Case VIII: Chapter 4: A Cause for Concern

Chapter 4: A Cause for Concern

Beth Ford was pleased with the Team and their progress. Her confidence in the individual Team members grew with each meeting and she continued to be impressed with their knowledge and initiative.  She was particularly pleased with the most recent meeting and felt they had an improved focus and direction.  She would relay this perspective to Dudley, but really wanted to voice her concerns.

Matthew Dudley was at his usual spot in the Dining Room the next morning and appeared deeply engrossed in the Wall Street Journal.  As Beth approached, he looked up and smiled broadly.  “You know, Beth, for a publication that is supposed to be all about Serious Business, they often have very clever and insightful pieces on other topics.  I was just reading an article entitled Designer Genes when you walked up.  I just glanced at the title and my mind tricked me into thinking it was about using Levi’s Jeans as a form of currency, which I’ve seen in some places in the State; it’s can be a status symbol, or in barter situations, etc.  When I looked again, I realized it was an in-depth article about the progress in gene therapy and how individual genes can be modified, designed, to accomplish a specific purpose.  Sorry. Please have a seat and let me get you a cup of coffee.”

“I’d actually prefer tea if there is some hot water available.’

“I’m sure there’s some in the kitchen and I know where Señora Angostura keep a supply of herbal teas.  I’ll be right back.”

As she sipped her tea, Beth summarized the most recent Team meeting and her growing confidence in their direction and progress.  “I want to discuss an area of concern that I believe could have a major impact on our overall effectiveness. Basically, with the passage of the Affordable Care Act, more people will be seeking healthcare, which is a good thing.  But, because the overall market for all forms of healthcare will be expanding, I am concerned that the sheer magnitude of the situation will invite potentially unscrupulous parties to get involved and take advantage of people.”

Dudley stared deeply into his coffee cup and without looking up said, “I am pleased that our Congress finally passed legislation that makes healthcare available to more people, but, as usual, I don’t think they thought things through.  And, in my opinion, they certainly did not consider all of the unintended consequences of this sweeping Act.  One stated goal was that more people would seek primary care from a physician instead of going to the Emergency Room as their first stop for any issue.  That would involve changing the behavior of lots of people which is a formidable task in itself. But, assuming that happens, I fear that the system will quickly become overwhelmed due to a shortage of primary care physicians.  Too few young men and women are going into primary care and the situation of primary care for seniors is even more critical.  If the system does become overloaded and people cannot get to a primary care physician in a timely manner, frustration will drive them back to the Emergency Room or to not seek care at all.  The notion of prevention would be lost, more people would suffer chronic illnesses which ultimately results in increased costs for everyone.”

“I do not believe that I am that clever or perceptive and that others have come to a similar view of the future.  The obvious conclusion is that there is a significant market and financial opportunity and there is evidence that some companies are already moving to establish a position.  For example, both Walgreen’s and CVS have expanded their traditional stores and are now offering what looks a lot like limited primary care services.  Some of the major local hospitals are building satellite facilities throughout the community to reach more people and, I suspect, try to keep them out of the Emergency Room!  These positive actions will hopefully fill what I perceive as a growing need or void in services.”

“On the other side of the coin, these potentially large and profitable market opportunities have also been noticed by people and organizations with shall-we-say less charitable intentions.  With more people seeking medical attention and with so many newer options available, like CVS’s Minute Clinic, it will become easier to set up a variety of fraudulent operations that look perfectly reputable.  I don’t mean to sound overly pessimistic, but I can see a great many people being taken advantage of.  Not only would they not get proper medical attention, but their personal information could be stolen as well as their money.  Perhaps I am still thinking of the situation with Mrs. Arthur and how she was deceived, but one of the basic tenets of the Affordable Care Act is the massive collection and use of information.  Have you been to the doctor lately?  They used to sit and talk to you, but now they seem preoccupied with typing everything into their laptop computer.”

“My other major concern and why I view the Team’s work so important has to do with the looming crises in care for seniors.  I fear that there are too many people in the Baby Boomer group with too little money set aside for their later years. I see a dramatic increase in the construction of all sorts of senior living situations.  But, the large number of people who will want to live in these places will be significantly larger than the spaces available, particularly at prices that many can afford.  Once again, there will be a large unmet need in the marketplace and all sorts of organizations will emerge to provide housing for seniors.  As we mentioned with basic healthcare, some of these so-called providers will be less than reputable and some of these retirement homes may be not much better than the horrible institutions of the past.”

“I apologize, Beth, I didn’t mean to go off on such a rant. It’s just that sometimes, the magnitude of the situation overwhelms me.”

“No need to apologize, Mr. Dudley. I see a similar situation developing, although perhaps not as draconian as you.  I can also understand why you are so passionate about the Team and our work.  Are there any specific actions you want to present to the Team?”

