Buy My Book Here

Fox News Ticker

Please check out my new books, "Bullied to Death: Chris Mackney's Kafkaesque Divorce and Sandra Grazzini-Rucki and the World's Last Custody Trial"

Sunday, May 11, 2008

Blue Cross/Blue Shield Vs. Private Family Physicians...Corruption in Texas III

If this is the first time you have read this series, then I suggest you read part 1 and part 2 first.

There are only three ways to digest what I have revealed in the first two parts of this piece. The first is that Dr. Shirley Pigott is off her proverbial rocker and I have been taken in by a fraudulent story. Thus, by extension, there is no larger meaning. The second is that Dr. Pigott's story is true and accurate however her case happened in a vacuum. The third, and the one I will explore, is that her case opens up a pandora's box of corruption in which BCBS has decided to systematically corrupt the system in order to weaken their rivals the private family physicians.

Let's review what I have laid out. Three doctors, Dr. Doug Curran, Dr. Keith Miller, and Dr. Fred Merian, were simultaneously in significant positions of power in the Texas medical community. Dr. Curran was the head of the Texas Academy of Family Physicians. Dr. Miller was head of the Texas Medical Board's Disciplinary Committee. Dr. Merian was head of the Texas Medical Association. At the same time, these three were also members of the super secret BCBS Texas Medical Advisory Board. In other words, they were playing both sides of the fence. They represented the interests of doctors, and at the same time represented the interests of BCBS against doctors. Furthermore, Curran and Miller played a crucial role in attempting to weaken and intimidate Dr. Pigott in a process known as sham peer review.

It is possible but unlikely that these three found their way into these simultaneous roles by accident. It is also possible but unlikely that Curran and Miller played such a crucial role in Dr. Pigott's sham peer review by accident. It is also possible but unlikely that the Texas Medical Advisory Committee at BCBS is the only state in which such a committee exists.--

What is more likely is that these three were helped into their position of power by BCBS in order to help execute corruption against doctors like Dr. Pigott. It is also much more likely that most if not all states have their version of the Texas Medical Advisory Board.

Again, the relationship between private family physicians and insurance companies like BCBS is a naturally confrontational one. That's because, like I mentioned in part 2, private family physicians are the most motivated class of doctors to maximize the amount of money they charge the insurance companies. This naturally confrontational relationship is probably good for the system as long as both groups maintain relatively equal power and both play by the rules. What this case illustrates is that BCBS isn't playing by the rules. I will also illustrate that the power is not split anywhere near equally.

It's important to understand that the private family physician is not the high ticket field in medicine. Private family physicians treat patients before they get sick. Thus, their bills are nowhere near the range of doctors like surgeons. While this may not mean anything to the average reader, it's important to realize that doctors leave medical school with likely six figures worth of student loans. There is an immediate lack of motivation for the field of private family physician among most other fields of medicine.

Yet, the private family physician is on the front lines health care. They treat patients before they get sick, and their worth is measured by how few of their patients actually do get sick. The concept of preventive medicine is most often practiced by the private family physician. You will only see a surgeon once you already are sick. You see the private family physician in order not to get sick. In fact, this is a concept that BCBS likely understands all too well. It's likely that they don't want to eliminate private family physicians. More likely, BCBS would simply like them to work for the medical equivalent of slave labor. In the case of Dr. Shirely Pigott, BCBS could have simply kicked her out of their contract. They had already found that her billing records were bloated and she had become a leader in bringing about change to challenge BCBS' own strong arm billing tactics.

BCBS never took that step, and that's likely because most of Dr. Pigott's patients never got sick. Her practice ultimately made them money. What BCBS wanted to do was pay her as little as possible for keeping her patients, and their insurance clients, well. This would be just fine if they were playing fairly and if the power was spread relatively equally between the two. Unfortunately, neither of those two happened.

It is likely that there are cases like Dr. Pigott's all over the country. It is likely that BCBS is trying to do such things to private family physicians everywhere. If that is so, then what BCBS is doing is destroying the market for future private family physicians. All those doctors who's job it is to keep us well will slowly disappear. While BCBS would like to keep them around at slave wages, that isn't how markets work. If it is impossible to make a good living in private family practice, then eventually medical students will stop gearing their educations toward that practice.

This campaign will have the future of health care at its center, and I doubt that anyone will talk about this case. That's too bad. This case of corruption and many others like it contribute just as much as any other reason to the skyrocketing costs of health care. It is my opinion that BCBS has decided to systematically weaken the one class of true capitalists in the medical system. If the system has been corrupted by one of the players, and the corruptor is sytematically making it impossible to work in another part of the sytem, then I would say that has just as much to do with the breakdown of the system as anything. Yet, none of the Presidential candidates are talking about cleaning up the systemic corruption going on in the system.

Did you know that health insurance providers enjoy limited exemptions to the Sherman Antitrust Act?

The exemption that the insurance industry has extends only to insureds. Insurance companies do not have an antitrust exemption in dealing with providers

Maybe, that's why in Texas BCBS holds insurance for about one third of all patients. Does it sound as though BCBS and the private family physicians enjoy relatively the same amount of power? In Texas, BCBS is nearly the only game in town as far as insurance providers. If you are a doctor and not licensed with BCBS, then I wish you luck in maintaining your practice. The doctor needs BCBS a lot more than the other way around. Thus, the old saying applies

absolute power corrupts absolutely

BCBS enjoys relative immunity from Sherman and the doctors have no choice but to use them. Is it really altogether surprising that the organization then goes on and attempts to corrupt the system?

Then, there is the media. Why am I the first media of any kind to publish Dr. Pigott's story? It certainly wasn't from lack of trying on her part. She approached most of the major media outlets in Texas. None of the print and television media followed up with this story.

This isn't the first time that I have been involved in a case of major fraud involved in the medical field in which the media has been nearly silent. I have covered the corruption at Grady Hospital in Atlanta, and there the AJC has been largely silent on the corruption as well. I also broke the story of a cover up of a serial killer nurse in South Carolina and in that case the media in South Carolina also refused to tell that story. Dr. Andrew Agwunobi has gone on a cross country tour of medical corruption and none of the media anywhere on his stops have ever done anything more than go through the motions in investigating him.

It is hard to know why the media won't cover this story, however I would bet that health insurance companies like BCBS are major advertisers. Their motivations are ultimately beside the point. Corruption only exists if the media fails to do its job. Until the media starts to take this sort of corruption seriously it will continue.

This problem won't be solved easily, but there is a good place to start. The place to start is by making sham peer review illegal and by the government on all levels making prosecution of its perpetrators a top priority. I have only scratched the surface with my reporting. There are thousands of doctors being abused by sham peer review every year. Not only does it disrupt and even ruin their lives, but it also corrupts the entire health care system. We can't solve the so called health care crisis if the system is corrupted. Hopefully, everyone reading this understands the implications of what it leads to. As we continue with the health care debate, it's time someone addresses the systemic corruption within it. Until we do, all other solutions will be of little use. A corrupt system is a broken one, and that is what we have in health care today.

For yet another case of corruption at the Texas Medical Board please read this story.

No comments: