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medicalquack · 5 years ago

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AMA and United Healthcare Combine Efforts to Once Again To Push CMS To Institute Algorithmic and ICD Coding To Rip Off Patients/Deny Access–It’s the Next Chapter of Excess Scoring in the US To Keeps Inequality/Segmentation Rolling

If you have not seen the latest with these two, take a look at to how they want to use segmentation for profit. It is so much of a "One Trick Algo” World out there anymore, the can’t hardly create enough bullshit commentary to cover up what’s really going on. These two have been doing stuff like this for years, as I’ve written about a lot of it during the active years of my blog. Way back in the early days of small developers creating EMRs before the government got involved, there were many of us that just sat back and wondered why the AMA always showed full on preference for anything United Healthcare (namely the Ingenix subsidiary which was being run by former CMS director Andy Slavitt at the time) came out with. It just went on and on and you too can search in the web’s archives and find a lot of it, as well as just searching my blog for that matter. AMA has been making money selling Ingenix (now Optum) coding books forever on their site. Here’s a link from 2010 below as an example of the cushy AMA/UNH relationship over the years. ClickFreeMD Selling Software EHR, Practice Management Bundled Records Solution–Emphasis on AMA Endorsement And Software “Powered” by Ingenix–Tethered or Untethered Now we have this data plague as I call it of an issue of Excess Scoring. I wrote about that a few years ago as our entire country is totally whacked out on the fact that everything needs to be scored, and that’s not true at all, some of the best things in life are NOT scored. Here’s some back links. 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.. The End of “Consumer Common Sense” in the US-Fueled by Excess Scoring for Profit, Sustained By Media Publications Serving To Further The Inability For Simple Every Day Life Decisions… United Healthcare Now Offering Employers Wearable Wellness Devices- UnitedHealthcareMotion–More Data To Mine And Sell With Related Risk Assessment Scoring Processes About You-Excess Scoring Actually when I was communicating with a former CMS executive about this, they said it was right out of United Healthcare's 2010 report, the stratification report, which also went way over the top on telling people how UNH thought they should raise their kids and indeed this is right on the same line of thought with these ICD Codes. Doctors, nurses alike think the the AMA and United Healthcare are out of their minds and can see especially with Part D, its a way to lop on more risk so UNH can bill the government more money, called RISK FIDDLING. So get a load of this nonsense on how the AMA and United Healthcare want to code you, so they can use the result sin run you through a ton of other data bases to deny or allow access. That’s what this is all about if you haven’t figured it out yet. You should also know that once you get coded or tagged with this nonsense coding and US caste system type of scores, that it never comes off. You will be stuck with one of these balls and chains forever, so hey WTF, let’s score everyone with Z60.82 for Inadequate social interactions. This is such a piss poor model that I bet even the Quants that created it must be cringing, you know they don’t have to like or believe all the crap their employers want them to do but they have families to feed.

You are already getting the crap scored out of you every time you fill a prescription, and yes it’s the PBMS using this scoring system that was created with Ingenix algorithms that were sold to Express Scripts in 2010, yeah another Andy Slavitt algo game for cash, as UNH made him and his former partner, Senator Warren’s daughter, Amelia quite wealthy in 1999 when UNH bought their company, which was basically nothing more than a script discount operation and they made money from the PBMs. So here’s how the pharmacists are directed to “score” you or they can lose their jobs. Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data… The bottom line here is that the AMA and United Healthcare are making complete fools of everyone thinking that some brainchild coding is going to change anything, as it won’t, it will more than likely end up costing more money as of course it will end up requiring software updates, right…LOL…and the AMA will get paid royalties for creating new CPT codes that will have to go along to match the ICD diagnosis codes so doctors can get paid to throw you under the Bad Algo Coding bus where you will not only see potential limitations in care today, but this will follow you forever and make it harder for you to jump through more algorithmic hoops that the Quants will model. If you’re not getting this, then watch my video at the link below and then continue on to watch the 4 videos from others and see how far down in the algo toilet you might be. Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel Again I’ve been writing about algo abuse and and cheating code for years, and it’s happening everywhere, as with software you can do something about anything, create little virtual worlds where folks function and create new little virtual values, but what happens when the real world comes knocking? The dupes sadly go click on One Trick Algos for even a deeper saturation of perception deception. That’s what this coding BS for care here is all about and somebody needed to say it, as they are virtual values that will not end up helping you one bit, but the AMA and UNH will profit royally as they have practices algorithms deception for years. I think today it’s only 15% of the MDs in the US are members of the AMA, so many have dropped out as it’s more of a lobby for money now versus representing doctors in the US and this movement has been going on for years. UNH is and has been the king pin for Quant modelers for years so everything modeled mathematically from that corporation needs extensive scrutiny as it geared for shareholders first, patients second, the massive number of algorithmic subsidiaries tells that story well. We need to index and license ALL data sellers so we can get an idea of what’s really going on in the black box scoring algorithms executing code unknown everyday, and remember we just see the front ends so remember there’s a whole other reality in how those algos collect your data, score you, screw you, etc. for the sake of corporate profits. “One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control

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medicalquack · 6 years ago

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Algorithms Rule Us All--Automated Risk Scores…Tons of Error Bars, Bias and More-The US Digital Consumer Scoring System For Corporate Profit Keeps Raging On…VPRO documentary–2018

This is a great watch and lot of information from Cathy O’Neil, author of “Weapons of Math Destruction” and computer scientist Jaron Lanier. Nobody is minding the shop as you can’t ask a machine for an appeal or know how the machine computed the results. “Engagement is just a santized term for addiction”…says Lanier. “So when you are giving over control to an algorithm, it’s giving control to a company and until you get clear on that, you’re going to be taken advantage of”. That being said, give some serious thought to all these healthcare organizations promoting “engagement” as well as banks, credit cards and so forth.

There’s a sector on a man being denied parole by an algorithm and nobody knows how it was computed. There are cases where judges can’t overrule a decision for algorithms, and it frustrates all. This is what I have to say about the big data business as relates to black boxes. Also follow the plight of the “gig” delivery guy and watch for how that ends.

“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control

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..

“The mathematicians and programmers begin to realize that the algorithms that are among all these automated decision systems are not neutral and may contain errors. Because the smart code may then decide more quickly than people, the results are not only sometimes defective, but sometimes downright dangerous. Should we be blindly guided by the decisions of the algorithm?

Where should they complain if something does not go as it should be? Legislatives are also emerging in the judiciary. For example, an American prisoner had to sit longer than comparable prisoners because the algorithm, which establishes a risk score, gave him an inexplicably high outcome. And unlike the decisions made by a judge, it turns out to be virtually impossible to challenge the assessment of an algorithm.”

“Algorithms don’t just predict the future they cause the future…and are causing winners and losers…built by companies looking to profit”…Algorithms are being used to “commoditize” us.”

Big Data and Artificial Intelligence is not going to save us, the perception of this has turned out to be wrong. Again this is a good documentary that explains what’s going on out there and how you might want to wake somewhere along the line. I’ve been writing about the “Attack of the Killer Algorithms” for years. At one one point a few years back I was over 60 posts tagged as chapters with real life examples. I issued a warning of this back in 2012.

Big Data/Analytics If Used Out of Context and Without True Values Stand To Be A Huge Discriminatory Practice Against Consumers–More Honest Data Scientists Needed to Formulate Accuracy/Value To Keep Algo Duping For Profit Out of the Game

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“This Call May Be Recorded for Quality Purposes”..Heck Not, Millions of Algorithms Have Been Turned Loose to Listen To and Analyze Your Voice When You Talk To Your Insurance Company As Algorithms Continue To Take Over the World… Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

It’s Time To Look At Some of the Proprietary Code Running in the US–Too Many Companies and Banks Are Playing “Techno-God” Saying “Trust Me” With the Numbers and Stats…

Somebody Needs to Start Calling “Foul” On Proprietary Predictive Algorithms When They Cannot Be Replicated For Accuracy As This Accelerates Inequality and Promotes Even More Data Selling For Profit

FICO Medication Adherence Scoring Should Be Banned As It’s Quantitated Justifications for Profit That Hurts US Consumers Using Proprietary Algorithms That Cannot Be Replicated For Accuracy or Audited

Quantitated Justification For Believing Things That Are Not True And Using Mathematical Processes To Fool Ourselves-The Journalistic Bot Functionality Debuts As Media Can’t Resist

“Cybertopia-Dreams of Silicon Valley”-Documentary About Politics, Economics and Debate on Where is the “Real” World Today? The Producers the Takers and the Dupers…

Computer Scientist, jaronLanier Explains How Big Data Is Used to Limit Our Freedom–The Value of Your Personal Data…

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medicalquack · 7 years ago

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Pharmacy Benefit Managers Are Not Much More Than “Complex Well-Greased Algorithmic Human Scoring Machines” That Deny or Allow Access To Drugs To Create/Substantiate Big Corporate Profits

So let’s get down to what’s really happening here. Once upon a time the PBM models were a different type of creature but as time moved on they became less about a better and affordable price for prescriptions and more about and algorithmic machine to create profits, hidden for the most part as we can’t see the transactions written in computer code where every execution comes along and takes their chunk of money. United Healthcare created the PBM model back in 1976 under the name of Diversified Pharmaceuticals, which ended up ultimately being purchased by Express Scripts via SmithKline Beecham. Express Scripts also purchased another PBM a few years back called Medco, so combine all the algorithims with both companies and you end up with a massive collection of algorithmic computer code, there to create profits.

