Health from The Center for Public Integrity

OPINION: hidden influence-peddling in Washington

2013-05-20T16:13:49-04:00

I was not among those who believed the Supreme Court’s Citizens United decision would open the floodgates of corporate money to influence elections and public policy. While the decision enables corporations to call for the election or defeat of federal candidates, those expenditures have to be reported and few corporations will take the risk of losing customers by getting involved in politics so publicly.

The reality is, the floodgates have been open for years, and the attention focused on Citizens United has actually been helpful to corporations, because it has diverted the public’s attention away from the deceptive yet perfectly legal ways corporations are able to deploy enormous sums of money to advance their political agendas.

The mainstream media, meanwhile, seems to willfully ignore what corporations and other moneyed interests do to get what they want in Washington. That was certainly the case last week after National Journal reporter Chris Frates disclosed how America’s Health Insurance Plans, the insurance industry biggest PR and lobbying group, funneled hundreds of thousands of dollars to a longtime ally with a better reputation to pay for an industry-serving communications campaign. The only media outlets I could find that picked up the story were The Huffington Post, Bloomberg Businessweek and ABC News online.

As Frates’ investigation uncovered, AHIP in 2011 gave the National Federation of Independent Business $850,000 to finance an effort to persuade Congress to repeal a provision of Obamacare that will actually help many uninsured people afford coverage. NFIB is a nonprofit that calls itself the voice of small business but which I know from my days in the insurance industry has often been a voice for my former bosses.

Insurers are delighted that Obamacare will require most Americans to buy coverage from them beginning January 1. That was one of their health care reform goals, along with making sure reform did not include the creation of a public option to compete with private companies. And insurers love the fact that the federal government will be sending them billions of dollars every year to help subsidize the coverage of low-income Americans who would otherwise be unable to afford their premiums.

Knowing that insurers would be getting a windfall in new revenue from all of that, drafters of the Affordable Care Act included a provision that would impose a tax on some policies insurers sell to help finance the expanded coverage that insurers will benefit from. Sounds reasonable, right?

Well, not if you are the CEO of a health insurance company who cares more about meeting Wall Street’s profit expectation than the health care needs of Americans.

But even health insurance executives know they’re not viewed as positively as small business owners. If AHIP spent that $850,000 in a way that could easily be traced to the insurance industry, the campaign to get the tax repealed would be considered — rightly — as self-serving. So AHIP needed a trusted partner with a better reputation to try to get the job done, and the NFIB was more than willing to sign on and take the money.

Exactly how the NFIB spent insurers’ money will likely never be known, but there is a good chance most of it went to set up and finance the operations of an outfit called the Stop the HIT Coalition. (HIT stands for Health Insurance Tax.) That’s the group that is fronting for the industry to get the tax repealed.

The NFIB, one of the organzations that challenged the constitutionality of the Affordable Care Act, undoubtedly was willing to partner with AHIP because insurers say they will pass the tax along to their small business customers instead of absorbing it as a cost of doing business or as goodwill from getting the additional business guaranteed by Obamacare. Rather than push back against the insurers, the NFIB clearly saw this as a new reason to attack and weaken the law.

Frates discovered this back channeling of money by looking at tax returns filed by both AHIP and the NFIB. It turns out the $850,000 from AHIP was the second largest contribution the NFIB received in 2011. To put that into context, the NFIB offers small business memberships for $180, so AHIP’s money (which comes from premiums insurers charge their customers), was equivalent to 4,722 small business memberships.

Other than the reporters at the Center for Public Integrity, Frates — who last year broke the story that AHIP funneled more than $100 million to the U.S. Chamber of Commerce in 2009 and 2010 to pay for an anti-reform advertising campaign — is one of the few Washington reporters investigating how corporations and trade associations hide the money they spend to influence Congress. As a result of this lack of media interest, Americans remain in the dark about how big special interests are able to control what happens in the nation’s capital. And Citizens United has nothing to do with it.

OPINION: ObamaCare myths and realities

2013-05-13T14:06:40-04:00

The House of Representatives is expected to vote for the 40^th time this week to repeal ObamaCare, not because anyone believes the 40^th time will be the charm, but because the exercise will enable Republican freshmen to vote for repeal and brag about it during their campaigns next year.

Those lawmakers probably won’t tell their constituents that two of the most important provisions of the law they profess to hate were actually Republican ideas the Democrats embraced in hopes of getting bipartisan support for reform. The first such provision is the requirement that all Americans not covered by a public plan like Medicare or Medicaid must buy coverage from a private insurance company. The second provision: establishment of state health insurance marketplaces (called exchanges in the law) where private insurers compete online for customers.

One of the first states to set up such a marketplace was Utah, among the reddest of states, which had its exchange up and running months before ObamaCare was enacted. Starting this fall, Americans everywhere will be able to shop in Utah-like marketplaces for coverage effective January 1, the date the GOP-inspired requirement to have health insurance kicks in.

The reason Republicans once liked health insurance exchanges is that in theory they will facilitate choice and competition, which should bring down the cost of coverage. If the exchanges work as planned — and as ObamaCare stipulates — consumers will be able to make apples to apples comparisons among health plans and pick the one that seems to offer the best value.

Based on news out of Oregon last week, there is reason to believe that the theory is holding up and that consumers will indeed benefit from price transparency that until now had never been available to the layman.

