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Archive for May, 2008
The Group Insurance Commission (GIC) in Massachusetts came up with a nifty idea: let’s grade physicians based upon efficiency and competence; we’ll reward those with high marks and penalize those who are (relative) failures. (The GIC administers health plans for public sector employees.) The GIC worked with the MA Medical Society (MMS) and a number of insurance carriers to come up with a reasonable methodology and metrics for grading doctors. After four years of planning, the GIC rolled out the program. Unfortunately, the MMS rolled out the lawyers: they are suing GIC and a number of health plans for defamation, interference, breach of contract, bad faith and violation of due process. Other than that, Mrs. Lincoln, what did you think of the play?
The suit claims doctors have been capriciously ranked into tiers, from 1 through 3, based upon a faulty analysis of billings. The tiers assigned to a given doctor result in progressively higher co-payments for their patients. For example, the Tufts Health plan has established the following co-pays for doctor visits:
Tier 1 doctor = $15 co-pay
Tier 2 doctor = $25 co-pay
Tier 3 doctor = $35 co-pay
The MMS claims, first, that the tiering system is based upon faulty data. For example, one doctor who specializes in treating severe cases of multiple sclerosis has an inflated “cost per patient” due to her inter-disciplinary approach. She has a tier 3 ranking. But this low score does not take into account the severity of her patients’s conditions or her success in treating them. In another example, one doctor simply examined medical records and provided an interpretation: he was held accountable for the ultimate treatment provided to patients he never actually saw.
With low rankings based upon incomplete and often inaccurate data, the MMS concluded that good doctors have been defamed.
In addition, MMS claims that patients have been defrauded, by being directed toward certain doctors for no particular reason. They pay less for tier 1 visits, even though they may not be getting the best available services; conversely, they have to pay substantially more for tier 3 visits, even though the quality may well exceed that of tier 1 doctors.
Dr. Bruce S. Auerbach, president of the MMS, said efforts to improve the tiering program have failed.
“There is a right way to do this, and a wrong way – and the Clinical Performance Improvement initiative is definitely not the right way.”
“We have worked with the GIC for four years to improve its program, and the agency has made changes in some limited areas. However, the GIC has refused to correct the CPI’s most glaring problem, which is its ranking of individual physicians using inaccurate, unreliable, and invalid tools and data.”
Not Close Enough
We all know that there are physicians whose services are mediocre and at times, dangerous. But the problem is in the data: how do you determine the quality of services? How do you distinguish between prudent and outrageous treatment? Data is data, but behind the numbers are stories of lives saved and lives ruined. Number crunching computers cannot tell the difference.
Unless the parties settle prior to trial, the discovery process will expose GIC’s methodology for grading doctors as clearly as an MRI. Based upon the MMA’s lawsuit, the GIC’s metrics appear to be fairly crude. The good news is that a number of mediocre doctors have been exposed. Unfortunately, the broad net cast by the tiering system has tainted the reputations of some very competent and compassionate physicians. In this particular endeavor, “reasonably close” assessments are not sufficient. The margin of error – where the reputation of a doctor is at stake – is very small indeed.
Medicine is both a science and an art. With the livelihoods of medical practitioners at risk, any methodologies for evaluating the quality and effectiveness of services must be precise and accurate to the nth degree. If your methodology cannot distinguish between incompetence and art, if it cannot place virtually every outstanding physician in the top tier, then the metrics are pretty worthless. At first glance, GIC’s admirable effort to triage the docs fails to pass muster. In all likelihood, the pending clash in court will send all the parties back to the proverbial drawing board.
In a few weeks, millions of teens will be joining the work force, many for the first time. For most, nothing out of the ordinary will occur, but for about 70, their jobs will be lethal. About every three minutes, a teen is injured on the job. Worksafe BC has compiled the true stories of four ordinary kids whose first jobs proved devastating. In this series of short, compelling video clips, each teen tells the story of their injury, how it happened, and how it has affected their lives. The teens’ parents also talk about things from their perspective. The clips are graphic, frightening, and real, and demonstrate just how quickly something can go wrong. They should be mandatory viewing for employers who hire teens, for teen workers, and for parents of working teens.
John’s story – how 16-year old John Higgins broke his back in a forklift accident.
