Shannon Brownlee
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 All of them are hmos, it turns out, or health maintenance organizations, but they work in a very different way from the managed care most patients have learned to hate. You'11 hear more in future chapters about how we could apply the principles they've used so successfully in order to improve the quality of the rest of the system and bring down costs.
In the meantime, there's no denying that one of the greatest tragedies here is the way in which imaging has increased the distance between doctor and patient. |
Jacky Law
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 A whole string of class-action lawsuits alleging that hmos withheld medical services to boost profits expressed some of the mounting anget over healthcare costs in general and drug prices in particular
Insurers, via hmos, also started contesting FDA decisions about safe, widely used drugs which they thought patients should pay for themselves in pharmacies rather than have prescribed at the insurers' expense. |
Charles Barber
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 The only area of mental health coverage that employers and hmos seem interested in funding is drug therapy. They'd rather just throw Prozac, or better yet, some generic substitute costing pennies a pill, at mental health problems."16 The strong likelihood is that the nightly fluttering of the two or three pills down her throat will be the extent of Julie's "mental health treatment. |
Craig Pepin-Donat
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 The one thing that doctors, hmos, hospitals, lobbyists and drug manufacturers have in common is their pursuit of money under the guise of health care. It is a broken, unworkable system that puts you in a vulnerable position. Until we have free health care for all Americans focused on disease prevention instead of disease management, our health will continue to decline and the costs to manage our self-inflicted diseases will continue to soar. |
| Today's untenable model forces us into hmos, which have a goal of spending the absolute minimum possible on health care in an effort to maximize profits. The constant pressure of employers to cut costs to improve their bottom line has many companies reducing benefits to employees, and for small businesses; it is almost impossible to provide decent employee benefits. According to a 2006 Kaiser Family Foundation study, the average American family pays $11,500 a year in health insurance. |
Too Profitable to CureBrent Hoadley, Ph.D.
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| The winners: pharmaceuticals, hmos, and allied medical groups. The losers: need I tell you? • Pharmaceutical corporations are now trying to patent, without patients' acceptance or knowledge, genes from some patients that could lead to cures being shelved for breast cancer and other diseases. What this means is that corporate America is trying to steal the genetic material inherent in some individuals. |
Jacky Law
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| A whole string of class-action lawsuits alleging that hmos withheld medical services to boost profits expressed some of the mounting anget over healthcare costs in general and drug prices in particular
Insurers, via hmos, also started contesting FDA decisions about safe, widely used drugs which they thought patients should pay for themselves in pharmacies rather than have prescribed at the insurers' expense. |
Shannon Brownlee
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| The AMA considered prepaid, staff-model hmos another threat, like Medicare, to the autonomy and income of its members. In the 1930s, physicians who joined prepaid group practices were often denied membership in local medical societies. The societies also strong-armed hospitals (at the behest of the AMA) into blackballing physicians belonging to salaried group practices. In one instance in the '40s, a doctor who worked in Washington, D.C., for a branch of Seattle's Group Health took a patient to a hospital for surgery and he and his patient were barred from the operating room. |
| Under pressure from hmos, hospitals welcomed the profits that high-dose chemo provided. When transplanters like Peters testified in court that the procedure was established practice, when in fact it was not, they stoked the perception among patients that high-dose chemo offered a shot at a cure.
Hope Rugo stopped performing transplants on breast cancer patients in 1999, shortly after the data from the five randomized trials came out. When I asked her the same question I asked Peters, if she had any regrets, she paused for a moment.Then she said, "We believed in it so passionately. |
| Many physicians supported government-provided insurance at first, until they realized that the Progressives didn't want simply to insure citizens; they intended to encourage doctors to form prepaid, group practices, modeled after early hmos like the Mayo Clinic. Doctors at Mayo, and later Kaiser Permanente, in California, and Group Health Cooperative of Puget Sound, in Seattle, worked in multispecialty groups and accepted salaries rather than fees for their services. |
| Utilization review was an idea managed care had borrowed from traditional hmos, which routinely monitored the performance of individual doctors, groups of doctors, and entire hospitals. Traditional HMO doctors were accustomed to being reviewed, and most of the time, they welcomed the chance to learn how to practice medicine better. Doctors on the outside, however, saw utilization reviews as just one more burden imposed by managed care.