Health insurers in Oregon were required to tell the state last week how much they planned to charge for the policies they would sell this coming fall on “Cover Oregon,” the name of the state’s exchange.

As reported in the Oregonian, when the state insurance department published the insurers’ proposed rates in a chart, some of companies that had planned to charge the highest rates wasted no time in saying said they had made a serious mistake and would quickly revise their offerings with lower rates.

The charts were made available online Thursday. Within 24 hours at least two insurers asked for a do-over, according to the newspaper. One of the companies promising to resubmit new rates was Family Care Health Plans, which had said it would charge $422 a month to cover a 40-year-old non-smoker in Portland, two and a half times as much as another insurer said it would charge for the exact same policy.

Another insurance company, Providence Health Plan, said that, oops, it had made a mistake in its cost projections and would reduce its planned rates by 15 percent. A spokesman for Family Care blamed its sky-high rates on overly pessimistic underwriters and said that, upon reflection (and after seeing what competitors planned to charge) it would cut its rates even more than 15 percent.

For years, insurance companies have been able to charge essentially whatever they wanted because there has been no organized marketplace for individuals and small business and no requirement that insurers provide information in a way that would enable us to make truly informed decisions. One of the most popular provisions of ObamaCare changes that by requiring insurance carriers to provide plan descriptions in a standardized format and in language we can understand. They also have to tell us how much our monthly premiums will be and provide examples of how much we’ll have to pay out of our own pockets if we get sick — or pregnant.

ObamaCare critics have charged that the rates insurers will be charging on the exchanges will be much higher than what insurers charge today because of other consumer protections in the law, such as the one that makes it unlawful for insurance companies to refuse to sell someone a policy because of a pre-existing condition.

While it’s possible that some people will have to pay more — especially those with low-benefit, high-deductible plans that are soon to be abolished — most folks who have to buy coverage without an employer’s help will likely pay less, thanks to income-based tax credits that will be available for the first time. As the Oregonian noted, at least half the people who buy coverage on the state’s exchange will qualify for a tax credit. And they’ll be able to determine quickly how much the tax credit will reduce their premiums simply by providing income information on the exchange website.

Americans in every state can look forward to these GOP-inspired consumer benefits and protections and the very real possibility of lower premiums, assuming ObamaCare goes forward. Which, of course, it won’t if House Republicans’ 40^th attempt to repeal ObamaCare does indeed prove to be the charm.

OPINION: health reform to be political fodder in 2014

2013-05-06T00:09:01-04:00

Will the implementation of some of the most important provisions of ObamaCare this fall and next year result in the “train wreck” Senate Finance Chairman Max Baucus (D-Mont.) predicted a few days ago?

No. But you can be certain that there will be no shortage of political candidates and high-powered political spin doctors who will be working relentlessly between now and the 2014 midterms to convince us that it will be.

ObamaCare — even though it already has reduced the number of uninsured Americans by several million and has limited price gouging by insurance companies — represents the best hope that many Republicans will have of maintaining or boosting their majority in the House and possibly retaking the Senate.

Think about it. The economy seems to be on the right track. Just last week the stock market reached record highs and the jobless rate fell to its lowest point in four years. The war in Iraq is over and most American troops are scheduled to be out of Afghanistan by the end of next year. The GOP appears to have lost the advantage to Democrats on gun control and immigration, and abortion and gay rights are no longer the reliable campaign wedge issues they once were.

That leaves ObamaCare and “big government spending” as just about the only issues that remain for right-leaning candidates, barring any unforeseen domestic or global calamity. But if their campaigns against ObamaCare next year are as successful as their campaigns against it were in the 2010 midterms — and the White House and supporters of the law are once again asleep at the switch — GOP candidates might not need anything else to talk about to take both houses of Congress.

When Barack Obama was inaugurated in January 2009, there was wide support for health care reform, and Republican strategists knew it. They realized they might be able to turn reform into a winning issue for their candidates by mounting a campaign to make people afraid of what the Democrats might try to do. So just as Congress was beginning preliminary work on what eventually became the Affordable Care Act, GOP message guru Frank Luntz persuaded his clients to condemn whatever the Democrats proposed as a “government takeover of health care.”

Even though the bill that ultimately became law was anything but a government takeover, GOP lawmakers and candidates never missed an opportunity to insist that it was. Luntz’ sound bite was repeated hundreds of times in floor speeches by Republican members of Congress in the hours before the House voted on its version of the bill on November 7, 2009.

Their fear-based campaign worked so well to influence public opinion that GOP candidates have never stopped using the “government takeover” meme, which is why the perception of ObamaCare as being exactly that has become a reality for millions of Americans.

When you consider the inadequate job that the White House and the President’s supporters have done in explaining how the law benefits just about every one of us — and never letting us forget why reform was necessary in the first place — it’s little wonder Republicans see opportunity once again.

There no doubt will be glitches when the online health insurance exchanges go live on October 1 for the relatively small percentage of Americans who will use them to shop for coverage because their employers don’t offer health insurance as an employee benefit. The exchanges will work just fine for the vast majority of people, but there will be some who will have complaints. You can expect the law’s critics to give every one of them a voice in their effort to create the impression that the exchanges are a disaster and that the government can’t do anything right.

