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never happen here? (fwd)
- To: email@example.com, Chip Holcomb <firstname.lastname@example.org>, email@example.com, firstname.lastname@example.org, David Burlingame <email@example.com>, firstname.lastname@example.org, email@example.com, firstname.lastname@example.org, email@example.com, firstname.lastname@example.org, SUSAN HARRIS <email@example.com>, firstname.lastname@example.org
- Subject: never happen here? (fwd)
- From: Peter Marshall <email@example.com>
- Date: Sun, 23 Jun 1996 12:27:23 -0700 (PDT)
- cc: Peter Marshall <firstname.lastname@example.org>, email@example.com
---------- Forwarded message ----------
Date: Sun, 23 Jun 1996 10:19:27 -0400 (EDT)
From: klaatu <firstname.lastname@example.org>
Subject: Now this is terrifying.
When you go to a doctor, you may be unsatisfied with their diagnosis, or
with their competance.
Under the Maryland Health Care Access and Cost Commission's 1993
authorization, a Statewide database has been built up. The Commission has
the legal power to force all physicians in the State of Maryland to
submit a report of _each_ and every encounter with every patient.
This includes identifying information about each patient, the diagnosis
for each problem, and other personal information. This information is to
be submitted without the consent of the patient. Or their knowledge...
this is the first time I've ever heard of it.
Now to be frank, I have a history of mental illness, nothing particularly
gruesome; for instance I am not schizophrenic. But my recovery depends,
among other things, on my privacy. The stigma attached to mental illness
of any sort can be frankly debilitating, much more so than is my actual
This law, which was enacted while I was out of the state (I just heard of
it this morning for the first time, in an op-ed piece on page C8 of
today's Washington Post), certainly explains a lot of things.
Frankly, one of the central features of my particular mental illness is
the delusion that my medical records are being centrally-collected and
are potentially accessible to potential insurers and potential employers,
not to mention anyone who can hire a private dick who's got a stringer
online with access to this system. To find, in black and white in an
op-ed piece written by a doctor, that the central tenet of my delusional
system is in fact no delusion, but is _instead an extant law_, is enough
to send me right over the edge - into litigation.
For instance, I once saw a rather amusing cartoon in a magazine, where a
doctor is talkingon the phone, and he says: "She's on her way over here
for a second opinion, eh? What's she got?" Amusing, eh? Well, with this
system, it is possible for this most egregious violation of medical
ethics to occur! A doctor need only get on the pipeline, and all of the
most private aspects of a patient's life and medical history can be his.
Of course, one says, surely no doctor would ever collude with another
doctor to convince a patient to have unneeded surgery, or to continue on
a course of medication or therapy which is clearly bad for the patient
(but good for the doctor's Mercedes payment).
The court records are full of such cases, although thankfully they are
not the norm.
Still, my general level of paranoia has at times skyrocketed through the
roof when I have sought treatment for physical ailments at various
Maryland hospitals, only to find that the friendly nurses entering my
name on their online terminals suddenly got a grim look on their faces,
and from the moment they saw on their screens whatever it was they saw,
all of their efforts were directed not towards treatment of very real
physical ailments, but towards committing me to their mental wards. I had
even gone so far as to ask if they had received online information about
me, and all denied it - categorically, and rather too glibly, I had thought.
This is a great relief for me to discover that my so-called paranoia and
so-called delusions are in fact more probably an emerging anti-privacy
bureaucracy defending itself. In effect a merging of medicine and the
State, with Psychiatry as the defined State religion (if someone can tell
you that you must look at the world in the manner that they prescribe, or
you can be locked up, drugged and subjected to electroshock therapy, and
the state empowers them to do this, I'd definitely call it the State
religion!), the implications for privacy-invasion and indeed Party
Thought Control are beyond staggering, beyond orwellian. The Socialist
aspects of this bring instantly to mind the Communist Party Apparatchiks
favorite punishment of those who dared oice opposition to the Party - the
dreaded _psykhushka_ or psychiatric prisons of the old USSR.
The primary difference between our psychiatric committment facilities and
those of the old USSR is that we in America could not, since the late 60s
and early 70s, be involuntarily committed, and there were extreme
safeguard to prevent collaboration among doctors seeking to force
committment on patients. Especially in psychiatric admissions cases, for
a second opinion to be valid, it is absolutely essential that there be no
communication whatsoever between the evaluators.
Now in the State of Maryland, any doctor or even thir nurses or
accountants, probably, can simply click a few keys, and the person
you consult for a second opinion can simply confirm "what you've got" and
pockets line with money and you lose another freedom.
attachment below is from
In 1993, the Maryland General Assembly enacted legislation
creating the Health Care Access and Cost Commission ("HCACC," or "the
Commission"). The legislation recognized that meaningful debate on health
care expenditures and access could not occur with out the benefit of
accurate information. Thus, the Commission was directed, among other
things, to construct a medical care data base to be used as a "primary
means of compiling and reporting data and information on trends and
variances regarding fees for services, cost of care, regional and national
comparison, and indications of malpractice situations." Health-General
Article, 19-1502(c)(7). From this data base the Commission is directed to
produce annual reports on: (1) the statewide variations in fe es and
utilization of health care services by health care practitioners and
office facilities; and (2) the total reimbursement in the State for health
care services generally and for certain specialties and procedures
beginning October 1995. The statute also mandates the HCACC to use the
data base to establish health care cost annual adjustment goals.
