Pharmaceutical Wholesalers Inc. File Legal Complaint Against OptumRx “Aligning Its Interests” with the Big Three Drug Distributors in US, Thus Acting as an Agent of the Government With Accreditation Processes

<p>This is a pretty interesting lawsuit and it includes named invidituals at HHS and CMS as well as participants.  You can view all the defendants included in the <a href="https://www.law360.com/cases/581cff6a5270e84d59000001">filing here.</a>   Being we are at the end of the Obama administration, the named directors Burwell and Slavitt in this case involvement once out of office may or may not still be included, but OptumRX portion looks like it won’t go away.</p> <p>This is basically collusion with the government giving exceptional regulation controls to OptumRX on <a href="https://lh3.googleusercontent.com/-nTq7yCVQmIU/WDHZppI5bzI/AAAAAAABM2o/Di60u0eZQ1Y/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="126" src="https://lh3.googleusercontent.com/-lTdcxFwJdc8/WDHZqc4qZgI/AAAAAAABM2s/C4HFa3C1W-Q/image_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a>the accredited distribution of drugs distribution of drugs in the US with basically setting up shop with only the 3 major distributors, and thus so it is making it harder for the secondary or smaller drug distributors to function and operate.  We know what less competition probably means, even higher prices at the drug store.  </p> <p>The lawsuit also points out that United Healthcare is a Medicare Part D insurer and with that fact it appears to be an “agent of the government” will also having the OptumRX subsidiary, the PBM manager having the authority to use the accrediting program called VAWD to basically let other smaller drug distributors in the game.  It would seem to make more sense to have pharmacies be accredited than distributors since they are the ones selling the drugs. </p> <p>OptumRX might be working to drive independent pharmacies out of business to and convert those customers to their mail order pharmacy or to Walgreens, their preferred pharmacy partner.  Recently there was a big partnership created there as well to allow higher profits via Walgreens.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p>The fear is that secondary drug distributors will be pushed out of business.  Effective October 1st, all prescription claims not not filled via a VAWD distributor could be denied.  There’s a long list of VAWD credited distributors.  Wholesalers in most states are already subject to inspection by state and/or federal regulators to ensure compliance so what’s the action with OptumRX to act as a 3rd party regulator of sorts?  All pharmacies who fill prescriptions are required to sign a contract with Optum, which I have read in some instances includes the pharmacists not being able to offer a cheaper cash price to the customer as they would be in violation of the contract.  </p> <p>Here’s an interesting tidbit on how OptumRX makes a ton of money from diabetes test strips, take notice of this and the <a href="http://www.pharmacychoice.com/news/article.cfm?Article_ID=1608884">entire article can be read here.</a>  Look at how this winds around with insurer United making big deals on test strips, but does this savings get passed on to the consumers, apparently not. </p> <p><em>“Tackling OTC supplies was the logical next step for OptumRX. OptumRX has a booming mail-order pharmacy business and diabetic test strips play a big role in their profitability. They champion one brand, Roche’s Accu-Chek, and by pooling their purchasing power get manufacturers to compete against each they secure steep discounts. To put this in real world terms: from a retail pharmacy, these <strong>test strips cost about $90 per 50 test strips to the consumer</strong> and is then adjudicated with<strong> insurance companies for about $95</strong>. However, with their steep discounts, it is <strong>estimated that OptumRX pays only about $10 per box of 50 test strip</strong>s because <strong>Roche only charges Medicare about $5 for that same box</strong>. </em></p> <p><em>This means that<strong> OptumRX stands to make up to $85 in gross profit per box, per month</strong>; multiplied by the diabetic population of their 65 million members, OptumRX is playing with real numbers. It sheds a lot of light onto American’s high insurance premiums and the resources they can call on to fight the legal action brought against their new bold policies in court.”</em></p> <p>If noting else, when you look at the big money that the OptumRX subsidiary of United is making, the paragraphs above shed some light on how this is happening and it’s all done with algorithmic business models with a series of algorithms for distributors and drug stores to jump through.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>Again states have regulations but now OptumRX in fact is becoming a 3PL regulation enforcer via the government on some of this?  I have read that OptumRX is giving folks some extended time to become VAWD certified before cancelling payments here and there, and wholesalers must already comply with the Drug Supply Chain Security Act (DSCSA) which requires the FDA to issue regulations regarding wholesale distributor and third-party logistics provider licensure.</p> <p>So basically smaller distributors who provide better drug prices might be edged out completely.  So again with more certification policies and adherence, is this going to fix any</p> <p> </p> <p>thing other than to allow OptumRX to charge more a the drug store counter and really accomplishe much?  Here’s the lawsuit on the “clawbacks” that are taking place when you arrive to get your prescription at the drug store with the OptumRX algorithms “front running” the script cost via the pharmacy software networks in place all over the US before you can physically even get there to fill your prescription too. </p> <h5><a href="http://ducknetweb.blogspot.com/2016/10/cigna-united-healthcare-face-class_16.html">Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store</a></h5> <p>I’ve often said it would be of real interest to have a video of a pharmacist filling a prescription via the software of the pharmacy benefit management systems in place at pharmacies today so the public can see what the process is for the pharmacist just to get you your bottle of pills, and maybe involving a call or two to the dreaded PBM pharmacy tech.  <p>Don’t forget that Optum 360 is now taking care of all your Quest Diagnositics lab bills too as their outsourcer.  Pay attention to the “too big to fail” health insurer, United with close to 300 subsidiaires that do all kinds of things out there outside of just insurance.  BD <h5><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</a></h5> <p>They’re buying up your doctors too, another reason you can’t keep your doctor as they own and manage physicians groups all over the US today.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html">OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</a></h5> <p>By thew way, if you have never seen how the automated prescription services work, take a look at this…complete audit trails that also feed <a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">medication compliance software data systems.</a>  That is yet another topic for conversation with flawed data using metrics about us that are flawed.  BD  </p> <p><iframe height="315" src="https://www.youtube.com/embed/SfXoQWnpIb4" frameborder="0" width="560" allowfullscreen></iframe></p> <p> <hr> WASHINGTON (Legal Newsline) - A not-for-profit trade association that represents independently-owned pharmaceutical wholesalers is suing a pharmacy benefit manager and the federal government over a new accreditation policy, arguing it violates various state and federal laws. The Association of Independent Pharmaceutical Wholesalers Inc., based in Pine Brook, N.J., filed its complaint in the U.S. District Court for the District of Columbia Nov. 4. </p> <p>The named defendants include OptumRx Inc., based in Irvine, Calif.; the U.S. Department of Health and Human Services; Sylvia Burwell, secretary of the DHHS; the Centers for Medicare and Medicaid Services; and Andrew Slavitt, acting administrator of the CMS.</p> <p>“OptumRx’s business relationships with the Big Three have resulted in the implementation of bad faith policies designed to steer market share away from the Secondary Wholesale Market and toward the Big Three,” AIPW alleges. </p> <p>For instance, AIPW claims OptumRx, in August, informed its participating pharmacies that effective Oct. 1, participating pharmacies were required to purchase all medications being dispensed to OptumRx members from a VAWD. VAWD, an accreditation offered by the National Association Boards of Pharmacy, essentially eliminates the secondary wholesale market, AIPW argues.</p> <p>“Plaintiff’s members have already been informed by their pharmacy customers that the pharmacies will cease ordering medications and supplies from Plaintiff’s members due to OptumRx’s VAWD-Accreditation Policy,” the association alleges. “This is because the pharmacy customers face PBM audits from OptumRx, whereby OptumRx actively threatens to ‘recoup’ 100 percent of funds paid to the pharmacy arising from the purchase of drugs from wholesalers such as Plaintiff’s members that are not VAWD accredited.”</p> <p><a title="http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system" href="http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system">http://legalnewsline.com/stories/511045586-pharmaceutical-wholesale-group-says-accreditation-policy-will-irreparably-damage-the-nation-s-prescription-drug-delivery-system</a></p>

Pharmaceutical Wholesalers Inc. File Legal Complaint Against OptumRx “Aligning Its Interests” with the Big Three Drug Distributors in US, Thus Acting as an Agent of the Government With Accreditation Processes

This is a pretty interesting lawsuit and it includes named invidituals at HHS and CMS as well as participants.  You can view all the defendants included in the filing here.   Being we are at the end of the Obama administration, the named directors Burwell and Slavitt in this case involvement once ou…

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Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