Similarly, some people who have been paying relatively low premiums for what they don’t realize is junk insurance will be upset when junk insurance is outlawed next year. Because real insurance costs more than junk, some invariably will complain about having to pay higher premiums for coverage that will actually be there if and when they need it.

You can also expect that a fair number of folks will squawk when the requirement to have health insurance kicks in on January 1. And you can bet that the opponents of the law will be aided, unwittingly in most but certainly not all cases, by the media. Just as local TV reporters tell us about the drivers who crash into each other instead of the rest of us who get to our destinations unharmed, the media will focus on the glitches. And they’ll interview far more complainers than happy campers.

I’m betting that Frank Luntz and other Republican strategists have already been hired to craft the sound bites to use against Democrats next year. If the Democrats and consumer advocates who support ObamaCare are not at work developing their own strategies to counter the coming barrage of misleading spin, the GOP will have an excellent chance of controlling Capitol Hill after the next elections.

Feds 'listen' for sounds of Medicare billing abuse

Baltimore,Maryland,United States — 2013-05-03T10:28:43-04:00

When news broke last September that some doctors and hospitals could be using electronic health records to overbill Medicare, top government officials swung into action.

U.S. Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder fired off a stern letter to five prominent medical groups threatening criminal prosecution for applying the technology to bill for more complex and costly services than merited — a practice is known as “upcoding.”

But the Centers for Medicare and Medicaid Services, which reports to Sebelius, is taking a much less confrontational stance as it opens a “listening session” this morning in Baltimore on the digital billing controversy.

The agency has lined up nearly a dozen health industry speakers representing mostly hospitals, doctors and the software industry to give their take on fair and honest billing and coding standards to impose as medicine wires up. No one at the meeting will represent patients or others who pay medical bills.

A CMS spokesman called the meeting "another step toward ensuring appropriate use" of electronic records, which are "critical to our efforts to reform the health care delivery system, lowering costs while improving the quality of care.”

The initial reaction from Sebelius and Holder came on the heels of the Center for Public Integrity’s “Cracking the Codes” series, a year-long investigation which showed that thousands of medical professionals billed sharply higher rates for treating seniors over the last decade — adding $11 billion or more to their fees. The findings suggested billing abuses could be worsening as doctors and hospitals switch from paper to electronic health records.

As the government has made good on plans to invest some $35 billion helping doctors and hospitals convert from paper to digital records, hundreds of technology firms have jumped into the market — often by promising doctors and hospitals that their gear can significantly boost the bottom line.

Most manufacturers and medical users contend the software merely allows them to more efficiently bill for their services, which in the past was often done by hand.

Critics argue, however, that with a flick of the wrist the devices can create a finely detailed medical file that’s often difficult for auditors to verify. Sebelius and Holder noted that in some cases, the machines can “cut and paste” information from previous doctor visits “in order to inflate what providers get paid.”

Sue Bowman, of the American Health Information Management Association, said her testimony in Baltimore would recommend research to figure out the precise role — if any — electronic records are playing in encouraging errant billing. “Like any tool (electronic health records) can help us be more efficient, but it can also be misused,” she said in an interview.

The Baltimore session takes place amid rumblings in Congress — at least among Republicans — that the multi-billion dollar initiative has veered off course.

Last month, six Republican U.S. Senators called for an overhaul of the plan, citing a range of concerns from patient privacy to stepped-up Medicare billing fraud.

Their report noted that many medical experts believe the digital systems can reduce health care costs and enhance medical quality by reducing wasteful testing and cutting down on harmful errors. But it also cited “troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled.”

OPINION: insurers hiding political spending

Cigna Corporation — 2013-04-29T09:47:40-04:00

If you have private health insurance, it’s almost certain that a portion of the premiums you pay every month is used to support political agendas that are not in your best interests. But good luck finding out how much of that premium money your insurance company spends to influence public opinion and public policy.

While all companies are required to report their federal lobbying and Political Action Committee expenditures, that money is just a fraction of what they often spend in the political arena to protect their profits. Millions more — probably billions more — are spent secretly every year by corporations and their trade associations to shape policy discussions and actions. Corporate America is determined to preserve that secrecy.

Among my responsibilities when I worked at Cigna was the administration of the company’s PAC. The money we doled out to state and federal candidates every year was not huge, but a lot of thought went into determining who got checks. The lion’s share each year would usually go to Republican candidates, but influential Democrats also benefited. In 2012, Cigna’s PAC reported contributing a total of $213,000 to 73 Republicans and 41 Democrats.

That’s pocket change compared to the $3.09 million Cigna says it spent lobbying lawmakers last year in both Washington and state capitals. And it’s also a fraction of what CIGNA probably spent through its trade associations and other groups to influence how you think about health care policy issues and how lawmakers vote on them.

We don’t know how big the total is because there are no laws or regulations requiring corporations to report those expenditures. But there is a growing movement among shareholder groups to force companies to disclose this kind of spending because it may dwarf what they invest in lobbying and direct contributions to candidates.

That undoubtedly was the case during the health care reform debate. The trade group America’s Health Insurance Plans, for which Cigna is a leading dues-paying member, funneled more than $100 million in 2009 and 2010 to the U.S. Chamber of Commerce to finance the Chamber’s advertising and PR campaign aimed at defeating reform. This “backchannel spending,” which the National Journal uncovered by poring over IRS tax filings, enabled insurers to state publicly that they were backing reform while spending millions in policyholder premiums as part of an industry-wide stealth campaign to kill it.