Jennifer’s story – how 19-year old Jennifer Fourchalk lost three fingers, which were caught in dough-making equipment in a pizzeria.
Michael’s story – how 18-year old Michael Lovett lost a leg when sucked into machinery in a sawmill.
Nick’s story – (raw language alert) – how 19-year old Nick Perry became paralyzed when crushed by lumber in a lumberyard.
Some of the common themes in the stories:
- Enthusiasm. These kids badly wanted to please and impress bosses and co-workers and to do a good job. The teens didn’t want to ask for help or to appear unwilling to do what was asked of them – they wanted to be mature and good work contributors.
- Inexperience. The teens seemed unaware of the power of equipment they were using and the potential for injuries. Jennifer didn’t realize how powerful the kitchen equipment was. Michael seemed unaware that he could refuse to engage in unsafe behaviors, like jumping off dangerous equipment. They appear to assume that dangers were just an inevitable condition of the work.
- Lack of training. None of these teens had been properly trained in the equipment they were using nor had they received basic safety practices and procedures, such as lock out/tag out. All of these injuries might have been prevented had the workers been trained and had machine safeguards been in place. John actually emulated unsafe practices he had observed other workers doing.
- Working alone. In most of these examples, the teens were not being supervised when the injuries occurred.
- Regretful parents. Parents assumed employers would look out for their kids. Several parents expressed initial misgivings about the jobs their kids had taken. Many expressed regret that they hadn’t looked into the work conditions more.
Resources for keeping teen workers safe
Tips for teens: Stay safe on the job
Employers: 10 tips to keep teen workers safe
Tips for parents: How safe are your favorite kids on their new jobs?
vlingo is a Cambridge MA firm specializing in voice recognition software. They have completed a study of driving habits, specifically, the prevalence of driving while texting (DWT) across the US. The results, in the context of the upcoming Memorial Day weekend, are nothing less than terrifying. In a survey of nearly 5,000 consumers, fully 28 percent of drivers (mostly under 30) admitted to texting while driving. Twenty eight percent!
The problem seems greatest in the south, with South Carolina ranking a dubious number one. (“Hw yal dun?”) The New England states appear to be a bit slower to adopt this radically unsafe practice. Massachusetts ranked 23rd in the study, with Maine, Vermont, and New Hampshire ranking near the bottom.
Memorial Day Warning?
The Insider has already blogged the first two recorded deaths attributed to DWT: Lucas Rolin in the United States and Marni Triggs in Tackley, England. Apparently, “Lucas” and “Marni” are just the first of many names to be carved onto a cell phone shaped monument.
In Massachusetts, we have long assumed that the “nut behind the (other) wheel” is full of aggressive tendencies. Apparently, we don’t know the half of it. As we barrel down the highway at 72 miles per hour, we might be next to some whackjob channel surfing his radio, fiddling with the GPS and exchanging text messages with a distant buddy. Yikes!
Fully 85% of survey respondents said they would not DWT if it were illegal. While it might seem like legislative overkill, that might just be the way to go.
What do Bank of America, Citigroup, Merrill Lynch, J.P. Morgan Chase and Morgan Stanley have in common? If you said they all have lost billions in absurdly risky loans, you would be right, but that’s not the answer we are looking for. We learn in the latest edition of Cavalcade of Risk, ably hosted by Jason Shafrin of Healthcare Economist, that these companies have all filled new positions entitled Chief Risk Officer (CRO). In fact, you will find that many of the companies involved in the great mortgage fiasco of 2008 are trying to mitigate future risks by hiring into these positions. It would be interesting to read the job descriptions. Being a Risk Manager is one thing; Chief Risk Officer sounds a bit more, well, exposed.
Good management teams empower everyone to focus on risk. Will CROs be able to do this? Or is the CRO just another way for senior managers to toss someone else under the bus? Only time will tell.
Rhode Island may be small, but when it comes to tackling the problem of undocumented workers, they think big. Last month, Governor Donald Carcieri issued an executive order encouraging law enforcement officials – from state police to local cops – to determine the immigration status of anyone taken into custody and take immediate steps to deport those who are here illegally. Rhode Island has basically concluded that the federal government is not going to enforce the law, so they will take on the burden themselves.