Peabody began to see doctors making decisions that were based not on what was best for the patient but on what kind of plan the patient was in. |
Dawson Church
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 For instance, hmos, hospitals, and doctors being paid fixed rates for the number of patients they see (called "capitation" in the jargon of the profession) benefit financially the healthier a patient is. Average amount spent per person for "health" care was $6,683 in the U.S. in 2005." A provider who is receiving $6,683 from a patient who is so healthy that he or she makes one or no doctor's visits in a year, and uses only a few complementary and alternative therapies to assist in maintaining peak health, ends the year with a big profit. |
| HMOs, nursing homes and so on) could be as much as $200 billion—a Hurricane Katrina every year."11
No wonder Andrew Weil, M.D., begins an authoritative survey of the medical profession, published in The Archives of Internal Medicine, with these words: "The chassis is broken, and the wheels are coming off."12
Asking questions like, "How can we slow the growing cost of our medical system," "How can we pay for the Medicare prescription drug benefit," and "How can we bring the uninsured into the system," have taken public debate in entirely the wrong direction. They are the wrong questions. |
| That's one reason why Kaiser Permanente, one of the largest hmos, much-studied for its efficiency, now offers Qigong classes, meditation classes, chiropractic, acupuncture, addiction recovery classes, and other similar therapies. Some Kaiser practitioners also use Energy Psychology techniques. It's not just good health care; it's good business. Such organizations are net winners when people are healthy
Others are net losers. |
Gary Null and Amy McDonald
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 With the hmos, medicine has clearly become a business. Every disease has become a drug deficiency. Aspirin has become a Motrin deficiency. Cardiac arrhythmia has become a calcium channel blocker deficiency. Hypertension has become a high blood pressure pill deficiency and depression has become a Prozac deficiency. All of the thought has been removed from medicine. It becomes a no-brainer. It's like a little receipt book of computerized flow sheets and the big emphasis is on labels. Label-itis is probably the number one cause of disease or death in the United States. |
Ray D. Strand
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 The medical community gives plenty of lip service to "preventive medicine" and even names its leading medical insurance plans hmos (Health Maintenance Organizations). By all appearances preventive medicine seems to be a top priority.
Yet less than 1 percent of our health-care dollars are spent on so-called preventive medicine. In reality the majority of our preventive medicine programs simply attempt to detect disease earlier. For example, mammograms, chemistry profiles, and PSA tests (for prostate cancer) are all designed to detect a problem or cancer as early as possible. |
Shannon Brownlee
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| From 1980 to 1990, only 137 news articles were written about hmos and managed care. Over the next decade, the number of stories swelled to 2,659, the vast majority of them tales of care denied. Readers were particularly outraged by stories of managed care "drive-through deliveries," the practice of sending women and their babies home within twenty-four hours of birth. Managed care companies based this coverage decision on sound scientific research, which had been conducted by Kaiser Permanente. |
Greg Critser
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 And it was, when one backed up and looked at it all — away from the political Sturm und Drang of Medicare drug benefits and hmos — a strange and wonderful thing to behold. Here was a nation that had launched, only twenty years prior, a grand new experiment, one in which pharmaceutical companies and its new surrogates in PR and marketing had joined doctoring as an equal partner. Many signs indicated that this new road was a hugely promising one, with chronic diseases arrested and lifespans, or "healthspans," enhanced. |
Mike Adams, the Health Ranger
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 Health insurance companies and HMOs: They pretend to offer coverage for health costs, but in reality, they are largely in the business of denying coverage and thus limiting payouts while driving health clinics to the brink of bankruptcy due to late payments.
Medical journals: They pretend to be the gatekeepers of scientific truth, but in reality most are for-profit publications that predominantly print pro-drug articles. By sheer coincidence, most medical journals are also largely funded by drug money (advertising dollars from drug companies). |
Mark Hyman, M.D.
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 This brings us to problem number seven: hmos.
Essentially watchdogs, these health maintenance organizations are more concerned with controlling costs than maintaining health. But who truly believes that cost should be the determining factor in health care? And hmos make no allowance for preventive treatments. A doctor may suspect his patient has a high level of homocysteine, a potentially dangerous amino acid. But if the HMO won't allow a homocysteine test, the doctor must wait until the patient has a heart attack. |
Joseph Glenmullen, M.D.
