The Human Race & Other Sports

Drugs, The Patient, and The Insurance Company

The desire to take medicine is perhaps the greatest feature, which distinguishes man from animals.
— Harvey Cushing, Life of Sir William Osler

Health insurance companies are constantly looking for new ways to make money. Two of the major impediments to their quest are sick people and the drugs they need. Clever, as a good corporation should be, they have figured out how to overcome the second of these obstacles. Two techniques are employed. The first is practicing medicine just the way doctors do even though few, if any, insurance companies have attended medical school.

When a doctor prescribes a specific drug for a patient (whom it has never met) the insurance company may decide that the generic equivalent of that drug is just as good for the patient as the one that the physician prescribed and refuse to pay for the physician prescribed drug. In that event, if the patient wants to use the prescribed drug the patient must pay for the drug out of his or her own pocket. There is, however, a built in appeals process that patient and doctor can go through if they would like to prove that the trained doctor’s decision is more medically accurate than the corporation’s but it is a somewhat cumbersome process. Why the company insists on substituting its judgment for the doctor’s judgment is best known to the insurance company. As creative as this is on the part of the insurance company, it is not the most dramatic example of saving money through creative insuring.

A recent report in The New York Times discloses that some insurance companies have realized increased profits by reducing the amount of money they are willing to pay for certain prescription drugs taken by their insureds. It seems like such an obvious thing to do that the only remarkable thing is that the insurance companies have not thought of it before now.

Before the companies became creative in reimbursing for drug costs, the insured was required to pay a fixed amout (known as a co-pay) for a prescribed drug that that went anywhere from approximately $5.00 to $50 the amount of the co-pay being determined by the company and on whether the drug was a Tier 1, 2 or 3 drug. The insurance company paid the difference between the drug’s co-pay and its actual cost to the insurance company. Then, a funny thing happened on the way to the pharmacy. The insurance companies invented Tier 4 into which they placed REALLY expensive drugs.

People taking Tier 4 are the beneficiaries of the new policy. Here is how three randomly selected insurers have made themselves its beneficiaries.

The American Association of Retired Persons (AARP) requires patients taking Tier 4 drugs to pay 30 percent of the cost of the drugs with no limit on how much the insured ultimately has to pay. The drug Sprycel is a tier 4 drug that blocks the growth of cancer cells and eliminates the need for chemical infusions. It costs $13,500 for a 90-day supply. AARP requires the insured to pay $4,500 for each 90-day prescription and AARP pays the balance. First Health Life & Health also charges a flat 30 per cent for Tier 4 drugs without any limit on what the insured pays.

Kaiser Permanente, by contrast, tempers profitability with mercy. It requires its insureds to pay only 25 percent of the cost of Tier 4 drugs and places a $325 limit on how much the insured has to pay for each prescription.

Increasing the insurance companies’ profitability is not the only benefit from the new program. For Medicare beneficiaries who have to pay 5 percent of their drug costs after they’re through what’s known as the doughnut hole, the increased amount they are forced to spend gets them through the doughnut hole more quickly. (Not all Medicare beneficiaries will see the benefit in that.) Another benefit that will, however, be obvious to its beneficiary is the cost savings that inures to the benefit of employers who furnish health insurance to employees.

Karen Ignagni is president of America’s Health Insurance Plans, an organization that represents most of the health insurance industry. She pointed out in the New York Times story that lower outlay for prescription drugs means the insurance companies can charge employers lower premiums, thus providing a cost benefit to employers. Adding those benefits to those enjoyed by the insurers makes it obvious that the new policy is a win-win except, of course, for those who can no longer afford to take drugs.

In George Bush’s United States 47 million people have no health insurance. In George Bush’s United States 9 million children have no health insurance. Thanks to the creation of Tier 4, we will soon have a new class of citizen. It will comprise people who have insurance but are unable to pay for the drugs needed to keep them in or restore them to, good health. In a few years we will know how many people are members of their class. They will join the uninsureds as statistics.

