Monday, February 28, 2011

Hawaii Senate Bill 1274 is an attack on our health care rights

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The health care rights of almost everyone in Hawaii with health insurance are under attack.
For anyone with employer-paid or Medicaid health insurance through Kaiser, HMSA, HMAA, Aloha Care, Evercare or Ohana,  if you get cancer or some other serious disease and your insurance company denies coverage, you have the right to appeal that decision with an independent local hearing, with expert witnesses and attorneys on your side. 
If Hawaii State Senate Bill 1274 is passed on March 10, we will all lose that right.
Please sign our petition to stop this bill from passing.

Here is the text of the email that will be sent to Governor Abercrombie as well as all our state Senators.


My health care rights are under attack and I need your help to stop it.

Right now, if my health insurance company refuses to pay for treatment that my doctor says is necessary, I have the right to appeal that decision at an independent, local hearing. I am entitled to a lawyer, and the insurance company will be required to pay for my lawyer and any expert testimony I need to prove my case.

S.B. 1274 will repeal HRS 432E-6.

HRS 432E-6 gives everyone with HMSA, HMAA, Aloha Care, Kaiser, Evercare or Ohana health insurance, whether paid for by their employer or Medicaid, the legal right to those independent local hearings. If you allow S.B. 1274 to pass, that right will be taken away. Insurance company decisions on life or death treatment will be reviewed somewhere on the mainland depriving me of the right to attend, let alone present expert testimony that could save my life.

You need to put a stop to allowing state legislation to be drafted by companies that can pay their top executives almost $2 million in bonuses for 2010.

You also need to put a stop to allowing life and death health care decisions for our most vulnerable citizens to be made by a company that paid its CEO over $9.4 million in direct compensation in 2009. Why are you allowing valuable federal funding to be spent supporting these outrageous profits?

Please protect our rights, and vote no to S.B. 1274.
Please help us spread the word!

Sunday, February 27, 2011

UnitedHealth under federal scrutiny in Hawaii over possible Medicare scam

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I reported on January 23 that a Kauai family claimed to have been duped by an employee of UnitedHealth into changing to the company's Medicare plan.

By February 8, federal Medicaid regulators from CMS were involved in the investigation.

This is only the latest in a long line of federal formal and informal audits, oversight and investigations plaguing Hawaii's Medicaid program since the fall of 2009.  In addition to CMS, the DHHS Office for Civil Rights, the FBI/DOJ and even the federal Office for Civil Rights of the Department of Education have all been involved.

I could understand why Lingle and Koller kept all this from the public.  They had built here in Hawaii a perfect Republican dream of how Medicaid should function under privatization, and small problems like deaths, let alone violations of federal laws, were just pesky details.

But where does our new Democratic governor stand with all this?  He seemed to promise an end to privatized Medicaid, but now is letting privatized Medicaid draft state legislation.

Meanwhile, life and death decisions continue to be made daily by people motivated more by profit than medical need.  

Governor Abercrombie, respectfully, you need to step in and put a stop to this before anyone else can be hurt.  Only you and the Feds can do that right now.  And you need to come clean with your voters about the state's dirty laundry and what you're going to do to wash it.

Saturday, February 26, 2011

When the Medicaid Hit Squad comes calling

UnitedHealth is sending "hit squads" out to the homes of medically fragile children. Their job is to bully and intimidate parents into agreeing to a reduction in the home medical services that keep their children alive. We are the families of children and adults whose disabilities are so complex and severe that the only alternative to institutionalization is for Medicaid to pay for providing nursing and care services in our homes.

Hawaii entered into its 2009 Medicaid contracts with UnitedHealth and Wellcare granting individual per person per month budgets ranging from $2,000 to $30,000. The purpose of the contract, and the higher monthly rates, is to pay for the nurses, personal aides, CNAs and other help that is medically necessary to keep each individual at home. Institutionalization costs more, not to mention the benefits of keeping someone home with their family, so the money is there to spend, so to speak, at least two-thirds of it federal in origin, without taking money from other programs.

Last summer, Evercare (UnitedHealth) and Ohana (Wellcare) once more got Hawaii to agree to raise the capitation fees. Did more money mean more medical services? No, not when the insurance company's profit depends on spending as little of that monthly per person fee as possible.

