalf of hundreds of thousands of patients who had been exposed to defective, in some cases, lethal medicines that had
been approved by the FDA. The drugs had continued to be marketed even as the human casualties mounted. (18 May 2003 ) ...
- Abbott Labs, Parent of Ross Products, to pay $622 million in federal probe to settle fraud case and charges that the
company worked with medical-care providers to bilk government health insurance programs for the poor and elderly
(Chicago Tribune, June 27, 2003) ... [MORE].
- Tap Pharmaceuticals (a joint venture of Abbott Labs and Takeda Chemical) $875 million in civil and criminal charges were
reported to mirror that of AstraZeneca's more recent June 2003 charges. (Oct. 2001) ...
Among a few of the more noteworthy investigations of fraud by MCOs (Managed Care Organizations) and Their Partnering
Companies and PBMs (Pharmacy Benefit Managers) include:
- Express Scripts, the country's 3rd largest PBM (Pharmacy Benefit Manager) was charged by NY Attorney General for
unlawfully inflating the costs of prescription drugs by millions of dollars, diverting and retaining millions of dollars
in manufacturer rebates, engaging in fraud and deceptive practices by inducing physicians to switch patients prescriptions
from one prescribed drug to another for which it received money from the second drug's manufacturer. Express Scripts, a
sub-contractor hired by long-standing contractor Cigna Healthcare, also named as defendant in the lawsuit claiming that
all moneys belonged to New York State's largest employee health plan, the Empire Plan. Of note: May be one of the first
prosecutions by a single state against a major national PBM and MCO (August 2004)
- Medco Health Solutions will pay Massachusetts $5.5 million to settle allegations that it cheated the state while it
managed prescription drug benefits for nearly 200,000 state employees and retirees according to documents filed in US
District Court today. (As Reported By The Boston Globe For Knight Ridder Tribune Business News, April 26, 2004)
- Aetna agreed to pay $470 million for defrauding 700,000 doctors in 2003. (May 22, 2003)
- Merck-Medco Managed Care,
one of the largest managers of prescription drug plans, according to Court documents disclosed
was paid more than $3 billion in rebates in the late 1990's from drug makers seeking to promote sales of certain drugs,
according to documents filed in a long-running class-action lawsuit. Medco, a unit of Merck & Company, then persuaded
doctors to prescribe those drugs to patients at the expense of similar medicines that often cost less, according to the
documents, which were filed by plaintiffs in the case. Medco promoted Merck's own drugs especially vigorously, the
documents say. In their current structures, the deals pharmacy benefit managers strike with drug makers actually help to
drive up health care costs for employers and consumers. Medco retained most of a total of $3.56 billion in rebates from
the drug companies in 1997, 1998 and 1999 according to official statement and other court documents. The plaintiffs also
say that Medco did not inform most of its customers about the rebates that it kept. (Reported NY Times March 13, 2003)
- PacifiCare paid the Federal Government $87 million a few years ago to settle alleged violations of Fraud in submitting
or making false claims (April 2002).
- Anthem Connecticut Blue Cross & Blue Shield paid the Federal Government $74 million to settle a Medicare alleged fraud
related case (December 1999).
