A filter by any other name would taste too sweet

Lead paint chips aren’t really the problem with lead paint. The problem is lead dust, which is much more difficult to deal with. And using a regular vacuum on lead paint chips can create a much worse lead dust problem.

An important part of the solution is to use a proper HEPA vacuum (a vacuum with an actual HEPA filter and a sealed system so that all exhaust air is forced to pass through the HEPA filter). And those are expensive: the cheapest HEPA shop-vac that I could find is about $500. So contractors and painters mostly refuse to buy them, and complain bitterly (and somewhat falsely) that HEPA vacuums are at least $1000. The reality is that contractors and painters hate the new lead rules and wouldn’t use a HEPA vacuum if it were free.

Or would they?

I’d like to see Massachusetts simply give a HEPA vacuum to every single licensed contractor and painter in the state. No more excuses about the cost of the vacuum, no more reasons to spread lead dust. Just a proactive approach that makes it clear we are serious about reducing this particular environmental hazard.

And we all benefit, whether the HEPA vacuum is being used in our own home, or on our neighbor’s property, or in our workplace or school, or in the restaurants and stores we go into, or in friends’ homes that we visit. This isn’t a gift to contractors and painters. It’s the smart move for all of us.

Interactive Health Solutions guts a hippo HIPAA

From terms and conditions that are only revealed (and must be agreed to) after a patient has provided their name, address, phone number, e-mail address, birth date, and employer:

"I understand that the information attained through this Health Profile will be held confidentially. However, I give permission to Interactive Health Solutions to share my medical data with a third party for the purpose of my disease management and health improvement."

I'm confused: will the information be shared or not?

IHS says that the information will not be shared, but that they will only screen patients who agree to give permission for the information to be shared.

If IHS shares my medical data with a third party, are there any limits on what the third party does with my medical data?

There's no substantive limit on the reasons why IHS would be allowed to share my medical data. If IHS decides that the purpose of my health improvement would be best served by making my medical data public (to obtain as broad support as possible for my health improvement goals), or by giving my medical data to a drug company (so the drug company can contact me about wonderful new targeted drugs), or by giving my medical data to my employer (so my employer can revise their health insurance plan to better accommodate people with my health condition), or by giving my medical data to Geraldo Rivera (so Geraldo can focus an expose on getting me treatment), I've given permission for any or all of those disclosures.

Why is the first sentence there at all? As I understand it, my medical data won't be held confidentially at all. Employees are offered $300 to do this health screening if and only if they are willing to give Interactive Health Solutions permission to share their medical data with third parties.

This is making a mockery of HIPAA. And it's underpaying me for my medical data, which is currently getting bids of $500 and up on ebay.

Can you pay me now?

Today’s Globe article says that Beth Israel Deaconess (our hospital) has stopped sending insurance claims data to Google Health to use as medical records. A patient finally pointed out that it could be a problem when his medical records falsely claimed that he had an aortic aneurysm and cancer in his brain and spine. I know that I was surprised to receive a postcard saying that I had multiple sclerosis a couple of years ago due to a similar misunderstanding of insurance claims data.

Medical providers want insurance companies to pay claims, because otherwise they don’t get paid. And insurance companies set up huge and complicated sets of rules that say that they’ll only pay for certain tests, procedures, and medications if the patient has certain conditions. So the medical providers routinely lie get creative with the billing codes. I think of it as insurance fraud, but medical providers and insurers think of it as just the way the system works. What’s the harm in telling the insurer that the patient has brain cancer if that’s what it takes to get the medically necessary MRI covered?

Apparently, the harm comes when a hospital forgets that their insurance claims are spun out of a fine blend of whole cloth and necessity, and starts conflating the deliberately false insurance claims with the only somewhat error-filled medical records. Then patients get outraged, and the media sees a fun story, and the hospital ends up admitting that they shouldn’t have pretended that their insurance claims were true.

I hate the resolution of the story. I hate that everyone accepts the idea that insurance claims should be filled with false information. The Globe and the hospital have used this story as an opportunity to explain why medical providers lie on their insurance claims, and to explain why insurance claims contradict medical records, but not to advocate for truth in billing. We don’t need an insurance system that practices medicine by spreadsheet, and we certainly don’t need to train yet more generations of health care professionals that lying is a core component of patient care.

Unleaded

Time for my annual post about testing lead in toys. In two months, a new law takes effect in the US that requires manufacturers and importers to test toys (at significant expense) for lead and phthalates. As implemented by the CPSC, there are no exceptions for toys imported from European countries with much stricter safety laws than ours. There appear to be no exceptions for toys made entirely of safe materials such as cloth or wood, or using materials such as paints that are already tested by manufacturers. No exceptions for handmade toys sold at craft fairs. But we will still allow toys that are made, tested, and certified in China, which can’t be trusted to keep melamine out of our food chain.

