Howie and Harlan are joined by Helen Burstin to discuss her career examining issues of equity and quality in healthcare, and her current role as CEO of the Council of Medical Specialty Societies. Harlan reports on new research about the daily health effects of coffee; Howie looks at two investigations of misconduct by the insurance company Cigna.
Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.
Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. This week, we’ll be speaking with Dr. Helen Burstin. But first, we like to check in on current health news. Harlan, I know you and I talked this morning, there’s a paper that I had an interest in and you said it was a good paper to talk about, so I’m excited about that.
Harlan Krumholz: Yeah, I thought this was kind of a cool paper. It came out in The New England Journal of Medicine. It was called “Acute Effects of Coffee Consumption on Health Among Ambulatory Adults.” This basically says what’s the effect of coffee on people who are generally healthy and walking around? They have got this amazing platform where what they can do is get people linked up digitally so that they’re collecting information, for example, about their heart rhythm and their activity and they can randomize them to different interventions and see what happens. This is kind of a new wave of research. It’s highly efficient, it’s using people’s mobile devices, and yet it can teach us something. There’s a question that people have had for a long time that hasn’t really been addressed in part because we haven’t had the tools to do so, which is what’s the effect of caffeinated coffee on extra heartbeats?
Besides that, if we’re going to do this study, how about on daily step count, and sleep minutes, and glucose levels? And you might think, “I don’t know, a couple cups of coffee. I mean, yeah, maybe it gives me a little bit of a buzz in the morning, but how can that really have much effect on all this other stuff?” They thought, “Let’s study this.” They took a hundred people and they were instructed by means of text messages, so really the whole thing was digital to, on that day, consume caffeinated coffee or to avoid caffeine during two-day periods. They basically were given an assignment for two days and the entire study was over 14 days, so they had seven two-day periods, and on any day, you would get the message to say what am I supposed to do for the next two days?
Now meanwhile, like I said, they wore a recording electrocardiogram patch to collect information about their rhythm. They were able to collect information, like I said, about steps and sleep and they were also being able to collect some information, by the way, about whether they went to coffee shops when they said they were avoiding caffeine because they were using this technique called geofencing so they could use the phone to track that. Anyway, they took all this stuff together and they took a look.
Interestingly, the main thing that they were looking at was, would you get extra beats that started at the top of the heart? They call these premature atrial contractions. Your normal heart’s going top to bottom, top to bottom in a very regular fashion every once in a while. The natural pacemaker you have is superseded by something else in that upper chamber to cause what they call a premature or early beat and they took a look at that. People have wondered for a long time whether coffee could cause you to have some of these extra beats. Lo and behold, there was no significant difference between the two groups in these extra beats that came from the top of the heart.
Now, they also looked at what are called premature ventricular contractions. These are extra beats, early beats that come from the bottom of the heart, so the ventricle, the main pumping chambers sometimes can take over and give you an extra beat. People sometimes feel it as a palpitation. They can feel the upper chamber too as a palpitation. In this case, interestingly, just with people having the days where they were drinking coffee, that they actually did have more ventricular contractions. For the people who were avoiding caffeine, there was about a hundred day. They got so many beats a day, 100 is not very many. They got 150 on average if they were drinking coffee. But that was interesting because we hadn’t really known before whether or not coffee can increase the extra early beats sometimes that people had. It turns out, looks like it does. But this is what I found even more interesting because these are really not many extra beats, even though it’s like a 50% increase. It’s not many in the long run. But actually, Howie, it affected sleep as well.
Howard Forman: Sleep is what got me. Yeah. That’s what’s fascinating.
Harlan Krumholz: This is really interesting. The days that people were drinking coffee, and I mean this is wild because they’re not thinking about their sleep, they’re going about their every day, and like I said, every two days, they’re being randomized to either caffeine or not caffeine. But on the days that they’re on caffeine, they’re sleeping about a half hour less, a little bit more than a half hour less. The average for the people who weren’t taking caffeine, this is the same people, by the way. It just means on the days you weren’t taking caffeine, they were sleeping 7.2 hours a night and the days they were taking caffeine, it was 6.6 and I think 30 minutes is a lot.