- Humana paid $14.5 million in Federal Government Medicare fines in the first ever settlement with a Medicare managed-care
company to settle allegations that the company provided inaccurate payment information from 1990 through 1998. Humana
incorrectly listed beneficiaries as eligible for both Medicare and Medicaid (October 1999)
- Humana was ordered to pay $8
million to settle allegations that it charged both Medicaid and Medicare for the same services. The allegations concern a
class of Medicaid recipients who were dually enrolled in both Medicaid and Medicare Managed-care Plans. Humana received
duplicate payments from both Medicare and Medicaid for the same individuals (Nov. 99)
- Tenet Healthcare Corporation (formerly National Medical Enterprises until a name change in 1995 to Tenet) is alleged
to have committed various related frauds exceeding $1 billion against Medicare and its contractors. Tenet was fined $379
million for Medicare fraud and illegal conduct in hospitals in 30 states (June 1994)
- HCA (Hospital Corporation Of America) formerly Columbia/HCA, headquartered in Nashville, TN is the largest alleged
fraud perpetrator in Medicare history. Of great interest is that it is reported that HCA was founded in 1968 by founders
Dr. Tom Frist, Sr. (Senator William Frist's Father) And Dr. Tom Frist, Jr. (Senator William Frist's Brother). It is
further reported that Dr. William Frist, the Present U.S. Senate Majority Leader, instead worked at a rival hospital. HCA
was fined a total of $1.7 billion dollars by December 2002, after some 10 years of well-publicized federal investigations
involving Medicare and Medicaid, HCA represents the largest fraud settlement ever by any U.S. Government contractor.
- Aetna was previously fined by the Attorney General For The State of Texas for fraud. It was among 21 insurers fined by
the Texas Department of Insurance Commissioner in 2001 for allegedly violating the state's rules on prompt payment of claims.
- Horizon Blue Cross Blue Shield, New Jersey's largest MCO and health insurer, previously had a class-action lawsuit
brought against it in April 2002 alleging that they routinely shortchanged thousands of doctors through late or improperly
reduced payments, has been certified by a New Jersey Court on August 4, 2004 permitting the case to go forward involving
upwards of some 40,000 physicians to collect damages. The suit alleges breach of contract and violations of prompt-payment
laws and also includes as defendants, Cigna Healthcare of New Jersey, United Healthcare of New Jersey and Oxford Health Plans.
(April 2002 - Present)
There are thousands more contractors on the lists of Medicare and Medicaid defrauders which include managed care organizations
(MCOs), insurance companies, doctors, dentists, chiropractors, therapists, equipment vendors, home care agencies, hospitals,
pharmaceutical companies and many other Medicare and Medicaid contractors.
Getting back to the U.S. Drug Companies and any talk by politicians regarding going to Canada for prescription drugs, know and be informed that it is a farce and another snake oil story that is being extolled and bantered about by politicians, organizations and anyone else with a
vested interest in the outcome of the upcoming 2004 election that is either looking for votes or trying not to lose votes, or
looking for an excuse that will take the heat, fault and embarrassment away from them and their office because there is no way
that Americans are going to be able to sustain or continue to buy their prescription drugs from Canada or Mexico or anywhere else by that
matter. Besides the fact that the U.S. Government has declared the purchase of U.S. drugs from Canada illegal ... that alone
is not going to stop many people especially those that cannot afford to purchase the much higher priced and considerably more
expensive drugs in the U.S. that they need to stay alive. Who will stop it from happening is the U.S. Drug Companies ...
and here's how.
The drug manufacturing industry in the U.S. is a $200b market for the U.S. prescription drug makers while Canada is only
a $1 billion market. All that the U.S. drug manufacturers have to do to stop the Canadian sales of their drugs to Americans
is control the supply and not allow for more than minor increases of possibly a maximum 10-15% increases in inventories and
purchases of their U.S. drugs by Canadian drug wholesalers and distributors. In doing so, there will be increased demand and
competition and not enough supply by Canada's pharmacies to fill prescriptions for both their American and Canadian customers
for the same drugs with relatively the same drug allotments from the U.S. drug manufacturers and if anything, it will wind up to
be a cash windfall for U.S. drug manufacturers as prices to Canada's patients for the same drugs they have been taking for
sometime will most likely significantly increase if not skyrocket and that will greatly impede if not completely stop the
sales of prescription drugs to customers from the U.S.. At this point Canada and Canada's pharmacies will have no choice but to
take care of their own, their Canadian customers first. In addition and to complicate things further for U.S. citizens looking to save
more than a buck, U.S. Drug Companies have recently indicated that their drug formulations for the U.S. and their drug formulations
exported to other countries are different and have only an approximate 30% common denominator.