There is an exception for toys that aren’t primarily for children, so the teaching aids I produce don’t have to be taken off the market. But I want to be able to buy the handmade wooden rattle, or the all-organic-fabrics stuffed animal, or the unpainted wooden train like the one I grew up with. I want to be able to buy German and English toys without traveling to Europe myself and sneaking them into the country as if they’re unpasteurized cheese. I want to be able to shop at the funky independent toy stores that sell American handmade and European toys. I’ll be glad if the CPSC can improve the safety of children’s products, but I’d like to see their focus start on where the problems have been: paints and plastics.

Yankee pill swap

Different ways of learning: Tutoring vs. the classroom. Individual therapy vs. group sessions. Individual medical appointments vs. group medical appointments. It’s nice to have options, and we surely need to try some new approaches to providing medical care.

Holy Copays, Batman!

Ah, open enrollment. A time of chaos and despair PowerPoint and false statistics, and always some new advice from HR. Last year, HR advised employees that having children was expensive for the company. This year, I learned a lot more at the benefits presentation:

1. If providing a benefit to the employees does not cost money, then HR believes it cannot have value.

2. If providing a benefit to the employees does cost money, then scolding employees for using the benefit is the best way to reduce usage. Don’t listen to your doctor; make your own health care decisions.

3. Chiropractic care is useless, and could even cost more money because chiropractors could injure their patients. Stop making your own health care decisions.

4. It’s important to be an informed health care consumer, so try to understand your EOBs.

5. There are never errors or fraud in medical billing, so stop trying to understand your EOBs.

6. It’s important to HR to regain our trust, as long as that doesn’t involve improving benefits, treating employees like adults, or answering questions. So the bold new step HR has taken to regain our trust is to reduce our direct interactions with anyone who works for HR.

There are so many internal contradictions in their presentation, you can’t help but agree with something they say. But the most informative minute was before the presentation started, when we talked to one employee who works directly for HR and another employee who HR used in an intranet video presentation about the medical plans. They’re both on their spouse’s health insurance instead of this one.

Healthways and HIPAA

We received letters last year which told us we had fibromyalgia and that Blue Cross had contracted with Healthways to provide support services. We were surprised to be given fibromyalgia by mail, as were many other people. This year we received similar letters which told us that we had other health problems and that CIGNA had contracted with Healthways to provide support services. From what we’ve been able to find out, a number of insurers contract with Healthways to offer support services for various ailments; the insurer periodically sends anonymized claims information to Healthways, Healthways decides what ailments anonymous you might have and tells the insurer, and the insurer un-anonymizes the results and tells Healthways your name, address, phone number, date of birth, and putative ailments. Healthways then contacts you to give you the good news. There are a few problems with this practice:

1. Your health information is supposed to be private. That’s what HIPAA is all about. The insurer is allowed to contract with others (called “business associates”) to perform some of their essential functions, but the support services offered by Healthways do not seem like essential functions, particularly if the patient does not use those services.
2. Your personal data such as date of birth or unlisted telephone number are supposed to be private.
3. The program is opt-out, rather than opt-in. And you can only opt out after your data has been forwarded to Healthways, so all you’re opting out of is harrassing phone calls. You can’t opt out of having your insurer give your personal data and health information to Healthways.
4. Healthways routinely lies about who they are, claiming over the phone that they are part of your insurance company. They aren’t.
5. Healthways refuses to provide a HIPAA notice or a privacy notice upon request.
6. Healthways refuses to remove your personal data from their computers upon request.
7. The insurer’s customer service department initially claims they have never heard of Healthways and would never give your personal information to another company without your permission.
8. The only way to have Healthways remove an erroneous diagnosis from your record is to give them additional medical information.
9. It’s very unclear which way the money flows. Information has value, so Healthways could be paying insurers for access to their subscribers. Services have value, so insurers may be paying Healthways to offer these support services. Healthways claims that the employer’s HR department pays for this program as part of the benefits package, but HR has denied any knowledge of this program (and they usually make sure to mention everything that could conceivably be called a benefit).
10. Oh, and one more thing. It’s really disconcerting to be diagnosed by mail. Especially when it’s a wrong diagnosis.

Perhaps the Office for Civil Rights of the US Department of Health and Human Services can sort some of this out, if I just fill out the correct sort of form.

Nationalize health care, or daydream #2

We desperately need to change how we provide access to health care in this country, and how we pay for it. The incentives are perverse, leading to rational choices that hurt us all: patients avoid preventive care and crisis care, doctors order unnecessary tests to satisfy health insurers and malpractice insurers, drug companies don’t release scientific studies, patients avoid genetic testing, medical students avoid going into general practice or geriatrics, and an increasing number of the healthy among us avoid the insurance system. Emergency rooms are overloaded with non-emergent cases because of their triple status as the release valve for onerous hospital admission policies, the salve for poor scheduling practices by primary care and specialist offices, and the accepted delivery system for offering health care to the poor and uninsured. The system is navigable by the educated and persistent, who find themselves at great risk of avoidable errors that harm and kill. Objective measures such as infant mortality rates and the increase in medical tourism indicate that our health care system is not just worse than it might be; it is worse than plenty of other systems.

