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never happen here? (fwd)

  ---------- Forwarded message ----------
  Date: Sun, 23 Jun 1996 10:19:27 -0400 (EDT)
  From: klaatu <root@earthops.org>
  Reply-To: privacy@ftc.gov
  To: privacy@ftc.gov
  Cc: archive@earthops.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 
  condition itself.
  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
  possible conclusions. 
  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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