Most of the $100 million came from “special assessments” contributed by Cigna and other AHIP member companies over and above their regular membership dues. We’ll never know how much of that $100 million came from Cigna, though, because corporations are not obligated to disclose such spending, and they have rebuffed calls that they do so voluntarily.

Among those pressuring companies to be more forthcoming is Rob McGarrah of the AFL-CIO’s Office of Investment. The union owns shares of stock in many companies, including Cigna, and is asking them to provide shareholders and the public with a more complete accounting of spending to influence public policy.

McGarrah was unsuccessful in persuading Cigna to disclose “special assessments” on behalf of AHIP and other groups, so the AFL-CIO submitted a shareholder resolution that would compel the company to report indirect funding of lobbying through trade associations and tax-exempt organizations, such as the American Legislative Exchange Council, which drafts “model legislation” to protect business interests.

At Cigna’s annual meeting of shareholders last Wednesday, Cigna shareholder Tom Swann spoke on behalf of the AFL-CIO’s resolution.

“Transparency and accountability in corporate spending to influence public policy are in the best interests of Cigna shareholders,” Swann argued.

But as expected, the resolution failed; Cigna had encouraged shareholders to vote against it — as the Chamber of Commerce is urging all companies facing such resolutions to do.

In its 2012 Political Contributions and Lobbying Activity Report, Cigna stated that the total dues it paid to AHIP was $837,377, including “any special assessments” it might have paid last year. But the company has refused to say how much of that was in the form of special assessments, and it has not disclosed how much it paid AHIP during the height of the health care reform debate in 2009 and 2010 when the trade organization was sending millions to the Chamber of Commerce. Cigna CEO David Cordani acknowledged that the company contributed special assessments to AHIP to pay for the Chamber’s advertising, but he would not say how much.

Although the resolution failed this year, the AFL-CIO and other like-minded investors are not throwing in the towel, and the Chamber is well aware of that. This coming Thursday, the Chamber’s Center for Capital Markets Competitiveness and its “Workforce Freedom Initiative” is inviting corporate executives to a meeting “to discuss the economic value of union-backed shareholder activism to investors and employers.”

You can rest assured that plenty of money in special assessments will go to the Chamber in the months and years ahead not only to influence public policy but to beat back attempts to get corporations to be more transparent and accountable. That’s just the way things work.

New urgency targets mysterious kidney disease in Central America

El Salvador — 2013-04-29T09:36:59-04:00

SAN SALVADOR, El Salvador — Bringing new urgency to a mysterious kidney disease afflicting the region’s agricultural laborers, Central America’s health ministries signed a declaration Friday citing the ailment as a top public health priority and committing to a series of steps to combat its reach.

Over the last two years, the Center for Public Integrity has examined how a rare type of chronic kidney disease (CKD) is killing thousands of agricultural workers along Central America’s Pacific Coast, as well as in Sri Lanka and India. Scientists have yet to definitively uncover the cause of the malady, although emerging evidence points to toxic heavy metals contained in pesticides as a potential culprit.

Following years of official inaction in the U.S. and beyond, Friday’s San Salvador declaration — for the first time — formally recognized the disease and its unique characteristics.

“This disease fundamentally affects socially vulnerable groups of agricultural communities along the Pacific Coast of Central America, predominates among young men, and has been associated with conditions including toxic environmental and occupational risk factors, dehydration, and habits that are damaging to renal health,” said the declaration adopted by the Council of Health Ministers of Central America.

The ministers pledged potentially meaningful new steps, including more detailed statistical tracking of CKD, the development of national and regional plans to investigate and treat the disease, and promotion of stronger regulation of agrochemicals.

The declaration represented a major victory for El Salvador and its health minister, Dr. Maria Isabel Rodriguez. Ninety years old and barely five feet tall, peering from behind enormous eyeglasses, Rodriguez has been a driving force behind catapulting the ailment from obscurity to formal recognition as a leading regional threat.

“This is a disease of poor people,” Rodriguez said. “This is a disease of people who work in the fields and have very bad living conditions.”

The outcome signaled a turnaround by the U.S. Centers for Disease Control and Prevention, which in 2011 helped beat back an effort by El Salvador to declare the malady a top priority for the Americas. The CDC now says it has devoted “several hundred thousand” dollars to support research of the disease, created a multidisciplinary internal task force on chronic kidney disease in Central America, and pledged to help fund a national survey by El Salvador to measure the prevalence of chronic ailments including CKD.

“We have that commitment to provide the support to follow and strengthen their investigations in the ministries of health,” said Dr. Nelson Arboleda, the CDC’s director for Central American Region.

The San Salvador conference also marked a threshold in international cooperation in combating the mysterious disease. Following years in which researchers battling parallel epidemics in Central America, Sri Lanka and India failed to compare results, Sri Lanka sent an official delegation to El Salvador and urged Central America to consider its research findings and policy responses as a model for future action.

“We are having enough clinical, biochemical and histopathological evidence to say this is the same disease,” said Channa Jayasumana, Sri Lanka’s delegate in El Salvador.