If we did not have to worry about our medical records being used against us, we could wholeheartedly embrace computerizing health care, which would offer numerous advantages for patients, doctors, and researchers. Imagine a universal data exchange system for all medical records. Any practitioner could pull up a patient’s history and test results, even from other hospital networks. Prescription errors and negative drug interactions could be greatly reduced, and off-label drug use could be studied. We could create a patient-centered me.med domain where patients could track their own symptoms, share stories, offer encouragement and advice, review their own records, annotate their own records and ask questions, set privacy and access levels, and start to become the empowered health care consumers that the advertising wants us to be. If the records are all centrally stored, NIH could track symptom and diagnosis patterns. Researchers could have a gold mine of data, and we could learn much faster that drug A is killing people, drug B is useless, and drug C is actually working against the latest variant of strep.

Our incomplete and inaccurate medical records are already for sale in uncontrolled ways, while patients are denied access to their own records in the name of HIPAA. Imagine going to me.med, logging in to your account, and having full access to your own records. You add a follow-up to your recent prescription record, noting when you stopped taking the drug because of a nasty side effect or confirming that you finished the course without missing a dose. You know that no employer will ever see these records, and you know that researchers only have default access to fully anonymized data. Oh, and here’s a note from a researcher, asking if you would answer a few specific questions or be willing to have some blood drawn to test for lead and bromine levels. There’s the randomly assigned anonymized ID code that this researcher has for you, along with a bar code for the clinic to use. You print out the bar code and go to the clinic, where they confirm in the system (without needing to know your name) that this is not a duplicate request, and that the researcher is immediately reimbursing the clinic $40, half of which goes to you in cash. And the results from the lead and bromine testing will be forwarded to your me.med account, so your doctor can advise you to seriously reconsider chewing on your windowsills. The researcher discovers that patients with elevated bromine levels have a negative reaction to Xatiremulch, and me.med lets the doctor know that they might want to reconsider renewing that Xatiremulch prescription until they check if your bromine levels are still elevated.

Nationalizing health care doesn’t mean that me.med will be designed well, any more than saying “We’re using XML” means that you’ve correctly solved your complex data tagging problems. But if we leave the continued computerization of the health care industry up to CIGNA and Blue Cross, I can guarantee that we won’t ever have a patient-centered me.med or a doctor-centered doc.med. Insurers are far from being the entire problem, but they are a critical piece of the problem.

Medical billing

Someone I know (let’s call her Lisa) went to a walk-in clinic in December because she had a bad cough that wasn’t going away on its own. The nurse took her temperature and blood pressure (as they do for any patient), the doctor listened to her lungs for approximately 4 seconds, and Lisa left with two prescriptions. A pretty easy medical scenario. We’re grateful that the walk-in clinic exists a mere 30 minutes from our house, that the doctors there are reasonable and considerate, and that medications often help cure health problems. As health care goes, this was a success.

The billing, however, is the usual mess. I want the world of medical billing to be transparent, honest, fair, and comprehensible. Even if the notion that health care consumers can somehow determine the cost for health care from a provider ahead of time is terribly false, we should at least be able to figure out what we paid for after the fact.

In many apparently simple cases like this one, the facility and the doctor charge separately, so it’s impossible to see all of the charges for a single simple visit on one bill. So much for transparency. The bills are sent to the insurance company, who never verifies any of the charges with the patient. That encourages rampant overbilling. So much for transparency or honesty. The billing is done using a code system. So much for being comprehensible.

The insurer says they received two charges from the facility: one charge for $204 and one charge for $96. The charge for $96 was coded as lab work, but the insurer doesn’t know what kind. Today we received a more detailed itemization from the facility:

WIC BRIEF EST PATIENT $102
PULSE OXIMETRY FOR O2 SAT $48
WIC BRIEF EST PATIENT $102
PULSE OXIMETRY FOR O2 SAT $48

Ok, the facility double-billed us. But the obvious double-billing was hidden from the insurer because of the coding system. And pulse oximetry is not lab work, but the insurer was not told that the lab work charge was for pulse oximetry. (A pulse oximeter is the little sensor they clip onto your finger to measure your heart rate and see whether you’re getting enough oxygen into your bloodstream. You can buy one for less than $100 if you want your own. It’s hard to describe how ludicrous it is to charge separately for taking the patient’s oxygen level if you’re not also charging separately for using the thermometer or the blood pressure cuff or the stethoscope or the waiting room chairs.)

We pointed out to the insurer that the facility double-billed us, and that pulse oximetry (whether it’s $48 or $96) is not lab work. The insurer (a) has no way to verify any of this and (b) has no interest in verifying any of this. So I’ll have to ask the facility a few questions:

1. Will they fix the double-billing?
2. Will they resubmit the claim with the correct billing codes?
3. Can we save $48 next time at the walk-in clinic by bringing our own pulse oximeter?

Almost every single component of this billing system is designed to prevent the patient who actually knows what health care was provided from being able to understand or verify the charges. When it’s this hard to sort out the billing for a simple doctor’s visit, it’s impossible to sort out the billing for an actual hospital stay. Perhaps the in-pharmacy minute clinics that Massachusetts just approved will try a different billing system. They’d be hard-pressed to create a worse one.