It was the feeling that too much corruption and price setting would occur if pharmaceutical companies owned pharmacy benefit managers so they divested themselves of the pharmacy benefit business and it got worse as the PBM businesses moved into the arena of the health insurance companies. Initially the PBMs were supposed to work as a partner to help insurance companies control costs, but it’s far from that today. Today all we see is a consumer “scoring” business that found out how to score you by mining and selling all your data to make big profits for the most part. Sure there’s still drug pricing in the picture, but it’s more about what the market will bear than it is affordability. What we have ended up with is more of a digital caste system with drugs that goes way beyond negotiating price and helps substantiate a digital caste system that is growing every year in the US. We don’t have the algorithms and the formulas to fight back and thus as consumers and small businesses we are just mowed under by what’s taking place and we have a Congress that is is flat out both too stupid to see it or has been sufficiently bought off by the big conglomerate, or both.

It’s hard today to even find really good journalism with the big media as they are all starving for revenue since Facebook came along with all their algorithms and functioned like a PBM to rob them of their advertising revenue so they are hanging on to what’s left on who pays for ads, and it circles right back to big pharma and health insurance companies, and nobody’s going to disturb what left of the golden goose that helps keep their doors open with new stories that give you the real picture today as they will not publish anything that will reduce what advertising revenue that they have left with anything detrimental reported about big pharma and health insurance companies. As I wrote a while back, news riggging is here, and done with algorithmic models that write the news for them today as well. It’s like your day trading software, you just plug in what you want and the software will write it up with a focus that you specify, or knock off news is also done this way, taking existing news and putting the bot to work t re-arrange an article (s) that’s already been written to create a new one with a bot that is smart enough to avoid any references that would create any plagiarism. It’s the way it works, with 60% of what you read today being produced in this fashion.

News rigging Has Arrived! Astroturf and Manipulation of Media Messages-TED Video About “The Fake Grass Roots” Of Big Pharma and Other Campaigns That Fool and Fool Again…

Coming back around to the PBM machines, these are all automated processed and you can’t see what’s really going on and it’s hard to make changes as they keep adding more layers of hidden computer code and then create a story that will dupe you into thinking that some new algorithmic processes are going to save the day for consumers, and that’s not true, the machines are there to create more profits, not a better world for us with getting our medications we need, they have a captive audience and they know it. If thing were really working the way they said they were, we wouldn’t have news stories and legal cases like this. You take the receipts, the cost as it’s been done many times on what you pay for your prescriptions, and you end up with the same thing, algorithms that lie to you and a big media service today that supports the algorithms that lie and cheat. It’s in your face and you can choose to look at reality or go off into a little virtual world where you convince yourself that this is just not happening, which many people do and then wonder why things are not getting any better.

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

It’s what I call a “One Trick Algo” world out there for consumers and the PBM business clearly leads the way in all of this with trickery used with computer code to make you think this is not the case. It’s all about selling, mining and scoring your data to rapidly increase the rate of inequality in the US and if you think that putting another layer top will fix things, you’re back in that virtual fantasy world as you can’t keep layering computer code and algorithms on top of bad models and expect anything to change, it will only get worse, more complex and that benefits corporate America when consumers have no clue about understanding the systems we are forced to deal with today, and you are told “just keep clicking” for those miracle fixes, which of course do not exist.

“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control

So there’s coupons out there for saving on your prescriptions, but did you know it’s just another pharmacy benefit manager financing the coupon? Why do they do it? They do it for money and and data. So as an example if your PBM is Express Scripts let’s say and you have a coupon from one of those discount card deals that will give you a better price, well it’s probably OptumRX (a wholly owned subsidiary of United Healthcare) that gives you the discount, so you’re still in the PBM game, just not the one that comes with your insurance plan to get your meds.

These coupons too all have what is called a “bin” number on them just like your insurance plan has and you can easily do a “bin” number search on the internet to see who’s financing the discount of your prescription. Drug stores have to pay a fee for the privilege of filling your prescription when a PBM card or discount is used and it’s called a DIR fee, and these get big as they do not all occur at the time of your transaction either. When you ask for a “cash” discount from an independent pharmacy the drug store gets to avoid this fee and can keep more of the revenue and not have to give it to the PBM. The DIR fees are yet another profit producing algorithmic machine of their own accord. Recently it was discovered that Caremark was charging their own CVS drug stores a much smaller fee than what was being levied on other drug stores where Caremark is the patient’s PBM, so this gets very involved with quants and analysts figuring how much profit they can make with these fees. Recently it was reported that the auditors at Publix Warehouse asked about the $25 Million Dollar DIR fees they had to pay, they didn’t know what they were and that’s a big charge so even the big corporations are getting screwed by the PBMs with these fees just to be able to fill your prescription. What a big profit making algorithmic machine, is it not?

So if you have one of those cards, the one getting the big profits are the company names attached to that “bin” number folks. A lot of pharmacists if you give them the chance will match that price or even give you a better price with cash, as both you and the pharmacist win that way versus having the PBM monster algorithms charging in to get their cut. Now we have Cigna wanting to buy Express Scripts so they can be liked United Healthcare and keep all that money, but there’s only one problem with Cigna being late to the dance here and that’s the fact that Cigna had a 10 year PBM agreement with PBM Catamaran which was bought by OptumRX (UNH) and there’s 5 years left, so no Express Scripts for those insured by Cigna, you have 5 more years of OptumRX unless they cut some kind of a deal and pay United Healthcare a boat load of money. Right now Cigna needs a bond sale to be able to buy Express Scripts as they don’t have enough money, so when’s that going to take place? I wrote this article back in 2015 when OptumRX bought Catamaran and few folks seem to be aware of this as they are too busy with their little virtual worlds of Facebook Follies and playing games I think.

If You Are Insured by Cigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare

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

Actually Express Scripts uses a lot of OptumRX algorithms already and has since 2010 with their bogus

black box scoring metrics, so yeah they’re already connected at the algorithms you could say.

Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On Ingenix Algorithms–We Want the Revenue Please Don’t Stop

And here it is a few years later, revisited to see what kind of a bogus data selling/mining business Express Scripts created with those Ingenix (Optum) algorithms, quite the deal when you are scored on bogus metrics every time you fill a prescription. Are you a man seeing a female MD, whoops that’s bad and do you have kids at home, that’s bad too as they will distract you from taking your meds. These companies get away with this crap and sell those scores to insurers right and left. So the choice is yours to start reading up and not being so stupid and speaking out and realize it’s an algorithmic computer code service that is running all of this.

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

Did you know FICO buys all this scoring data from PBMs and sells it too? Sure they want to cash in and mix this crap in with your credit scores! Please get angry about this and start speaking up as the well greased algorithmic machines are taking over your meds every way they can. Big pharma buys these scores too and if they can show that folks aren’t really taking their meds with a bunch of bogus stats, it helps them keep the prices high with their political campaigns for profit as they come back with arguments that patients are not taking their meds so why should they offer them for less! Look at the image from Express Scripts, they want to make the patients the problem! Non-adherence is not a disease to be cured, it’s the price of the drugs that adds to people not taking their drugs, wake up to the scam for bigger profits.

It’s pretty wild is it not that Express Scripts decided to turn medication adherence into a disease! It’s not a disease at all. They want you to think of it like you have cancer, diabetes, etc. Beware of PBM marketing for profit.

Be aware too of the next step of the PBM algorithms for profit, connecting coupons to your medical records. This is promoted to doctors to provide you with an e-coupon that goes directly to the pharmacy in lieu of using your PBM discount. When this is done electronically, you cannot ask for a cash discount from the drug store as the price is locked in and the drug store is electronically stuck with the DIR fee to pay that I discussed above. If you are offered one of these, have the doctor print it out and give the drug store a chance to match it with a cash discount instead of sticking it to the drug store. See how these algorithms for profit work and you had no idea at all. It’s PBM wars you could say as if you don’t use your PBM for your script, or you don’t have one, by using a coupon, a DIR fee is created for the drug store to pay and cha ching, cha ching they make some money.

PBMs want no prescription filled without a PBM getting a DIR fee, how they make the big money.

Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX

Actually if you pay cash the PBMs come knocking at the door of the drug stores in time as well if they can’t track a credit card transaction or one of these coupon things, along with any other data supporting a purchase and you’ll be labeled a non compliant outlier if you use cash as well. Get a load of that as the pharmacists at the drug stores get presented with lists of patients who are not compliant, only because they pay cash. See how these black box analytics are really bogus! PBMs are right in there pushing the war on cash. Too many cash clients make the drug store look bad, which is ridiculous!

Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…

I have quite a few more posts in the archives of this blog that explain a lot of this as well, read them and learn up as when you hear laws and rules are being created to control the costs of medications today, just laugh like I do at those attempts as they are fruitless and Congress is way too stupid

to understand how the well greased PBM algorithmic machines work, as you can’t change the machines with verbiage and expect any changed outcome, corporate America just codes around the verbiage and cheats if they want as the code and algorithms are all locked up in black boxes which nobody except the PBM has access to, so as long as they can tell a story that their code is complaint with verbiage, the nightmare lives on and nothing gets changed and they’ll keep telling you to go hang out in your little virtuals worlds of the Facebook Follies and the likes to speak out. Nobody listens to any of that anymore as well, it’s just a place to vent and you get trapped in their well greased algorithmic machines as well. Here’s a big part of the problem.

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…

Privacy Duping of America-The Intangible Threat Model Has Changed Significantly-Companies Hide The Code On the Web, $180 Billion Dollar A Year Business, Welcome to The Duperville World of Inequality..

So in closing I hope helped make the case and explained a bit more about the well greased PBM algorithmic machines that are in control out there, and the only way to do anything is to dump some of these black boxes and furthermore get to see their code that’s patented and running everything. Until something is done is, no laws, rules, etc. will have much impact, they just call in their quants and code around it. You can hear more of that from a presentation I did a few months ago where I spoke and spelled a lot of this out at a big doctor convention. Here’s a spoiler screen to the right…how do you like that patent? Time to wake up dupes and speak up. BD

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medicalquack · 7 years ago

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Optum/United Healthcare Quietly Sold Optum Hospice to Compassus in December of 2016-And Compassus Is Now Contracted Under Optum Services to Manage the Facilities, Services and Provide the OptumCare Doctors

Optum certainly kept this very quiet when they sold their hospice facilities to Compassus and I don’t think they even told their own investors. I could not locate any SEC 10k filings or even a Form D from a search I did and this sale took place a year ago. Optum is not not out of this business though, they want to manage it instead, just as they manage surgeons and physicians with Surgical Care Affiliates and OptumCare doctors. The worst nightmare for those in hospice has come true, the thought of Optum utilization managers prowling around Compassus Hospice facilities as they intend now to use Optum Hospice Services to manage them. The old webpage of Optum Hospice is now gone as well, and has been replaced with a page featuring “hospice services”.

Hospice care by the algorithms is what we are looking at here with even more undue and not proven analytical scoring of patients taking place at their last days of their lives. I think the screen from this Compasssus PowerPoint presentation on the revenue growth here tells the story of what this company’s (Compassus) goals are revenue and not patient care being the first priority. You can see the other hospice services Compassus has acquired as well as Optum. Their goal here is to create a model (made up of algorithmic functions) to design care for those patients in hospice services. One might also guess that OptumRX will be the PBM of choice for these hospice facilities as well, all part of United Healthcare.

And here’s the management plan as you can see below with touting the Optum Partnership. Compassus is owned by private equity firms, Formation Capital and Audax Private Equity. Private equity firms are currently draining the money out of nursing homes too, look at Kindred and HCR Manor (the one that Carlyle just walked away from as they couldn’t bleed it anymore). With Kindred being purchased by Humana and two private equity firms, we can just assume that Humana is in there to make money from their Humana PBM from the drugs prescribed with the hospice services and the 2 private equity firms might be looking for any assets they can find to drain to line their own pockets, so that future there for patients and their care seems to look somewhat dim. The real estate assets seem like they are always the first to be sold off, to leave the hospice and nursing home locations as “renters” for their facilities with high monthly payments, sometimes to another private equity firm held company that owns the properties.

So after private equity has finished bleeding US retailers to the point of bankruptcy, is this is the next level, nursing homes and hospice services for the next asset drain? It certainly is beginning to look like it. Unlike the retailer asset bleed, this time we are dealing with people’s lives and a big potential for patient endangerment, all for the sakes of the private equity companies being able to put more money in their own pockets.

Again, one has to wonder why this was kept secret and given no press at all, and it’s only now that the facilities themselves are making the name changes that this has come to light. I would search out a non profit for a family member for sure versus this hospice for profit group here, as that’s what hospice should be, for the patient and not come with a profit portfolio at the starting gate. BD via Blogger http://ift.tt/2E3FgRi

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medicalquack · 7 years ago

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Algorithms, Scoring Metrics, Privacy and more in today’s Healthcare business world–The Healthcare Algo Cartel

This is a video of a recent presentation I did at the 74th Annual AAPS (American Association of Physicians and Surgeons) meeting. I don’t do too much blogging anymore as I don’t want to be confused with all the “junk” news out there but thought this is worth a look and listen for all.

The presentation was initially intended for a physician crowd, but after I thought about it, consumers can learn a lot from this as well. We have too many folks today choosing “virtual” values and getting lost in the real world and don’t realize what goes on behind the scenes, and it’s a lot, things you can’t see rising from corporate America to gain control of us lesser valued serfs it seems.

Every direction you turn today, somebody is mining up some behavior data and scoring you today, so we have so many scores, and many of them secret, who knows what value some big corporation or government is putting on our head today? I’ve been writing about this for years and unfortunately we have gone beyond just good production software that helps us in life and in doing our jobs into a somewhat digital caste system. I used to write software and this is my attempt here to let the average consumer know more about what’s really taking place out there. I thought the Obama administration was getting way too virtual, but it seems the new Trump administration is just as bad with not seeing the real world and embracing virtual world values as well, so I guess it doesn’t matter which person or party is in control out there today, they don’t like the ugly real world and keep pushing virtual values on all of us to keep consumers in the dark.

I call it a “One Trick Algo” world and that’s what you’re getting too often out there today, some algorithms and computer code, written by corporate America to profit that tricks you into things you would rather not do if you knew the whole story. I call this “Operation Perception Deception”, which was a post I wrote back in 2015 and sadly it’s getting bigger every day. So take a look and see what’s going on behind the scenes in healthcare, and don’t deceive yourself too badly with virtual values as people can’t seem to be able to tell the difference anymore. BD

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medicalquack · 7 years ago

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Pharmacy Benefit Managers Invade Medical Records and Electronically Connect Cash Patients to RX Discount Cards-OptimizeRX-to SingleCare to OptumRX

This should not really come as a big surprise as what hasn’t the pharmacy benefit managment business touched? So what is OptimizeRX? Most have probably not heard of this software but it is a connect to EMRs that will send your prescription right to the pharmacy. Oh, now you say, well the PBMs do that and they do but what they have been missing is a way to collect data on patients who are not using their PBM prescription card or those who do not have one. It’s all about getting more data about you to “score” and of course sell those scores to insurers and other interested parties. Once the pharmacy has the transaction, it does not fall under HIPAA rules as it’s a prescription, linked to an EMR to provide a transaction. As we all know, your medications in an EHR are protected but again, I’ll repeat this for those who still think HIPAA is covered at the pharmacy, it is not. It’s been a sore spot for years with privacy.

If your doctor is using one of the medical records systems in the image at the right, they are partners with OptimizerRX. From the website:

“OptimizeRx® has developed an extensive network of EHR and eRx platform partners*, as well as partnerships with media and creative agencies, making it easy for marketers to achieve excellent reach with their HCP customers. View the partner network information below for details. EHR and eRx partners benefit from the partnership by adding OptimizeRx’s suite of services seamlessly into their platforms, providing relevant patient support, patient education and other services that are welcomed by their HCP customers. Integrating OptimizeRx into an EHR or eRx platform is simple and easy, and can usually be completed in less than eight hours!”

Did you catch this, it’s about marketing and at least they say as much. When you look at the executive page, you’ll find most of these folks came from the pharmaceutical business. Here’s another screenshot to “auto send” the prescription along with the RX pricing information direct to a pharmacy. What this means is the price is locked in and a pharmacist has to honor that as it’s aready in the data base, precluding the availability to offer a cheaper discount. Certainly it appears to make it easier for the patient, but is it the best price? We don’t know. In addition, the providers can print a coupon for those who say “no, don’t do that’.

This RX discount card also can text and email you. So there you go, it’s all about the data that drug companies and PBMs want on folks not using their PBM discounts. If you let the MD do the auto send, you’re stuck with that price and can’t compare. There’s this little item I wrote about a while back about medication adherence prediction compliance and if you are not aware of this game, read the link below and this has been around for a while and was originally created with Ingenix (OptumRX now) algorithms that goes back to 2010 when Express Scripts put out a press release on how they were going to score you, and they all do that now. This is some real flawed information too as the 300 metrics used have zero to do with taking meds. You get a bad nick for example if you are a male seeing a female MD and so on. This is not science, it’s behavior bullshit that at best may show trending. So this OptimizerRX is software to use the EMR to drag in the so called “Outliers” who pay cash and are not using a PBM discount. Part of the job of a pharmacist today is to identify their outliers and fix them, but if the data is flawed and they pay cash, it’s just a bunch of flawed data.

Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “outliers, Pharmacists Required to Fix outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…

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

So now we have talked about OptimizeRX (which just happens to sound a lot like OptumRX) let’s move to the next step here and talk about the discount card. Read the press release below, OptimizeRX has a partner called SingleCare, which actually resembles the HealthAllies company that Andy Slavitt and Senator’s Warren’s daughter sold to United Healthcare, except this one is free. SingleCare includes other available discounts, a few of them but hey well all know it’s about getting the pharma PBM money to support the entire project, not a 20% discount at a gym or free teeth cleaning.

OptimizeRx Partners Exclusively with SingleCare to Bring Patient Savings and Price Transparency to Healthcare Providers at the Point of Prescribe

SingleCare started out much like Script Relief (another RX discount card that markets under a ton of names run by Loeb Enterprises in New York) to get some users of the discount so they could collect money from the PBM. All the Script Relief cards make their money back from OptumRX on the fees and other charges and they pay independent sales people $10 a hit for every patient who activates a card. Script Relief was originally connected with Catatmaran, which was bought by OptumRX (United Healthcare) and played a big role with Cigna getting sanctioned by CMS for a long time from selling Medicare D policies. Here’s a couple archived links on tha topic and once the OptumRx purchased Catamaran, who was the in-house PBM for Cigna, all insured had a new PBM called United Healthcare (OptumRX) PBM.

United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion

So what kind of executives does SingleCare employ? Well you could probably guess this one easy enough, former United Healthcare and big time former Catamaran executives. Check it out. In addition the company also says it will bill patients who use their discounted MD, dental cleaning, etc. services. Yikes as a patient, I would much rather pay the doctor direct and not have some big corporate conglomerate chasing me who also wants my data to score and sell. Many MDs have already figured out how these virtual credit cards hit them up for big fees anyway, so they keep part of that money for giving you a discount.

Health Plans and Claim Clearinghouses With Virtual Credit Cards-Racking Up Additional Fees From Doctors

So what PBM do you think is supporting this? My guess would be OptumRX but you can’t find that stated anywhere, but hey put two and two together. So if you use the card, you are added to a PBM data base with data to score and sell and again, we think it’s OptumRX. If you noticed above, Allscripts is one of the partners and is it not a coincidence that all OptumCare MDs are required to use Allscripts? Here’s more on that topic along with a picture I snapped of one of their OptumCare owned MDs in the OC. Don’t forget too that all the Surgical Care Affiliate outpatient surgery facilities are now owned and will be run by OptumCare, so I might guess Allscripts will be over there too, or OptimizeRX will sign up more EHRs to bring in the SingleCare discount card over there too.