I had been hearing of these "hit squads" for several months but didn't experience one for myself until February 18. It's taken me since then to sort through the experience enough to isolate why it was so deeply disturbing. Under the guise of a standard quarterly nursing evaluation of Hannah's medical needs, my ability to be a good mom to my daughter was attacked. I was a bad mom if I couldn't provide the same level of professional medical care to my daughter that she gets from her nurses. The point was to get me to agree to taking over some of Hannah's nursing shift hours, thereby lowering UnitedHealth's "medical loss ratio" for my daughter and thus increasing company profits.

Unless you "live the life" so to speak, it can be hard to understand the daily stress of living with the potential your child could die at any minute, while surrounded by medical technology and treatments that you may or may not completely understand. Studies released in November 2009 showed the parents of kids with disabilities are prone to "shell shock", "battle fatigue", or PTSD as it's now known.

My daughter has seizures ninety percent of the time she is sleeping, and almost continuously when she is awake. She is at constant risk of death from something called SUDEP - Sudden Death in Epilepsy. Nurses are with her so that if any of those seizures start to escalate, it can be stopped before we reach the point of calling an ambulance. Every time her seizures have reached the point she needed to be flown to Kapiolani, it was when there wasn't a nurse home with her.

I've sat next to my little girl in an ambulance when she stopped breathing. There is a panic that sets in now if I'm alone with her and she starts seizing, to ensure she keeps breathing. That panic doesn't allow me to do the five other things that need to be going on simultaneously when she starts seizing: get the pulse oximeter hooked up, get the oxygen out and set up, get the diastat out and ready, cool her down if her body temp has gone over 99, all while keeping her in a position to minimize gagging since she's stopped swallowing.

Yet the rude, belligerent attack I experienced on February 18 was designed to make me feel I was a bad mom if I couldn't handle all this with the same skill and detachment as a professional nurse.

I am not the only one who has come away with similar impressions after visits from one of these "hit squads". Another mom was attacked with the accusation that she wasn't spending enough time with her child or she would know how to take care of her. A third family, for whom English was a second language, was belittled and intimidated for not understanding the technical medical terms for all their daughter's care.  Even taping the so-called evaluations did not inhibit the viciousness of these attacks on parents.

There is no doubt these attacks are designed to provide a justification for cutting home services. In December, UnitedHealth cut home services for a young man by sixty percent, on the basis he could use his hands and arms to move himself. The UnitedHealth employee who did the "evaluation" and recommended the cuts in services had spent the previous six years signing off on medical care reports for her previous employer, acknowledging he had no use of arms or hands. His medical situation had not changed overnight, only her employer had.

This is the same UnitedHealth that experienced a ten percent increase in earnings in fourth quarter 2010, "as the health insurer continued to benefit from people's relatively lighter use of medical services."  That Wall Street Journal article goes on to say

UnitedHealth's medical claims in relation to its revenue, a key statistic called the medical-loss ratio, were lower than financial analysts' views, and, according to analysts Leerink Swann, were the lowest in five years. The lower medical-loss ratio helped to boost per-share earnings beyond analysts' expectations.

For a company deriving forty-six percent of its $87.14 billion annual income from federal Medicare and state Medicaid "capitation" contracts, a lower medical loss ratio means the company has more likely cut services than mysteriously benefitted from "people's relatively lighter use of medical services." A simple read of UnitedHealth's SEC filings, along with the unsealed federal whistleblower complaint which includes taped conversations where Wellcare executives openly discuss strategies for committing Medicaid fraud, makes it clear these lower medical loss ratios are no accident.

It's what I've called "the new Medicaid Math", where sixteen to forty percent of state payments to private health insurers are being skimmed off the top by means of these lower "medical loss ratios". The Affordable Care Act tried to make health insurance companies responsible to their policy holders for how much of each monthly premium is spent on actual care. For private enrollees (i.e., non Medicaid or Medicare policyholders), the Act was trying to set a maximum twenty percent profit, and the insurer would have to rebate any difference to the policyholder at the end of the year. A financial analyst with Oppenheimer found that if that limit had been in place for 2009, private health insurance companies would have had to rebate over $1.9 billion back to policy holders.