The disease has felled thousands. In Sri Lanka, more than 8,000 patients are receiving treatment for CKD of unknown cause, an official report found, a figure representing just a fraction of those affected by a disease that remains latent until its advanced stages. More than 16,000 men died of kidney failure in Central America from 2005 to 2009, with annual deaths increasing more than threefold since 1990, according to an analysis of World Health Organization data. In El Salvador, CKD has become the leading cause of hospital deaths among adult men.

The Debate over Pesticides

Although the declaration reflected broad agreement to take action, the two-day conference that preceded its signing was dominated by a forceful debate. The central question: whether there was adequate evidence to declare the disease is linked to agrochemicals and respond by restricting their use.

At the conference, El Salvador presented findings from an ongoing official study, conducted jointly with the Pan American Health Organization, suggesting that pesticides and fertilizers containing heavy metals may be to blame. Environmental tests of soil and water samples in a village heavily affected by CKD, Ciudad Romero, found the presence of high levels of cadmium and arsenic, heavy metals toxic to the kidneys. Among a sample of 42 residents of Ciudad Romero who suffer from CKD, all reported applying pesticides without any protective equipment.

A national sample of 46 CKD patients found that 96% reported using pesticides, and medical tests of these patients revealed additional symptoms such as impaired reflexes and damage to arteries in the lower limbs that suggest toxic poisoning.

El Salvador’s findings echo those in Sri Lanka. An official study there, conducted by the Sri Lankan health ministry in partnership with the World Health Organization, documented elevated levels of cadmium and arsenic contained in agrochemicals and within environmental samples from the endemic region — and found the same heavy metals in samples of urine, hair and nails of patients. Sri Lanka also found residues of several pesticides in the urine of many of the affected patients.

Since publication of its report, the Sri Lankan government has imposed a ban on four common pesticides from use in the endemic region. Rodriguez, El Salvador’s health minister, said she also hopes to ban pesticides that are potentially linked to the epidemic.

Yet other researchers questioned the weight of evidence pointing to pesticides. El Salvador found arsenic above permitted levels in one location in Ciudad Romero and cadmium above permitted levels in another location in the same village — hardly proof of widespread contamination, critics say. The nation also has yet to complete toxicology tests that will determine whether the heavy metals came from pesticides, or whether heavy metals and pesticide residues appeared in blood, urine, or tissue samples of CKD patients.

Basic questions about the pesticide hypothesis remain unanswered in both El Salvador and Sri Lanka’s reports, including evidence of how the agrochemicals are entering victims’ bodies or what products are at fault. Despite the dramatic parallel findings from the recently released reports, no peer-reviewed studies in more than a decade of research have established a definitive link to agrochemicals.

“There is still no direct causal connection,” said Dr. Ramon Trabanino, a Salvadorean nephrologist who published two of the first studies demonstrating the presence of the disease. “I think all of this is political. They want something to blame.”

The controversy came to head in the final portion of the scientific conference. The argument pitted skeptics of the evidence against conference organizers who argued that the Sri Lankan and Salvadorean results were clear enough to create a moral obligation to take precautionary action. The debate was concluded by Rodriguez, who delivered a forceful defense of El Salvador’s findings.

“What has been presented here is scientific fact, and I will defend it with my nails,” she said, holding up bright red-painted fingernails and reducing the room to laughter.

Chemicals in the Spotlight

Two chemicals in particular have come into investigators’ crosshairs in both El Salvador and Sri Lanka: 2,4-D and glyphosate. 2,4-D is a common herbicide used to control weeds, and glyphosate is the active ingredient in the world’s most popular herbicide, Roundup. Both are used worldwide, including in countless areas not affected by this distinctive form of chronic kidney disease.

The El Salvador sample of CKD patients from Ciudad Romero — the community shown to be contaminated by heavy metals — found that 100 percent and 75 percent of the patients, respectively, reported using 2,4-D and glyphosate. In Sri Lanka, both are used heavily and were found in urine samples of some sick patients.

Glyphosate was developed by Monsanto, but the patent has expired so numerous companies now sell glyphosate products. Monsanto said it currently sells glyphosate products in Sri Lanka but did not confirm whether it sells such products in Central America.

Dr. Daniel Goldstein, a Senior Science Fellow at Monsanto, said “glyphosate does not cause renal failure.” He said he was aware of the official findings from Sri Lanka, and that glyphosate contains phosphorus, an element whose molecular similarity to arsenic can result in small amounts of arsenic byproduct in quantities not threatening to human health. But the “plausibility of relationship is virtually nil” between glyphosate and the Sri Lankan kidney disease epidemic, Goldstein said.

Dow Chemicals, which developed 2,4-D, did not respond to requests for comment. Like glyphosate, the patent on production has expired and other companies also produce pesticides containing 2,4-D.

According to the Environmental Protection Agency, excessive quantities of glyphosate and 2,4-D in drinking water can cause damage to the kidneys. But little research has been conducted into other types of exposures, and particularly on long-term health effects on humans.

“I'm appalled at how little [research] there is on humans,” said Dr. Stephanie Seneff, a Senior Research Scientist at the Massachusetts Institute of Technology. Seneff published a study last week raising concerns about a variety of potential health effects from long-term exposure to glyphosate.

Scientists from the Salvadorean and Sri Lankan research teams also suspect that toxic additives to pesticides, or dangerous combinations of chemicals, may pose health risks additional to those presented by the products themselves.