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 In an ironic twist in the last year, the skyrocketing prescription drug costs of hmos have made national headlines.79 For most hmos, drugs now exceed their total costs for all types of medical and surgical hospitalizations. The drugs costing them the most money are the serotonin boosters, because these drugs have been so thoughtlessly pushed on patients. Now that this policy has backfired financially, hmos and managed care insurers are trying to get doctors to prescribe the older, tricyclic antidepressants, which are as effective as the Prozac group. |
Greg Critser
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| The industry was being hit hard by generics, by pressure from hmos and pharmaceuticals benefit managers to ratchet down prices, by advocacy groups that were constantly finking on pharma for over-the-top marketing practices, and from the media, particularly from the Wall Street Journal and Peter Jennings, who seemed to pump from a deep well of antipharma news stories that year. ("That gawd-dam Jennings," a woman sitting in front muttered in a gravelly whisper.)
Kelly then queued up another visual, this one the "I'm not gonna take it anymore" scene from the movie Network. |
Peter Rost
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 This $720 billion law includes $139 billion in profits to drug manufactures and
$46 billion in subsidies to hmos and private insurance plans.28 The program has been such a disaster for our poor; at least twenty-four states have been forced to enact emergency measures to ensure access to medications during the implementation of this law.29 That's what a million dollars buys in Washington.
So how could this happen? The answer is simple. The American democracy has been stolen by our new class of robber barons—the CEOs of our largest corporations. |
Greg Critser
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| It could be a lot better, he said, if hmos were not so chintzy in their reimbursement departments, constantly making bigger and bigger demands on everyone to justify long drug regimens. That's why increasingly motivated patients were critical to pharma's business. Yet these, he believed, would only come when patients trusted big pharma a lot more: "We want people to feel they can snuggle up to us at night." And that could happen only at "the magic moment."
What was the magic moment? It was when the first prescription was written. |
Earl L. Mindell, RPh, PhD with Virginia Hopkins, MA
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| HMOs so they can more directly control your drug intake.
BIG DRUG BROTHER IS WATCHING YOU
In an issue of Forbes magazine published in the late1990s, a spokesman for a major drug company proudly boasted about how profitable his company was going to be in the next decade because they were aligning themselves with hmos and would work with them to ensure "greater patient compliance" in taking drugs. This is a stunningly insensitive point of view. Obviously the man had considered the financial implications of what he was saying but not the effect on the people involved. |
Joe Graedon, M.S. and Teresa Graedon, Ph.D.
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 Everyone seemed to fall in love with Prozac—physicians, pharmacists, patients, and, most of all, the big payers (insurance companies and hmos).
Prozac—a selective serotonin reuptake inhibitor, or SSRI—was so successful because it got great PR, and because it seemed to have fewer side effects than traditional tricyclic antidepressants. At least it was less likely to cause sedation, dizziness, constipation, or dry mouth. It also was more effective—or at least that was the impression among physicians and patients. |
| The guidelines we used are certainly different from those used by many insurance companies, the FDA, and hmos, none of which believe there is a problem when NTI drugs are dispensed generically. We always believe in erring on the side of caution, however. In our opinion, these medications are safest when they come from a single manufacturer. If you can afford the brand-name drugs or your insurance company will spring for them, we think that is the way to go. |
| Insurance companies and hmos were doing everything in their power to switch people from pricey brands to generic alternatives. They created three- and four-tier co-payment schedules. If you and your doctor went along with a low-cost generic on the approved drug list, you might be charged only a $5 or $10 co-pay. If your physician selected a brand-name medicine on the formulary, it might cost $25. If she insisted that you needed a brand-name product not on the approved list, you might end up paying $40 to $60. |
Greg Critser
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| Of course, the pair also noted, that was not surprising, particularly given the economic imperative: "Kaiser Perma-nente, one of the first hmos, recently published guidelines for the treatment of depression which suggested that psychotherapy be recommended only after two consecutive trials of antidepressant medication have failed."
To get a better handle on the issue, particularly Ritalin use, Carter and Winseman requested that Novartis send a representative to discuss the uses of their drug and, just as important, a way to track the growing abuse of Ritalin on campus. |
Joe Graedon, M.S. and Teresa Graedon, Ph.D.
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| Some insurance companies and hmos are now charging a $40 or $50 co-pay for brand-name prescriptions.
Generic drugs are frequently promoted as the best solution to the high cost of prescription medicines. The savings can be dramatic. For example, at the beginning of this chapter, we listed the cost of 100 pills of Valium ($193.89). If you opted for the generic (diazepam) instead, you'd pay less than $20. Who wouldn't choose to take advantage of this kind of a deal? After all, generics are supposed to be identical to their brand-name counterparts.
But how good are they, really? |
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