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

We also have this action going on relative to OptumRX and Catamaran with lawsuits being filed over the price of prescriptions when a cash offering is less expensive than what the PBM is offering.

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

Bottom line here is to get the algorithms connected to the EHRs now and get that price locked in and get the data from the folks who are not using a PBM price.

Also the MedExpress urgent care locations are also connected to, guess who, OptumRX and you might be seeing those SingleCare RX discount cards used there as well. United Healthcare also has another service they market where they want to be the EHR integrator for Allscripts and other medical record companies.

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

United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond

How convenient to be an EHR integrator and get that OptimizeRX connected in there to the medical records to promote the SingleCare discounts and collect data on folks who are not using their PBM program or are paying cash. By the way too, Optum is also now doing the billing for Quest Labs in case you missed that one. Optum does the billing of course for their very close partner, the Mayo clinic, who’s CEO just took a board seat with Merck Pharmaceutical. Are you seeing some kind of a pattern yet, maybe? Of course if you are insured by United, you have been told to go to LabCorp for years for actual tests.

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

The prescription discount game is heating up out there and Express Scripts doesn’t want to be left out as they too now have an RX discount card, called Inside RX which is a partnership with GoodRX, as they too didn’t want to get left out of the lucrative “fee” business here. Sounds like OptumRX was cutting them out of some of the money mabye, so off to Express Scripts they went.

Here’s a post I did a while back with some good videos from actual independent pharmacists that tell you the story on how the RX discount cards work and how a lot of time they might still be able to give you a better cash price that doesn’t support all this markeing.

The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

So backon topic here with SingleCare benefits, be aware of what’s going on with the algorithms of the PBMs as they are now invading medical records to get that script and and that data about you. I would be very careful about wanting to use any of the texting and email services they offer as they collect and monitor everything today and will “score” your behavior with their services to toss some kind of risk in a profile about you! Recently, VC arm of Optum/United Healthcare invested money in another cesspool Silicon Valley risk assessment company, Mindstrong to monitor people with cell phone behavior and when they get done scoring all that type of data, we’ll all be at risk for mental health issues if we “hesitate” on responding to text messages.

So be aware now as the PBMs have infiltrated medical records and stalking you there, with going beyond just regular PBM plans, they want to get data on everyone who pays cash to “score” and sell a data profile about you and your behavior. Once you get locked with with your doctor doing an automatic send to the pharmacy, the pharmacist may not be able to offer you a less expensive price if they have one to offer on your medication. BD via Blogger http://ift.tt/2stje6J

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medicalquack · 8 years ago

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“One Trick Algo World” Needs to be Licensed and Indexed–Spurious Correlations “For Profit” Are Out of Control

With prediction tools and apps being all the rage today, their reliability and accuracy are not always there. Before the word “prediction” took over, we used to have words like “trending” and number crunches used for a lot of what we saw, but today it’s the big buzz word “prediction”. Machine learning algorithms certainly can be useful but they too make errors. A while back I connected data selling to lack of privacy and it got some attention, but I think not enough.

Today as companies see revenue streams disappear from their line of business, they turn to the easy solution of buying and selling consumer data, but it just doesn’t end there, they have to do something with it to create value, and that line of business today is called “scoring”. It’s happening all around you and it’s evolved to what I call “Excess Scoring” as you have data scientists cranking and wrangling statistics and data every which way but loose to find out how to find some data with queries to sell. Bloomberg bought a data mining company which they intend to use in house and also sell to their clients so they can predict the behavior of clients. Bloomberg of course might be motivated as they stand to lose a lot of money when JP Morgan and Bank of America cut thousands of Bloomberg terminals which rent for $21,000 a year, which has been the life blood of the financial world for years. Replace that revenue, mine and sell data.

Bloomberg is only one of many examples out there too as you also see IBM pushing this cognitive data mining like crazy, and that’s what 13 quarter of declining sales and too many years of stock buybacks end up producing, where do you make up the lost revenue, mining and selling consumer data. Sure there are some value areas with mining big data when it comes to “real” research like some in healthcare, but even some of that gets blurred as you end up being marketed to believe some app is a diagnosis tool, when in fact it’s nothing more than another risk assessment that gathers, mines and scores you and sells the data and the scores.

CVS and IBM Watson Project–Please Make It Stop-13 Quarters of Declining Profits for IBM, Is This Is What We Get, More Algorithms Biting Us Constantly So More Data Can Be Mined and Sold Resulting In Excess “Scoring” of US Consumers..

Many healthcare companies get around the HIPAA areas with in fact not selling your data that they have, but rather just selling a “score” and there’s little HIPAA help there and with that, so goes any privacy. When computer scientists and Quants are under pressure to create a revenue producing model, things go a bit crazy and correlations become spurious and data becomes flawed.

Silicon Valley Is At It Again Confusing the Public With Calling Risk Assessments a Form of A Diagnosis Tool…

So what happens when the data becomes flawed? Are there avenues for consumers to use to correct the flawed data and scores being produced and sold for money, which by the way is a $180 Billion dollar a year business? Few and limited. Argus Analytics is one firm that buys up credit card data and puts out tons of “scores” about your behavior patterns. How many of you have heard of that company? Probably not many I would guess.

Argus Analytics Produces “Share of Credit Card” Data On Consumers - Digs Up The Dirt on Your Credit Card Behavior Patterns-US Consumer Protection Agency Is A Client-We Are Paying for Richard Cordray’s Slow Education Process

There have been some very faint efforts in Congress, they spend a lot of time talking about it, but again you have lawyers selling pixie dust that some magical new algorithms are going to protect consumers and on the deception goes. With indexing and licensing data sellers, at least we would know who they are and where go to corrected flawed data. Do we have that now? No! You can find some of them but not all, especially the obscure companies that are taking the data and “scoring” you and selling those results.

Senators Create a Bill to Go After the Data Brokers Selling Our Personal Data But It Doesn’t Go Far Enough-Tons of Companies And Banks Are Also Selling Our Data and Repackaging Information About Us…

BDEX is a “scoring” and data selling company, you probably never heard of. Take look over there and see what’s going on with “scoring” you and your data. They’re getting everything they can get their hands on and also tech and promote (and make money)showing others how to score you as well. You’ll find Live Ramp from Acxiom over there too as a partner, Acxiom one of the biggest data brokers around.

Most people have no clue that all their electronic transactions are for sale, there’s no privacy so use cash when you can if you want a little bit of privacy. It’s all over the place and read the link below on now how CMS wants to sell Medicare data (link below). Andy Slavitt, former director at CMS is a big promoter of “scoring everything and everybody” with a background of being a former Goldman banker and a high ranking United Healthcare Executive that racked everyone over the coals. His big claim to fame was the error producing Ingenix Algorithms with physician pay and then later with medication adherence predictions with Express Scripts, selling algos to them. The lawsuits still continue. CMS wants to ��approve” those who get the chance to buy and sell your Medicare data though, but we know how that goes, no regulation there as all as again, we don’t know who all the data sellers are in the US and exactly what they do?

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

Unfortunately Data Scores get used frequently out of context and you have no idea how many times and how you have been scored. When it comes to skewing a correlation to make money, data scientists and quants will stop at nothing if it makes money as their job may depend on it. So in fairness there’s some outside pressure to keep a job that might make them cheat a bit and go spurious.

The World Privacy Forum was all over this a couple years ago with their extensive report “The Secret Scoring of America” and it’s a good report. In virtual worlds everyone gets to be LeBron, but in the real world, there’s only one LeBron. We can thank Larry Ellison for those words of wisdom as sure he sees it loud and clear as well. He’s a software engineer by trade and people that write code and create software are all very much aware of the bad side, but choose whether or not to talk about it. Take note of the Alter egos of software engineers, data scientists and anyone who codes for big profits, i.e. Facebook.

World Privacy Forum Report - The Scoring of America: How Secret Consumer Scores Threaten Your Privacy and Your Future - One Big Element that Fuels the Continued Attack of Killer Algorithms & Demise of the Middle Class Creating Profiteering And/Or Denial of Access

As consumers it’s only right that we at least know who’s scoring us and using our data when it gets flawed. Are we to live out lives out with flawed profile created about us for the sake of corporations making big money selling it? Why even get out of bed every day when we are “scored” to the hilt with risk assessments that are like a ball and chain around our ankles I ask?

Junk Science Appearing Everywhere, Even The White House “PR Templated” Correspondence Creates Spurious Correlations…

Sure there’s some useful scoring going on out there and we need some of that but there’s a lot of it that’s gone over the top. Even UCLA this week came out and said they suggested to stop using the BMI to determine a person’s over all health. Data Scorers can take that number and wrangle it into a massive amount of other data bases and turn you into a huge “risk” assessment that shouldn’t be allowed to walk on this earth! That’s where we are getting today as more and more bogus risk assessments are created that are nothing more than algorithms and math models to make money.

Step one for any real privacy to exist is to determine who all the data sellers are and what they sell. I’ve had honest quants and mathematicians alike as well as the World Privacy Forum agree with this as a first step of action versus the whacked out perceptions that are being promoted out there now as privacy efforts. How about when you get (your data) gets repackaged and sold? None of the privacy dupes are talking about that and it does exist. If you don’t think this exists, you have been spending too much time living in some virtual worlds out there that exist. Look at the recent case with Uber and Unroll.me.