In an interview in San Salvador, Rodriguez reacted with surprise to Monsanto’s position that glyphosate does not threaten the kidneys.

“Ah, Monsanto!” she said, a look of consternation crossing her face. “They are the ones that will be fighting us.”

Anna Barry-Jester contributed to this report.

Support for this report was provided by the Stabile Center for Investigative Journalism at Columbia University.

OPINION: Vermont law illuminates claims statistics

Vermont,United States — 2013-04-22T09:52:12-04:00

When you’re shopping for health insurance, wouldn’t it be great if you could find out every insurer’s claim denial rate? And how much each one spent on lobbying and advertising — and how much they paid their CEO?

You can now find all of that information and more if you live in Vermont, thanks to a law that was enacted last year at the urging of the Vermont Public Interest Research Group.

In compliance with that law, the insurers that do business in Vermont have just disclosed data they’ve been able to keep secret for years. And that information should come in handy when Vermonters begin shopping for coverage at the state’s online health insurance exchange in October.

With just 626,000 residents, Vermont is the second smallest state in terms of population (only Wyoming has fewer people), and it has only three major health insurers — Blue Cross Blue Shield of Vermont, MVP Health Care and Cigna, the company I used to work for.

Blue Cross Blue Shield of Vermont is by far the biggest and the only one based in the Green Mountain State. MVP is headquartered in New York, and Cigna, the for-profit company among the three, is based in Connecticut.

Which of the trio do you think denied the most claims on a percentage basis in 2012?

If you guessed the for-profit company, as I did, you would be right. But even I was shocked to see how Cigna compared with its competitors, especially Blue Cross.

Of all the claims submitted to it last year by health care providers and policyholders, Blue Cross denied 7.6 percent. Cigna denied 21 percent. MVP was in the middle at 15.5 percent.

Since Vermont is a pretty small state, chances are pretty high that all three companies have the same doctors and hospitals in their provider networks. One would have to wonder why Cigna felt it necessary to deny more than one of every five claims submitted by those doctors and hospitals while Blue Cross denied only one of every 13.

Most of the claims denied by all three companies were categorized as “administrative,” meaning they were denied because a provider presumably used an incorrect procedure code or made some other clerical error when submitting their claims for payment. It defies reason to think that the doctors and hospitals in Vermont submitted inaccurate claims to Cigna at almost three times the rate they did to Blue Cross.

One of the things you need to know about the private health insurance business is that insurers make a lot of money when they delay paying a claim. I would be willing to bet that many — if not most — of the claims the Vermont insurers denied were eventually paid. When an insurance company delays paying a claim by days, weeks or months, it can take advantage of “float.”

The longer you can delay paying a claim, the more investment income you can make on the premiums you take in from your policyholders. And investment income is especially important to for-profit insurance companies because it contributes significantly to the bottom line. Shareholders and Wall Street financial analysts like that, even though much of the money on which the investment gains were made should have been paid to health care providers.

The data reported by the insurers is consistent with recent claim denial rates in California. A California Nurses Association analysis of 2010 data submitted by insurers to the California Department of Managed Care showed that Cigna’s claim denial rate was 39.6 percent. Aetna’s denial rate, by contrast, was 5.9 percent.

The Vermont disclosures showed that Blue Cross and MVP spent far more money lobbying state officials last year — $258,347 and $55,366, respectively, than Cigna, which spent only $9,141. But Cigna spent much more lobbying federal officials: $1.59 million. MVP spent $160,000 lobbying in Washington. Blue Cross of Vermont spent nothing, although the Chicago-based Blue Cross Blue Shield Association, which represents all of the country’s Blues plans, spends a lot on lobbying every year, as does America’s Health Insurance Plans, of which Cigna and MVP are members.

Cigna, a much bigger company than the other two, reported paying its CEO $3,970,833 in total compensation last year, compared to $1,250,000 for the CEO at MVP and $587,184 at Blue Cross. And Cigna was especially generous in paying its nine board members: $3,199,855. Board members at Blue Cross earned a combined $246,632. MVP did not pay its board members anything.

The one area in which Blue Cross Blue Shield of Vermont spent much more than the others was advertising and PR. The company spent $743,968 for marketing last year in Vermont, compared to $516,358 for MVP and $66,849 for Cigna.

Cigna notified the state earlier this year that it would not seek to sell policies to individuals and small businesses on Vermont’s exchange, leaving that part of the marketplace to Blue Cross and MVP. But Cigna will still have at least one big client in Vermont — the state of Vermont. Cigna has had a contract for several years with the state to provide coverage to state employees. If I were one of them, I would ask for an explanation of those high claim denial rates.

GOP senators call for overhaul of electronic health records program

2013-04-16T16:01:39-04:00

Six U.S. Senators are calling for an overhaul of the federal government’s $35 billion plan for doctors and hospitals to switch from paper to electronic medical records, citing concerns from patient privacy to possible Medicare billing fraud.

The report issued Tuesday by the half-dozen Republicans concedes that many lawmakers and medical experts believe the digital systems can reduce health care costs and improve the quality of care by reducing duplicative testing and cutting down on medical errors.

But the report asserts that the Obama administration’s push to use billions of dollars in stimulus money helping doctors and hospitals buy digital systems needs to be “recalibrated.”