The Private Tax Collector Came and Went

My civil neighbor, the tax-gatherer, is the very man I have to deal with, for it is, after all, with men and not with parchment that I quarrel,-and he has voluntarily chosen to be an agent of the government.
— Henry David Thoreau, Civil Disobedience

It was impossible to know how it would turn out. Of course, there were a few hints. But they were so subtle that only someone with a bit of brain would have picked up on the clues. And it seemed like such a great idea-turning delinquent taxpayers over to private collection firms that make contributions to politicians instead of letting the Internal Revenue Service attend to that mundane task-that no one would have foreseen the disastrous outcome.

The idea got its start as a result of the American Jobs Creation Act of 2004. The purpose of the act was not simply to create jobs. It was to transfer to the private sector jobs that had theretofore been performed by the public sector almost certainly a guarantee of success since conventional Republican wisdom is that whatever the public sector can do, the private sector can do even better. (That approach reached its zenith in Iraq where Dick and George turned over lots of the work formerly done by U.S. troops to private contractors who, the two pals believed, could do it more efficiently and cheaply than U.S. government personnel.)

In 2005 the IRS began farming out delinquent tax collections to private collection agencies. Three debt collection agencies were initially used and two of them had special qualifications for the work. They had made significant financial contributions to politicians. Pioneer Credit Recovery came from the district of Rep. Thomas M. Reynolds of New York and one of the things that qualified it to be a debt collector for the federal government was that it had given congressional candidates and political action committees $117,450 since 1995. Mr. Reynolds received $16,250.
Linebarger Goggan Blair & Sampson of Austin, Texas and its employees and spouses gave political candidates and PACs of both parties more than $400,000 between 1995 and the time the program was started. (After 2007 the firm was fired although the government isn’t saying why that is. It might have to do with the fact that the firm made a $2000 donation to the mayor of Mansfield, Texas a month after he was elected or it may have had to do with the vacation it paid for a contract officer in Chicago that got the firm fired from doing work for that city.)

Mark Everson who was the commissioner of the IRS at the time outsourcing tax collection was decided on admitted that outsourcing tax collection is more expensive than keeping it in house. He nonetheless supported the privatization of collection efforts claiming he could not get sufficient funding to permit him to hire more public sector tax collectors. (Following that ill-fated decision Mr. Everson left the IRS to head up the Red Cross where he served only long enough to begin an affair with the member of his staff that resulted in his loss of the job. When he left the IRS and began working at the Red Cross his 18-year old daughter said having left the IRS people would again like him. She was inadvertently prescient.)

According to a report in the Washington Post the program has been a disappointment. The goal of the program was to collect $1 billion from deadbeats owing $25,000 or less. Instead, most of those folks have gotten a tax holiday. Instead of collecting $1 billion, the private debt collectors only collected $49 million. The cost of the program was $98 million suggesting to the mathematically swift that it produced a net loss of $49 million.

Commenting on the program in a statement on the floor of the Senate, Senator Ben Cardin of Maryland observed that Nina Olson, the National Taxpayer Advocate told Congress that the IRS was losing at least $81 million a year by using private debt collection companies. She observed that if the $7.65 million spent by the IRS to operate the program were spent instead on its automated collection system it would generate $153 million in revenue. Not everyone would agree with her.

Jim Ramstad is the ranking Republican on the Ways and Means Oversight Committee. He is unimpressed by the statistics furnished by Ms. Olson. He said the “real choice is whether we use private collection agencies or let these tax debts go uncollected. I hope we don’t take an enormous step backward in our efforts to close the tax gap by eliminating a program that’s working.” He didn’t say what part of the program is working. He’ll probably want to explain to Ms. Olson and Senator Cardin (and Senator Byron Dorgan of North Dakota, another critic) the part that is working since they are apparently unaware of its successes. He may also want to explain it to his constituents.