Anthem Data Breach–Crooks Want to Sell Data Too–The Impact of the “Data Selling For Profit Epidemic” That Exists in the US With Scoring Consumers Removing Access and Human Dignity

Prescription medication adherence scoring turns you into a non compliant Outlier and that data gets sold all over the place. Most have no clue on how much money gets made selling your prescription data. If you pay cash and they can’t find enough credit card data to prove you are filling a prescription, you default to being a non compliant Outlier. Nice, huh? How do you fix that? These scores are all secret and you can’t get them, so you now there’s a double whammy, secret scores and secret data sellers you have no access to, can’t fix anything as a consumer that corporations “score” about you for a profile.

The post below was generated by a conversation I had with a real pharmacist with these concerns. Read it and take a look at bogus metrics being used to substantiate your behavior, which of course as humans is subject to vary every time we change our minds, so a lot of flawed data reported about you here with their scores. The pharmacies have to make their numbers, not so much worry about how they educate you, just make those numbers using this flawed software.

Oh Crap, Now Hospitals Are Now Buying Data From Acxiom - Data Selling Epidemic Continues to Evade on Personal Privacy As “Algo Duped-Stat Rat” People Try to Implement Virtual Models That Won’t Work…

Again this is a calling for those in our Congress to stop and do something for the consumer, give us at least the opportunity to know who’s scoring and selling our data? We have to fight years ago to get that right for credit data and it’s gone way beyond that now with bringing in all other types of business entities with their secret scoring. I guess at some point when the data scientists correlate to the point to where their spurious numbers are too far even for the dupes of hazard society to believe, well who knows what we might see, attacks on data centers? So here’s my campaign that’s been out there for a few years now and I predicted this about 3 years ago too that data selling with skewing context about consumers would be the greatest attack on our liberties we’ve ever seen, all for the sake of corporations make money. Scroll down and watch the 4 videos in the footer for some additional information from folks smarter than me. BD

Index and License all Data Sellers- Who Are they? Put the brakes on this corporate profit making epidemic!

Related Reading from some archived posts:

Gamification–You Have Won and Now We Know All About You - It Didn’t Cost One Cent-Insurance Companies Have Games To Find Out More About You Too– “Attack of Killer Algorithms” Chapter 11

Congress To Investigate the Data Sellers - Need To Create a Law to Tax Them As The Algorithms Used For This Business Generate Billions of Dollars, Partly Why Corporate Profits Are So High - Remove the Medical Device Tax as They Produce Needed Jobs/Tangibles

PLOS One Abstract–Methodology for Detecting Manipulation of “P Values” To Show Significant Statistical Value, “Inappropriate Fiddling” Which Can Lead to “Algo Duping” Situations And Numbers

Hiding, Falsifying, And Accelerating Risk Has Become the Achilles Heel of the US Economy As the “Real” World” Clashes With the Values Created From a World of “Fictional Values” Of Formulas and Math

“Data Scientists”– An Oxymoron? Is Finding the Value in Data Bases Queried Together in the Business World To Make Money Actually Science?

Cathy O’Neil, Mathematician/Quant: Wall Street Quants The Culture, Big Data Mechanics, Algorithms, Data Mining, Lack of Privacy, Web Profiling, Health Insurance Profiles and Modeling Abuse…

Does the US Government Need a Department of Modeling and Algorithms–Is Data Addiction and Abuse the Next Up and Coming 12 Step Program, Some Classic Posts & Topics Revisited

Insurance Companies Are Buying Up Consumer Spending Data-Time is Here to License and Tax the Data Sellers-As Insurers Sell Tons of Data, Gets Flawed Data When Data Buyers Uses Out of Context Too

Big Data–The Data Science Code of Ethics-Designed By Those Who Create Models - Don’t Fall Victim To Write Fictitious Code and Models Just to Make Money With Clients Demanding Such

Modeling for Inequality With Segmentation, Insurance Industry Uses Backwards Segmentation As Some Models Stand to Threaten Overall Democracy

Data Floating Around the Web and You Don’t Know How It Got There? Time to License and Excise Tax Data Sellers–Identify “Flawed Data” Epidemic At The Root of the Problem

Licensing and Excise Taxing Data Sellers, Facial Recognition Yet One More Tool Used To Secure & Match Data - The Epidemic, Billions in Profits for Banks and US Corporations Using Killer Algorithms to Further Erode Consumer Privacy

FTC “Reclaim Your Name Campaign” Not Good Enough–No Path for Regulation Identified–All Data Sellers Including Banks, Insurers, Etc. Should Be Required to Buy a License

Data Selling Game Now Exploits the Non Regulated Billion Dollar Epidemic–”Data Dealer” The Attack of the Killer Algorithms Gamified

Pharma and Health Insurance Companies Pairing Up, Humana’s Analytics Subsidiary and Lilly To Figure Out How to Save (Make) Money and Provide Better Patient Care–Selling Research Data That Competes With FDA Sentinel Initiative

Insurance Company “In-Network” Complex Erroneous Algorithms Continue to Wreak Havoc With Patients and Doctors When It Comes To Coverage and Purchasing Insurance–Time to Begin “Sniffing Some Data”, To Include Labeling And Identifying Killer Algorithms

MasterCard As Well As Other Financial Institutions Using Big Data To Get Into Your “Online Pants” As Many Consumers Seem To Be Accidentally And Inadvertently Leaving Their “Internet Fly” Open

White House Office of Science and Technology Policy (OSTP) and MIT Co-hosting Public Workshop - Big Data Privacy-Not Possible Unless We License and Excise Tax The Sellers, The Corporate Profit Epidemic Continues to Spread

Big Data In Farming, Back to the Data Selling Business Once Again With Concerns of Where the Data is Sold and Who Uses It To Profit, Paying for IP With the Food We Eat Today

60 Minutes Blasts The Data Sellers, FTC Admits They Have Lost Control - Time To License and Excise Tax “ALL” Data Sellers, Banks, Companies, Etc. - Congress Needs to Act On This…

Fraud Algorithms Failing at Indiegogo Crowd Funding Site-Some Getting Through With Physicists Claiming the Technology Claimed Is Not Possible-Healthcare Related Apps/Devices

Limitations And Risks Of Machine Ethics (That Really Don’t Exist) - Abstract Basically Substantiating the Existence of What I Coined As “The Attacks of the Killer Algorithms”…

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medicalquack · 8 years ago

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DOJ Enters WhistleBlower Law Suit Against United Healthcare–Risk Fiddling for Profit, A Walk Back Down Ingenix Memory Lane Again

Here we go again, back to those Ingenix algorithms and business models, getting a rerun of sorts of what occurred in 2011. In 2011 there was one main lawsuit from the AMA along with many others that were filed (some being still settled) over using formulas that short changed doctors and patients on out of network chargees. In addition, all other insurers who licensed and used the formulas were also drug into court for settlements. This was a big deal and now we have another lawsuit with again, other insurers being named for using the formulas of Ingenix once again. Here’s a case that has not settled yet as an example and one that just recently settled.

Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…

Ingenix (Optum-United Healthcare) Lawsuits Still Bouncing Around Out There–One Recently Settled in New Jersey With Horizon Blue Cross Blue Shield That Was Still Using the Flawed and Corrupt Data Base for Out of Network Payment Calculations

A couple years ago Medicare said they were going to rerun the Medicare risk assessment scores, so there was no secret as to what was going to occur with an audit.

CMS to Rerun the Medicare Advantage Risk Scores–Dating Back to 2008 To Catch the Automated Risk Fiddlers of Said Insurer Fraud Amounting to Around $70 Billion–Be Ready For It…

There are other lawsuits on the books that have not settled yet in other areas, like this one with mental health that could go to a class action suit too.

Class Action Lawsuit Filed Against UnitedHealthGroup and Their Various Subsidiaries There Of Relative to Mental Health Claim Denials & Violation of Parity Laws

Here’s a back link to the big settlement by the AMA. Again this is only one of many and at the time I was writing a series of blog posts called “The Attack of the Killer Algorithms and this was chapter 19.

AMA Announces Doctors And Patients Can Expect To See the UnitedHealthCare/IngenixClass Action Settlement Checks In the Mail Soon - Out of Network Short Payments–Attack of

the Killer Algorithms Chapter 19

UnitedHealthcare ERISA Class Action Lawsuit Expanded to Include DME and Ambulatory Surgical Center Providers

If you missed this along the way, things go so ugly with the Ingenix name, United Healthcare changed it to Optum, which you see all over the place today, as they are buying up broke doctor practices and urgent care centers like they are going out of style. There’s 2 sides to United Healthcare, one that does insurance and the other Optum side that’s buying up and creating software was well as consuming and acquiring companies that have anything to do with doctors.

UnitedHealth Group Announced Re-Branding of Business Units-Focus on “Optum”–Changes IngenixName to OptumInsight

So again with this new lawsuit, which was created from the efforts of a high ranking former United Healthcare executive, not just an employee, we are seeing the same process again, Ingenix algorithms and models followed to fiddle with risk scores, make patients look sicker and get more money from the government this time instead of doctors.

Express Scripts ended up at one point in time a while back buying the old United Healthcare pharmacy benefit business and acquired some software and algorithms in the process and in 2010 was bragging how they are going to predict if you will take your medications. This flawed scoring still goes on today.

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

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

The entire lawsuit can be read here and there’s quite a few pages to the pdf to read. Benjamin Poehling was the former high ranking executive that filed the whistle blower lawsuit. It’s kind of uncanny that Poehling came from Arthur Andersen, where the current CEO of United Healthcare worked as Anderson’s CFO and all the Enron issues were on his watch. Enron lead to the end of the Arthur Andersen auditing firm due to fraud. Here’s a few quotes from the suit…

“United’s senior management push relentlessly to increase United’s revenue from risk adjustment. Tellingly, UHMR has assigned risk adjustment to its Finance Department, not one of its clinical departments. (Relator was assigned to his job despite having no clinical background.) In 2010 and 2011, UHMR has implemented projects referred to as “remediation plans”, “focus area projects,” or “affordability agendas” to increase IOI.

UHG engages in an aggressive and extensive effort to find a justification or pretext to submit risk adjustment claims for additional diagnoses—regardless of whether the patient had or was actually treated for the diagnosis in the relevant period by a qualifying provider. United’s program has some components that are broad-based, and others that target specific high value HCCs. As an overall goal, UHG attempts to reach each of its members at least once every two years through one of its programs designed to find additional risk adjustment claims.

Ingenix conducts chart reviews on behalf of UHMR, UHCS, and commercial clients. In the retrospective chart review process, Ingenix identifies provider charts to review and arranges for the charts to be collected. It uses both internal coders and also contracts with external vendors to review and code the charts. 129. These vendors review charts using a blind review. In a blind review, the reviewer codes every condition he or she identifies from the chart without knowing what codes the provider identified from the chart previously. Thus, the reviewer works from the raw chart material and reaches independent conclusions.

Under the COI program, United pays providers approximately $100 for each diabetes patient they assess for diabetes complications, submit a supporting diagnosis via a claim, and submit a medical record with matching documentation. In addition, it pays $200 for each doctor that receives training on the COI program and diagnosis coding. Recently, the COI program has expanded to other conditions that United suspects are frequently undercoded, such as chronic kidney disease (“CKD”), and chronic pulmonary disease (“COPD”).

Relator knows that at least the following United executives know about some or all of the problems discussed herein, and have participated in the scheme to continue submitting fraudulent claims and to refuse to correct previously submitted false claims: Stephen Hemsley, UHG Chief Executive Officer; Gail Boudreaux, UHG Executive Vice President and CEO of United Healthcare; Larry Renfro, Optum CEO; Tom Paul, UHMR Chief Executive Officer; Cindy Polich, UHMR President; Lee Valenta, Ingenix’s former Chief Operating Officer (and current President of Ingenix’s Life Sciences Division); Jack Larsen, former CFO of PSMG (and current CEO of UHCS); Scott Theisen, UHMR Senior Vice President of Finance; Jeff Dumcum, Senior Vice President of Ingenix; and David Orbuch, PSMG Chief Compliance Officer.

And this….

“United’s refusal to correct errors in its risk adjustment claims is so extreme that it submits risk adjustment claims to CMS for diagnoses taken from claims that it itself refuses to pay as being fraudulent and/or abusive.

United developed “playbooks” containing ideas for increasing its risk scores. These playbooks are garnering top-level attention at the company while the myriad problems with United’s risk adjustment programs and processes go unresolved. 195. United conceals the one-way nature of its risk adjustment programs from CMS and even its investors. For example, United’s remediation plan for 2010 that sought to increase IOI by $800 million allocated $100 million to “Project 7.” Project 7 was United’s codeword for initiatives to increase risk adjustment payments. The company used a codeword (as opposed to “growth,” “enrollment,” or “claims”) because it did not want CMS or other investigatory government agencies to know it had a campaign to claim an additional $100 million through risk score increases.

United customizes its kickbacks depending on the nature of its overall reimbursement arrangement with the provider group. The providers United chooses to pay additional amounts for increased risk scores are those that do not already have an incentive to upcode diagnoses. United uses three basic payment structures for its providers: (1) percent of premium capitated providers, which receive a percent of United’s CMS premiums for its patients; (2) “fixed” capitated providers, which receive PMPM payments from United that are not tied to United’s CMS premiums; and (3) feefor-service providers, which are paid based on the claims they submit to United.”

If you made it through those paragraphs you can easily see how complex insurers have made medical billing for sure. Once again we come back to the business models of Ingenix and some of the automation in the IRAD data base to work these claims. Here’s another billing subsidiary United bought, again we’re talking coding and billing here.

Ingenix (Wholly Owned Technology Subsidiary of UnitedHealth to Acquire A-Life Coding Software/Services–Tons of Money and Profit With Coding Transactions and Algorithms - Subsidiary Watch

I talk too about the United/Optum incest at times too with HHS and CMS and here’s a blast from a few years ago…this was the beginning of pushing “population health” that all know the term and nobody really knows what it does half the time to even include vendors of the algorithmic processes. This is where the government bought yet another United Healthcare model.

"Reach for the Top" Program Combines Prototype from Ingenix (A Wholly Owned Subsidiary of United Healthcare) for Public/Private Community Health Data on HHS.Gov Site

Simon Stevens, who is now running the NHS and worked at United Healthcare a few years ago had this to say…

United Health Care Says Cheaper Efficient Doctors and Reducing Hospital Visits by the Elderly Would Help Reduce the Cost of Healthcare

Former Acting director of CMS, Andy Slavitt claims Simon is a good friend of his and let’s not forget that Andy Slavitt was the CEO of Ingenix when a lot of this was going on. Larry Renfro came in later from his executive position at AARP to run the Ingenix show.

United Healthcare sure seems to be lining up some big executives as well with last year hiring the former CEO of Stanford University Healthcare to work for United as a VP and recently in the UK, Optum hired Nick Seddon, who worked for David Cameron as his special healthcare adviser. There’s a group in the UK that is also bringing attention to the fact that one company, United/Optum has been taking over way too much ground and is not leaving enough competition out there with other countries.

The entire suit takes a while to read but there’s a ton of detailed explanations as to what United and other insurers taking advantage of their consulting and billing services are accused of. Again, do leopards change their spots? Here’s another suit you might want to read about…it just does not stop when you have complex built algorithms that can spin around faster than you can take a deep breath to score and stick you with more risks than you ever dreamed of, all for the sake of making money from the government.

Feel free to search this blog, there’s plenty of information like this written since 2008 on how companies cheat with computer code and algorithms…BD

United Healthcare, the largest provider of Medicare Advantage (MA plans) services, is being sued by the Department of Justice (DOJ) for fraud. To give you a sense of United Healthcare’s size consider that just their third quarter revenue was $46.3 billion, up 11.6 per cent from the same period a year earlier, and the bulk of the growth was billing services and data analysis for healthcare groups, which ws up 34 percent since the beginning of 2016.

Medical charts, the primary source of diagnostic data were reviewed looking for incremental increases but not for errors that would decrease the risk adjustment. New diagnostic codes were submitted, but an erroneous diagnosis was not deleted. On a two-way street, “they do not look both ways.” And these reviews were profitable, a $30 cost for chart review resulted in an average of $450 in additional payments. Ingenix sought to find additional diagnosis by using data analytics to identify practices, where chronic conditions were underreported based on population prevalences or where a new diagnosis was suggested by medications patients were receiving. Here the physician was contacted with patient assessment forms (PAFs) to consider these diagnoses for the patient. Physicians receive a small fee for reviewing these PAFs. Ingenix also developed initiatives designed to get patients to visit their doctors each year. But wait a minute, these programs encourage physicians to screen patient’s more carefully and to encourage annual checkups.

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medicalquack · 8 years ago

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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 out of office may or may not still be included, but OptumRX portion looks like it won’t go away.

This is basically collusion with the government giving exceptional regulation controls to OptumRX on 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.

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.

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.

Walgreens Signs Agreement With PBM OptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts

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.

Here’s an interesting tidbit on how OptumRX makes a ton of money from diabetes test strips, take notice of this and the entire article can be read here. 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.

“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 test strips cost about $90 per 50 test strips to the consumer and is then adjudicated with insurance companies for about $95. However, with their steep discounts, it is estimated that OptumRX pays only about $10 per box of 50 test strips because Roche only charges Medicare about $5 for that same box.

This means that OptumRX stands to make up to $85 in gross profit per box, per month; 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.”

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.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

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.

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

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.

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.

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

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

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.

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

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 medication compliance software data systems. That is yet another topic for conversation with flawed data using metrics about us that are flawed. BD

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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.

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.

“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.

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.

“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.”

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medicalquack · 8 years ago

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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.

If You Are Insured byCigna, Guess What You Have a New Pharmacy Benefit Manager Named United Healthcare

I call this “front running” the consumer at the prescription counter if you will, 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 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. Less than a month ago, United Healthcare received the same type of lawsuit for doing the same thing. Below are a couple links with some videos that explain how this works in the words of the pharmacists.

The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve

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.

Cigna Launches New Company, CareAllies To Manage Patient Care, Doing Same Things as Does Optum

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 tha represents for the employees with reductions in pay, benefits, etc. in order to save money as that’s why they outsource.

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

So how did this marriage occur? United Healthcare under their “Optum” subsidiary bought a pharmacy benefit management company named Catamaran, 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. Cigna was around 2 years into a 10 year contract with Catamaran 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 none other than former United Healthcare Executive CMS Andy Slavitt makes the call on when to allow Cigna to sell Medicare D policies again. 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.

Remember that 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 (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.

CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed

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.

Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…

United Healthcare had a $10.5 Billion dollar bond sale to acquire Catamaran PBM and wrap into OptumRX in record time with importing customers. It was well stated all over the web outside of this blog that both companies were using “like” technologies 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 as a reseller of Ingenix/Optum Revening 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.

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.

United Healthcare Buys Helios Workman’s Comp PBM and Their Other Related Businesses

The link at the bottom of this page 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.

Pharmacists in this whole scheme are also required to use software to input data so PBMs can produce a predictive secret score, 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 presciption. 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.

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…

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

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.

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…

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 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. 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. Of course this is where the pharma business comes into play here as well to boost their sales.

It’s to the point now where there are way to 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.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

There seems to be some rotten algorithmic eggs out there slinking around in the pharmacy benefit management business and they all do it to some degree but some are much worse than others. With the recent CMS 5 Star ratings of Medicare D insurers, it’s starting to stink over there too. 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 OptrumRX.