“Now, nearly four years after the enactment…and after hundreds of pages of regulations implementing the program,” the document says, “we see evidence that the program is at risk of not achieving its goals and that $35 billion in taxpayer money is being spent ineffectively in the process.”

Among the report’s conclusions:

Despite expectations of cost savings, the digital systems may be increasing unnecessary medical tests and billings to Medicare.
The government has not demanded that the various digital systems be able to share medical information, a critical element to their success.
Few controls exist to prevent fraud and abuse. Many doctors and hospitals are receiving money by simply attesting that they are meeting required standards.
Procedures to protect the privacy of patient records are “lax and may jeopardize sensitive patient data.”
It remains unclear whether doctors and hospitals that have accepted stimulus funding will be able to maintain the systems without government money.

Some of the concerns cited were detailed by the Center for Public Integrity’s “Cracking the Codes” series last year. The year-long investigation found that thousands of medical professionals have steadily billed higher rates for treating seniors on Medicare over the last decade — adding $11 billion or more to their fees.

The Center’s probe uncovered a broad range of costly billing errors and abuses that have plagued Medicare for years—from confusion over how to pick proper payment codes to outright overcharges. The findings indicated that Medicare billing problems are worsening as doctors and hospitals switch to electronic health records.

Addressing the coding abuses the senators wrote: “However, early reports raise concerns that health IT may have actually accelerated the ordering of unnecessary care as well as increased billing for the same procedures.”

The administration’s Office of National Coordinator, which oversees the program, referred a request for comment on the report to the Centers for Medicare and Medicaid Services. A CMS official did not respond to written questions.

It’s unclear what steps administration officials are taking to combat fraud and abuse from errant billing, a process known as “upcoding.”

U.S. Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder last September notified five medical groups of their intention to ramp up investigative oversight of upcoding, including possible criminal prosecutions, but it is not clear if any follow-up actions are underway.

In addition, the Centers for Medicare and Medicare Services on May 3 is holding a summit in Baltimore to discuss electronic records systems, “the increase in code levels billed for some Medicare services, and appropriate coding in an increasingly electronic environment.”

The Congressional report, titled “REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT” was released on Tuesday by Senators John Thune (R-S.D.), Lamar Alexander (R-Tenn.), Pat Roberts (R-Kan.), Richard Burr (R-N.C.), Tom Coburn (R-Okla.), and Mike Enzi (R-Wyo.).

OPINION: 'limited benefit' plans are no real bargain

2013-04-15T06:00:02-04:00

Among insurance executives, Aetna CEO Mark Bertolini has been among the most vocal in warning of “premium rate shock” when major provisions of Obamacare kick in on January 1.

"We've done all the math, we've shared it with all the regulators, we've shared it with all the people in Washington that need to see it, and I think it's a big concern," Bertolini told his company’s big shareholders and Wall Street financial analysts in New York last December.

If Aetna does, in fact, hike premiums by more than 100 percent for some of its customers, as Bertolini suggested at the meeting, no doubt part of that money will go to covering his shockingly lucrative paycheck.

While many Aetna employees were lucky to get two percent raises last year, Bertolini’s compensation nearly quadrupled. That’s right, quadrupled.

Aetna disclosed in a filings last week with the U.S. Securities and Exchange Commission that Bertolini’s total compensation in 2012 was $36.36 million, up from $9.7 million in 2011. If you include the $11.1 million in stock awards he was given that will vest later, his 2012 total jumps $47 million.

Bertolini’s “pay shock” so angered many current and former Aetna workers that several of them posted scathing comments on the Hartford Courant’s website.

“All Aetna employees should be picketing outside the office building in protest of this disgrace,” a former Aetna employee wrote. “What kind of leader gives his employees 2% while his earnings nearly quadruple???? Totally selfish.”

One of the reasons Bertolini mentioned “premium rate shock” to his company’s investors undoubtedly is that Aetna won’t be able to continue selling some of its most profitable health plans next year—the ones that have relatively low premiums but such limited benefits that they’ll actually be banned next year.

Since 2005, when it bought a firm that specializes in limited benefit plans, Aetna has been a major marketer of policies that provide such coverage — coverage so skimpy that former Connecticut Attorney General —and now U.S. Senator— Richard Blumenthal once called an Aetna limited benefit policy “virtually worthless.” Blumenthal was concerned that folks who had bought the policies “were led to believe they had significantly more coverage than they actually had."

Often called ‘junk insurance’ by consumer advocates, limited benefit plans typically have an annual cap of $1,000 to $15,000 and have significant restrictions on specific types of care, especially hospitalizations. But the marketing materials for these plans seldom draw attention to what is not covered.

As a consequence, many people have been shocked to find that they are on the hook for hundreds of thousands of dollars in hospital care they thought would be covered by their insurance policy.

One Aetna policyholder, Lawrence Yurdin of Austin, Tex. told The New York Times in 2009 that he and his wife had been forced into bankruptcy because of unpaid medical bills totaling nearly $200,000, even though he had what he thought was adequate insurance. As the Times reported, the brochure the Yurdins were provided indicated that their policy covered up to $150,000 a year in hospital care. Deep in the fine print, however, was language that excluded nearly all of the care Yurdin received for a heart condition at an Austin hospital.