For the record, the scale of the undocumented worker problem in Rhode Island is relatively small: the governor estimates that there are between 20,000 and 40,000 such workers in the state. What is not clear from the executive order is just how proactive the governor wants law enforcement to be: it’s one thing to check people’s status after they become involved in the criminal justice system; it’s quite another to go out looking for immigration violators. Do you check for citizenship after a motor vehicle citation? After a domestic disturbance? When you hear people speaking Spanish?
The Workers Comp Perspective
The RI Workers Compensation Court has its own view view of the rights of undocumented workers, one which appears to be in conflict with the Governor’s. Chief Judge George Healy recently told community advocates: “Believe me when I tell you, we do not inquire about the employees’ documentation. That is not an issue that the court concerns itself with.”
Earlier this year we blogged the story of Edgar Valasquez, an undocumented worker who was seriously injured in an accident involving a chain saw. His employer dropped a dime on Edgar, who was arrested and deported while on his way to a workers comp hearing. Eventually, Valasquez was able to collect his benefits (he currently is back home in Mexico).
Despite the assurances of Judge Healy, there is no way for the workers comp system to ensure the rights of injured illegal workers. The latter can pursue statutory benefits, but they do so in the shadow of the governor’s new enforcement effort. Judge Healy cannot prevent law enforcement from arresting comp claimants outside his courtroom.
The governor has taken an additional step to disenfranchise undocumented workers: he has proposed a bill that would explicitly exclude them from workers comp coverage. This is a draconian approach to an increasingly unstable situation. Undocumented workers are already operating in a twilight zone of unfair labor practices and unsafe working conditions. If they lose their access to workers comp, they will be at the mercy of their marginal employers. Once hurt, these workers would have no access to benefits of any kind. They would have to disappear and try to make their way back home. (Cynics may think this acceptable, but it is unfair and unAmerican.)
Donald Carcieri invokes the authority vested in him as governor of the “State of Rhode Island and Providence Plantations.” It appears that he takes the “plantation” part of his title seriously. He is creating a segment of the workforce with few more rights than slaves.
We all agree that there is a problem here that desparately needs fixing. Despite the continuing inability of the Congress to fashion a coherent legislative approach, this is no time for individual states to jerry-rig their own solutions. A little patience is required. In this key policy area, the “Ocean State” will soon be lost at sea.
Postville Iowa is a one traffic light town with a population of 2,300 people. Last Monday, as we read in the Washington Post, 17 percent of the town’s residents were arrested in a raid coordinated by the Immigration and Customs Enforcement (ICE). All were employees of AgriProcessors, the nation’s largest producer of kosher meats.
The unusual story goes back to 1987, when Aaron Rubashkin and other members of a Lubavitch Hasidic sect moved from Brooklyn to (mostly Lutheran) Postville. That would have been a culture shock (on both sides) worth observing. In the years since, AgriProcessors has established itself as the town’s main employer. The company has also become notable for dubious workplace practices: routine violations of fair employment laws, hiring underaged workers, falsifying documents on workers, wastewater pollution problems and inhumane slaughtering of animals.
So once again (remember New Bedford?) we have one of those highly ambiguous situations: the feds raid an employer who is exploiting undocumented labor. Federal actions have a veneer of concern for the workers, but these quickly evaporate in the context of ICE’s primary function: arresting and deporting illegal workers. Some of these undocumented workers have been with the company from the beginning. As Eduardo Santos, 27, a worker who lost two fingers in the plant put it: “The raid was fair…but it’s bad for everybody. There’s no work.”
Eduardo, if you will forgive the pun, has put his finger on the crux of the matter. These are jobs few are willing to take. The working conditions are abominable. The company owners may invoke a “higher law” in attempting to follow kosher rules, but they are demonstrably deficient in their application of the more mundane laws which govern the way we work.
Big Fish, Little Fish
There is a sense in all of this that the workers may not be the primary target of the raid.(See an excellent summary by Debra Nussbaum Cohen in the Jewish Weekly.) To be sure, the workers face very difficult times, leading inevitably to deportation for most. The feds, however, have positioned themselves to go after AgriProcessors’s owners. Rabbi Sholom Rubashkin, the plant operator, finds himself accountable to rather formidable authorities of the conventional sort.