<p>Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers.  Cigna provides the insurance benefits and then it’s pharmacy benefit manager, PBM OptumRX (biggest revenue sector subsidiary of United Healthcare) that runs all their formulas via the computer and tells the pharmacist what to charge you.  (Video at the break below-watch it!)</p> <h5><a href="http://ducknetweb.blogspot.com/2015/10/if-you-are-insured-by-cigna-guess-what.html">If You Are Insured byCigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare</a></h5> <p><strong>I call this “front running” the consumer at the prescription counter if you will,</strong> as that’s a term we hear used in stock trading all the time and it’s somewhat a very similar model with providing the drug stores advance information before you can even physically get there to ask for a cash price<a href="https://lh3.googleusercontent.com/-q-UPZgdLZ_c/WAPNzlK3WoI/AAAAAAABM1o/Ujtb-Zpcwds/s1600-h/Clawback-Cigna2.png"><img align="right" alt="Clawback-Cigna" border="0" height="154" src="https://lh3.googleusercontent.com/-QhPJyRFePt8/WAPN0Pb6L0I/AAAAAAABM1s/2x_J2Gm4Ij8/Clawback-Cigna_thumb.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Clawback-Cigna" width="244"></a> from the pharmacist.  Markets work the same way with dealing on advance information provided by their brokers and investment analysts, before their clients get a chance to see it.  <strong>Less than a month ago, United Healthcare received the same type of lawsuit for doing the same thing.</strong>  Below are a couple links with some videos that explain how this works in the words of the pharmacists.</p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/05/be-aware-of-prescription-claw-backs-as.html">Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve</a></h5> <p>In my own observations, Cigna is kind of living under the thumb of United Healthcare right now anyway and if I were them I would not be too happy having a competitor meddling in various areas of customer data that probably goes beyond prescriptions as United is the second largest healthcare data seller out there, behind IMS.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/cigna-launches-new-company-careallies.html">Cigna Launches New Company, CareAllies To Manage Patient Care, Doing Same Things as Does Optum</a></h5> <p>Actually the data selling algorithms provided mostly by United Healthcare/OptumInsights even goes beyond prescriptions and such algorithms were sold to a subsidiary of Quest Diagnostics called Exam One and they use the same formulas to score you and sell that data as well.  Also, in case you missed it, United Healthcare will be preparing your Quest Labs bill as well.  Another United Healthcare company, Optum 360, to which Dignity Healthcare is a partner will be doing their billing for them.  Over 2000 Quest employees were let loose and rehired under the Optum 360 name, and we kind of all know what that represents for the employees with reductions in pay, benefits, etc. in order to save money as that’s why they outsource.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/09/quants-of-optum-carve-out-new.html">Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries</a></h5> <p>So how did this marriage occur?  <strong>United Healthcare under their “Optum” subsidiary bought a pharmacy benefit management company named Catamaran,</strong> who was the exclusive PBM (pharmacy benefit manager) for Cigna.  In addition, Catamaran was in a bit of hot water and partially responsible for getting Cigna sanctioned by CMS with denying drugs and access to care. <strong>Cigna was around 2 years into a 10 year contract with Catamaran </strong>and I assume that was a big lure for United Healthcare as with buying the PBM, they increased their OptumRX revenue by around 25% and there were about 8 years left on this agreement.  This sanction has been in place since January of this year (seems like a long time) and<strong> none other than former United Healthcare Executive CMS Andy Slavitt makes the call on when to allow Cigna to sell Medicare D policies again</strong>.  If you look at how this all came about and the competition with health insurers, it certainly gives the appearance that CMS Slavitt could very well be making sure his former employer, United Healthcare benefits.  </p> <p>Remember that<strong> HHS Secretary Burwell was able to provide pardons for Slavitt (so he could do his job, the reason) to discuss policy and healthcare business with United </strong>(to include the CEO) any time he wants, so who knows how often the two might get together for lunch and chew some healthcare policy and some fat.  Here’s the story on the sanctions levied against Cigna in January of this year.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-sanctions-cigna-no-more-selling-any.html">CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed</a></h5> <p>Cigna is also still saddled with yet another Ingenix lawsuit that has not completed and that goes back to the days when CMS Andy Slavitt as CEO of Ingenix was caught using algorithmic formulas to short pay doctors on out of network payments.  This was discovered by Andrew Cuomo and there were multiple class action lawsuits filed, including the big case from the AMA on the fraudulent activity in 2010.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/cigna-legal-case-with-ingenix-flawed.html">Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…</a></h5> <p><strong>United Healthcare had a $10.5 Billion dollar bond sale to acquire Catamaran PBM</strong> and wrap into OptumRX in record time with importing customers.  It was well stated all over the web outside of this blog that <strong>both companies were using “like” technologies</strong> so the process would be quick and easy.   Being a former developer and what I have seen over the years, there’s probably a good chance that Catamaran was licensing the old Ingenix or OptumInsights algorithms, as all the pharmacy benefit management software seems to come back to that being the tech or algorithms being used.  It’s not uncommon as for another example you have Cerner as  a reseller of Ingenix/Optum Revenue Cycling technologies with their medical records systems.  The link below gives you more information on the acquisiton of the Cigna Catamaran PBM by United Healthcare/Optum.  <h5><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html">United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</a></h5> <p>In addition last year United is getting into the workman’s comp area of pharmacy benefit management with buying Helios and the largest customer serviced by Helios is the US Post Office.  <h5><a href="http://ducknetweb.blogspot.com/2016/01/united-healthcare-buys-helios-workmans.html">United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses</a></h5> <p><a href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">The link at the bottom of this page</a> from the story reported (the source) has copies of the actual court documents filed against Cigna and United Healthcare and it’s called racketeering.  Be sure and check it out.  Most all the links in this post are prior posts from the Medical Quant that give you additional information relative to what’s going on.  Pharmacists are being told to not disclose the cash price unless you ask so be sure to ask. <p><strong>Pharmacists in this whole scheme are also required to use software to input data so PBMs can produce a  predictive secret score,</strong><a href="https://lh3.googleusercontent.com/-ygEDmyDQtho/WAPN0hN7ouI/AAAAAAABM1w/5I3HGXrY51Y/s1600-h/EQUIPP4.png"><img align="right" alt="EQUIPP" border="0" height="293" src="https://lh3.googleusercontent.com/-Yhjo_rObwDQ/WAPN01XTkCI/AAAAAAABM10/LliBi2CGen4/EQUIPP_thumb2.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="EQUIPP" width="288"></a> than can also be sold to predict if you will take your meds.  Read up on that one as well.  Most consumers have no clue they are being secretly scored with software that does produce flawed and bias data every time you fill a prescription.  One of the programs is called EQUIPP and recently Rite-Aid has rolled out this software to their drug stores and current users include Wal-Mart and more.  <h5><a href="http://ducknetweb.blogspot.com/2015/12/rite-aid-pharmacies-are-latest-to-begin.html">Rite Aid Pharmacies are the Latest to Begin Used Flawed Data Provided by the EQuIPP Platform Relative to “Scoring” Patients for Predictive Medication Adherence–The “Outlier” Patients…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p><strong>Do pay cash when you can at the drug store for your own privacy benefits when you can, even though you risk being coded at an Outlier by the software, it’s less other data that can get linked to you.</strong> </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to FixOutliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p><strong>You can click on the image to read a short screenshot on what they do and if you as a patient are not in the 80% percentile, your pharmacist is required to hammer you to bring their numbers</strong> up so they can meet their goals and sometimes even keep their jobs, as the culling effect on pharmacist performance is out there as well as what doctors put up with today. <strong>If you are a diabetic and your pharmacy uses the EQUIPP program, the pharmacists are required to hit you up to tell you to ask your doctor about statins so more drugs can be sold</strong>.  Of course this is where the pharma business comes into play here as well to boost their sales.  <p>It’s to the point now where there are way too many consumers getting hit with the “co-pay” algorithms of the pharmacy benefit managers and the health insurers, so lawsuits have been filed.  