Presently, it has been reported that for those seniors, extremely few in numbers who have enrolled in one of the new
prescription drug programs for seniors out of the 50-75 various programs to choose from, if they saved at all, they are
lucky to have saved 10-15% AT BEST IF AT ALL, over the past months and that is just the beginning of a very rough ride
for seniors having been sold down the river and for those baby boomers who will be next to be seniors. We are constantly
asked about our near flawless if not 1000 batting average for being so accurate in our reporting of the alleged unlawful
activities reported on our website as we have been asked by so many in the investigative media, law enforcement and by
average people how we are so consistently accurate with all the information published on the website. The answer is that
we don't have to guess as the investigatory work is laid out for us to sort through beforehand.
So, you might ask how FBIC is always right and on target especially in cases years before illegal allegations of wrongdoings
become exposed to the Public and Enforcement Agencies, and the answer is that FBIC knows through its growing grass roots
network and their respective trades. FBIC reports on the pending lawsuits by the states Attorney Generals Offices, The
U.S. Justice Department And DHHS (Department Of Health Human Services) against health insurers and their partners. FBIC
collects and receives information and bad faith insurance related complaints against PBMs, Health, HMO, Disability and
Long Term Care Insurers which come from: (a) individuals with injuries and disabilities with complaints against bad faith
insurers submitted on our website using the “Bad Faith Survey”; (b) managed healthcare providers, professionals such as
doctors, lawyers pharmacists, nurses, that own or are employed in businesses and practices that work everyday in related
areas with MCOs and their partnering companies such as PBM, etc. that know either firsthand or through their trade many
of the illegal and unlawful activities; (c) managed healthcare providers third party billing and collections administrators
with hospitals and in private practices. They all tell the same stories pertaining to complaints against health and related
insurers regarding improper denial of coverage, non-payment of legitimate claims and/or other bad faith related insurance
practices and their problems collecting the appropriate billed amounts or by that matter in many cases, any amounts. [In
addition, FBIC collects and receives related information and bad faith insurance related complaints against property &
casualty (P&C), auto, homeowner, business, accident, workers compensation, malpractice, liability and personal injury
insurers from those that are in businesses that work everyday in related areas with these insurers and know the related
alleged fraudulent bad faith activities of many that FBIC also hears from, such as: (a) lawyers, independent public
adjusters, home repair, roofing contractors, auto body repair; (b) individuals and victims with claims that are dealing
with bad faith insurers and use our onsite “Bad Faith Survey” to report their bad faith insurance related complaint;
(c) third party billing and collections administrators.] As these complaints are submitted and received, FBIC
monitors looking for common trends that once they are spotted, FBIC reports the information on its website. FBIC has
learned that some state attorney general's (AG) offices are besieged and increasingly overwhelmed by the amount of bad
faith insurance related complaints their offices have and are receiving, some Department Of Health & Human Services
Offices (DHHS) and The U.S. Department Of Justice (DOJ) along with some other related enforcement agencies as they are
taking appropriate legal action against some of the alleged perpetrators of fraud organizations, insurers and their partnering
The people that work everyday with insurance companies, insurers contractors, sub-contractors, vendors and other service firms,
And the many insureds, like you and me, that buy insurance for ourselves, the claimants that have claims that are paid promptly
And properly by good faith insurers and those many claimants who are victims of bad faith insurers are all part of FBIC's
growing national network intelligence and an important and integral part and reason for FBIC's grass roots significant and
substantial progress. They know what the insurance companies are doing and have been doing for years as most if not all
regretfully have to deal with them (the bad faith ones) everyday or else they would have significantly fewer customers and
most likely wind up having to close down their businesses as the managed health care insurers control most of the buyers
if not nearly all the business and therefore the providers have no other choice but to deal with them day in and day out,
much to their dismay. The feeling is almost universal if not unanimous that all healthcare providers would rather
see all the managed care organizations (MCOs), their partners and subcontractors, the PBMs, vendors and service firms
disappear from the scene without playing any part of the American Healthcare system as they and only them have clearly
exhibited to be the healthcare system's only positive beneficiaries showing very substantial and hefty profits for their
companies and personal self-enrichments.
