Life-or-Death Medical Plan Decisions

The information provided here presents information provided by a former federal agent who spent several years as a pharmaceutical detail person for a major pharmaceutical firm, four years as caregiver to a woman diagnosed in 2008 with Stage IV esophagus cancer, and later, his experience after being diagnosed with Stage III kidney cancer.

A comparison is made between fee-for-service health plans and HMO plans. Reference is made to the thousands of people that die every year from medical errors in hospitals. Reference is made to the denial of contractual care and the unpublicized number of people who die from physician misconduct.
 

Two recent books:


Fee-for-Services Medical Treatment

In a fee-for-service type of medical treatment, physicians and other medical care providers order tests and treatments as they determine necessary. In this form of medical care the person is free to select the physician and medical provider of his or her choice.

There is virtually no incentive for physicians or other medical providers to withhold treatment. In some cases there is an incentive to order more tests and more treatment than is necessary, but this normally does not result in death. There is a risk of a risky treatment, but at least the patient has the ability to make a decision.

In this form of medical care, the insurance carrier pays or reimburses the physician or health care provider for the treatment performed; it does not take a direct role in either selecting the provider or on determining the treatment. (Further legal explanation at Peagram, 120 Supreme Court, at 2148-49.)

Despite this being in some ways a better type of health plan, this writer encountered serious problems as he sought medical care for his "co-pilot," Glenda. She suffered as a result of what was originally greed on the part of a skilled nursing facility, and that misconduct was followed by a series of wrongful and probably criminal acts that resulted in her premature death. A Greek tragedy in America's medical industry!


HMO Medical Plans

HMO medical plans operate primarily under a fixed monthly payment. They are usually relatively satisfactory for people in relatively good health, and financially satisfactory for the HMO corporation. They have a strong incentive to keep costs low, and that translates into avoiding tests to determine the reason for symptoms. Or, to even withhold universally recognized tests and treatments.

The integrity of the HMO corporation, and of the HMO physicians, play a major role in whether the plan members receive proper treatment. In some cases, it becomes a life-or-death situation. And more often then realized, the outcome is death due to denial of recognized tests and treatment.

Where some members may feel that being a member of an HMO for years gives them assurance of the best of care, they don't realize that they become a financial liability for the HMO when they develop a costly-to-treat illness, such as kidney cancer. The sooner they die, the sooner this financial burden is removed from the HMO group. Denying treatment that could eventually cure the costly illness, or bring about remissions, becomes

Because of financial incentives, for the HMO corporation or the physician group, there is a financial interest in providing less care. (See Pegram, 120 Supreme Court at 2149.) The determination of life-affecting medical care and treatment depends upon the physician's moral and legal interest, and whether the life of the patient outweighs the financial self interests.


Pros and Cons of HMOs

The benefits include:

The negatives include:


The Good, the Bad, the Ugly,
At Kaiser Medical Facilities

Kaiser Permanente HMO health plan, while excellent in some area, constitutes a medical crime in areas motivated by profits. (There are for-profit segments in the Kaiser Permanente physician arrangements.) Discover the death panel experiences by this writer while a member for 50 years with Kaiser Permanente in the  Walnut Creek, California  facilities, especially during the time while he was under great stress caring for the love of his life, Glenda, also a pilot, including while suffering grief from her recent death on February 1, 2012. See the sordid conduct of certain physicians at this for-profit groups of Kaiser physicians, the culture responsible for an unknown number of preventable deaths outside of the 30,000 reported preventable deaths every year in hospitals.


HMO Physician's Incentives For
Denying Life-Affecting Treatment

Physicians at most of the HMO corporate health plans usually operate under a capitated type of compensation plan. Under that arrangement, the physician group receives a given amount of funds by the parent corporation based upon the number of people enrolled. At the end of the year, the physicians receive a financial bonus based upon the difference between the cost of the tests and treatments that they have ordered and the amount of the funds allocated.

Therefore, any member that develops a medical condition requiring a series of long costly treatments, such as some forms of cancer, becomes a liability for that physician group, as well as the HMO corporation. The physicians can reduce the costsand increase their end-of-year bonuses, by not ordering tests when the enrollee's symptoms dictate such tests.