As a matter of fact the pharmacy benefit management business is so profitable it’s the #1 revenue stream for United Healthcare, ahead of their insurance groups and we’ll see if Q3 is yet another barn burner for them with PBM revenue.  OptumRX also just secured a 5 year contract with CALpers to manage all of their drug programs worth about $5 billion.  <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p><strong>There seems to be some rotten algorithmic eggs out there slinking around in the pharmacy benefit management business</strong> and they all do it to some degree but some are much worse than others. <strong>With the recent CMS 5 Star ratings of Medicare D insurers, it’s starting to stink over there too.</strong>  CMS has been running models created by United Healthcare for years and now some of them are either failed in concept creation or are failing as time are failing.  Humana is now being hit with a loss of CMS money for not providing “quality” care.  We all know these surveys CMS uses are a joke and now the algorithms compiling all of this are at the point to where they are hurting the stock of Humana and Cigna, who again is sitting under the thumb of United Healthcare with the PBM OptumRX.  </p> <p>If I were Humana, and this is just me speaking I would consider suing CMS and Slavitt on this point, and Humana has already put out a press release contesting the 5 Star ratings.  What you are seeing here is a diminish of available insurance for consumers, using flawed and evil algorithms <a href="https://lh3.googleusercontent.com/-hnSHs9PwzoY/WAPN1Q-laQI/AAAAAAABM14/otqoznra0Lw/s1600-h/CAP3.png"><img align="right" alt="CAP" border="0" height="84" src="https://lh3.googleusercontent.com/-it-CR4E6LBE/WAPN1nZn-YI/AAAAAAABM18/BOXPg2y7vjQ/CAP_thumb1.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="CAP" width="240"></a>with United flexing their power where they can to gain an edge. It’s getting to be pretty visible if you look as that’s how they grew their business, math and algorithms.  Watch the 4 videos in the footer of this blog to understand how this works as there’s not a ton of difference between some financial models and tweaked health insurance models today. I saw this evolving way back in 2009, but it takes a while for more to clue in, I get that.</p> <p><strong>The incest of United Healthcare with HHS/CMS began years ago when Lois Quam, a former big VP at United Healthcare took a leave of absence from United and worked at the White House as the senior advisor to Hillary when “Hillarycare” was created.</strong>  You can also see a lot of this incest over at the John Postesta created CAP (Center for American Progress) with several former and current United Healthcare executives as “fellows”, some even earning the name of a distinguished fellow.  Currently former Senator Tom Daschle, a big lobbyist for Aetna is one of the CAP’s distingushed members, along with others such as Larry Summers as with their financial interests.  <a href="http://ducknetweb.blogspot.com/2016/01/zeke-emanuel-joins-venture-capital_14.html">Zeke Emanuel</a> and Jonathon Gruber can also be found at the CAP, writing US Healthcare policy as contributors. <h5><a href="http://ducknetweb.blogspot.com/2015/11/hhs-joins-optum-labs-as-research.html">HHS Joins Optum Labs as Research Partner–Back Peddles Support of FDA Sentinel Program That Does the Same Thing-More Impact from the Six Degrees of Bob Rubin Running Healthcare in the US</a></h5> <p>Here’s another good read written by a former CMS analyst and Tillman pretty much lines up every player in the ACA and their connections to United Healthcare along with their actions in turning healthcare in the US in to a “Cottage Industry”.  I would guess she should know after many years spent on the inside track involved in ACA policy.  It’s along read but worth it.  </p> <h5><a href="http://hardnoxandfriends.com/2016/01/10/hillarys-obamacare-fraud/">Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/ Optum, and the Center for American Progress</a></h5> <p>Good luck getting any real anti-trust action going here as our head of the Department of Justice is also a former United Healthcare anti-trust lawyer during the time she worked at Hogan Lovells (current lawfirm name).  If you <a href="https://lh3.googleusercontent.com/-XOP8Lxs0BLg/WAPN2c40UOI/AAAAAAABM2A/kaODx1jwYbU/s1600-h/Zeke8.png"><img align="right" alt="Zeke" border="0" height="64" src="https://lh3.googleusercontent.com/-hgWpC4FyWAE/WAPN2uX_9FI/AAAAAAABM2E/iLrV5UZX5lc/Zeke_thumb3.png?imgmax=800" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" title="Zeke" width="263"></a>look over there you will find a few former Untied Healthcare lawyers working there today, including the one who wrote this letter of recommendation to Grassley to approve her nomination.  In addition with the expansion of the large number of urgent care clinics that United/Optum has opened or purchased (MedExpress) they have even more outlets to push their OptumRX pharmacy benefits to patients to gain more revenue.  <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/08/optumcare-doctors-to-get-allscripts.html">OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own</a></h5> <p>So here we have it, two insurers, Cigna and United Healthcare both using the same OptumRX (owned by United Healthcare) <img align="right" src="http://lh3.googleusercontent.com/-dclAvjnezyI/Vi7i3HcWjII/AAAAAAABMkc/j5mxORCgLmA/image%25255B4%25255D.png?imgmax=800" style="float: right; display: inline">PBM management company, both front running consumers at the pharmacy counter.  I always tell people, pay attention to what’s going on with the  subsidiaries of big insurers and follow the data algorithms to really see what’s going on out there today as you see very little mention in major  news today as insurers are some of their biggest advertisers, so we know what that means…<a href="http://ducknetweb.blogspot.com/2015/04/news-rigging-has-arrived-astroturf-and.html">news rigging</a> (grin).  Don’t think because you fill your prescription at Walgreens that the OptumRX data is not there on the pharmacist’s computer, as it is, they are connected everywhere.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/03/walgreens-signs-agreement-with-pbm.html">Walgreens Signs Agreement With PBMOptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts</a></h5> <p><strong>It doesn’t stop there either as “co-pays are in your veins” too with CVS buying Omni-Care and OptumRX with buying AxelaCare.</strong>  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/05/cvs-buys-omnicareselling-drugs-to.html">CVS Buys Omnicare–Selling Drugs to the Elderly Via Nursing Homes and Assisted Living Homes And Pays Over $2 Million Dollar Fine In California for False Advertising</a></h5> <p>Here’s another trick that is used to get more co-pay money from you from CVS.  <h5><a href="http://ducknetweb.blogspot.com/2014/10/cvs-to-charge-consumers-higher-co-pays.html">CVS To Charge Consumers Higher Co-Pays With Prescriptions Filled at Drug Stores That Still Sell Tobacco Products–Killer Algorithms Attacking Once Again To Make SureCVS Gets the Prescription Revenue And Your Data To Score And Sell</a></h5> <p>The data selling and predictive flawed modeling scores in healthcare and pharmacies needs an over haul indeed as today, it’s once again the consumer having to stay one step ahead of the “front running” of drug prices out there with the PBM algorithms that are there to test you and get more money from you every step of the way.  <p><strong>We just want fair drug prices and a stop to the<em> “tricky front running </em><a href="http://www.ducknet.net/attack-of-the-killer-algorithms/"><em>killer algorithms</em></a><em>”</em> that soak us for more money when we fill our prescriptions!</strong>   <p>Be sure and ask your pharmacist every time for the “cash” price and circumvent some of algo duping taking place out there today for profit.  BD <p> <hr> <script type="text/javascript" src="http://WVUE.images.worldnow.com/interface/js/WNVideo.js?rnd=703235370;hostDomain=www.fox8live.com;playerWidth=630;playerHeight=355;isShowIcon=true;clipId=12820629;flvUri=;partnerclipid=;adTag=News;advertisingZone=;enableAds=true;landingPage=;islandingPageoverride=;playerType=STANDARD_EMBEDDEDscript;controlsType=fixed"></script><a title="FOX 8 WVUE New Orleans News, Weather, Sports, Social" href="http://www.fox8live.com">FOX 8 WVUE New Orleans News, Weather, Sports, Social</a> A spreadsheet given to FOX 8 News by a pharmacist in the Midwest shows Cigna Health Insurance overcharged at least 70 customers for prescription medication in one month, at just one community pharmacy. The spreadsheet details how the insurance company paid the pharmacist $25 for an acne cream. But Cigna instructed the pharmacist to collect a $187 copay, overcharging the customer $167. That money went right back to Cigna. <p>"One of the claims that we brought in the case is a RICO case, a racketeering case," says plaintiffs' attorney Craig Raabe. "And part of the racketeering case is a scheme to defraud - essentially an entity is engaging in fraud use through interstate commerce. And that creates the racketeering. So, it's a term of art in what we do, but in common sense terms it's fraud - saying one thing and doing another." A Massachusetts woman filed the class action lawsuit against Cigna at a federal court in Connecticut, where Cigna's corporate headquarters is based.</p> <p><a title="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash" href="http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash">http://www.fox8live.com/story/33395259/zurik-cigna-faces-class-action-suit-amid-medical-waste-backlash</a></p>

Cigna & United Healthcare Face Class Action Suits-PBM Over Charging Customers for Prescriptions, OptumRX Pharmacy Benefit Management Software-“Front Running” Consumers With Killer Algorithms at the Drug Store

Here we go again.  If you haven’t figured this out yet, when you buy a Cigna Health insurance policy you get a two for one with 2 insurers.  Cigna provides the insurance benefits and then it’s pharmacy benefit manager, PBM OptumRX (biggest revenue sector subsidiary of United Healthcare) that runs al…

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Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries

<p>If you don’t know what a Quant is, take time out and watch video #2 in the footer of this blog as they are not just limited to working at financial firms.  As a matter of fact, hedge funds and banks can’t hire enough of the and the same holds true for insurers and other healthcare entities.  These are the math wizards today that are working without a net of any “proof of concept” any more and are just tossing a lot of models out there to see if they stick.  I know that’s a crummy way of putting it, but that’s the reality of folks being soaked on models and numbers<a href="https://lh3.googleusercontent.com/-QO1huLc4Ves/V92AEN8UY9I/AAAAAAABM0E/wF13WZgVGJU/s1600-h/image%25255B15%25255D.png"><img align="right" alt="image" border="0" height="78" src="https://lh3.googleusercontent.com/-CtZcwaQXId4/V92AE7cCDcI/AAAAAAABM0I/5rN3NG1tJRI/image_thumb%25255B9%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="244"></a> they don’t question, it’s the Dupes of Hazard society that exists everywhere today.  What the Quant do well, is to use math to create profits, no matter if it hurts individuals or not.  Look at what was recently done at Wells Fargo with the low level employees, as they didn’t just decide to sell fake accounts on their own, there was a pay for performance model created by quants with a number of carrots and probably some sticks attached.</p> <p>If you have not heard of the Optum 360 subsidiary, the link below will explain how it works and how the subsidiary solicits hospitals and other healthcare entities (now Quest Labs) to hand over their billing, also know as revenue cycling with the big hopes of saving money and collecting more money.  Employees are usually let go by the healthcare entity and rehired as an Optum 360 employee with maybe less pay and worse benefits.  I read some of the reviews from Dignity Hospital reviews on GlassDoor and they said the benefits were a lot worse once they came under the Optum umbrella.  You could almost say it’s an internal US H1B process as the pay and benefit results seem to follow the same pattern.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/04/mayo-clinic-is-latest-to-outsource.html">Mayo Clinic is the Latest to Outsource Revenue Cycling to Optum 360, A United Healthcare/Dignity Health Company Pursuing Hospital Contracts All Over the US For Profit…</a></h5> <p>The real deal here of course is the access to all the data as the data miners and sellers of the healthcare industry will take the data, score you and put the data into other “new” data bases and turn around and sell it.  This process is called repackaging and when this occurs, most of the time as consumers we have no idea where it goes or who originated the data.  As long as prescription data is not taken from a HIPAA covered entity such as a medical record, it’s out there for sale to who ever has the money.  Quest is also promoting their own “outsourcing” program with hospitals and <a href="www.prnewswire.com/news-releases/quest-diagnostics-completes-acquisition-of-clinical-laboratory-partners-outreach-laboratory-service-business-in-connecticut-300227605.html">just bought another hospital lab service,</a> so that makes about 5 or more they have bought.  20-30% of the services performed for hospitals with this service end up going to their own Quest diagnostic centers to be worked.  </p> <p>Subsidiaries of companies are something I have told all for years to pay attention to as that’s where all the data work is done and<a href="https://lh3.googleusercontent.com/-sUPaYPmhyqY/V92AFd84B4I/AAAAAAABM0M/LqEegYGImOk/s1600-h/image%25255B4%25255D.png"><img align="right" alt="image" border="0" height="138" src="https://lh3.googleusercontent.com/-DCiT1MZO3zc/V92AF8wyKTI/AAAAAAABM0Q/WM0FsT80Jtc/image_thumb%25255B2%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="288"></a> computer code is written to create big profits with running proprietary code that nobody ever gets to see or audit for accuracy.  </p> <p>ScriptCheck, offered by ExamOne, a subsidiary of Quest Diagnostics is a big data mining firm, and so how many were not aware that Quest has been in the data mining and selling business for years?  Anyone buying a life insurance policy could very well be investigated and a full data pull created to get information for underwriting.  Sure we know some of this is necessary, but when do they cross the line?  Any more it’s all the time as the data gets repackaged and resold with data mining.  They take the list of meds and try to “guess” what medical conditions you have or “might” get.  That’s the scary part is the “might” or what is abused today and openly called predictive analytics.  In this <a href="http://articles.latimes.com/2013/oct/21/business/la-fi-lazarus-20131022">article written in 2013, David Lazarius</a> does a pretty job with explaining how this works.  <p><strong>There is an update though as ExamOne bought a bunch of Ingenix (now called Optum Insights) algorithms in 2014</strong>.  We maybe all know that the former Ingenix subsidiary of United Healthcare is where current acting CMS administrator Andy Slavitt called home for a number of years and was taken to court over cheating on out of nextwork payment for MDs by using formulas beyond comprehension of most to inflate United Healthcare profits. <strong> I call it “Code Hosing”</strong> when I see this occur as you and I as a consumer have no access to either the math or the models used to create these profit centers and it ends up being a bunch of <a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">quantitated madness due to the fact that people are afraid to contest any form of math,</a> good math or bad math. <p><a href="https://www.linkedin.com/pulse/20141027182707-39299902-examone-acquires-assets-from-optuminsight?forceNoSplash=true">Heres a few clips that tell you all about Quest Diagnostics ExamOne service</a> and their purchase of the Ingenix MedPoint (OptumInsights) Algorithms in 2014 and what ScriptCheck is all about.    <p><em>“LENEXA, KS, October 27, 2014 / -- ExamOne, a Quest Diagnostics company and leader in helping insurers meet their underwriting needs, is pleased to announce the acquisition of certain proprietary assets from OptumInsight that support the ability to provide rapid responses to data inquiries for use in life and health risk assessments. The acquired assets will streamline and improve the ScriptCheck® service offered through ExamOne.”</em> <p><em>Along with ExamOne’s expansive suite of insurance services (also known as Policy Express) the acquired technology is designed to accelerate the underwriting process, improve risk assessment, assess the accuracy of health statements and discover undisclosed doctors<img align="right" border="0" src="http://lh5.ggpht.com/_v3zjJigoAPE/SkL9GOgy_rI/AAAAAAAATec/4yxb2jf7CV8/image_thumb%5B5%5D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px"> or medical conditions for underwriters.</em> <p><em><strong>About ExamOne</strong><br>ExamOne has provided a portfolio of services to the insurance industry since 1972. It has grown significantly through continuous innovation that meets the evolving needs of life, health and disability insurance providers and their customers. Laboratory testing was part of the company’s original services, which over time have expanded to include paramedical examinations, fraud detection, electronic data collection, and gathering attending physician statements and motor vehicle records. ExamOne also has expanded into helping individuals learn about their own health through its Inside Look™ product.</em></p> <p>Part of the real scary part about this agreement is that now Optum also will be able to get any biometric screenings provided by Quest as well.  We have all seen the nighmare Orwelian companies like Red Brick (which was started by a one time United Healthcare young exec) that are into<a href="https://lh3.googleusercontent.com/-DRG5tPihlZE/V92AGSOr7MI/AAAAAAABM0U/O5NN6zkMnyk/s1600-h/EQUIPP%25255B5%25255D.png"><img align="right" alt="EQUIPP" border="0" height="457" src="https://lh3.googleusercontent.com/-rKZvRY4yzrk/V92AG2s461I/AAAAAAABM0Y/Rc7GljKudEM/EQUIPP_thumb%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="EQUIPP" width="449"></a> monitoring every move we make and this looks like an open loop hole here for United Heatlhcare/Optum to get that data, what else can you say?  There’s nobody in their right mind that wants their insurance company to have all types of data and information that the insurer could easily miscontrue and take out of context to avoid paying a claim!  That’s what this does.  Actually it’s not just Quest and United Healthcare/Optum deal alone, we have a huge problem of “Excess Scoring” in the US taking place with consumer using flawed data, queries and proprietary code to where we do not have the ability to even correct it.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/09/excess-scoring-of-us-consumers-us.html">Excess Scoring of US Consumers, US Citizens-Scored into Oblivion By Proprietary Algorithms and Formulas, Never Duplicated or Tested for Accuracy-Profits of Big Business And A White House Executive Command To Continue the Abuse..</a></h5> <p>If you get a chance to talk candidly to pharmacists today, they’ll tell you all about what’s going on and how you are “scored” with every prescription you fill too.  There’s this EQUIPP program out there that tells them what to do and how to dig in and find outliers, some of which are diabetics who are not on statins.  The pharmacists who are forced to work this EQUIPP program model have to find their “outliers” or they could end up like the employees at Wells Fargo and be be out of a job if they don’t play the game.  In the drug industry, they couldn’t get doctors to push statins and other monitoring flawed data programs, so now the boom is lowered on your retail pharmacists who need their jobs.  Click on the image at the right and see what I’m talking about.  <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>So my guess here is that with United Healthcare/Optum having this new additional data of labs to query into the prescriptions, your lab tech could very well be the next person out there suggesting not only monitoring but also in a round about way, pushing more drugs.  <p><strong>This really even gets more interesting with the Quants of Optum and their models for profit as United Healthcare has a contract with LabCorp as their exclusive Lab and has had that contract since 2007.</strong>  Optum and United Healthcare already get all that lab<a href="https://lh3.googleusercontent.com/-k-dnOpmw8Ow/V92AHa6pxII/AAAAAAABM0c/SxBgk_dHybQ/s1600-h/image%25255B19%25255D.png"><img align="right" alt="image" border="0" height="101" src="https://lh3.googleusercontent.com/-W_L3qRa38CQ/V92AH4GFwtI/AAAAAAABM0g/qfsi9ppy29s/image_thumb%25255B11%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="187"></a> information from LabCorp and the contract continues until 2018, so that’s what makes this Quest deal interesting and data rich with data selling.  If patients all over the country are already being directed to LabCorp facilities, how would Optum get a chunk of this money?  I suppose the answer is what just happened with the Optum 360 subsidiary now getting do most all of the billing for Quest Diagnositcs, right?  <p><strong>Talk about quants working over time working both models of each lab to increase revenue, right?</strong>  Again watch video #2 in the footer and learn what a quant does as we have that same mentality running CMS with Andy Slavitt being both a former McKinsey consultant and a Goldman banker running everything.  All he is concerned about is numbers as he’s just an Algo Man who cares little about anything else.  Follow him on Twitter and it’s not hard to see at all. <h5><a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">The Rise of the Quants, Again! This Time In US Healthcare- Taming the MACRA Beast of Quantitated Madness For A Lot of Things That Are Probably Just Not True</a></h5> <p>So what happens when you get a lab test done?  Depending on the result of course, you might get a prescription for a drug, we all know that by now (grin), so look at how this data mining is working today.  With Optum having all the lab information will this have a tendency to push more drugs, and the drugs that are covered by pharmacy benefit managers that make the most profit for them?  It is not far fetched in my book <a href="https://lh3.googleusercontent.com/-XgfibL-ArlQ/V92AIYYGhaI/AAAAAAABM0k/HXiYtXMIqGc/s1600-h/image%25255B9%25255D.png"><img align="right" alt="image" border="0" height="194" src="https://lh3.googleusercontent.com/-suvBkbofYL0/V92AI4FEAxI/AAAAAAABM0o/4R765Soth94/image_thumb%25255B5%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="265"></a>at all as I used to work with data, wrote software and it’s how the mentality works.  If you haven’t noticed by the way, the OptumRX is the largest revenue stream that United Healthcare has now, larger than each of their insurance groups when compared.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>So this is adding yet another element of behaviorial scoring and data mining for profit if you will and we’re not getting any breaks on cost.  As a matter of fact, this is a good link to look at that explains the coupons and discount cards at the pharmacy, as they tell you how it works. </p> <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <p>Again, look at the subsidiaries of these big corporations and what are doing with data for your answers as it’s all there as the<strong> quants in healthcare keep modeling away to attain the best models for profit,</strong> not necessarily for better care, Moneyball as Optum calls it, which really only works well for baseball where everyone knows the rules, but with healthcare the rules change every day.  BD <p> <hr> UnitedHealth Group Inc.’s Optum health-services arm has struck a deal to oversee billing processes for lab giant Quest Diagnostics Inc., substantially expanding its growing business of handling such transactions for health-care companies. Under the 10-year pact, Optum will take over a number of key revenue-related services for Quest, including billing health insurers and consumers, and collecting and processing payments from both. About 2.400 employees who did such work for Quest will become Optum employees, but they will generally remain physically in their current locations.</p> <p><a title="http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800" href="http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800">http://www.wsj.com/articles/unitedhealths-optum-unit-to-oversee-quest-diagnostics-billing-processes-1473760800</a></p>

Quants of Optum Carve Out New Outsourced Billing Deal with Quest Labs, Will Also Serve to Enhance The Scoring & Data Selling Business Conducted by Both Companies via Powerful Subsidiaries

If you don’t know what a Quant is, take time out and watch video #2 in the footer of this blog as they are not just limited to working at financial firms.  As a matter of fact, hedge funds and banks can’t hire enough of the and the same holds true for insurers and other healthcare entities.  These a…

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“Sully”, The Government’s Flawed Algorithms and Simulations Were Wrong, What Doctors Can Learn From Pilots…

<p>I had to include the bit about the comparison here about doctors and pilots as this correlation over the years has been used so many times and some very strange writings as doctor are not pilots, but some folks seem to think the two are more similar than they really are.  What is similar is how they are “scored” by algorithms though, which are proprietary for the most part and nobody gets to see the magic black box formulas.  Aviation though does have one advantage though as they do have a real “black box” that does record data and the conversations and actions of pilots.  They try to do something like this in healthcare, but it doesn’t work as pilots are dealing with an object, which is a jet, but doctors are dealing with humans, a person, not a jet.</p> <p>As a matter of fact the only real correlation between doctors and pilots was revealed a few years ago where a <a href="https://lh3.googleusercontent.com/-yUVXdZ6cAzo/V9WFyFxYJoI/AAAAAAABMzk/3tCAymVzC10/s1600-h/Sully%25255B3%25255D.png"><img align="right" alt="Sully" border="0" height="309" src="https://lh3.googleusercontent.com/-uDmgPHpT3-Y/V9WFy30eB3I/AAAAAAABMzo/o3sQqr9C6VQ/Sully_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="Sully" width="205"></a>former United Airlines pilot duped even the AMA on the fact that he was a cardiologist and even had to <a href="http://retractionwatch.com/2011/04/13/remember-william-hamman-the-pilot-who-claimed-to-be-a-cardiologist-a-retraction-appears/">retract several papers he had written.</a>  William Hamman was a pilot for United Airlines who had started in med school years ago but never finished.  After he was exposed, <a href="http://abcnews.go.com/Health/MindMoodNews/fake-cardiologist-william-hamman-duped-real-doctors/story?id=12395288">his pilot job at United</a> soon disappeared.  So in my opinion only, this is really the correlation between doctors and pilots I ever found (grin).</p> <h5><a href="http://ducknetweb.blogspot.com/2014/02/what-can-healthcare-learn-from-aviation.html">What Can Healthcare Learn From Aviation? Watch Your Models As The Virtual World Can Be Far Different From the Real World When It Comes to Designing And Implementing Software & Hardware</a></h5> <p>I went to see the move “Sully” yesterday and that is the screaming value that I walked away with, <strong>don’t let flawed data and bad algorithms (flawed) produce inaccurate information that makes you begin to question who you are</strong> and use data to turn an individual who is hero into a zero.  The NTSB with their algorithms had it all wrong.  If you have read my blog for any amount of time, I preach this all the time on how folks get too wrapped up in stats and numbers and forget the “human” element and that’s what this move was all about.  Sure algorithms can be good as well and its more in the fact about how we use them for knowledge, and not about scoring people into data oblivion with flawed data and assumptions from Quants and Data Scientists who “think” they have the ultimate answers, especially in the area of predictive analytics.  </p> <p>Due to a lot of the over hype of the power of algorithms and how they are marketed, we have a real problem today in the fact that people can’t seem to tell the difference anymore on what’s a “real world” value and what’s a “virtual world” value.  I wrote about that initially in 2013 and it seems to be getting worse all the time, and so far I have not read any news stories of folks looking for Pokemon on a commercial airliner yet, but I have this feeling that the “dupes” who confuse both values will show up there soon as they have appeared everywhere else such as hospitals and police departments (grin). If you follow me on Twitter at all, I have a special name for this scenario, “The Dupes of Hazard Society”.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/virtual-world-values-and-real-world-we.html">Virtual World Values and The Real World, We Have A Big Problem: People Can’t Tell the Difference Anymore as Perceptual Madness Grows to Further Accelerate Inequality…</a></h5> <p>In the course of my life I have happened to run across and meet a couple other pilots who were in these types of life and death situations and there’s not a lot of time and in both of those instances, it too was the human element that saved the day, just like Sully did.  As a matter of fact, there is an airmanship award given every year by the Fraternal Order of Daedalians for the act of heroism by a commercial airline pilot. After seeing the movie and how the NTSB was stuck on their algorithms to turn the tide into discounting Sully, I feel he was left out of the award given in 2009.  <a href="http://www.daedalians.org/awards/george.htm">You can read about the award here</a> and see how no award was given in 2009.  Here’s a clip from the page that tells what the award is.  There are a number of awards and it’s mostly for the military but this is one award given to commercial airline crews.  If you look and see, in 2009, there’s no award for Sully on the Hudson river.  In 1998 you can see the award for <a href="http://www.memphisflyer.com/memphis/bruce-harris/Profile?oid=3704124">Bruce Harris from Delta,</a> who also “sucked in birds” and was able to save the day and all the passengers.  </p> <p><em><strong>“Lieutenant General Harold L. George Civilian Airmanship Award: A Daedalian trophy and award presented annually to the pilot, copilot and/or crew of a United States certified commercial airline selected by a Federal Aviation committee to have demonstrated ability, judgment and/or heroism above and beyond normal operational requirements. (First awarded in 1956.)”</strong></em></p> <p>Back on course, I couldn’t help  but notice how the movie created a “personal struggle” with Sully in the fact that after a while, you do have a tendency to doubt yourself and we all do it, so there’s nothing new about that, but when you have forces such at the NTSB pushing the envelope with flawed data and simulations, anyone would start to wonder if there was anything that could have been done differently.  The item they forgot which was brought out in the movie is the fact that this as a life or death panic situation and the flipping algorithms after the fact to try to show that the judgement on the part of Sully was purely wrong.  Sure continue the investigation to get to the truth, but to try and take away the heroism shown with this type of decision that had to be made with very little notice and the lives of 155 passengers, was obscene.  <strong>It’s like being in the “panic room” with a lot of company, the passengers.</strong>  </p> <p>Perceptions are a big part of our world and I liked the fact that the movie did address what I call Perception-Deception with the NTSB and their attitudes with their simulation algorithms.  I see this all the time where the Dupes of Hazard will fight with some math formulas and algorithms to death to defend their numbers which are usually based in an idea or thought that has no proof of concept.  Ok so now I get the chance to be tacky and take a dig as I see this every day with Andy Slavitt who runs Medicare in this country.  Everything he authors, talks about, etc. is all about numbers and he never goes to human side and we end up with a bunch of Quant models running healthcare with flawed data and methodologies.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/operation-perception-deception-into.html">Operation “perception-Deception” Into Full Swing in the US, With Killer Algorithms, Algo Fairies, Algo Duping, The Grays, and Of Course, Flags As Consumers Confuse Virtual World Values With the Real World…</a></h5> <p><strong>Indeed in the movie, Sully too had a bunch of “quantiated madness” and faulty simulations to deal with as well.</strong>  Doctors every day are getting ripped with flawed data and algorithms and scored into oblivion with things that are just not true as well.  You can read more about this at the link below at the quantitated madness dished out to their occupations by folks who bow to the all mighty algorithms without looking at the human side of care.</p> <h5><strong><a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">The Rise of the Quants, Again! This Time In US Healthcare- Taming the MACRA Beast of Quantitated Madness For A Lot of Things That Are Probably Just Not True</a></strong></h5> <p>So, sure Sully gets offered mental health counseling after the incident, and not being there, we have no <img align="right" src="http://lh3.ggpht.com/-6HDDm04lOwA/Ts0zq-EuFHI/AAAAAAAA4d8/nMT-KL0JEDY/image_thumb%25255B12%25255D.png?imgmax=172" style="float: right; display: inline">clue on what it could have entailed but again one could ask would such behavioral analytics serve a purpose to make one doubt themselves even further?  It could if the therapie were tweaked the wrong way.</p> <p><strong>Turns out I’m not the only one who writes about this topic</strong>.  I’ve writing about what I call <strong><a href="http://www.ducknet.net/attack-of-the-killer-algorithms/">“The Attack of the Killer Algorithms”</a></strong> for a number of years.  I saw it come to surface with the Occupy Movement as that was a cause without a cause you could say as the perception of the general public seemed to view it.  Deep down it was not without a cause, but they couldn’t find the focus and that’s because it was hidden in proprietary algorithms they couldn’t see, talk or relate too, but they knew something was wrong and that was sufficient to make a statement.  There’s a new book out by <a href="https://mathbabe.org/">Cathy O’Neil, a former Wall Street Quant</a> during the financial crisis that’s worth a read.  I have to be honest and say I have not read the full book yet, although I feel like I almost have as I have read her blog for years on the same topic, the dark side of big data that she covers.  I try to group together other like minds on the Killer Algorithms page of videos and links to help folks understand what’s going on out there.  For a preview of such, just scroll on down to the footer here and watch the 4 videos.  </p> <p><strong>“Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy”</strong> is the name of the new book and you can <a href="https://www.amazon.com/Weapons-Math-Destruction-Increases-Inequality/dp/0553418815/ref=cm_cr_arp_d_product_top?ie=UTF8">link here to Amazon</a> to find out more about it.  The book has been longer over due and she tells you how this insideous insidious “scoring” systems of algorithms works.  There’s some good examples on how teachers are “scored” and what happens to them when subjected to flawed data and flawed methodologies of “scoring”. <a href="https://lh3.googleusercontent.com/-1T-X0vt3giE/V9WFzQijODI/AAAAAAABMzs/yZI7oAgqSOg/s1600-h/image%25255B4%25255D.png"><img align="right" alt="image" border="0" height="193" src="https://lh3.googleusercontent.com/-KJ672vOBiEw/V9WFz-Y0qlI/AAAAAAABMzw/Tpnl68wFr3o/image_thumb%25255B2%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="133"></a> She’s a lot smarter than me and I used to develop software so I know as well as anyone does who writes or has written code on how dishonestly for profit can live in proprietary computer code.  </p> <p><strong>Cathy takes you to the next level up which are the mathematical models that are created before the computer code is created to automate “scoring” processes.</strong>  A model is written first and then comes the code that you can’t see, hear or touch.  It’s just there, gathering all kinds of data about you from God knows where and “scoring” you into some value system.  In her words, Cathy states we are all members of a cult without knowing we’re in one and that’s pretty much how it is.  To understand how this works, watch video #2 in the footer as the Quant documentary does a pretty good job for the layman to understand the basis of how these complicated formulas work.  <strong>In the words of Bill Gates “software is just a bunch of algorithms working together”.</strong>  </p> <p>As people we can’t be bias or are not supposed to to be, <strong>but what happens when the algorithms (that are created by humans) are bias?</strong>  Nobody’s doing anything about the <strong>“Code Hosing”</strong> that is taking place out there.  Again if you follow me on Twitter, I call <strong>it Code Hosing as that’s what it is, people being hosed with computer code they know nothing about other than how they are marketed to “trust it”.</strong>  People like Cathy have been urging the release of some of this proprietary “scoring” algorithms and code so we can see what makes it work, as how else can you validate models and code?  Want to see how you get scored every time you fill a prescription, something that all of us do?  Read the link below and see how these bias algorithms use all kinds of non scientific metrics to “score” you.  Pharmacy benefit managers get away with this garbage and soon the score may block you from access to some expensive drugs too.  This too is secret and you have no access to the score of methodology used to give you a prediction grade.</p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>If you watch the Quant documentary in the footer, <strong>Mike Osinski who wrote the software for the mortgage scams</strong> that took place and crashed the economy, he’s has some real words of wisdom for his part.  He wrote the software the banks used and states is was never meant to be used the way it was to refinance loans.  His best quote from the video is <strong>“with software you can do something about anything, create all kinds of virtual worlds to function in, but what really matters is what happens in the real world”.</strong>  That’s a fact as again as I mentioned above people get involved in chasing all types of virtual values and forget about the “real” world and God knows he saw it first hand.  I like the part where he coudn’t even sleep at night for all the bankers and financial folks wanting more code and as he said “you have to right, you can’t be wrong”.  What those words really meant though during that time was<strong> “you have to be right and shove the money to the direction of the banks”.  </strong></p> <p><strong>Virtual worlds impact and affect all of us</strong>.  I like to use the world of <strong>Volkswagon who cheated with their computer code</strong> as a damning example as everyone knows about it by now that they cheated with their proprietary computer code.  Stop and think about this as the company created a perfect little “virtual” world of cars that did not pollute; however, in the real world they did pollute, so be a <a href="http://ducknetweb.blogspot.com/2013/10/on-being-data-skeptic-modelers-have.html">skeptic when you need to be.</a>  Sometimes the only way get “get on” to the cheaters is when we notice the output of the algorithms not putting out results that can be trusted.  The link below is also another of Cathy’s publications that is worth a read as well from a few years ago. </p> <h5><a href="http://ducknetweb.blogspot.com/2013/10/on-being-data-skeptic-modelers-have.html">“On Being a Data skeptic- Modelers Have A Bigger Responsibility Now Than Ever Before”–A Must Read Essay, Start “Sniffing the Data”…</a></h5> <p>Charlie Siefe, NYU, in video #1 in the footer also tells you about the Code Hosing taking place today and how we all take in numbers that are tossed at us with nobody questioning what is written, context is everything indeed.   It’s interesting as his talk is a Google’s NY headquarters telling their employees how they get duped.  Big people with money and somewhat good intentions get duped.<strong>  We all remember how Bloomberg and Frieden who now runs CDS were duped on Big Gulp.  I</strong>t was just another model created that was supposed to change behavior on what size of soft drinks people could buy and it failed miserably.  I’m sure both of them would maybe like to erase this chapter in their lives of the <strong>Big Gulp Dupe</strong>, as it was so much in the news as well as it’s failure.  They sucked in flawed data and a big failed model.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/11/how-many-more-bloomberg-big-gulp-failed.html">How Many More “Bloomberg Big Gulp” Failed “Proof of Concept” Models Can We Sustain Before Everyone Splits a Gasket?</a></h5> <p><strong>Bottom line is that all of us as citizens in the US are “scored” into oblivion</strong> and why even get out of bed every day (satire) as <strong>we have these huge, heavy ball and chains of what are called “risk assessments” that are tied to our ankles</strong>.  We get tired of walking around with that excess weight, which is exactly what it is.  Shoot we are so risk assessed that one wonders so any of us have the right to walk around this earth as we are a risk to everything!  Sure there is legit scoring and qualifications that need to exist and those models are not going anywhere soon but we’ve taken “scoring” to a new limit to where nobody has much worth except the algorithms and those who worship those virtual values!  This not how the world is supposed to work.  </p> <h5><a href="http://ducknetweb.blogspot.ca/2015/09/excess-scoring-of-us-consumers-us.html">Excess Scoring of US Consumers, US Citizens-Scored into Oblivion By Proprietary Algorithms and Formulas, Never Duplicated or Tested for Accuracy-Profits of Big Business And A White House Executive Command To Continue the Abuse</a></h5> <p>Anway, back on course here with <strong>Sully, my big take from this movie is the fact that it did put “scoring”, flawed data, and bad models flat in your face</strong> on how we are looking at value today and the NTS<strong>B was worshipping the Holy ground of some flipping algorithms </strong>and tried to denounce a real hero named Sully.  </p> <p>All algorithms are not bad and they do help us with knowledge and better managment and skills, <strong>but somewhere along the line we got off course and are somehow bowing down to the all mighty algorithms and functioning in virtual worlds instead of the real world</strong>.  Give that some thought next time before you go hook line and sinker into a set of numbers, statistics or scores that are presented to you, before you give the numbers more credit than deserved. BD</p> <p>Just for good measure, here’s a few related posts from the archives here…</p> <h5><a href="http://ducknetweb.blogspot.com/2014/01/movie-her-good-example-on-how-folks.html">Movie “HER”– Good Example On How Folks Can’t Separate And/Or Unite The Virtual With The Real World, Billionaires Are Made Out of Those Who Know How to Keep These Areas “Gray” With Creating and Maintaining The Addictive Code That Does It…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/06/virtual-unreality-maybe-good-read-after.html">“Virtual Unreality” - Maybe A Good Read After the Fake Facebook “Science” Report To Help You Figure Out What’s A Virtual Value and What’s A Real Value Out There</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/01/silicon-valley-is-at-it-again-confusing.html">Silicon Valley Is At It Again Confusing the Public With Calling Risk Assessments a Form of A Diagnosis Tool…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/10/citizen-score-in-china-huge-warning-for.html">“Citizen Score” in China, A Huge Warning For America About the Loss of Privacy, Lifestyle and Personal Worth As Noted by the ACLU With This Orwellian Nightmare</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/05/the-great-math-mysterysoftware.html">“The Great Math Mystery”–Software Engineering-Looking for Where It Does and Doesn’t Work-The Physics Connection…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/06/when-models-are-too-complex-with-too.html">When The Models Are Too Complex With Too Many Bits of Data-Sometimes Quants, Data Scientists Just Guess and Assign a Number Value And “That’s Not Science At All “</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/03/obamacare-one-big-attack-of-killer.html">Obamacare - One Big “Attack of the Killer Algorithms” No Matter Which Direction You Turn, Compounded With a Lot of Government and Consumer “Algo Duping”….</a></h5>

“Sully”, The Government’s Flawed Algorithms and Simulations Were Wrong, What Doctors Can Learn From Pilots…

I had to include the bit about the comparison here about doctors and pilots as this correlation over the years has been used so many times and some very strange writings as doctor are not pilots, but some folks seem to think the two are more similar than they really are.  What is similar is how they…

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ICD-10 Conversion Allows Insurance Companies and Pharmacy Benefit Managers the Ability to Push More Drugs and Make Bigger Profits-The Illusion of Better Care Didn’t Happen-Cat Is Out of the Bag

<p>Everyone now has made the big change to convert from ICD9 to ICD10 Coding for medical billing.  When all of this was taking place, many said it would really not improve care and so far, that’s what we have seen.  The big coding change has not any impact in the “real” world; however when it comes to the “virtual” world the impact has been pretty big for analytics with insurance claim data.  It was an effort to where doctors and hospitals had to change their billing codes to add thousands of more specific codes.  Sure we all laughed at some of the codes and what they represented and some that would rarely be used if at all.</p> <p>The big sleeping monster on all of this is the use in behavior monitoring with all patients.  When fee for service items are billed by doctors and hospitals, this is the first code that is used to determine a diagnosis.  The second code is the CPT code which determines what the line item payment will be.  The two work together and the US is the only country that has this massive correction between the two for medical<a href="https://lh3.googleusercontent.com/-tWBotw6Xue8/V68k18unLrI/AAAAAAABMy8/j0A7lc_9qDE/s1600-h/image%25255B7%25255D.png"><img align="right" alt="image" border="0" height="143" src="https://lh3.googleusercontent.com/-KbTmiuOWJSM/V68k2kRMBdI/AAAAAAABMzA/W2ZsaJMws7E/image_thumb%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a> providers to get paid.  Sure in other countries is may be observed, but in the US, the coding is literally taken to heart everywhere as this is a linear function that doesn’t include the fact that with each patient you have variables, as no two people are the same, so it’s a bit of what I call Quantitated Madness.</p> <p>Most people have not a clue on how this works, but insurance companies are using “machine” learning technologies to further this linear process, which does become flawed as we do have “variables” with every patient.  Now when you visit your doctor and they submit a claim, those claims are being analyzed against machine learning technologies, which I prefer to call “trending” as that’s a much less concerting term if you will.  Sure we all learn and gain knowledge by following trends and patterns, but now it’s gone over the top and flawed data is being kicked out to your providers all the time, and in essence it is being used as a platform to push drugs.  </p> <p>Now insurers with their doldrums of “risk” assessing that doesn’t stop, doctors are being graded with these ICD10 numbers included on the claim.  If a doctor states that diabetes may not be managed perfectly by the patient with an ICD10 code, they get notes back from the insurance company about “compliance” with analytics that may not be true.  In other words, the information that is coming back to them is that they are missing an opportunity to prescribe more drugs, and of course all of this goes into the “magic” formulas they use to “score” our doctors today.  If you ever wonder why your doctor is in network today and then gone tomorrow, this analytical scoring of doctors from how they code a medical bill is part of the story.  I wrote about that a while back, “The Secret Scoring of America’s Doctors”.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/08/the-secret-scoring-of-americas.html">“The Secret Scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..</a></h5> <p>Ok, so you visit your doctor, discuss any chronic conditions and items you need to talk about related to better healthcare.  In order for the doctor or hospital to get paid for that service, they bill this information via an ICD10 code that describes the purpose of your visit.<a href="https://lh3.googleusercontent.com/-UUB5Z8eGbQY/V68k3d_DoyI/AAAAAAABMzE/fbJdGdO2TEM/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="142" src="https://lh3.googleusercontent.com/-fgOPxCW3l3M/V68k35A9qqI/AAAAAAABMzI/6o7nMdXN6Hg/image_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="451"></a>  Insurance have spent billions of dollars to create system that will take this billing, analyze it and then come back with so called “opportunities” for the doctor to evaluated.  I have included a screenshot here from Dr. Wes, who was kind enough to put this on Twitter so you can see what they are bombed with by the time the insurance company does all their expensive analytic processes.  In this example, the insurer (United Healthcare) is telling the doctor that the numbers, when crunched say that the patient is not at 80% compliance on taking their medications.  Again, this can be totally false as it is all based on a code which can be totally taken out of context.  This happens a lot today, not only in healthcare but in other businesses as well and that is how we end up with all these bias analytics. <p>Pay attention is this is the type of analytics that is being created about all of us and in this example, you can see, it’s clearly promoting a pharma agenda and of course we know United Healthcare has a big interest in this as OptumRX is their number one dollar producting revenue stream, more than Medicare Part D and their two other reporting groups.  Here’s what I wrote about the United first quarter and the second quarter was the same story with where the big money was coming in for 2016. <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>The company has clearly made a change in their operation to focus on partnering with big pharma to profit as a priority.  If you were not aware, that is how United Healthcare got started in business in the 70s as the first pharmacy benefit manager in healthcare.  They later sold the company to a drug company and used the sale profits to buy insurance companies and began as a healthcare insurance company. <img align="right" src="http://lh6.ggpht.com/-3szEXZPRIqQ/U7qv_R169gI/AAAAAAABKxc/evT7Y_hxGEc/image121.png?imgmax=800" style="float: right; display: inline"> A couple years later, Express Scripts bought the company from the pharmaceutical firm and so Express Scripts was able to get all the magical analytics code that runs today, with even more compleities added.  Outside of this blog, many times over United Healthcare has been covered by many other articles that talk about the millions or billions the company makes selling your data as well. <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>So when you look back on this big push for ICD10 conversion, it has not done anything to provide better care for patients with doctors, but in reality added another level of complexity so you could be further “scored” and “risk assessed” by insurance and drug companies.  Again, with using linear measurement standards you end up somewhat being “scored” or “graded” on this so called curve of machine learning, which may not represent your entire health picture at all but ends up being more flawed data that doctors have to deal with and an analytics platform to push more drugs. From the consumer side, you are “scored” on what the Pharmacy Benefit Managers “predict” you adherence and compliance will be. Read the link below to find out about the 300 metrics used, that actually Express Scripts bragged about that are proprietary and hide the bias, all for the sake of creating these flawed scores relative to your behavior.</p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>Here’s a link from the archives that tell about Express Scripts buying those “Ingenix” algorithms to score consumers on medication adherence and this was the root of it as PBMs went over the top with their “flawed prediction” software.</p> <h5><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html">Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On IngenixAlgorithms–We Want the Revenue Please Don’t Stop</a></h5> <p>This further graduates to the retail pharmacists who fill our prescriptions and how they are graded on their pay for performance levels on how you are predicted to take your meds.  Sure this is always a work in progress chore and pharmacists over all do a good job, and the patient may be well in compliance but they worry too about this flawed data that “scores” them.  You read the link below and watch the videos on the threatening letters they receive if they give you a cash price that is less than your insurance co-pay is.  In other words, they get penalized for helping the consumer with price if it is not what the insurance company supplies.  Why?  They can’t track the data as efficiently if you pay cash.  <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <p>By the way, you cannot even get this “medication adherence prediction” score that is calculated about you from your “data” behavior as it is secret.  So you have two sides of this flawed at work, from the doctor side and from the pharmacy side with insurers beating both over the head with wanting them to further control your behavior.  We all know that one person can’t control another person, but this is the perception-deception being sold out there.  Education is still the best method and to rate and grade patients on flawed data analytics is just wrong and fraudulent.  <p>So there you have it, the big ICD10 change was not to provide better care for patients and has not done one thing to improve that as you can read the news every day, we are all paying for additional flawed analytics that go nowhere except into the profits of insurers and pharmacy benefit managers with perceptions of the data taken out of context and skewed to make everyone look worse than they are.  <p>All of this analytics work with claim data about you of course is all sold and CMS Slavitt (an Algo man, former Goldman banker and McKinsey consultant) is all over it with wanting <img align="right" src="http://lh6.ggpht.com/_v3zjJigoAPE/TLZdsFwnFqI/AAAAAAAAiIY/NIhj9oaZrLo/image_thumb%5B4%5D.png?imgmax=800" style="float: right; display: inline">to sell all this claim data as well so more companies can create even more flawed analytic scores about you so more software companies can jump into the “Code Hosing” game. Read more about that at the links below.  <h5><a href="http://ducknetweb.blogspot.com/2015/06/cms-chasing-wild-virtual-horses-big.html">CMS Chasing Wild Virtual Horses-A Big Distraction on the Hope of Finding Some “Algo Fairies” By Giving Entrepreneurs Access to Medicare Claims and Other Data…Marketing & Astro Turfing “The Sebelius Syndrome”..</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-medicare-proposing-more-data.html"><strong>CMS Medicare Proposing More Data Selling of Both Private and Medicare Patient Claim Data - A New Dignity And Privacy Attack on Both Consumers and Doctors</strong></a></h5> <p>So the cat is out of the bag, ICD10 was a new avenue for analytics in healthcare and does not one thing to produce better care, but was rather one more form of Health IT software that all were required by law to invest in.  So a little satire, here, why even as a consumer even get out of bed in the morning…you’re already risk assessed to the hilt!  We have no value when you look at all this nonsense and we all seem to be a risk to the world anymore.  What happens next on Infusion compliance?  As you can see insurers are buying those companies up as well.  Will each vein be risk assessed next?  There’s a ton of cronyism at the link below as well to include a discussion on Loretta Lynch as one example being a former lawyer who represented United Healthcare with anti trust lawsuits so you can see she’s in on the game or the dupe, one of the two.  BD  <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5>

ICD-10 Conversion Allows Insurance Companies and Pharmacy Benefit Managers the Ability to Push More Drugs and Make Bigger Profits-The Illusion of Better Care Didn’t Happen-Cat Is Out of the Bag

Everyone now has made the big change to convert from ICD9 to ICD10 Coding for medical billing.  When all of this was taking place, many said it would really not improve care and so far, that’s what we have seen.  The big coding change has not any impact in the “real” world; however when it comes to …

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OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own

<p>I’m starting to see more doctors in Orange County selling out their practices to United Healthcare’s Optum subsidiary.  Sometimes when patients go for their next appointment, in addition to see their doctor’s name on the door, it also now says OptumCare.  So now it appears at minimum <a href="https://www.optumcare.com/medical/locations/ca-orange-county/ocmg-huntington-beach.html"><img align="right" alt="WP_20160509_17_31_38_Pro" border="0" height="260" src="https://lh3.googleusercontent.com/-8J7WUJZ5Rz0/V6gUnXYM1OI/AAAAAAABMyg/p3uPnTCP6xc/WP_20160509_17_31_38_Pro%25255B7%25255D.jpg?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="WP_20160509_17_31_38_Pro" width="199"></a>that doctors practices that are owned outright by Optum will get Allscripts medical records and perhaps the affiliated doctors working for the Physicians Associations they own, such as Monarch Healthcare as an example.  The article was not explicit to explain enough about how this will work exactly.  If you click on the picture at the right, I did a snap shot of a new OptumCare Clinic in Orange County that was just opening and this is where a doctor recently sold his practice to Optum and they provided him with a physician’s assistant in his office and are running the operation.  Here’s a couple examples of the IPA affiliations at the links below. </p> <h5><a href="http://ducknetweb.blogspot.com/2011/08/united-healthcare-to-buy-huge-chunk-of.html">United Healthcare To Buy Huge Chunk of Orange County, California Managed Care Business with the Purchase of Monarch Healthcare–Subsidiary Watch</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2013/10/uc-irvine-affiliates-itself-with.html">UC Irvine Affiliates Itself With The Largely Managed And/Or Owned Orange County UnitedHealthCare Subsidiary Manifesto</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/05/memorial-healthcare-ipa-in-southern.html">Memorial Healthcare IPA In Southern California Has Been Merged Into MonarchHealthcare, a Wholly Owned Subsidiary of Optum Health, A United Health Company, “Lives and Providers Have Been Dropped From Inventory” At Memorial Healthcare IPA…</a></h5> <p>We all should probably know the squeeze is on the small practices to where the admistrative end of running a practice is under attack by the government with CMS and their new MACRA payment plan which is still up in the air as of this writing.  Practices of less than 24 doctors will pretty much be penalized and will not be able to sustain the cuts.  The new payment plan has no proof of concept and is just a model being put out there with a bunch of quantitated madness to again push more small practices out of business.  As an average, doctors who contract with United Healthcare get paid around 12% LESS THAN MEDICARE.  </p> <p>That will give you the idea of where all of this is headed.  In addition, the doctors who are affiliated via an IPA, Independent Physicians Association who are smaller practices no doubt will have to pay for the Allscripts EHR as wel.  I don’t know how it will work exactly for the “owned physicians” where Optum has bought them outright.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">The Rise of the Quants, Again! This Time In US Healthcare- Taming the MACRA Beast of Quantitated Madness For A Lot of Things That Are Probably Just Not True</a></h5> <p>In addition, there’s a lot of other interesting items taking place with Optum and Urgent Care centers as they have opened up some of their own and they also bought Med-Express, who runs urgent care centers and is also soliciting doctors to sell their practices to their company. <h5><a href="http://ducknetweb.blogspot.com/2015/04/optum-united-healthcare-buys-medexpress.html">Optum (United Healthcare) Buys MedExpress Urgent Care Business- 141 Full Service Clinics In 11 States–Company Advertises They Are In the Market to Buy Your MD Practice, As A “Too Big To Fail Insurer” Moves Forward With More Acquisitions</a></h5> <p>Other insurers don’t have the “fox in the hen house” with the Feds either like United does and has for a number of years and here’s one more example.  <h5><a href="http://ducknetweb.blogspot.com/2015/11/hhs-joins-optum-labs-as-research.html">HHS Joins Optum Labs as Research Partner–Back Peddles Support of FDA Sentinel Program That Does the Same Thing-More Impact from the Six Degrees of Bob Rubin Running Healthcare in the US</a></h5> <p>Below are a couple of links that tell you more about the secret fudning of $36 Million that was created to finance <a href="https://www.optumcare.com/medical/about-optumcare/health-care-providers.html"><img align="right" alt="image" border="0" height="99" src="https://lh3.googleusercontent.com/-Q5pZlaR9W4c/V6gUnz-UwhI/AAAAAAABMyk/ggkMWp9ssdU/image%25255B4%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a>this entire subsidiary of Optum, Optum Clinics Holdings as well as the money raised, huge bond sale to by the Catamaran pharmacy benefit management company, which also increased their business as Catamaran had a 10 year contract with Cigna so under the OptumRX subsidiary, United Healthcare picked up a ton of revenue there.  I don’t know much about anti-trust but enrolling with one insurer and having a pharmacy benefit manager from another insurer seems to be cutting down competition in the prescription arena.  You can read more about the Clinic Care side of this in Southern California and link to what’s going on in other states <a href="https://www.optumcare.com/about-optumcare/health-care-providers/practice-models-locations/california.html">from here.</a>  This link appears to be additional practices in <a href="https://www.optumcare.com/medical/locations/ca-orange-county.html">Orange County that sold their practices to Optum.</a>  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/07/united-healthcare-having-big-bond-sale.html">United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion</a></h5> <p>Here’s what is being advertised to doctors…again probably at that 12% less than Medicare payment schedule.  Here’s a link to the “practice acquisition” page with one <a href="https://www.optumcare.com/about-optumcare/health-care-providers/howard-bland.html">doctor talking about how he sold out.</a>   I used to drive by that practice all the time on my way home a few years ago, and it’s not a new one.  </p> <p><a href="https://lh3.googleusercontent.com/-_1sgRxRunDo/V6gUoczPZbI/AAAAAAABMyo/fVn01w-QpsU/s1600-h/image%25255B9%25255D.png"><img alt="image" border="0" height="158" src="https://lh3.googleusercontent.com/-pe1wP13h0kI/V6gUoxeUBHI/AAAAAAABMys/0si9jM_5ID4/image_thumb%25255B4%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="715"></a> <p>So now with Allscripts Medical Records, there will be more access to your data from the big conglomerate, that’s for sure.  Optum used to sell their own EHR called Care Tracker and they sold it off about a year or so ago.  Optum has been advertising for a while that they also want to be your medical records integrator, for AllScrips and a few other big companies. <h5><a href="http://ducknetweb.blogspot.com/2014/02/allscripts-ends-up-with-loss-for-2013.html">Allscripts Ends Up With a Loss for 2013 of $104 Million-United Healthcare Subsidiary Ready To Step In To Be An allscripts Implementer And Beyond…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2013/11/united-healthcare-optum-insight.html">United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond</a></h5> <p>So if you are a patient, be aware that many small practices are being bought by United Heatlhcare, and there’s also a bunch being purchased by large hospital systems as well.  When I took the picture above, in a small strip mall you had the OptumCare office on one side and a new Tenet MedPost Urgent Care Clinic opening up a few doors down, again a small strip mall, large enough for both?  BD <p> <hr> </p> <p>Health services company OptumCare, part of UnitedHealthcare subsidiary Optum, announced on Friday that it has tapped Allscripts TouchWorks suite as its electronic health records (EHRs) platform for its physician practices. Implementation will begin later this year, the company said. OptumCare serves more than 8 million people in 49 geographic markets. </p> <p>Allscripts will integrate its EHR and practice management software with the technology OptumCare’s physicians currently use. The combined technology and single platform will facilitate the integration of patient’s care across the ambulatory continuum of care, the company said.</p> <p><a title="http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/" href="http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/">http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/</a></p>

OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own

I’m starting to see more doctors in Orange County selling out their practices to United Healthcare’s Optum subsidiary.  Sometimes when patients go for their next appointment, in addition to see their doctor’s name on the door, it also now says OptumCare.  So now it appears at minimum that doctors pr…

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Hospital Mergers and Acquisitions-Providence and Southern California Based St. Joseph Get Regulator Approval to Begin the Process

<p>Irvine will be the home of a Providence St. Joseph system office once everything gets integrated.  The overall corporate office will remain in Washington.  This process began back in November of 2015 so the approval has now just been given for the merger to go forward.  The new company names combined both former company names.  </p> <p>This merger now creates the nation’s third-largest nonprofit health system.  There are five in Orange <a href="https://lh3.googleusercontent.com/-JxszddRzcE4/V2_pniB2DGI/AAAAAAABMx0/4MOOoyN4LP8/s1600-h/image%25255B7%25255D.png"><img align="right" alt="image" border="0" height="67" src="https://lh3.googleusercontent.com/-kGOx-tojEMI/V2_pobS1ZLI/AAAAAAABMx8/viFAxBREpSE/image_thumb%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="204"></a>county and six in Los Angeles county to come under the umbrella.  St. Josephs has a total of 16 hospitals and Providence has 34.  The hospitals in Orange County are St. Joseph in Orange, Mission in Mission Viejo and Laguna Beach, St. Jude Medical Center in Fullerton, and Hoag Hospital in Newport Beach and Irvine.  Hoag for many years has been Presbyterian affiliated and still is so this makes it interesting again as the facility is rolled up into Catholic healthcare ownership once again.  In case you missed it, Hoag already had their affiliation with St. Josephs a while back.  </p> <h5><a href="http://ducknetweb.blogspot.com/2013/02/st-josephs-and-hoag-hospital-in-oc-form.html">St. Josephs and Hoag Hospital In the OC Form New Healthcare Network Combining Hospitals</a></h5> <p>Also don’t forget you have St. Joseph rolling out this program with home healthcare too…so in time will we recognize some of the organizations caring for us?  It’s just an interesting question to ponder.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/02/st-joseph-healthcare-in-southern.html">St. Joseph Healthcare in Southern California Becoming a “Nurse Next Door” Franchisee-Acquiring 26 Locations With Option for Another 12–Their Current Private Home Care Business To Be Transitioned To This Model</a></h5> <p>As far as contracts, this may open things up again for physicians and insurers to do their thing so keep an open eye for such changes and rules that could be subject to change again.  In April, many patients received a check for $242.00 data breach that went back to issues with St. Jude and their medical records program at the time.  BD</p> <p> <hr> </p> <p>California Attorney General Kamala Harris has conditionally consented to Irvine-based St. Joseph Health’s proposed affiliation with Providence Health and Services. <p>St. Joseph will form a nonprofit corporation with Renton, Wash.-based Providence that’s referred<a href="https://lh3.googleusercontent.com/-rjGVCx0zsfA/V2_po1-KrXI/AAAAAAABMyA/CXcXYkst-ps/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="58" src="https://lh3.googleusercontent.com/-hh_lBa0iKwY/V2_ppDnaGrI/AAAAAAABMyI/J3cG-REHNm4/image_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a> to in filings with Harris’ office as Providence St. Joseph Health. The new entity would be based in Renton and keep a regional office in Irvine. <p>It would oversee a health system with 43 hospitals and 13,544 licensed beds ranging from Washington state down to southern Orange County and east into Texas. Local facilities include St. Joseph Hospital-Orange; St. Jude Medical Center in Fullerton; and Mission Hospital, which has campuses in Mission Viejo and Laguna Beach. <p><a title="http://www.ocbj.com/news/2016/jun/22/ag-grants-conditional-consent-providence-st-joseph/" href="http://www.ocbj.com/news/2016/jun/22/ag-grants-conditional-consent-providence-st-joseph/">http://www.ocbj.com/news/2016/jun/22/ag-grants-conditional-consent-providence-st-joseph/</a>

Hospital Mergers and Acquisitions-Providence and Southern California Based St. Joseph Get Regulator Approval to Begin the Process

Irvine will be the home of a Providence St. Joseph system office once everything gets integrated.  The overall corporate office will remain in Washington.  This process began back in November of 2015 so the approval has now just been given for the merger to go forward.  The new company names combine…

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