But here’s one more thing. I know I’m talking a lot, but I’ll give you the last kicker that was also interesting was that the steps on the days they were drinking coffee were about a thousand more than they were on the days that they were avoiding coffee. Again, same people, this is about comparing days where they’re avoiding caffeine and taking caffeine. They’re not getting any direction about what to do with steps or sleep if they’re just being observed and they’re walking about 10,600 steps a day on average for the days that people are taking coffee and 9,600 when they’re avoiding it.
Anyway, this was quite interesting. By the way, they also looked at glucose. No difference in glucose, so it wasn’t affecting the way the body somehow was managing glucose metabolism. But anyway, bottom line, this relatively small study and people weren’t blinded. They knew when they were drinking coffee and they knew they weren’t. But again, they were really testing things that particularly the extra beats that people didn’t overtly have control over had a little bit of effect on the ventricular, the bottom heart extra beats. But sleep and steps were different depending on whether you were taking caffeine. Anyway, I thought it was fascinating.
Howard Forman: Yeah, this is one of those studies that has something for everyone, I like to think. I mean, you can’t always say that, but this one does because I got off of caffeine 12 years ago for a multitude of reasons, but the biggest reason I stayed off was because I felt like it was affecting my sleep and I also hated the feeling of being addicted. This is the type of study that at least allows me to justify why I’ve done that because quite frankly, there are other studies that show that caffeinated coffee can be better for you for certain types of other conditions. There’s really no dominant evidence that says caffeinated coffee is bad for you. This was one of the areas that we really had questions.
Harlan Krumholz: Anyway, I want to get to our guest because we’ve got a really great guest today, Helen Burstin. Howie, take it away.
Howard Forman: Dr. Helen Burstin is the executive vice president and chief executive officer of the Council of Medical Specialty Societies, a medical society founded in 1965 to provide an independent forum for medical specialist discussion. Today, it represents fifty specialty societies with a collective membership of more than 800,000 U.S. physicians. She’s also a clinical professor at George Washington University School of Medicine and Health Sciences, and previously she served as the chief scientific officer of the National Quality Forum. She was an attending physician at the Brigham and Women’s Hospital and at the same time an assistant professor at Harvard Medical School. She received her bachelor’s degree at the City College of New York, where I also attended around the same time when I first crossed paths with her, and she received her medical degree at the State University of New York, SUNY Upstate Medical University, and her MPH at Harvard School of Public Health. She completed her residence—
Harlan Krumholz: Just to say, Howie, you had a connection with her from way back, right?
Howard Forman: And you too.
Harlan Krumholz: And I have a connection with her from going to School of Public Health together, so—
Helen Burstin: That’s right.
Howard Forman: Oh, that’s right!
Helen Burstin: Oh my god. I forgot about those stories. Yeah.
Harlan Krumholz: Yeah. Well, it’s a special pleasure for us.
Howard Forman: We’re going to come to another commonality in just a second. She completed her residency at Boston City Hospital and a fellowship at Brigham and Women’s Hospital in Harvard Medical School. She’s the author of over 100 peer reviewed publications, most of which are highly cited. First, I just want to say welcome to the podcast and then I want to follow up with that by asking about the first published paper you had, which really ties together your training at Boston City Hospital, your fellowship, and leads into your career, and that is that you were the first person to document that the uninsured are at greater risk of suffering medical injury due to substandard medical care. You did this publishing this in The Journal of the American Medical Association, a very prestigious journal at a very early stage in your career. How does that start you off on your path?
Helen Burstin: Oh, it’s such a good question. It’s really a thrill to be here with both of you. I think what’s interesting is some of this just comes from what you most believe in and what you want to work on. For me, it was always around equity. It was always ensuring access to those who don’t have care. I think some of this is, Howie knows my parents are both Holocaust survivors, and I think there’s always this sense in me that we have to make everything right. We have to make sure people have access when they need it. They have to get the right kind of care. Even when I decided to train at Boston City, it was because I would train at a community health center. I would have just this incredible opportunity to do research and clinical care, but in a community that I really wanted to take care of.
Interestingly, it was sort of a strange story. I was a second-year resident and we had a nursing strike and we had to treat and transfer all the patients. My chief resident at the time, Jeffrey Samet, who I’m sure you guys probably know, renowned addiction researcher, said, “I noticed that all the patients were coming back who we treated and transferred to other Boston hospitals.” He said, “Let’s study it.” And so we did and ultimately found that it was those who were homeless and IV drug users who were denied admission, equally sick at the other hospitals. He was the one who said to me, “If you had some skills, quantitative skills that you could tie to your advocacy interests, you would be a more powerful advocate.” That was the logic of doing the program that Harlan and I did together when I did the fellowship.
Then my research mentor at the time was Troy Brennan, who was one of the leaders of the Harvard Medical Practice Study. They had collected almost all the data and his thought was, “What would you like to work on from this massive dataset?” And I said, “Equity.” It’s interesting because that was before a lot of people were very focused on this.
Howard Forman: Way before.
Helen Burstin: I particularly was always very concerned having trained in a public hospital and seeing what happened to our patients when they went elsewhere. It wasn’t just an access barrier, right? You could sometimes get in the door, but what this paper really showed was even if you managed to get your foot in the door, your care was worse, and so that was really a powerful moment for me.
Harlan Krumholz: Howie, experience for me with Helen is to see someone in class who was really even at that time, so deeply devoted towards research of consequence and very empathic, of course, brilliant and highly motivated to make a difference for those who were in difficult circumstances, and it’s just been a pleasure to see your career unfold. Helen, I wonder for people who are listening, if you could just give us a little bit of a sense of the path you’ve taken because it’s not been a usual one. I mean you’ve worked in a lot of different organizations and have found ways to contribute that I think people would enjoy hearing a little bit about. So okay, you leave fellowship, you’ve got now some tools, you you’re capable of producing scholarship that matters. But can you just tell us a little bit about what did you do then? How did it unfold?
Helen Burstin: Yeah, no, it’s a great question and I often question myself when people ask me what’s the path? I think a lot of it was forging paths that really didn’t exist. But I spent the next eight years on faculty at the Brigham after my fellowship mainly doing healthcare quality and equity work. We did a large ED—emergency department—quality study, a large ambulatory quality study across all the Harvard facilities, and I kind of knew, this is sort of an interesting insight for me, that I loved doing the research. I loved finding the answer. I loved figuring out how to use it, and I was bored silly doing the three revisions for papers. There was this one paper I submitted like four times to Medical Care and they finally rejected it. It was just like, I can’t do this.
On the other hand, I did a paper with one of my fellows when I was there looking at patients who didn’t speak English in the emergency department, finding they were far more likely to bounce back to the ED if they didn’t have an interpreter. I used that with my fellow, Olveen Carrasquillo, and there was actually a Massachusetts state law that mandated the use of interpreter services in emergency departments in Massachusetts. That just felt much closer to my heart and what I wanted to do, so I always knew I wanted to do research that was directly policy-relevant or could actually have an impact.
Then, when I was halfway through my time there, I was asked to be head of quality measurement for the hospital, and this is way before the days of chief quality officers or anything. I realized I loved that. I loved hearing about an issue on the floor and being able to work with our entry folks and just fix it in a way that I couldn’t do as a pure researcher waiting for the manuscript to be rejected or come back with revisions. It was just a lot of insight for me as to what I liked and what I didn’t like, so that was a wonderful opportunity.
Howard Forman: Before we move on from there, I want to just point out another unusual thing that even before you finished medical school, you decided to take a year off and be president to the American Medical Student Association. I mean, obviously that’s not something too many people do, but you are willing to go into a completely different path really early on even before medical school is over, so you like working within organizations to change them for the better. Can you tell us how that may have influenced the next steps?
Helen Burstin: Yeah, it’s a good point and I often forget about the AMSA stint, but I decided to leave medical school, spend a year in Washington, D.C., doing policy and program development. A lot of it was really creating, as we called it, the alternative medical school for medical students. We did all these placements, helped motion disease placements and communities for med students, things that med schools really weren’t offering at the time. I think I just got the sense that I was able to be more effective when I had some effector arms rather than purely being a researcher, which just wasn’t satisfying enough.