There are no clear winners here. The workers have been freed from jobs which they willingly embraced; they are about to be thrown out of their adopted community. Jewish consumers have lost their primary source of kosher meats. The town of Postville has lost its primary employer and will soon see the evisceration of its tax base.
The Postville saga is indicative of the overall undocumented worker dilemma: workers of last resort tolerate intolerable conditions because they are not supposed to be here in the first place. They take jobs no one else will take. Their pay and conditions fail to meet our basic standards, but are still far superior to what is generally available in Guatamala and Mexico, where most of these particular workers came from.
The ICE raids put a temporary halt to unacceptable working conditions in one small town. A handful of undocumented workers will be sent home. Some managers might end up in jail. It’s not even a drop in the proverbial bucket. It’s a drop in the ocean. Nonetheless, if members of Congress pay attention to the single drop hitting the water, they might remember it. They might actually try to do something about it.
Norma Perez is a psychologist who leads the post-traumatic stress disorder (PTSD) program at a medical facility for veterans in Temple, Texas. As we read in the Washington Post, she is pretty busy with claims. Given that veterans with a PTSD diagnosis are eligible for up to $2,527 a month in disability benefits, she came up with a great way to reduce caseloads and save money: stop making the diagnosis.
In an email to mental health specialists and social workers at the facility, she recommended that they consider using a diagnosis of “Adjustment Disorder” (which does not involve a disability payment). She added that they “really don’t have time to do the extensive testing that should be done to determine PTSD.” An interesting concept, given that Perez was in charge of a PTSD unit.
Unfortunately for Perez, the email was leaked to veteran advocacy groups and all hell broke loose. John Soltz, chairman of VoteVets.org and an Iraq war veteran stated that “many veterans believe that the government just doesn’t want to pay out the disability that comes along with a PTSD diagnosis, and this revelation will not allay their concerns.”
Melanie Slaon, executive director of Citizens for Responsibility and Ethics in Washington (an oxymoron, perhaps), was more blunt: “It is outrageous that the VA is calling on its employees to deliberately misdiagnose returning veterans in an effort to cut costs. Those who have risked their lives serving our country deserve far better.”
Stressed Out Norma
The VA has tossed Perez under the bus. Veteran Affairs Secretary James Peake issued a statement calling Perez’s email “inappropriate” and incompatible with VA policy. The Perez doctrine “has been repudiated at the highest level of our health care organization.” Peake went on to state that Perez has been “counseled” and is “extremely apologetic.” She remains in her job.
Let’s face it. Perez has been under a lot of stress lately. She could probably find a shrink to put her out of work for a few weeks, but she should not count on workers comp to pick up the tab. Stress claims are rarely compensable. Norma’s stress is both work-related and self-induced. When it comes to benefit entitlements, she is on her own.
Jason Shafrin of Healthcare Economist hosts this week’s edition of Health Wonk Review in newspaper style – it’s lean and clean, and packed with interesting pointers to the latest news.
NCCI conference – Peter Rousmaniere attended the annual NCCI Conference this year and reports back on his findings, posted at Joe’s place.
When less is more – Joe Paduda of Managed Care Matters beats a drum that needs beating. Why do buyers use unit cost reductions rather than total cost reductions as a metric of savings in measuring network performance? It’s a perverse incentive that encourages utilization.
You-Don’t-Say Department – a recent survey of small businesses shows that many are spending work comp dollars without knowing what they’re buying. About one out of every seven couldn’t name their insurer and don’t understand their coverage. In a related survey, almost one in five respondents who had just switched to a new insurer weren’t able to name that insurer. Our experience has been that small employers often learn about workers comp the hard way – it would be great if as an industry, we did a better job communicating what workers’ comp is and how it benefits both employers and employees.
Missouri gets tough – Missouri employers who try to cut corners by not carrying workers comp should think twice – the Supreme Court recently upheld a felony conviction for an employer that failed to carry workers comp coverage for his employees. The conviction includes one year in prison and $30,000 in fines and penalties. (More about the Court’s proceedings.)
Useful resource – 101 little known scholarship sources for nurses – a good reference list for both undergraduates and graduates.
And the winner is… – In an interesting bit of insurance trivia, Fireman’s Fund Insurance names the riskiest film of 2007.