But these limits do not apply to state Medicaid contracts. Florida recently found that all eight contractors for one specific Medicaid program were out of compliance with a required 80% medical loss ratio, with actual MLRs as low as 60%.

And so we've come back full circle to the Medicaid Hit Squads, whose ultimate purpose is to lower the company's "medical loss ratio" for adults and children like my daughter. They are targeting families where loved ones require what's called "total care" because we are where they get the biggest financial bang for the buck cut. If they're getting paid, say, $15,000 per month from the state to provide home medical services for a particular person, slashing those services by sixty percent puts more money into company coffers than cutting services to folks they get paid only a few hundred dollars a month for from the state.

I do not understand why neither state governments with health care deficits nor the disability rights community nor even the media have looked at the billions of federal Medicaid and Medicare dollars wasted on private corporate profits. The resulting levels of human misery being created in our caregiving families to support these outrageous profits isn't even being recognized.

Wellcare attorneys drafted Hawaii health care legislation

In a State hearing yesterday, attorneys for Wellcare's Hawaii operation admitted to drafting S.B. 658. This is the proposed new law that would make consumers filing appeals against their health insurers responsible for insurance company legal fees even when the consumer wins the appeal.

S.B. 658 was deferred indefinitely yesterday, but the question remains why our new governor is sending out legislation written by health insurance company lawyers?

The story gets better. After the Ohana/Wellcare lawyers admitted writing the bill, they proposed an amendment that would had made it apply only to people insured under Medicaid. In other words, it would only have applied to their own members.

In my post on Thursday, I asked why Abercrombie was supporting legislation so blatantly anti-consumer. The question has now become why is he letting health insurance company lawyers write proposed legislation.

If you google "wellcare medicaid fraud", you may decide to share my incredulity that Abercrombie is even associating himself with these people.

Thursday, February 24, 2011

Why did Hawaii's Governor introduce anti-health consumer legislation?

Right now in Hawaii, almost everyone with health insurance has a right to a local hearing process if their health insurance company doesn't agree with their doctor on what is "medically necessary." Whether you've got insurance through your employer or getting Medicaid through companies like UnitedHealth (Evercare) and Wellcare (Ohana), in most cases HRS 432E-6 gives you the right to a local hearing, complete with attorneys and witnesses, when your health insurer refuses to pay for something your doctor says you need. (Exceptions include federal health plan members, self-insured companies like Hawaiian Tel, Hawaii Pacific Health and a few others.)

The Hawaii Senate Ways and Means Committee is discussing today Senate bill (S.B. 1274) that would deprive all of us of that right. Its silent "companion" bill, S.B. 658, will effectively prohibit anyone from filing any sort of appeal against the decisions made by health insurers by making patients responsible for both their own legal fees and those of the insurance company, even if they win.

Last fall's federal case where Rafael Del Castillo was on one side of the aisle, lined up against fifteen or more lawyers (and staff) from the insurance companies on the other side, is a clear example of why no one will dare file for an appeal if HRS 432E-6 gets repealed. Who but the very richest could comprehend assuming financial responsibility for a $4,000 per day legal case, knowing they have to pay even if the insurance company is found wrong?

These bills, which came out of our new administration, are about as anti-health consumer as you can get. The only folks who are going to benefit are the insurance companies, particularly the two that get guaranteed monthly checks from DHS for $50 million or so, regardless of how much they actually spend on medical services.

Why would the new administration propose legislation that favors health insurance companies so blatantly? Or has no one else recently searched Ho'ohiki for Evercare, United Health and Wellcare?

Wednesday, February 2, 2011

Urgent legislative alert: proposed Hawaii bills put medical decisions in the hands of those who profit from them

The attorney who wrote the letter I am attaching has represented my daughter Hannah, and several of the other children who I have helped to advocate for home medical care.  Governor Abercrombie seems to be trying to get this legislation, which appears very anti-consumer, through quickly and silently.