Harlan Krumholz: I wonder if we could just pivot a little bit to this work around quality. You and I both have a deep interest in trying to promote quality. We identify that there are many issues around quality and safety in the country. You spent a long time with an organization that was working to organize and codify the ways that we could measure quality. After doing that and you transition to this new job, but when you reflect back on the time at the National Quality Forum, what do you think are the frontiers ahead still for us and why aren’t we making faster progress in quality? I mean, what would you like to see happen right now that would finally ensure that people are getting safer and higher quality care, getting better outcomes with the knowledge that we’ve already got, because the systems are working better?
Helen Burstin: Yeah, and I think it’s exactly that, Harlan. I think the systems are working better and although we’ve talked about the digital transformation of this field for years, I can see it now actually happening. I think given everything we’ve seen during COVID and the incredible administrative burden on docs and other clinicians, this is not the time to add more burden to them, especially if we’re asking them to put measures together, that they don’t feel are relevant, they don’t see as tools they can use to improve care and be actionable. I think even more so, it’s the right time to think about where we use digital to actually truly see how somebody’s care evolves over an episode and really understand, from the patient’s point of view, from the clinician’s point of view, what worked, what didn’t work, and you and I have both shared this passion for a long time, Harlan, about the voice of the patient. I think that’s the sweet spot.
Harlan Krumholz: And just to come on real quick, so now you’re working a lot with the professional societies. I mean, is it that the professional societies also want to embrace quality but they just don’t want bad measures, they don’t want to be put in a position where they’re being evaluated for bad measures or do you see that there’s just a movement against measurement in general?
Helen Burstin: I think it depends on whether or not they have a clinical data registry, and the ones who do, I think, are more invested in getting to better measures using digital tools, which I think has been a challenge. If you have to have a clinician go in and add the outcomes by hand or add screenshots or paper, it’s just harder to do. I think we’re seeing a lot more of those who have the digital capability or looking to it thinking about what is the next generation of measures.
I mean, just as an example, the IRIS Registry, which is an ophthalmology, has outcome measures for every single procedure in ophthalmology, every surgery. That’s extraordinary. They can do that in ways they were never able to do that before. Similarly, in urology, a place we’ve talked about for years. Harlan, you and I heard those stories of this patient decision-making for the guys who needed to have their prostates out and peeing in the snow as you recall, all those stories they talked about and we were able to—
Harlan Krumholz: Just for people listening, the question is if you’ve got a prostate condition, it can impede the flow of your urine, and so your ability to write your name in the snow, for example.
Helen Burstin: Right. Especially after surgery, and that was one of the big risks. There’s always this big question, should you get surgery or not? Harlan and I were taught by one of the leaders in that field, Al Mulley, who always loved to tell the story of the patient after prostate surgery, just delighted that they could still pee in the snow in Vermont.
Harlan Krumholz: Write their name with their pee in the snow.
Helen Burstin: Write their name in the snow, yeah. But I think that’s where we got to go. You and I have both had this passion, Harlan, about really thinking about how we bring the voice of the patient to this, both patient experience but, really importantly, patient outcomes. I think it’s the sweet spot. I think it’s the spot where for the clinician and the patient, did you get better is profound. It is just at the core of why we do what we do and being able to get that information from the patient directly, I think is a place we’re going to be able to get to now quicker than I think we were able to before.
Howard Forman: You come from a background of real primary care, and you’re now leaving an organization of specialty societies and, quite frankly, different specialties have very different priorities. They’re not always growing in the same direction. How difficult is it for you to get them all to be aligned? And second part of that question is, you’ve used the platform of your organization to address social issues and how difficult is it to get all of them to be in the same direction on those specific issues and you could speak to them as you wish.