When a definite diagnosis is made of cancer, it becomes profitable to lie to the cancer victim and urge them to do nothing until they experience personal symptoms of the cancer as it advances unchecked through the body. Or more bluntly, absolutely refused to provide standard tests and cancer treatment drugs, giving the cancer victim some ridiculous argument.


Criminal Aspects of Withholding Universally Recognized
Medical Care in Prepaid Medical Plans

The need for, and the laws permitting, criminal prosecutions of HMO denial of care decisions are thoroughly addressed in an article written by Ohio State University professor, John A. Humbach with dozens of legal citations showing criminal offense from HMO withholding of life-affecting treatment.

A Boston Globe article at www.boston.com (April 13, 2011) under the heading, "Woman who withheld son’s cancer drugs found guilty," stated:

LaBrie’s attorney, Kevin James, said yesterday that the jury apparently did not understand the burden his client experienced in caring for an autistic son who developed cancer. He had also argued that social workers and doctors at Massachusetts General Hospital, where Jeremy was treated, should have done more to make sure she was fit to care for her child and administer the medications.

"What we wanted to get across to the jury is the tremendous burden my client had to carry, as well as the fact that the support that should have been in place for her was not in place,’’ James said in an interview.

James said he asked for the sentencing to be postponed at least until Friday in part so that he could gather evidence of support his client has received from many people who never met her, but who understand the difficulties of raising a developmentally disabled child with cancer.

O'Keefe, LaBrie’s sister, said she understood jurors were required to follow the legal directives given to them, but that her sister never sought to hurt Jeremy.

“It’s too hard for them to know what my sister was going through at that time,’’ O’Keefe said, holding back tears. “I don’t think my sister had any intentions of hurting Jeremy, ever. I never will believe that in my life, never.’’

Prosecutors said they will not comment on the case until LaBrie is sentenced.

Legal analysts said yesterday that the case was the most unusual since prosecutors brought manslaughter charges two decades ago against a couple who refused to authorize surgery for their toddler, who was suffering from a treatable bowel condition. The couple, David and Ginger Twitchell, then of Hyde Park, were Christian Scientists and believed the boy could be healed by spiritual treatment. He died within several days after his diagnosis in 1986.

The state Supreme Judicial Court, in reviewing that case, determined in a landmark decision that parents have a legal duty to provide medical care for gravely ill children, regardless of religious faith.

Legal analysts said yesterday that the case was the most unusual since prosecutors brought manslaughter charges two decades ago against a couple who refused to authorize surgery for their toddler, who was suffering from a treatable bowel condition. The couple, David and Ginger Twitchell, then of Hyde Park, were Christian Scientists and believed the boy could be healed by spiritual treatment. He died within several days after his diagnosis in 1986.

The state Supreme Judicial Court, in reviewing that case, determined in a landmark decision that parents have a legal duty to provide medical care for gravely ill children, regardless of religious faith.

Boston attorney J.W. Carney Jr., of Carney & Bassil, said LaBrie’s case was troubling in that she was portrayed as a mother who was overwhelmed. He said the case should have also focused on the failure of LaBrie’s doctors to intervene quicker, once it became obvious that she was not administering medications.

"It can be so overwhelming for a single parent to deal with a child who is autistic, nonverbal, and developmentally delayed,’’ he said. “It is cruel to add to that burden a diagnosis of cancer and a requirement that the mom administer medicine that will cause the child even more pain."

The attempted murder conviction carries a maximum penalty of 20 years in prison. Under state sentencing guidelines, LaBrie — who does not have a criminal record — could face up to 7 ˝ years in prison, according to legal analysts. That determination will be made by Judge Richard Welch, who could consider outside factors.

“A judge is authorized to go downward, with mitigating factors, or depart upward if there are aggravated factors,’’ Carney said.

Boston-based defense attorney Randy Gioia added, “I think there are mitigating factors and aggravating factors in this case. One of the aggravating factors is you have a vulnerable victim with a disability in this case. That is one of the factors the judge is going to take under consideration.’’

Valencia can be reached at mvalencia@globe.com; Ballou at bballou@globe.com. Article at the following address:

http://articles.boston.com/2011-04-13/news/29414342_1_hospice-care-medication-young-son/2.


Elimination of Safeguards

What should be protections for the health plan members have been removed by members of Congress or regulators. Legislation has permitted HMO corporations to be relieved of legal liability from bringing about the death or harm from denying contracted medical care. Or by requiring binding arbitration, thereby reducing access to the courts, and relieving the powerful corporations with their political contributions (i.e.. bribes)

If cancer should be detected, the uninformed cancer victim is then misled by corrupt HMO physicians that urge the medical plan enrollee to do nothing, or flat out refuse to do what is universally recognized treatment.

Not explained to the cancer victim is that by the time he or she experiences positive signs of the spreading cancer, the curative or remission benefits of costly cancer drugs will have been lost. And for the HMO corporation and physicians, the near-death condition that their irresponsible denial of care caused to occur, the costs are limited to relatively inexpensive palliative pain relief, and for a relatively short period of remaining life.

Criminal prosecution for enabling the death to occur is possible, but the laws permitting this have not yet been used. Just as the criminal acts by financial corporation executives are usually settled through financial penalties rather than criminal prosecutions, the sometimes criminal acts of HMO corporations go unpunished.


Repeated Death Decrees by
Rogue PhysiciansWith Impunity

Hard to believe for the uninformed, some HMO corporations and HMO physicians will deliberately withhold tests in response to symptoms that would reveal the need for expensive cancer-fighting drugs, especially in those cancers where the primary cancer-fighting drugs are on patentand costly, easily costing tens of thousands of dollars a year. In that case, the quick death of the HMO health plan member is desired. Therefore, in cancer cases, for instance, the first step in reducing costsand increasing end-of-year bonuses for the HMO physicians in a capitated form of employment group--is to withhold diagnostic tests.

If cancer is diagnosed, the next money-saving step is for HMO physicians to deny the periodic blood tests and CT scans and argue that the treatment plan is to wait until the cancer victim personally experiences symptoms of the cancer. What the HMO physicians don't tell the patient is that the curative or remission benefits of costly cancer treatment drugs and other medical procedures are long gone, and that by that advanced cancer stage the most probable remaining efforts are end-of-life palliative pain relief.

The cancer victim, who may have been a member of that HMO for decades, is now a financial liability, and anything done to hasten the member's death is a financial plus for the corporation and the physicians.


Sham Nature of Appeal to Medicare for Denial Of
Nationally Recognized Cancer Treatment

Like most other federal regulatory groups, the improper or even corrupt withholding of life-affecting universally accepted medical care under the flat-fee HMO Medicare policies is aided and abetted by the regulatory agency personnel paid to provide relief. This is standard aiding and abetting as found in other regulatory agencies, such as seen in the Wall Street scandals, the Housing mess, the aviation safety agency, and others. The consequences are in money lost, homes lost, deaths in otherwise preventable aviation disasters, or deaths by denial of standard universally recognized care.

In denial of health care such as cancer treatment, a  Medicare HMO policy for which the Health plan is paid a specific financial amount for providing coverage can easily withhold costly cancer treatment using sham and medically irresponsible arguments. The primary so-called appeal rights is to file an appeal with Maximum Federal Service, which is empowered to review and decide if the health plan was improperly withholding care under the Medicare HMO plan. This problem is unlikely to occur in a few-for-service Medicare plan.

In one example, the first indication that the appeal procedure was a sham became obvious when the Medicare HMO recipient was blocked from seeing the argument presented by the health plan to justify their refusal to provide cancer care. The HMO health plan corporation can openly lie in response to the complaint, and the person filing the complaint is unaware of the false statements and cannot respond to them. Nor could an honest Maximus panel reach a honest decision under these conditions.

The final decision by the Maximum group can easily omit the key reasons for the complaint, and by legal trickery aid and abet the powerful HMO health care corporation. In  the appeal number, 1-847801106, the request to obtain an out of Kaiser cancer treatment referral was based upon the following:

In the November 14, 2011, decision, Maximus Project Director Janice Eidem denied the Medicare cancer patient's request for an out-of-plan treatment determination, claiming that treatment decisions were available within the plan. She and the Maximum group ignored the fact that a group of rogue oncologists were refusing to provide the standard and universally recognized treatment, and using sham and medically ridiculous arguments for their cost-saving denial of cancer treatment. Fax of November 27, 2011, protesting Maximus complicity with Kaiser corporation.