Dear all:
I apologize for this lengthy correspondence.  THIS IS A VERY CRITICAL ISSUE.  I am asking you to submit testimony opposing a bill in the Legislature that is being heard by the House Committee on Health Friday at 9:00 a.m. 
Please forward the attached to anyone you like.  Inexplicably, the Abercrombie Administration has introduced bills in both houses to repeal the part of the Patients Bill of Rights known as the “external review.”  Simply put, we have a law that provides for a hearing on a pretty level playing field if your health plan denies care your doctor is recommending, or refuses to pay for emergency or other care you have already received.  The review is local and the patient can afford to retain legal counsel and experts to help present the case because the Commissioner can award the fees and costs incurred in the case (in other words, patients don’t have to pay fees and costs to get benefits rightfully due them, and if they lose, they still don’t have to pay).  
Feel free to use the draft testimony attached.  The deadline for submitting testimony is Thursday at 4:00 p.m.  It would be great if you could be there in person.  (We will have additional opportunities to put on more testimony.)  Feel free to personalize the testimony with your external review story.  I have just given you a skeleton that has information about the bills and the external review process we now enjoy.

Over the past 10 years, Arleen and I have won many cases, often with life threatening issues, for patients through the external review.  These days, many cases do not go to the review process because we are able to settle them with the plan and get the care.  That is one of the very positive effects the law has had (it has taken years, but is now very effective).

This year the health plans have come forward with legislation to get repeal the external review and also a bill to make patients pay attorneys’ fees and costs (more about that bill later).

This bill, HB 1047, proposes to outsource reviews to the mainland under a complex 67-page process.  Patients will not have an advocate supporting them as they do in the external review.  They will be on their own.  They will also have no right to appeal a decision (not sure that is even constitutional).  Do you think the health plans want this bill passed?
HB 1047, the first of these bills to come up, is being heard Friday morning at 9:00 a.m. by the House Committee on Health.  I have attached two things:  the hearing notice and a draft testimony that you can use for the form and also for the email and fax address.
I plan to present testimony from across the state and am traveling to the neighbor islands to collect video stories, but because the Legislature moves fast these bills come up for first  hearing quickly,   Petitions are being gathered and I will present them.  Nonetheless, the Committee needs to hear from a broad base of consumers that this bill is a bad idea.
I have not attached a copy of the bill.  You can get it online and I encourage you to do so.  It is 76 pages.

Full disclosure:  the external review comprises part of my practice.  Arleen and I have funded our patient advocacy for the past 10 years in part with the fees the Commissioner has awarded.  On the other side of the coin, I will not be able to continue advocating for patients against benefit denials if the external review is repealed.

I hope you will help me oppose this really damaging legislation.  As I said, I have not discerned a reason for the Abercrombie Administration’s instigation of this legislation.  The justification it is offering is that it will create a uniform process but that is simply patently false.  One quarter of a million people who have the right now will be excluded.  Half a million will have to submit to various other processes.  Uniformity is not the reason.
Rafael del Castillo

New proposed Hawaii legislation is anti-health consumer

This bill will be discussed on KKCR at about 9:15 this morning.

Hawaii House bill 1047 (and the companion Senate bill 1274) will strip away fundamental health care consumer rights.

Right now if your managed care company doesn't agree with your doctor, you can file an appeal with the state's Insurance commissioner.  They do what is called an "external review."  If you win, your lawyer's fees are paid, so there is no financial pressure against people filing for their medical rights.

The new bills will do away with this.  People will have to pay their lawyers up front because the law forbids the looser from paying the consumer's attorney bills.

It will do away with the ability to go to court if you still don't like the insurance commission's review.

It puts all the responsibility for medical care decisions on to the people who are profiting from our privatized Medicaid system.

About Me

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I'm the mom of a child with disabilities. Hannah's first neurologist said she might never develop beyond the level of a 2 month old infant, and there wasn't anything I could do about it. The brain damage was just too severe. Nine years later, she walks, uses a touchscreen computer and I've just been shown she can learn to construct sentences and do simple math with the right piece of technology. Along the way, I discovered I needed to teach myself what Hannah's rights to services really were. Learning about early intervention services led to reading about IDEA and then to EPSDT. I've been waiting for the Obama administration to realize the power and potential of EPSDT for the medical rights - including the right to stay at home with their families - of children with disabilities. The health reform people talk about long term care, and the disability people talk about education and employment, but nobody is talking about EPSDT. So I am.