Helen Burstin: Yeah, no, it’s a great question, Howie. In some ways, it’s not that different than my experience at NQF of trying to build consensus across stakeholders, except these are all the same stakeholders, but between specialty at times, could be as different as between stakeholders and I do think we see significant differences. There was an article probably I think about five or six years ago in The New York Times that showed specialty by party, showing that your psychiatrist is probably a Democrat, your surgeon’s probably a Republican. I mean, those are real differences, especially as the country has gotten so incredibly divided by party. I mean, even the way people approach COVID and getting vaccinations has been so driven by party that I do think there are party differences and I think we’ve seen some of that in terms of which organizations are willing to step out and which organizations are not.
But I think in many ways, the pandemic was such a watershed moment that the coming together around a set of aligned issues, particularly around things like in the early days, masking and vaccination were just obvious and a place where I think professionalism became really the point of the realm, and that’s regardless of specialty. I think as we got into issues like Dobbs and some of those decisions and I think affirmative action eventually, I think we’ll see more of those differences. But I think what we were able to do, which I find really satisfying, is there’s still a way to find that nugget that still ties back to you as a doc, as a clinician, that matters. In the case of Dobbs, in the case of protecting trans patients, it really came down to the fact that you need to protect the patient-physician relationship, and you have to keep others out of that.
Those are decisions to be made between a patient and their doc and you shouldn’t have government interference, and everyone agreed with that. We had no issue with that. We probably wrote 30 versions of our statement on Dobbs about whether the word abortion was in/not in, reproductive health. I mean, that was a real learning experience for me. But I think at the end of the day, we were able to come to a place where you could still get to people’s sense of professionalism and doing what’s right for the patient. I think when we take that lens and we don’t get overly political for politics’ sake, I think it’s a strategy that so far has worked.
Howard Forman: To your great credit, I just want to finish this, to your great credit, you’ve been able to do that very quickly. It’s not like it took you six weeks to issue a statement.
Helen Burstin: No, fast. Yeah. It’s amazing, actually. I think the other thing that has happened through COVID is I think even the societies could see more where they were stronger together and where bringing their voices together really mattered. It isn’t just political things. I mean, just recently, American Society of Anesthesiology, their journal was sued by a drug maker who didn’t like a paper that said their device didn’t work and sued them in court. We actually supported an amicus brief across all of our societies on behalf of ASA on the appeal, and they just won, actually just a couple days ago, the appeal. That’s, again, the kind of thing that isn’t overtly political, but you shouldn’t have these external forces interfering on what is evidence and what is evidence-based medicine.
Harlan Krumholz: Now, Helen, I want to just focus back on this, the patient’s side of this. You’ve been a champion for patient involvement at every level and more recently, have been involved in a PCORI-sponsored project around trying to develop standards and guidelines for researchers and people who want to participate with the researchers in ways that would be most likely to optimize the interactions and ensure the best outcomes.
You worked with a group from Patient Led Research, Hannah Davis, Hannah Wei, Gina Assaf, Lisa McCorkell, Athena Akrami, is that group and have done so, these are the most amazing people I’ve met. They are facing health challenges themselves, but yet have found it in themselves to have the energy to try to help actually change the field and change the dynamic and change the discussion and conversation. Can you just reflect a little bit on this project, what you’ve learned and what do you think it’s going to take for us to change the status quo in research, which has been very hierarchical and research on top? “Subjects.” I don’t even use the word subjects anymore, it’s really teammates and people who are participating. But what’s your own thoughts about this now and what’s the future of it?
Helen Burstin: I have to say it’s the most meaningful work I’ve ever done working with these women who really led the development and the definition of long COVID. I mean, they truly did it. They wrote the Lancet paper, they did the international survey in ways that I think most people would think they couldn’t do and would’ve discounted their ability to do so. I think I’ve just gotten a lot of incredible learning from them about what’s possible. I love the way we developed, as Harlan knows, because he was on the advisory committee, we developed these scorecards of how patients and others could really assess how willing you were to have patients lead or co-lead. I love the fact that when we developed it, they decided to have the scale go from negative numbers to positive numbers because they wanted to establish that what was zero was just kind of okay, and what was negative-1 and negative-2 must be stopped and that the place we want to go were those positive numbers. I think we are truly establishing a completely different baseline.