This Annual Report on Expenditures and Utilization represents the
Commissions first step in meeting the statutory directive. To complete
this report, the Commission conducted one of the most extensive data
collection efforts ever undertaken in Maryland. The results of this
effort provide a first glimpse on expenditures and utilization in the
$13.3 billion health care industry in the State. <p>
This report is the result of cooperative activities by the Commission,
other state and federal agencies, payers, and practitioners operating in
Maryland. To provide background information on the health care system in
the State, the Commission obtained a lready existing data from the
Department of Health and Mental Hygiene, the Health Resources Planning
Commission, the Health Services Cost Review Commission, and the Maryland
Insurance Administration. National data sources were also tapped to
provide benchmarks against which the Maryland information could be
compared. No existing data sources existed in the State for the analysis
of health care expenditures and physician services. Under the authority
granted by the legislature in the enabling statute, th e Commission
collected claim and other aggregate information from private sector
payers, as well as from Medicaid and Medicare to form the Interim Medical
Care Data Base. Given that this initial report represented a first step,
and that existing data col lection capabilities among private sector
payers varied greatly, the Commission did not mandate submission of
detailed encounter data or even aggregate information. Most major payers
whose information systems contained the needed information submitted dat a
voluntarily. Many other payers whose information systems were not as
sophisticated provided aggregate information. The Commission is extremely
grateful to the twelve payers that provided detailed encounter information
and the other payers that submitted aggregate information.
Health Care Status and Resources
Population characteristics, health status, and available resources affect
the use of health care services. Because data are incomplete, the
Commission cannot yet identify precise linkages between these factors and
utilization and expenditures, Chapter 2 of this report highlights aspects
of the Maryland health care environment which impact on health care
consumption. Health care coverage is a major factor in determining access
to health care services. Marylands working population without health
insuranc e (17 percent) is only slightly below the national average,
although estimates of the uninsured are for 1993, a time prior to the
introduction of small group market reform. The Commission is currently
examining alternatives such as practitioner surveys for gathering
additional information on services used by the uninsured population. HMOs
share of the privately insured market in Maryland is among the highest in
the nation. The continued growth of HMOs and other managed care
arrangements will likely ha ve a significant impact on future demand for
health care resources.
The availability of health care resources in the State varies
significantly by expenditure category. Although the number of hospital
beds per capita are below the national average, physicians and other
health care professionals per capita are well above national averages.
Most analysts believe that excess capacity in all expenditure categories
exists nationwide. Health care resources levels in Maryland must be
interpreted cautiously as many people travel across state boundaries to
obtain care, particularly hospital-based services.
State Health Care Expenditures </H4></b><p>
Constructing aggregate health care expenditures allows purchasers of
health insurance to identify how their use of health care services
compares to the State and sub-regions. Specific provider groups can use
this information to examine their share of th e health care dollar and its
rate of change relative to other provider groups. The analysis of
aggregate expenditures in Chapter 3 enables policy makers to examine how
the use and mix of services changes over time, by region and payer
categories. As a number of data sources were examined, including the
detailed encounter data, estimates presented in the chapter represent a
complete accounting of all services used by state residents. The key
findings from this analysis are summarized below:
The health care economy in Maryland was a $13.3 billion industry in 1993
and represented 11.5 percent of personal income for the State. Health care
expenditures grew by 4 percent from 1992 to 1993. The size and complexity
of the health care sector requires careful monitoring in view of the
substantial changes that appear just over the horizon for private
purchasers, Medicaid, and Medicare.
Health expenditure categories are growing at different rates. Although
physician expenditures (5.5 percent) and total hospital expenditures (5.1
percent) grew more rapidly than overall health care spending, that growth
was not as rapid as the increase in home health care (14.4 percent) and
other professional services (6.1 percent).
Spending for government programs increased more rapidly than private
sector spending between 1992 and 1993. Total Medicare and Medicaid
expenditures increased by 9 percent and 7 percent respectively compared to
an overall increase in pr ivate sector spending of only 2 percent. Much
of the Medicare growth was driven by increasing enrollment, as Medicare
per capita spending increased by a mere 1 percent. This compares to a 4
percent jump in Medicaid and a 2 percent increase in private sec tor
spending per capita.
Use of health care services differs substantially by payer, reflecting
differing population mixes, cost containment strategies, and coverage
policies. Only 7 percent of 1993 Medicaid payments were made to
physicians, but 43 percent of H MO payments were for physician services.
By comparison, in 1993, 26 percent of Medicaid expenditures were for
nursing home services. Overall, Medicaid accounted for 86 percent of total
third party payments for nursing home services.