If I were Humana, and this is just me speaking I would consider suiing 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 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.

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. 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 distingushed 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. Zeke Emanuel and Jonathon Gruber can also be found at the CAP, writing US Healthcare policy as contributors.

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

Here’s another good read written by a former CMS analyist 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.

Building the Infrastructure of the Affordable Care Act: Hillary Clinton, UnitedHealth Group/ Optum, and the Center for American Progress

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 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 explansion 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.

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…

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

So here we have it, two insurers, Cigna and United Healthcare both using the same OptumRX (owned by United Healthcare) PBM management company, both front running consumers at the pharmacy counter. I always tell people, pay attention to what’s going on with the subsidiaires 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…news rigging (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.

Walgreens Signs Agreement With PBMOptumRX (United Heatlhcare) and Anthem Then Sues Express Scripts

It doesn’t stop there either as “co-pays are in your veins” too with CVS buying Omni-Care and OptumRX with buying AxelaCare.

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…

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

Here’s another trick that is used to get more co-pay money from you from CVS.

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

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.

We just want fair drug prices and a stop to the “tricky front running killer algorithms” that soak us for more money when we fill our prescriptions!

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

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.

"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.

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medicalquack · 8 years ago

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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

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 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.

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.

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…

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 just bought another hospital lab service, 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.

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 computer code is written to create big profits with running proprietary code that nobody ever gets to see or audit for accuracy.

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 article written in 2013, David Lazarius does a pretty job with explaining how this works.

There is an update though as ExamOne bought a bunch of Ingenix (now called Optum Insights) algorithms in 2014. 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. I call it “Code Hosing” 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 quantitated madness due to the fact that people are afraid to contest any form of math, good math or bad math.

Heres a few clips that tell you all about Quest Diagnostics ExamOne service and their purchase of the Ingenix MedPoint (OptumInsights) Algorithms in 2014 and what ScriptCheck is all about.

“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.”

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 or medical conditions for underwriters.

About ExamOne 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.

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 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.

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.

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

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.

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. Optum and United Healthcare already get all that lab 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?

Talk about quants working over time working both models of each lab to increase revenue, right? 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.

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

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 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.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

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.

The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

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 quants in healthcare keep modeling away to attain the best models for profit, 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

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.

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medicalquack · 8 years ago

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“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 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.

As a matter of fact the only real correlation between doctors and pilots was revealed a few years ago where a former United Airlines pilot duped even the AMA on the fact that he was a cardiologist and even had to retract several papers he had written. William Hamman was a pilot for United Airlines who had started in med school years ago but never finished. After he was exposed, his pilot job at United soon disappeared. So in my opinion only, this is really the correlation between doctors and pilots I ever found (grin).

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

I went to see the move “Sully” yesterday and that is the screaming value that I walked away with, don’t let flawed data and bad algorithms (flawed) produce inaccurate information that makes you begin to question who you are 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.

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”.

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…

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. You can read about the award here 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 Bruce Harris from Delta, who also “sucked in birds” and was able to save the day and all the passengers.

“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.)”

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. It’s like being in the “panic room” with a lot of company, the passengers.

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.

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…

Indeed in the movie, Sully too had a bunch of “quantiated madness” and faulty simulations to deal with as well. 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.

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

So, sure Sully gets offered mental health counseling after the incident, and not being there, we have no 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.

Turns out I’m not the only one who writes about this topic. I’ve writing about what I call “The Attack of the Killer Algorithms” 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 Cathy O’Neil, a former Wall Street Quant 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.

“Weapons of Math Destruction: How Big Data Increases Inequality and Threatens Democracy” is the name of the new book and you can link here to Amazon 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”. 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.

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. 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. In the words of Bill Gates “software is just a bunch of algorithms working together”.

As people we can’t be bias or are not supposed to to be, but what happens when the algorithms (that are created by humans) are bias? Nobody’s doing anything about the “Code Hosing” that is taking place out there. Again if you follow me on Twitter, I call 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”. 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.

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

If you watch the Quant documentary in the footer, Mike Osinski who wrote the software for the mortgage scams 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 “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”. 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 “you have to be right and shove the money to the direction of the banks”.

Virtual worlds impact and affect all of us. I like to use the world of Volkswagon who cheated with their computer code 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 skeptic when you need to be. 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.

“On Being a Data skeptic- Modelers Have A Bigger Responsibility Now Than Ever Before”–A Must Read Essay, Start “Sniffing the Data”…

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. We all remember how Bloomberg and Frieden who now runs CDS were duped on Big Gulp. It 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 Big Gulp Dupe, as it was so much in the news as well as it’s failure. They sucked in flawed data and a big failed model.

How Many More “Bloomberg Big Gulp” Failed “Proof of Concept” Models Can We Sustain Before Everyone Splits a Gasket?

Bottom line is that all of us as citizens in the US are “scored” into oblivion and why even get out of bed every day (satire) as we have these huge, heavy ball and chains of what are called “risk assessments” that are tied to our ankles. 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.

Anway, back on course here with Sully, my big take from this movie is the fact that it did put “scoring”, flawed data, and bad models flat in your face on how we are looking at value today and the NTSB was worshipping the Holy ground of some flipping algorithms and tried to denounce a real hero named Sully.

All algorithms are not bad and they do help us with knowledge and better managment and skills, 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. 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

Just for good measure, here’s a few related posts from the archives here…

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…

“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

Silicon Valley Is At It Again Confusing the Public With Calling Risk Assessments a Form of A Diagnosis Tool…

“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

“The Great Math Mystery”–Software Engineering-Looking for Where It Does and Doesn’t Work-The Physics Connection…

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 “

Obamacare - One Big “Attack of the Killer Algorithms” No Matter Which Direction You Turn, Compounded With a Lot of Government and Consumer “Algo Duping”….

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medicalquack · 8 years ago

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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

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.

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 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.

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.

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”.

“The Secret Scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..

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. 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.

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.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

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. 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.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

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.

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

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.

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

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.

The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

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.

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.

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 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.

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”..

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

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

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…

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medicalquack · 8 years ago

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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

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 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.

United Healthcare To Buy Huge Chunk of Orange County, California Managed Care Business with the Purchase of Monarch Healthcare–Subsidiary Watch

UC Irvine Affiliates Itself With The Largely Managed And/Or Owned Orange County UnitedHealthCare Subsidiary Manifesto

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…

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.

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.

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

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.

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.

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

Below are a couple of links that tell you more about the secret fudning of $36 Million that was created to finance 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 from here. This link appears to be additional practices in Orange County that sold their practices to Optum.

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…

United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion

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 doctor talking about how he sold out. 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.

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.

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…

United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond

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

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.

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.

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medicalquack · 8 years ago

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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 combined both former company names.

This merger now creates the nation’s third-largest nonprofit health system. There are five in Orange 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.

St. Josephs and Hoag Hospital In the OC Form New Healthcare Network Combining Hospitals

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.

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

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

California Attorney General Kamala Harris has conditionally consented to Irvine-based St. Joseph Health’s proposed affiliation with Providence Health and Services.

St. Joseph will form a nonprofit corporation with Renton, Wash.-based Providence that’s referred 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.

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.

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medicalquack · 8 years ago

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The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!

One thing we all hate is the high prices we pay in the US today for our prescriptions. Sure we do get some discounts, but that too has become an effort in algorithmic shopping to click here and click there to get the best price. It shouldn’t have to be that way, but it is as that’s how the systems have been built. There are a ton of discount prescription cards floating around out there and they all vary in one way or another, but the big thing to remember about all of them is that they are a marketing firm that can and will sell your data to make money. In addition, the discount cards act just like a pharmacy benefit manager with getting all your information when you use them to fill a prescription. In addition, some of them offer referral fees so they can increase the size of their data base of patient information. Data means money today and it can be repackaged and resold over and over, and yes, that’s us.

I found a video on YouTube done by a pharmacist that very well in detail describes how the whole process takes place and how these discount cards work. He tells you what to expect and how the pharmacist reacts and uses them for their required input when filling your prescription. He uses some real life examples on a couple commonly prescribed drugs with a brand name and a generic drug. Yes indeed some of this information makes its way to the big pharmacy benefit managers as well.

What is interesting too is that the pharmacist points out with one example, the patient is getting charged the normal “cash” price the pharmacy would have given anyway with an additional $4.00 as a fee added on, so before jumping into any of the discount cards, be sure and ask the pharmacist for the “cash” price first as you may not even need the card at all. It all depends and you have to really check each time. Again the pharmacist makes the point to where they have to send the discount card company information about you so you can get a discount when you use one of them to include the name of your doctor, medication name, etc. so the company now knows who you are, who your doctor is, date of birth, and more. The data is resold to market you for something else, or to compile lists of people taking certain drugs (sold to pharma as an example)

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When it comes to privacy policies, you get stuck with the same old legal routine with a policy written by lawyers to be interpreted by lawyers basically that has a lot of “double talk” in the verbiage. This is one big reason I have my campaign and have had it out there for a few years now to get Congress to pass a law to require all data sellers to be licensed-who are they and what are they selling! This really comes in to play when the data about you being sold is flawed and frankly the data sellers don’t care as bad data gets the same price as good data as nobody looks at the data. Why do you think there’s referrals promoting these cards-to get more data to sell!

Again ask the pharmacist for the “cash” discount first as you may not need one of those cards, so find out first. Some pharmacies will refuse to take the cards if the cost of the prescription causes them to lose money as well. I read somewhere that Wal-Mart with their $4.00 generic drug plans being pretty large, no longer will accept the cards. So again using the prescription cards, all comes back around to data for a discount and companies marketing such end up selling or giving the information back to pharma, other marketing companies or even companies like IMS, the largest data seller of health information in the country, making so much money they had an IPO last year and a lot of folks got wealthy from it.