For example, our clinical practice guidelines groups across all the societies are updating their guidance around guidelines. They’re using the scorecard, Harlan, to talk about how patients are engaged in guideline development. I think it should be changing everything we do in terms of quality measurement in patient engagement, boards of various things, and just things like I need to be there as a patient from the moment you’re thinking of a hypothesis, You’re thinking of the outcomes, all the way through to the point where I’m an author on that damn paper. I think they’ve pushed the envelope far enough that I think people have heard it and the patient community has been really energized by it, and so I really hope we could use it with the medical community, the research community, and I think also the funding community needs to use that to assess the readiness of clinicians and researchers to really work with patients as partners.
Harlan Krumholz: Yeah. Kudos to them and also your involvement, But we always want to highlight it’s just been an inspired effort. I’ve been admiring it from the very outset. What it does is people will ask, how do I involve patients? Or what would be the properties of a very good project that would involve people in this kind of way? I think it provides a roadmap as well as metrics. It’s a combination, right? Because people need help because we weren’t socialized into thinking about this. I still say, I’ve been in it for a long time, I still make a lot of mistakes. I need help to see things that I just don’t see right away, so I’m always trying to improve in this way, but I know I’m not still even quite where I want to be on this.
Helen Burstin: No, me either, but it’s been by far one of the most enriching learning experiences of my life, and I just thank them immensely for partnering with us. It was kind of a strange marriage, but it really kind of worked.
Harlan Krumholz: Let me say, we’ll put a link on our website for this podcast to some of that material so that if people are interested, they can read more. Maybe you’ll share that with us and we’ll put it up—
Helen Burstin: Absolutely.
Harlan Krumholz: ... if those who are listening want to be able to follow the trail on this, they’ll be able to.
Howard Forman: I just want to first say, you are from my part of Brooklyn and you went to the largest—
Harlan Krumholz: What does that mean? What does that mean, Howie, “my part of Brooklyn”?
Helen Burstin: The not very nice part of Brooklyn.
Howard Forman: Yes. Unfortunately.
Helen Burstin: We’re not talking Brooklyn Heights here.
Harlan Krumholz: No. Pre-gentrified Brooklyn. Is that it?
Howard Forman: We are part of a Brooklyn that people don’t know. It’s the part that basically was the flight path for the Concord and other planes. But I point this out because you went to a massive high school. It’s the same high school I was zoned for and my sister went to. I mean, literally the largest high school in the United States at the time, but you did not get lost. There’s some people that might get lost in a big high school. You didn’t. I’m just curious if you have any reflections to people on how you were able to not get lost among the masses.
Helen Burstin: It’s such a good question, and it saddens me somewhat because I think what tends to happen is you tend to find your peer group and that’s positive, but it’s also negative. I look at our yearbook and I realize I don’t know 90% of those people because they weren’t in the honors classes, they weren’t in those more advanced classes, or they weren’t in orchestra. It cuts both ways, but those friends are friends for life because we bonded and knowing which hallway you didn’t go down and which staircase we know was always filled with pot. You just knew. You just figured it out and you needed your friends to do that. Also, some wonderful teachers, both in high school and in college, and Howie I had the treat to recently meet up with one of our college professors.
Howard Forman: Yes. Yeah. I will say as a last comment though, you were one of the very few people in my life who when I look at Facebook, I have to figure out whether we are intersecting on the professional side or we’re intersecting on the local Brooklyn side and sometimes both, but rarely.
Helen Burstin: And saying happy birthday to [Howie’s dog] Ashley, of course.
Howard Forman: Yes, of course.
Helen Burstin: It covers everything.
Howard Forman: It does. And [Helen’s beagle] Luna as well at this point. I feel like I was there at your decision to adopt Luna into the family.
Helen Burstin: Absolutely.
Howard Forman: I’m so glad. But anyway, thank you so much for joining us on the podcast today.
Helen Burstin: Oh, my pleasure. This was fun.
Harlan Krumholz: Thank you, Helen. It’s great to see you, great to have you on our show.
Helen Burstin: Thanks again.
Harlan Krumholz: That was a really terrific interview. I’m so glad that we had Helen on. But let’s pivot to the next section, which is hearing what’s on your mind this week.