Practitioner Payments and Utilization
Physicians and other health care practitioners accounted for about
one-third of total health care expenditures, yet practitioners, through
the services they provide, trigger use of other health care services such
as hospitals, outpatient clinics, labor atories, and imaging centers. In
Chapter 4, the Commission presents an analysis of health care practitioner
expenditures. These results require more careful review as analyses are
based on encounter data provided by twelve payers including Medicare and
Medicaid. While the volume of information is significant, private sector
payers, particularly HMOs, are under-represented, and information on
uncompensated services is missing altogether. The Commission believes that
an analysis of this information is an important first step toward
providing a better understanding of health care practitioner expenditures
in the State, by payer category, and among the regions. The key findings
from the 1993 data are summarized below:
Procedures for diagnostic and therapeutic services accounted for 69
percent of expenditures to practitioners, with the remaining 31 percent
attributable to evaluation and management visits. Surgeries of all types
accounted for 25 percent , and diagnostic procedures accounted for 18
percent of total expenditures to practitioners.
Chest x-rays, psychotherapy, urinalysis, electrocardiograms, and back
manipulations by chiropractors are the most frequently performed
procedures in the State. These and fifteen other procedures
accounted for 30 percent of all the volume of pro cedures
Psychotherapy, cataract surgery, childbirth,
echo exams of the heart, and chest x-rays had the highest shares of total
expenditures. These and fifteen other procedures accounted for 23
percent of total expenditures. These findings must b e interpreted
with caution as some specialties use a very limited number of procedures.
A significant share of all psychiatric services is assigned to one high
rank procedure code, and cataract surgery accounts for 64 percent of total
payments to ophtha lmologists. The mix of services provided
by primary and specialty care practitioners differs markedly by payer
category. Although primary care practitioners provide 31 percent
of total services measured by expenditures, this share ranges from a low
of 23 percent for Medicare, to 31 percent for private payers and up to a
high of 77 percent for Medicaid. These differences are significant, and in
future studies, the Commission will examine how use of services differs
among comparable populations.
Regional differences in the use of services appear related to the mix of
specialties available. The Maryland suburbs of Washington DC have the
lowest use of primary care practitioners (27 percent), despite also having
the lowest share o f Medicare beneficiaries. In Western Maryland, with
the highest share of Medicare beneficiaries, primary care practitioners
provide 35 percent of the care. Primary care practitioners constitute 41
percent of physicians in Western Maryland and 38 percent in the Maryland
counties that are suburbs of Washington, DC.
Medicaid physician payment rates are significantly lower than Medicare and
the private sector, although, more recently, private payers have also
reduced payment rates.
and now for the scary parts.
Conclusion and Next Steps</H4></b><p>
Discussions about potential health care reforms have shifted significantly
since the passage of the Commissions enabling statute. It is clear that
government alone cannot make the changes that are needed in the health
care system. Indeed, the private s ector has been the most successful in
slowing the growth of health care expenditures. Although rapid increases
in costs have abated, at least temporarily, many of the problems that
generated the need for information remain even as new questions arise.
Purchasers have intensified efforts to identify the best values in an
increasingly managed health care environment. The Commission believes
that collection of encounter data will enhance these efforts, but the
initial data collection that led to lead to creation of the Commissions
Interim Medical Care Data Base identified weaknesses that must be improved
upon. The key findings are summarized below:
Further standardization of data submissions is essential to efficiently
construct a common data base for comparing services. Recently adopted data
regulations (COMAR 10.25.06) will require submission of data in standard
formats using co mmon coding conventions. Standardization will benefit
practitioners by reducing coding differences among payers.
HMOs are providing increasing amounts of care, and information on these
services should be obtained through participation in data collection. The
Commission recognizes that HMOs pay for services under a number of
arrangements and will work with these organizations in a cooperative
manner. Beginning in 1996, the Commission will collect information on all
fee-for-service and capitated specialty care services from HMOs through
the data collection regulations. The Commission believes that these
services constitute the majority of encounters provided by HMOs.
This data collection effort, in conjunction with the HMO Quality and
Performance Evaluation System that also begins in 1996, will provide
Maryland with unparalleled information on HMO services .
The Commission needs to further examine differences in
utilization patterns among payers. While some differences exist
by region and payer category, underlying population differences confound
Extensive changes in health care are occurring outside of the public eye
today. Managed care is expanding in Maryland; evolving hospital network
organizations are beginning to purchase doctors practices; and doctors are
forming medical groups and ass uming financial and insurance risk for
health care. Reforms to Medicare and Medicaid are imminent. No one seems
to fully understand the consequences of all these changes. Further, many
people continue to worry about the adequacy of insurance coverage and
access to health care should they become ill.
The health care debate is far from over. In a rapidly changing health care
environment, the need for objective information is more important than
ever. To meet this need, the Commission intends to move ahead
deliberately and responsibly in its data collection efforts, cognizant of
its obligation to balance the legitimate interests of the many affected
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