In this way, regulators aid and abet the death decree to HMO Medicare patients, and the ailing, weakened, and often time elderly cancer victims have no where to turn. Although the cancer patient can file a further appeal with an Administrative Law Judge, the cost and time consumed is usually beyond the ability of the suffering and often senior Medicare patient.

Further, even when the HMO Kaiser corporation refused to recognize denial of care complaints, thereby nullifying the Medicare appeal process, the Maximum group refused to respond.

Sampling of deception and lies used to withhold mandatory contractual medical care to kidney cancer patient by Kaiser Permanente physicians and management, as stated in a December 8, 2011, fax; and sampling (December 12, 2011) of the deceptive decisions by Medicare's appeal group, Maximus Federal Services, showing their complicity. One of several notices to U.S. Department of Health and Human Services making the controlling agency aware of the pattern of criminal misconduct.


Kaiser Permanente Doctor Sues Kaiser for
Denying Medical Care to Thousands

KPCC, Los Angeles, Oct. 8, 2010 | Patricia Nazario
(http://www.scpr.org/news/2010/10/08/19979/kaiser-lawsuit/.)

 
A former Kaiser Permanente doctor is suing the health care provider. He claims the non-profit organization denies adequate care to thousands of chronically-ill patients to save money. At issue is Kaiser Permanente’s Special Needs population. It’s a group of about 60,000 people, mainly in California. Some are chronically ill children and adults, most are seniors. All are covered by Medicaid/Medi-Cal.

“And Kaiser has what are called Special Needs Plans in which these members belong," said Dr. Richard Della Penna. Della Penna worked for Kaiser Permanente for 23 years and coordinated national programs for the health plan’s special-needs population. The doctor says there were never any written internal directives, but he says there was a general consensus to provide minimal care to about 95 percent of the patient pool to save money. Della Penna says when he spoke out on behalf of his patients he was forced to an early retirement.  “As a result of my advocacy for geriatrics, elder care, for the special needs population, for the people with advanced illness, I found myself being more and more marginalized.”

Della Penna’s lawsuit against Kaiser lists several claims, including retaliation against a physician for patient advocacy and violation of public policy.


Google Search for Medical Horror Stories
Kaiser Permanente Health Plan

The following are a small sampling of the many reports found by a Google search under the search words, "Kaiser Health Plan malpractice" or Kaiser Permanente malpractice.

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Army of Lawyers and Law Firms
Fueled by Kaiser's Victims of Medical Misconduct

Denial of universally accepted medical care and incompetence by certain Kaiser Permanente physicians fuels armies of lawyers. The following are sampling of Internet sites for lawyers that have filed malpractice lawsuits against Kaiser doctors or the Kaiser allegedly not-for-profit health plan or hospital groups, and the for-profit Kaiser Permanente parent corporation.

Putting Kaiser Permanente into a Google search engine reveals an endless series of deaths caused by denial of medical treatment. Further problems at that HMO are revealed in the book, Making a Killing-HMOs and the Threat to Your Health.


Sampling of Cancer Treatment Sites
Relating to Kidney Cancer

The following sites describe in detail the standard universally recognized kidney cancer treatment, each of which were withheld by oncologists at the Kaiser Permanente HMO medical plan, who refused to provide any treatment, using sham and medically-ridiculous reasons for decreeing a premature death.


Expectation of Honest Care and Emotional Support

People with cancer have serious medical problems facing them, and depression; it is a scary time. They need competent and caring doctors.  Many cancer victims find a cancer diagnosis difficult to cope with, and go into stages of depression. Many groups are formed for the sole purpose of providing counseling to cancer victims.

 


Encyclopedia of Endemic Corruption and
History of Tragedies: the basis for
America's peaceful but firm "Arab Spring."


 
   

   

   

     

   

   

 

All of the books are available at amazon.com, in print and on digital formats, and at many other Internet sites. They bring together the various pieces of the puzzle to better understand the overall picture, and why the same conditions continue year after year. Information on the books by former government agent Rodney Stich

Sampling of early books reviews

Sampling of complimentary letters/faxes to author/activist Rodney Stich.


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