Hiding Truth [1]

About 60 years ago, I said to my father, “Old Mr. Senex is showing his age; he sometimes talks quite stupidly.” My father replied, “That isn’t age. He’s always been stupid. He is just losing his ability to conceal it.”
— Robertson Davies, New York Times Book review (May 12, 1991)

The wonderful thing about having George Bush as president is that a commentator can write about the same subject repeatedly and it will always be timely and fresh. That is because when George Bush finds a bad thing to do, he does it repeatedly because he’s too sure of his own good judgment to notice that it’s a bad thing. One of his favorite things is hiding facts to protect myths. One of his favorite myths is that the war in Iraq is going swimmingly. Among one of many ways the myth is perpetuated is by not letting journalists photograph service personnel being brought home in coffins as they arrive at Andrews Air Force Base. Another, we have now learned, is not letting members of the press get near burial services taking place at Arlington National Cemetery.

According to a report in the Washington Post, at the burial of Lt. Col. Billy Hall, the family wanted the press in attendance to record the burial of one of the senior officers to be killed in Iraq and, by reporting on it, to honor Colonel Hall’s patriotism and sacrifice. Mr. Bush’s Pentagon believes Colonel Hall’s sacrifice can be better honored privately, the family’s wishes notwithstanding. Accordingly a yellow rope kept the press 50 yards from the grave site. A photographer complained there could be no pictures of the family without the yellow rope being in the way to which an employee of the cemetery responded: “This is the best shot you’re going to get”. When the reporters complained that the pastor’s eulogy, in which he presumably talked about Colonel Hall’s valor and sacrifice, could not be heard, the Arlington official responded by saying “Mm-hmm.” As a result, all the press could report to commemorate this brave man, father and husband was that it could not report anything. Mr. Bush likes it that way.

Another myth in which George Bush believes, is that in a well-run country politics should always trump science. The Union of Concerned Scientists released a report the end of April disclosing that science and ignorance (the latter clothed in garments purchased for it by Mr. Bush and his courtiers) have been in mortal combat during the Bush administration’s tenure and ignorance has proved its worth winning easily in many of the confrontations.

Focusing on the Environmental Protection Agency that has received attention in this as well as other places, the report discloses that in a survey of scientists at the agency, more than half disclosed there had been political interference in scientific decisions during the preceding five years. (George Bush has been president for seven years and presumably the reason for interference during only the last five is that it takes a while for someone like George to figure out those areas in which commonly accepted scientific notions are deficient and should give way to political considerations.)

In the survey fifty five hundred questionnaires were sent out and 1,586 scientists responded. More than half said they had observed political interference in scientific decisions made by the agency. Some said the Office of Management and Budget, interfered for political reasons. As a threshold matter that would seem a singularly inappropriate agency to be interfering in matters scientific until one realizes that if scientific decisions are to be made by the ignorant, it is a singularly appropriate agency to be making those decisions.

The Office of Management and Budget is not alone in thwarting science. According to the Post report, when E.P.A. staff members came to the non-startling conclusion that greenhouse gasses were bad for public health, efforts at creating regulations halted after the White House received its findings. Mr. Bush also caused the agency to weaken its proposed limits on smog-forming ozone, he having apparently concluded ozone is not the problem the scientists believe it to be.

Following publication of the most recent survey, Jonathan Shradar defended his boss, Stephen L. Johnson, E.P.A. Administrator. Mr. Shradar said Mr. Johnson carefully weighs the input of staff in all agency decisions. An example of how Mr. Johnson uses the scale to weigh agency decision can be seen in the decision to deny California the waiver it sought in 2007 to reduce tailpipe emissions by 2016 to 30% instead of to 40% by 2020 as mandated by the December 2007 Energy bill. The staff at the EPA was reportedly in favor of granting the waiver, being possessed of scientific knowledge and unencumbered by political considerations. Placing his thumb on the scientific scale, Mr. Johnson concluded his staff was wrong and denied the waiver. Mr. Shrader told the Post reporter that the findings in the Union’s survey would not change anything. That is very likely true-at least for the next 8 months. Thereafter one can hope that science will once again be recognized as a valid field of study, the findings of which are entitled to at least as much, if not slightly more weight, than the conclusions of politicians led by the Grand Pooba in the White House.