To think that because Congress was concerned about the annual increases in medical and drug costs were approaching 6% in
the early 1980s, the managed healthcare system and industry was born and brought into being to lower the costs and since
then the industry has only known consistent double digit increases which profits only wind up with the insurers at the
expense of all the providers and all their patients and customers! From informal polls, again, the only people that have
positive to say and generally with exception seem to like their health insurers and the managed healthcare system are the
younger workers who never have to use their insurance, politicians who have their own private or special plans, the MCOs and
health insurance companies, their contractors, subcontractors, vendors and services firms.
There is a growing belief by many Healthcare Providers And Patients alike that the present U.S. Managed Healthcare system is so corrupt and broken beyond repair, especially as judged and confirmed by The World Health Organization (WHO) which at last glance ranked the U.S. healthcare system #86 and has presently reported the U.S. system to be ranked over #100 out of some 181 developed countries healthcare systems, that the present system cannot be salvaged or repaired and that it needs to be scrapped. For those Americans who care about the quality of the U.S. insurance system and those that did care until they became a claimant and since have been victimized by bad faith insurers, we have learned the Presidential election tactics of 2004 for either side don't work, and that when it comes to choosing whether it be between the proliferation of the U.S. healthcare industry enrichment, OR, expanding healthcare coverage ... for those Americans who care, we all agree that we could all do much better by pulling out whatever few if any worthwhile improvements and services exist from the present system that may seem to work well for "ALL" and scrap the rest except for "one possible area of exception" ... that we would be far better off by going back to the old system slightly modified by considering incorporating some of the few minor present day system improvements.
Many of those same people regarding Property & Casualty (P&C) insurance (i.e. auto, homeowner, etc.) feel the same way that going back to the old system, buying insurance to protect your property and yourself and simply having your insurance company pay you for your property and casualty claims is best ... none of this fault or no-fault options, complications or other loopholes to address and entertain.
According to highly regarded and respected Dr. Marcia Angell, MD and Editor-in-Chief for the New
England Journal of Medicine, "We certainly are in a health care crisis. If we had set out to design the worst system
that we could imagine, we couldn't have imagined on as bad as we have." Here's a system in which we spend over twice what
the next most expensive country spends on health care -- that's Switzerland. We spend roughly $4500 for every American,
whether they have insurance or not. (Of FBIC Note: We can thank the insurance industry who designed and crafted the system
as it went along and whose only concern other than trying to maintain the daily appearance and perception of being objective
for as long as possible, when they only had concern for their own financial best interests). Dr. Angell continues
"We're of the 25 richest countries in the world, we're somewhere around 22-23 in terms of our health."
"The only way to both reduce cost and increase access and quality is to change the system, to scrap it and start over.
Yes, because it's based on a false premise. Our health care system is based on the premise that health care is a commodity
like VCRs or computers and that it should be distributed according to the ability to pay in the same way that consumer
goods are. That's not what health care should be. Health care is a need; it's not a commodity, and it should be distributed
according to need. If you're very sick, you should have a lot of it. If you're not sick, you shouldn't have a lot of it.
But this should be seen as a personal, individual need, not as a commodity to be distributed like other marketplace
commodities. That is a fundamental mistake in the way this country, and only this country, looks at health care. And that
market ideology is what has made the health care system so dreadful, so bad at what it does. Yes, it does do what markets
are supposed to do. It expands. That's what markets are supposed to do. And it distributes a good according to the ability
to pay. But that sure is not what we want of health care."
"I would pay for health care in a single payer system, and what goes into that pot can vary. our health care system creates
ethical dilemmas that no health care system should create."