Howard Forman: Yeah, so this is me back to being a little dower after some good news last week. There were two related stories about Cigna, the health insurance company, the health plan, that have come to light recently. I can’t speak to even whether Cigna is particularly worse than other health plans, but they have behaved poorly and drawn the attention of both journalists and the Department of Justice.
First, regular listeners already know that Medicare Advantage is the private insurance plan that Medicare beneficiaries can choose as an alternative to traditional fee-for-service Medicare, and the majority of new enrollees do, in fact, choose Medicare Advantage because it often offers extra benefits and may have lower out-of-pocket costs. Medicare Advantage usually covers hospital, outpatient, and drug costs and the companies that provide it go through a somewhat competitive bidding process managed by the federal government and then the payments that they receive, and here is the key part: The payments they receive are adjusted to the overall level of sickness in the population, morbidity in the population. If you, as an insurance company, end up with more patients with diabetes or lung disease or cancer, you get a higher payment than if you ended up with a more normal distribution within that population, okay?
Medicare Advantage plans, like all businesses, can make more money by two things, either spending less or receiving more dollars. These plans aggressively try to do both, often to the detriment of patients. How do private health plans, including these Medicare Advantage plans, spend less? They mostly try to reduce utilization of services, hopefully and specifically those services that have little or no value to the patient. Patients often hear about pre-approval or pre-authorization of a surgery or a procedure. That’s how health plans try to hold down costs.
If they deny a service that is inappropriate and saves money, that’s better for the patient, we want them to deny paying for things that don’t help the patient. But a ProPublica article from this weekend points out that Cigna is derelict in their denial of coverage and the narratives they tell are really disheartening. Short of this form of exposé, beneficiaries often feel quite impotent to push back against large companies telling them their necessary medication, service, test, or surgery is not available to them. That’s one negative piece of news with Cigna, and it probably applies to a varying degree, for others.
On the revenue side, Medicare Advantage plans make extra money by, hopefully, accurately coding their patient populations to capture the true morbidity in the population. This is legal and appropriate, but there’s fairly compelling evidence that these firms, and in particular Cigna, in this case, have aggressively upcoded or overcoded these populations to capture revenue that they otherwise don’t deserve.
In October of this past year, the Department of Justice filed suit against Cigna, alleging that they have hired nurses and other professionals to visit the homes of these beneficiaries with the sole or main purpose of capturing as many comorbidities as possible, even making some of them up. Here’s a quote from the Department of Justice. The U.S. Attorney Damien Williams said, “As alleged, Cigna obtained tens of millions of dollars in Medicare funding by submitting to the government false and invalid diagnoses for its Medicare Advantage plan members.” I don’t believe Cigna is the only firm that is abusing this program. I’m sad to see these two stories hit the news. I’m glad to see that there are going to be consequences to this behavior. I think if we’re not going to have a national healthcare reform, we’re going to have to rely more on the Justice Department and the spotlight of news media to get better behavior from these health plans.
Harlan Krumholz: Well, look, that’s really disturbing to hear, and I’m concerned that the amount of penalties that might be imposed would just be concerned with the cost of doing business and worth the risk because of they get away with it, provide such benefits. I’m worried that we’ve got a system here that is not really providing value back to patients. Maybe there is a big, long discussion, but thanks for introducing this, Howie, and I think we should all be thinking hard about the ways in which we can protect the interests of patients in the course of a system that is driving ever towards profits.
Howard Forman: Yeah.
Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.
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Howard Forman: And I’m @thehowie. That’s at T-H-E-H-O-W-I-E. You can also email us at firstname.lastname@example.org. Aside from Twitter and our podcast, I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email from more information on our innovative programs where you can check out our website at som.yale.edu/emba.
Harlan Krumholz: Health & Veritas is produced with the Yale School of Management. Thanks to our researcher, Jenny Tan, and to our producer, Miranda Shafer. They are absolutely amazing and contribute importantly to how good we are, if we’re good at all. Talk to you soon, Howie.
Howard Forman: Thanks very much, Harlan. Talk to you soon.