The Prostitute and The Moderators-A Suggestion

Was this the face that launched a thousand ships,
And burnt the topless towers of Ilium?
Sweet Helen, make me immortal with a kiss.
Her lips suck forth my soul; see, where it flies!
Christopher Marlowe, The Tragical History of Doctor Faustus [1604]

Lowest common denominator. That’s what George Stephanopolous and Charles Gibson of ABC news were appealing to during the first half of the debate for which they recently served as moderators. That explains the reason for the really dumb questions they not only posed but pursued with remarkable, if mindless, persistency about lapel pins, helicopter landings, bitter people and sermons, none of which has the slightest relevance to determining which of the debaters would be a better president. (George Bush never appears in public without his American flag lapel pin and few believe he was a good president. Hillary Clinton never appears in public with a lapel pin and that does not suggest she would be a bad president). Since appealing to the lowest common denominator was the goal of Messrs. Gibson and Stephanopolous, I have a suggestion for a future program that will draw even more viewers than did the debate and will appeal to an even lower common denominator. They should interview Ashley Youmans for an hour and a half.

Ashley Youmans, now known as Ashley Alexandra Dupré is the woman whose face, metaphorically speaking, brought down an empire. Or at least a governorship. Ashley is the young woman at the center of the Eliot Spitzer scandal.

Without casting aspersions on either of the two presidential candidates who debated (each of whom is well dressed and attractive) all would agree that to the extent anything interesting was elicited from the candidates by their inquisitors, it was unrelated to what they were wearing. It is safe to assume, on the other hand, that no matter how pathetic the questioning, Ashley would have made a better visual impression than either of the candidates, especially if she had been counseled to attire herself in such a way as to display those attributes that make her both interesting and successful. Furthermore, she could provide information that would be of interest to lots of viewers, especially those with mildly prurient interests that encompasses more viewers than the viewers would like to admit.

Since the economy is undeniably in a slump, she could have explained how competitive pricing works in the industry in which she is employed, thus introducing transparency to a profession that frequently operates in the dark. It would almost certainly be of interest to the viewer to know and understand why, for example, radio executive, Tom Athans, of Michigan, who is married to U.S. Senator Debbie Stabenow and was recently arrested in a Residence Inn near Big Beaver and Interstate 75 (no double entendre intended and apologies to Kurt Vonnegut) paid a woman engaged in Ashley’s line of work only $150 whereas Mr. Spitzer reportedly paid Ashley $4300. It is not adequate to attribute the difference in price to depressed economic conditions in Michigan nor can it be attributed solely to the length of the encounter. As an examination of the rate structure of Ashley’s company set out below demonstrates, for $150 at her employer one would get little more than a cup of water with which to down a Viagra pill.

It would be interesting to hear Ashley explain, in response to questions from the ABC team, the details of the price list formerly displayed on the Emperors Club Website. (The site uses the apostrophe sparingly and inconsistently.) The quality of the services are, as restrooms at gas stations were in days gone by, measured by diamonds and, conveniently, (as gas stations were not) in dollars, euros and pounds so that prospective customers know what to expect. The rates are either hourly or by the day. A 3 diamond encounter of one hour’s duration costs $1000 or 700 Euros whereas a 7 diamond encounter of the same length costs $3,100 or 2200 Euros. (Based on today’s exchange rates it makes more sense to pay in dollars.) Day rates that are described as “dawn to dawn” range from $10,000 to $31,000.

Ashley could have discussed competitive pricing, variation in pricing depending on locales, and how income is shared between Emperors and its subjects.

There will be readers who suggest that such a program would be a waste of time since only those of prurient interest would want to watch. To them I can only say Gibson and Stephanopolous offered so little worthwhile in their one and a half hours that any subject, no matter how trivial, would be an improvement. Would it were otherwise.