"In managed care, doctors are paid for doing less. The employers pay the HMO a certain amount, as little as they can get
away with, and then HMO often pass along that risk to the doctors themselves in the sense that the HMO gets a set premium
and if they spend more than that premium taking care of their enrollees, then they're in the red. If the spend less than
the premiums on their enrollees, then they get to keep what's left over. And some HMOs pass those incentives along to
doctors, to individual doctors and say to the doctor, "Your salary depends on doing less, and you will have something
deducted from your salary if you do more."
"I think doctors are really suffering now. They're suffering in the sense that they feel torn between
serving their patients in the best way they can and dealing with all of requirements of the insurance companies ... and the
increasing pressures to do less and less for their patients. In a nut shell, their loss of autonomy. ...Now the patients
and the doctors are both more or less helpless."
"I think there are a lot of reasons we've stayed here, and I think one reason is that the economy has been so terrific in the
past decade. It can't go on forever, this wonderful economy. Since the demise of the Clinton plan in 1993-94, nobody wanted to
go near health care reform after that. But it's back on the front burner. And I think people will start to feel pain soon.
People are already annoyed as all get-out with their HMOs. People don't like being told that "This is covered, this isn't
covered. They don't like not being able to collect and having to pay out of pocket. They're not happy with their health care
system. I think they've been afraid, so far, to go for any big changes, partly because of the propaganda about the government."
"the most successful part of the American health care system is Medicare. And Medicare, which is a single payer, government
financed health care system -- what Canada has essentially is Medicare for everyone -- but this is a government financed,
single payer system for people over 65 and it's the most popular part of our health care system now."
"Look, a decent society provides certain things for its citizens and health care is one of those things." Some people get
sick expensively and some people are well all their lives and then drop dead one day and they cost the system nothing.
But we share it all and we say we're all in this together. We could do in that direction. And probably begin by, while we
still are in the time of prosperity, extending Medicare decade by decade. Instead of over-65, going over 55. And maybe working
up from children toward the middle. Ah, and then we would have a single payer system. Now naturally the insurance industry
will fight this like crazy. In Canada they just said overnight, "You're out of business. No more health insurance here.
You're out of business," to the private insurance companies. I'm not sure we could do that ..."
[MORE OF DR. MARCIA ANGELL, MD].
So, getting back to FBIC's far flung idea to scrap the system,
the action is more main-stream than previously thought after hearing it for the first
time. As far as the rest of those Americans who don't really care about the quality or know what
it is to be accountable or are only interested in what the system can do only for their own self-enrichment, we mentioned
a "slightly modified" old system which would have a "very limited" but strictly accountable either state
or federal system in place for those Americans who really don't care one way or the other about quality and this is where
the "one area of exception" for the present system and bad faith insurers might come into play. In this case, we
would also agree and recommend that a single payer Medicare run system replace the current system and the present (heavily weighted bad faith)
Managed Care Organizations (MCOs) could handle the uninsured Americans part of health insurance with government oversight run something like an insurance pool
of sorts for handling these groups. Then, let a single-payer Medicare based system compete with the new Managed Care system.
This way, the U.S. could very well have the opportunity and a chance
to have a first rate quality "good faith" healthcare insurance system for ALL and not the bad faith
insurance based system for the personal self-enrichment of the FEW that we have now. [Of FBIC Note: Possibly, if
not probably, as Dr. Angell states "the reason why we probably can't do that" ... get rid of the MCOs and the
private health insurance companies is because the insurance industry is the wealthiest and
most powerful and has shown at least in the present and past recent decades that money and power in the hands of the few in using its purchasing power, always seems to manage and win in buying the support of Congress over the rest of the populous ... its the New American Way].
So although it may sound great, so much for dreaming ... we can all now get back to reality and win anyway, regardless, just remember The FBIC Citizens Action Movement to "Only Buy Insurance From The Good Faith Insurers And To Boycott And Not Buy Insurance From The Bad Faith Insurers" ... You Can And Are Making A Difference As We Are Already Starting To Win!