IMS Health Buys Cegedim Information Systems to Include CRM and Intelligence Software - Data Selling Business Gets Healthier and Wealthier But Can’t Say the Same for the Health of US Citizens - It’s All About Making Money Selling Data, The Epidemic

So yes in short, the big pharmacy benefit managers work in one way or another with the big pharmacy benefit managers and can add to the their bases of prescriptions filled using these cards as the card folks sell it to them. I wrote about how pharmacies and insurers are now doing what is called “medication prediction scores” on everyone, and be aware it’s a secret and you cannot get your score, but your insurer can. FICO does this and thinks that everyone should run around with a “score” on medication just like we do with credit, but the big problem is that the data is so flawed everywhere you turn for their prediction scores. It’s a rip on consumers. See what Express Scripts tells you about these scores, and worse yet, they “brag” about these scoring algorithms!

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

I found a review on GoodRX, who does provide a listing of current drug prices on their website and they too are “doing data”. All you have to do is take a look at their job listings, and you get the picture of what’s going on over there with looking for Channel marketing director, email marketing director and from the data side a python developer (python is the choice of computer languages for the financial firms), and a java script contractor. With someone doing a review of the company it saves me the time of having to say a lot more about their card, and they focused on the same gray privacy policy you are starting to see templated on most web sites anymore.

They make their money charging the pharmacy a fee for the referral, and do reserve the right to sell data. It’s crazy that we have to jump through all kinds of hoops anymore with shopping for prescriptions, but that’s what the insurance and pharmacy business had created with their business models and contracts. Here’s another post below on what pharmacists call “clawbacks” with using a pharmacy benefit price with either your PBM or even one of the discount cards. You can end up paying more, so always ask for the “CASH” price first as pharmacy benefit managers are now telling the pharmacists they can’t volunteer this information, you have to ask. The RX Bin number tells the pharmacist who to bill. The discount card folks all have your data to do whatever they please with it as well as the pharmacy benefit managers and transaction records are accumulated.

Be Aware of Prescription “Claw Backs” as Pharmacy Benefit Management Profit Centers Continue to Evolve

Here’s another good video done with a taste of humor that explains the role of the Pharmacy Benefit Manager, the middleman cashing in big! It’s done well and the Pharmacy Benefit Manager is jumping all over the counter during the video, getting in the middle.

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So in short, we are all getting ripped one way or another and have to “play this game” instead of just a simple process of filling a prescription. The government has their hands in this till as well as now pharmacists are seeing patients with the use of another prescription monitoring program called EQUIPP to see your “star” rating if you are on Medicare as far as medication adherence goes. Yes indeed, before you even show up data has already calculated a score about you that shows how they predict you will be with compliance. It’s a real nasty game, and oh yes, those folks who use cash to pay for prescriptions, well they are now called Outliers as they can’t track enough data on you, so if you like and want privacy, pay cash. Rite-Aid is the latest to announce using the data mining compliance software from EQUIPP.

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…

The flawed prediction scores are indeed a dangerous business as they will end up denying you access at some point as well. “Give old Jane the cheap stuff as our numbers predict she won’t take the expensive meds”…as a simple example.

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…

As a matter of fact, take a look at the first quarter revenue from United Healthcare, as their OptumRX revenue is exceeding that of the revenue produced by their insurance groups, more money made by United Healthcare with their OptumRX pharmacy benefit management company than Medicare Part D policies..the world is changing and they are chasing the money. Within the last few weeks, OptumRX has secured a few large contracts, like CalPers retirement system, Texas employee retirement system, etc. so they do want to control what drugs you can get and when. Don’t forget the clawback video above as they are the pharmacy benefit manager featured in the news report, although they are all doing it.

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

Look what else gets involved with OptumRX pharmacy benefit management, infusion drugs so they may show up to provide that service for you as well. The link below about OptumRX buying the infusion company has a side listing of a lot of government cronyism in healthcare too if you want to read about it.

There’s a company that’s a subsidiary of United Healthcare, HealthAllies that was created by current CMS Adminsrator Slavit and Elizabeth Warren’s daughter (funded by Soros these days with her think tank) both former McKinsey consultants that will sell you a card to get both care and prescription discounts at the cost of $25.00 a month too. It’s very dirty and corrupt these days in healthcare to say the least.

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…

The discount card business has become very complex with just trying to get a prescription filled today and it’s done with complexities on purpose as everytime we don’t check something, we get fooled and pay more. This is what I call the world of the Attack of the Killer Algorithms as it is math models and computer codes that run everything so be aware, be very aware as it’s a game of being able to click for the right price anymore to the extremes and it shouldn’t be that way. BD

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medicalquack · 8 years ago

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Cigna Launches New Company, CareAllies To Manage Patient Care, Doing Same Things as Does Optum

By now we should all know the insurers are looking at ways to keep the cost of healthcare down and now it’s coming down to pretty much an “algorithm stick” for the doctors to deal with. This new company, interestingly enough is being headed from a former White House Executive, Dr. Julian Harris. He’s the former OMB Associate Director for Health. The revolving door between insurers and US Healthcare never stops.

Seriously, now when you look at one insurers page you get the same rhetoric about empowering and motivating physicians, same text different insurance carrier and I bet the doctors are a bit tired of the quantitated madness they deal with today as it’s not doing much for them. Just like Optum it’s a bunch of algorithmic formulas (and hey maybe they licensed some of those algos from Optum) to “score” and cut costs and access. Here’s what happened one time a while back when Cigna and most all other health insurers licensed United Healthcare (Ingenix, now named Optum) algorithms, lawsuits.

Cigna Legal Case With Ingenix Flawed Formulas for Out of Network Payments Allowed to Proceed Under ERISA, Can’t Avoid the Claims…

Our CMS is being run today by Quant mind sets and there’s like no changing it as they “think” all this quantitation is going to save the day. It will deny access and drugs at times though. As a matter of fact, Cigna is still on the hot seat for quality issues and currently can’t sell any Medicare Part D plans as CMS has them sanctioned.

I think there’s more that than the book cover myself as there’s this big merger with Anthem trying to take place as well and when you buy a Cigna plan now, you get another insurer, United Healthcare, under their OptumRX subsidiary to be your pharmacy benefit manager.

CMS Sanctions Cigna-No More Selling Any New Medicare Advantage Policies Until Algo Problems Denying Medical Coverage and Prescription Denials Are Fixed

Cigna was one of the first companies that started using software to analyze and determine your current state of mind over the phone with their customer service centers and they just about do that now, so be aware when you use the call centers for customer service, that your state of mind is being actively scored and maybe that data gets sold to some behavioral business too.

Insurers Certainly Like Consumer/Business Healthcare Apps: Subsidiary of Blue Cross Rolls & Couple Others Out $20 Additional Million in Funding to Audax First Backed by Cigna & Cardinal Health

A few years ago Cigna increased their Medicare HMO business by purchasing another HMO called Spring.

Cigna Buys HealthSpring Inc For $3.8 Billion, Who Bought Bravo Medicare HMO Who Had Profits of a Billion in 2010-Subsidiary Watch

It’s going to be interesting to see how the insurance mergers and all these “managed care” algorithms all come into play and you can look forward to more flawed data as they have built massive data lakes and the bigger the lakes, the more errors you get. I addressed that a couple years ago.

Health Insurance Business Is Driving Itself Off a Cliff & Doesn’t Know When to Stop With Collecting, Analyzing and Processing Non Relevant Data With Little Or No Impact On Giving Good Care..

It is also interesting to note that HHS Healthcare.Gov CEO is also touting Cigna as expanding their ACA insurance polices for sale, this of course since United Healthcare is pulling out of all but 3 states. Keven Coulihan from Healthcare.Gov was also a former Cigna Healthcare executive, so more cronyism there as well. I’ve kind of laughed at wondering when the co-marketing with Cigna and United Healthcare might begin on ACA and maybe even other policies as if Cigna gets the sale, then United Healthcare shares in the money as the pharmacy benefit manager. By the way, you should look and see that United Healthcare/OptumRX revenue stream is making more money than their 3 insurance revenue streams and appears to be going back to their roots with making a lot of money with drug companies, how the company got started in the late 70s. United sold the PBM a drug company who sold it to to Express Scripts (who I’m sure still uses Optum Algos today) a year later. So co-marketing now so OptumRX can make even more money on pharmacy benefit management? BD

United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups

BLOOMFIELD, Conn.--(BUSINESS WIRE)--The nation’s health care system is moving from volume to value, yet it remains fragmented and complex. Health care providers are facing increased pressure to move from fee-for-service to value-based payment, yet current market solutions to accelerate this journey have been criticized as too rigid to meet complex provider needs. Cigna (NYSE: CI) has partnered with health care providers for many years to help them align their financial incentives with patient health outcomes, resulting in joint success through shared risk.

The new company, CareAllies, Inc., will deliver the systems, capabilities and management services that providers need to be successful under a variety of value-based and risk-sharing models across the value-based reimbursement spectrum. CareAllies will offer services to help ease providers’ administrative burden across payers and can even help providers launch and manage their own health plans.

The new CareAllies will combine assets from Cigna, Cigna-HealthSpring’s management services division for independent physician associations (IPAs), and QualCare Alliance Networks, Inc. (QANI), which Cigna acquired in 2015. It will leverage these companies’ extensive histories of successful and innovative provider collaborations. Dr. Julian Harris has been named president of CareAllies, Inc., which will operate as a wholly-owned subsidiary of Cigna.

CareAllies is similar to UnitedHealth Group Inc.'s health care services subsidiary, Optum Inc., said Vishnu Lekraj, senior equity analyst at Morningstar Inc. in Chicago.

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