Funerals and Abortions

But optics sharp it needs, I ween,
To see what is not to be seen.
— John Trumbull, McFingal (1782)

What does George Bush have in common with prostitutes? For the answer see the end of the next paragraph.

As was observed in last week’s column, photographs of French president François Mitterand’s funeral, showed his widow, mistress and their daughter, all gazing sadly at the casket. Had Eliot Spitzer died while consorting with prostitutes there would have been no photographs of the prostitutes standing sadly by the coffin with Mr. Spitzer’s wife and daughters. That’s because prostitutes don’t do funerals. Here is the answer to the riddle. Neither does George Bush.

George Bush doesn’t even like to be in the presence of coffins even though it is thanks to him that the sad remains of more than 4000 service personnel have found resting places in coffins.

Unlike other presidents who in time of war have shared the grief of families of fallen soldiers by attending funeral or memorial services as time and location permit, Mr. Bush has avoided such displays of respect for the fallen and has barred the media from photographing the coffins of fallen service people returning from Iraq lest the sad sights create hostility towards Mr. Bush’s legacy war. What the American public doesn’t see or recall, Mr. Bush believes, probably hasn’t happened. That explains the most recent events involving Johns Hopkins University.

The Johns Hopkins episode involves “abortion” something George Bush opposes. That is why, for most of the years of the Bush reign, funding from the United States for family planning clinics in Africa that provided abortion counseling was reduced or eliminated even though the reduction in funding meant the clinics would be unable to distribute condoms, devices that are intended to reduce the need for abortion or provide protection against AIDS. Mr. Bush’s most recent attack on abortion was an attempt to remove information about abortion from a prominent Internet site.

Johns Hopkins manages POPLINE, the world’s largest database on reproductive health. According to Robert Pear of the New York Times, it has more than 360,000 records and articles “on family planning, fertility and sexually transmitted diseases. The database is funded by USAID, an agency that imposes severe restrictions on funds being given to any NGO that performs abortions or actively promotes it in foreign countries as a means of family planning.

As a result of brilliant and thorough research, out of the 360,000 articles in the data base, Sandy Jordan, director of communications in USAID’s Office of Population and Reproductive Health, discovered two articles that, said she, “were one-sided in favor of abortion.” As a result, the organization asked that the articles be removed from the database. Explaining what might otherwise seem like the mindless act of another Bush “You’re doing a great job Brownie”, she said: “We are part of the Bush administration, so we have to make sure that all parts of the story are told. The administration’s policy is definitely anti-abortion and the administration does not see abortion as a part of family planning policy.

Because of Ms. Jordan’s concern, beginning in February, Johns Hopkins programmed its computers’ search engines so that they would treat the word “abortion” the same way they treat the words “a”, “the”, “an” etc. People using that word in searches would get no results. By taking steps that resulted in the removal of the word “abortion” from the POPLINE data base, the Bush administration accomplished the same thing Mr. Bush has accomplished by not publicly acknowledging the deaths of American service personnel in Iraq except on very rare and carefully controlled occasions. The deaths do not go away. Public awareness of them does. By causing “abortion” to be removed from the POPLINE search engine, girls and women could still get abortions. What they couldn’t get, at least from the Johns Hopkins site, was information about abortions. The school told those inquiring about the change in policy that “abortion” was not a valid search term.

Johns Hopkins being an institution of higher education run by people with brains and common sense rather than ideology, is more enlightened than the Bush administration. When the Dean of the Public Health School, Dr. Michael J. Klag, learned of the restrictions in early April, he ordered the restrictions lifted saying: “I could not disagree more strongly with this decision, and I have directed that the POPLINE administrators restore ‘abortion’ as a search term immediately. I will also launch an inquiry to determine why this change occurred.”

The answer is not hard to come by. It changed because the country is run by Orwellian ideologues who believe that the way to control the country is to control the minds of its citizens by limiting information available to them. It has been stunningly successful. One can only hope that in January 2008, the minds of the citizens are restored to their rightful owners.