It turned out that that $150,000 was for room and board. Coverage for “other hospital services”—which included just about everything else, including expenses incurred in the operating room—was capped at $10,000.

As the Times noted, “Aetna would have paid for Mr. Yurdin to stay in the hospital for more than five months — as long as he did not need an operation or any lab tests or drugs while he was there.”

Beginning January 1, Aetna and other companies that have made millions of dollars in profits from such plans, including Cigna, where I used to work, will no longer be able to sell them, thanks to the consumer protections in Affordable Care Act. Policies will have to provide decent coverage for hospitalization and other “essential benefits,” and the annual and lifetime caps will be banned. Insurers will also have to provide information in plain language about what is covered and in a format that will enable consumers to make apples-to-apples comparisons among plans.

Aetna CEO Bertolini probably was thinking of the thousands of people who are currently enrolled in limited benefit plans when he warned of premium rate shock. And he has a point. The premiums for such plans are low compared to policies that actually cover medical care doctors and nurses provide to cure you once you’ve been hospitalized. It’s not unreasonable to think that Aetna would charge its existing limited benefit customers more for real insurance—maybe even twice as much. But because insurers market limited benefit plans to low income workers, most likely will qualify for subsidies to help them pay the premiums.

Indeed those people might be shocked when Aetna tells them how much they’ll have to pay for a plan that is not “virtually worthless.” But at least they will be saved from the kind of shock that Lawrence Yurdin experienced when he realized that the money he had been paying Aetna in premiums—some of which went to pay Mark Bertolini’s salary—was not enough to keep him out of bankruptcy court.

OPINION: Obamacare's help for small business

2013-04-08T06:00:02-04:00

With April 15 approaching, some small business owners who provide health coverage to their workers are not going to be as indebted to Uncle Sam as they have in years past, thanks to Obamacare. That’s right, thanks to Obamacare.

Mike Roach, owner of Paloma Clothing, a women’s clothing store in Portland, Oregon, is among them. He is one of several hundred thousand small employers who have taken advantage of a provision of the reform law that provides a substantial tax credit to companies that offer health insurance to their employees. And not only is Roach able to save money, now that he’s offering coverage, he’s no longer losing valued employees to large department stores that have long provided benefits as a recruitment tool.

Roach had always wanted to offer coverage to his 12 employees but had found the premiums too steep. He said the message he kept getting from insurance companies was, “We don’t really want your business, but we will do business with you as long as we can gouge you.”

Small businesses like his have always had to pay considerably more for the same coverage as large employers. At big companies with hundreds or thousands of workers, insurers’ and employers’ risk is spread across a much larger “pool” of people. A few employees getting sick or injured in a given year at a big company would have a negligible effect on the risk pool.

Not so at a shop like Roach’s with just a dozen workers. Small business owners pay more because underwriters at insurance companies know that if just one worker at a small business gets sick, the insurer could wind up losing money on the account. Small businesses also lack the bargaining power of large firms.

As a consequence, more and more small companies have dropped coverage in recent years while big employers have continued to offer it.

“Not offering health insurance puts a small business like ours us at a distinct disadvantage,” said Roach, “especially when you consider that we are competing to have the best employees we can have to provide the best customer service against crack competitors like Nordstrom’s.”

So when he heard that the Affordable Care Act makes tax credits available to small employers that offer coverage, he talked with his accountant, who told him that the tax credits would make coverage affordable—not cheap, but affordable—for the first time.

Another motivation: his store manager was considering taking a job with a competitor that offered benefits.

“We didn’t want to lose her, and she didn’t want to quit,” Roach said, but her husband had just lost his job. She needed to work for a company that offered coverage.

Roach decided to go for it. He now pays about $29,000 in premiums for his workers, but he has received tax credits that have averaged $5,000 over the past two years. And he’ll save even more next year.

Under the law, small businesses that employ fewer than 25 people whose average wages are less than $50,000 get a tax credit equivalent to 35 percent of the employers’ contribution to the workers’ premiums. It will go to 50 percent starting next year.

Also next year, companies with fewer than 100 employees will be able to buy coverage through the online health insurance marketplaces (referred to as exchanges in the ACA). This should make polices even more affordable because the exchanges will pool the purchasing power of small businesses together. And starting next year, insurers will no longer be able to dramatically increase small business health insurance premiums because an employee got sick or older or because the business hired more women, who historically have been charged more than men.

Companies with fewer than 50 employees will not have to offer coverage, but Roach says he believes many if not most will do so once the exchanges are up and running and more employers learn of the tax credits.

“I would really encourage every business to take a serious look at it because if you can do it, you’re going to have a better workforce,” Roach said. “The employees you’re going to have are going to feel better about coming to work. They are more likely to stay with you, and they’re probably going to be more productive because they’re not going to have to worry as much about access to health care.”

Most small employers that provide coverage typically offer only one type of plan because offering multiple options increases administrative costs. That, too, will change, thanks to the exchanges, meaning that employees like Mike Roach’s will eventually be able to choose among competing plans just like employees at many large firms. The effective date of that change was originally scheduled to be January 1, 2014, but the Department of Health and Human Services is considering delaying it for a year. Even if it is delayed, though, many small business employees already are getting employer-subsidized coverage for the first time. And companies like Paloma Clothing are finally on a more level playing field with their bigger competitors.