“Please don’t get me wrong, Beth.  I believe that the Team is off to a great start and I would not change anything.  I am also certain that the Team will have an impact and that’s really all anyone could ask for.”

“Thank you for that vote of confidence. I encourage you to sit in on our next meeting.  We are gathering some very specific information and I hope it will provide even more focus for our next steps.”

 

A few days later, the La Vida Aureo Community Assist Team gathered discuss the information they had learned in their interviews.

Mikaylah Willis spoke first.  “Well, I went to visit some of my friends at Pfizer and I can tell you that even a powerful pharmaceutical company like Pfizer sees the healthcare environment changing more rapidly than they ever anticipated.  They are much too professional to admit that they are scared, but my impression is that they are scrambling to stay ahead of the game.  I noticed a large increase in the number of Marketing-type people on the local staff as well as the HUGE number of patent attorneys.  These folks are doing everything possible to keep their current money-making drugs generating cash.  They talk about the perceived threats to their dominant market position from generic drugs and the increasing power of the Pharmacy Benefits Manager organizations.  Traditionally, big pharmaceutical companies like Pfizer have focused on the development of blockbuster drugs, but the field has become so diversified and specialized and they are struggling to adapt. The emergence of these smaller bio-tech firms have dramatically impacted how the market works and the kind of drug therapies now available.  Obviously, Pfizer has an active program to acquire these firms that can quickly advance their work in a specific field.”

“I don’t believe that companies in the Big Pharma category can be a resource to our efforts, but I believe more firmly than ever that we must understand how these Pharmacy Benefits Managers operate.  They are the ones putting pressure on the drug companies to lower drug costs which is consistent with our goals.  It is interesting that both CVS and Walgreen’s are major players in that area which is further evidence of their growing importance to us.”

At this point, the door of the conference room opened and Matthew Dudley walked in carrying a large tray. “I brought fresh coffee, some hot water for tea and a plate of fresh pastries for the Team.  I don’t want to see your energy level drop, so I thought some caffeine and sugar would help!”

Everyone laughed, welcomed Dudley and encouraged him to join the discussion.  “I’ll just sit quietly in the back and listen if you all don’t mind.  These pastries are from my friend Guzman at his Saville & Sons shop in Old Town. If I nibble on one, I promise to not interfere with your meeting.  Please carry on.”

Arnetta Valencia was a soft-spoken person and the room got quiet so that no one missed a word. “Mila and I spent several afternoons visiting with the Staff which proved to be quite informative.”  She turned to Dudley. “I think I can speak for the entire Team to thank you for arranging the opportunity to talk openly with the Staff. They are a remarkable group and their experiences and insights are invaluable to the Team.  I want to report on one specific topic and then let Mila talk about a rather disturbing bit of information.”

“Several members of the Staff told stories about how a seeming minor accident in the home completely transformed a parent’s life, and for the worse. An injury that probably didn’t require surgery was the beginning of a prolonged downward spiral in the quality of life.  The injury resulted in a lack of exercise and mobility, which led to significant weight gain, which in turn triggered a host of health problems.  In hind sight, it would have been relatively easy to make simple modifications to the home to minimize the occurrence of these accidents, typically falls.  Stairs could be clearly marked, furniture rearranged, etc. I am more convinced than ever that our focus on accident prevention in the home would allow more people to remain at home and fully independent for much longer.’

“I am encouraged by what I learned and have been invited back to talk with the Staff to actively explore all the things that can be done in this regard. Together, we see this as a Workshop or even a Laboratory to try out all sorts of ideas.”

“I learned a great deal as well, added Mila Espalin, but am confused by much of what I heard.  I’ll just report to the Team and maybe someone can help me understand what I heard.”

“I talked to two women who had similar experiences.  It turned out that one of the women, Luna, is actually my second cousin and I know her parents very well.  In each case, their parents wanted to gain access to the healthcare they heard about on TV. While shopping, they were approached by someone sitting at a card table just outside the store.  The two instances occurred in different parts of town and at different types of stores, but were almost identical.  The person who approached them said she could help them sign up because she knew the process was confusing.  So the parents sat down and proceeded to answer a series of questions and, in the process, provided very detailed personal information.   They answered questions about their health history as well as numerous questions about their financial situation and arrangements.”

“That sounds very suspicious to me,” interjected Mikaylah.  “Were these women sure that their parents had not just been victims of identity theft?”

“They were most certainly concerned,” continued Mila. “But, after this first encounter, nothing happened.  Each family got a card in the mail that looked official and a form letter that stated that they were now “registered with the Affordable Care Act and enrolled in the System”.  When I probed further, both women from the Staff said that they had looked over their parents’ bank statements to see if there were any charges that could not be explained.  For one family, that was pretty easy since they do not use a bank.  They remain distrustful of all banks and handle everything in cash or by barter. And, I know from personal experience that there’s actually quite a bit of that in the City. For the second family, there were no charges that could not be explained.”

“Both families are relatively healthy and did not make use of their new opportunities for healthcare.  With many of the older people here, they are just as distrustful of doctors and hospitals as they are of banks.  They rely to a great extent on herbal medicines provided by a local curandera.  Now, here’s the interesting part and what I really don’t understand.  At the end of every calendar quarter, they would get a statement showing all of their medical expenses for the previous three months.  This included doctors’ visits, prescription medicines, medical equipment like oxygen tanks, etc., etc. But neither family had actually used any of these goods or services, none at all! They weren’t charged for anything; the statement simply said that everything was covered by insurance.”

“That is most unusual”, said Beth.  “Did either family report these discrepancies, or tell their daughters?”

“No. The families, usually the husband, said that this just proved how screwed up the Government was and they either filed the statements or just threw them away.  They assumed that the insurance company would eventually straighten things out.  Besides, they weren’t actually being charged for anything so there was no incentive to pursue the matter. The daughters I spoke to only learned of this months later in sort of a general family discussion.”

“From your description of things, Mila, I find this all very suspicious,” offered Beth.  “You worked for the State Department of Health; did you ever see anything like this during your time there?”

“No. We received extensive training about the confidentiality of personal and health information that is covered under HIPPA.  I see no reason why anyone would ask for this type of information, particularly not while sitting at a card table at the shopping center!”

Minot spoke up. “I’ve been doing some checking with the Chamber of Commerce and other sources and it appears that there are a lot of new businesses in Albuquerque offering a similar service.  Most of these are small store fronts located in a strip mall with medical or insurance-sounding names.  Virtually all of them say they are an authorized agency under the Affordable Care Act and their sole purpose is to help people sign up for the healthcare benefits to which they are now entitled.  Personally, I think it’s a bunch of crap, if you’ll pardon my French.”

“I believe any such organization would have to at least apply to the State Department of Health to qualify under the Act as “authorized”, said Mila. “I can check that out, but I tend to agree with Minot; this sounds a bit fishy to me.”

“Let’s stop there for today,” interjected Beth. “Mikaylah and Arnetta have provided us with some very significant information and there are certainly things we can do on both issues.  It sounds like the Home Safety issue is one where we could have a major beneficial impact.  Let’s think about how to move forward with that initiative.  Arnetta, would you take the lead on that?

“I’d be happy to, but I’m sure I’ll need some help as we move forward.”

“OK,” said Beth.  Does anyone have anything else they want to add?  Mr. Dudley?  If not, let’s continue with our respective tasks and plan to get together again next Monday, same time, same place.  Mr. Dudley, we appreciate the pastries and would certainly welcome you and them again!”

 

As everyone was leaving, Beth stopped Minot and together they caught up with Dudley in the hallway outside the conference room.  “Can the three of us go back to the conference room for a moment?”

As soon as they were all inside the room, Beth closed the door and said, “Well, Doc, what did you think of Mila’s report?”

“Well, she worked for DOH and I know they were constantly reminded about the privacy restrictions in the HIPPA law.  If she finds it confusing that there are people out there in the community asking people for this kind of information, then I agree with Minot.  If it looks like crap and smells like crap, then it probably IS crap!”

“I agree. Here’s what I suggest.  You and I should visit several of these store front operations and pretend to be interesting in signing up my aging mother, your wife, for healthcare benefits and see what happens.  I propose we select places in different parts of town to see if there are any similarities in approach. I can get my husband to go with me to a few more places with essentially the same premise and see if it’s any different.  What do you think?”

“While Dudley was considering Beth’s proposal, Minot spoke up.  “It’s hard for me to believe that all of these are independent operations. I’ll be interested to see if you guys get similar results at different places.  I suspect they may all be operating off a standard script.  And, while you’re out playing Secret Shopper, I think I’ll spend some time trying to dig a bit deeper into any registration or other official filings that these so-called services have made. I know how to make Google search for things that aren’t generally obvious.”

“I’m a bit hesitant to be deceptive, said Dudley, but I don’t have a better way of gathering the information.  You do know, Beth, that my wife is dead?”

“So’s my mother. Now we can be true co-conspirators!  I’ll meet you in the Dining Room tomorrow morning about 10, if that’s OK.”

 

As they parted, Minot knew that there was someone who really new how to extract information from Google as well as other sources. She composed a text. “Emily, I have a project to challenge your skills.  Wine at your place at 8?”

 

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