Confidentiality of Medical Records
Price of Paradise · Hawaii Public Radio · aired 1998-07-05
Guests: George Bussey (Medical Director, Queen's Health Plans); Arleen Jouxson-Meyers (physician and health-reform activist)
Duration: 1:05:03

[00:00:00] Speaker 1: Ah, this is host of the Price of Paradise show. We're broadcast live Sunday mornings on KHPR and KKUA and then rebroadcast Sunday evenings beginning at 8 o'clock on KIFO. Everyone who works to bring this program to you is a volunteer who believes in the importance of lively and informed public dialogue. We believe the brightness of any community's future is directly related to the level of activity in its marketplace of ideas. Our sponsor, the Hawaii Community Foundation, is an organization that encourages grass root efforts to improve the quality of life in Hawaii and that administers charitable funds with efficiency and compassion. Today's show is the first of a two-part series on changes in the healthcare industry.

[00:00:40] Speaker 1: A recent Wall Street Journal article referred to this as the battle over the soul of medicine. At least initially, my guests this morning are going to focus on a relatively narrow topic within that bigger topic. Today, we're going to start at least by talking about the confidentiality of medical records. My guests in the studio are George Bussey and Arlene Jackson Myers. George is a physician and a lawyer, who currently is medical director for Queens Health Plans. Arlene is a pediatrician whose practice is located in Wahiwa. She also is in her third year of law school and serves as president of the Hawaii Coalition for Health, a group that advocates for patient's rights in healthcare.

[00:01:21] Speaker 1: George and Arlene, good morning.

[00:01:23] George Bussey: Good morning.

[00:01:23] Arleen Jouxson-Meyers: Good morning.

[00:01:24] Speaker 1: I've read the articles that each of you wrote and appeared on page B3 of the Honolulu Advertiser, the op-ed page. George, I suppose I'll ask you to start this conversation, and again, we're going to at least initially focus on just a fairly narrow issue, confidentiality. Most people, I suspect, are like me. They assume that if they say something to a physician in the quest for health, that that's going to be confidential unless, at some point in time, with their knowledge and consent, it's passed on to somebody else. But from your article, I now know that that's not really true.

[00:02:03] Speaker 1: Can you explain a little bit more about the degree to which it's not true, and why it's not true?

[00:02:09] George Bussey: Well, I think it's not true in at least two different respects. As I said in my article, the whole notion of the confidentiality of the doctor patient communication comes out of the original Hippocratic oath that is kind of the basis of physician ethics. And in back in those days, it really was a diadic relationship. It was one-on-one physician and patient and no one else was involved. Since that time, medicine has gotten a whole lot more complex both in the way in which it's delivered and the way in which it's paid for.

[00:02:47] George Bussey: Just looking at the delivery side of the picture, when you go to a doctor's office now, not only is the doctor writing notes down in your record and examining your record, but odds are, before you actually see the doctor, there's a nurse that interviews you and puts some information down in that record. And there's probably a transcriptionist some place who, if the doctor dictates his notes or her notes, is hearing what is being put into the medical record. They're billing people inside the physician's office that are having to extract out of the record what services were provided and needed to be billed for.

[00:03:26] George Bussey: And that doesn't even address the complexity of what happens when you go into a hospital and you're dealing with lots of people there. So just on the delivery side, the idea of privacy of information being restricted just to yourself or one other person really isn't there. And what we are becoming more concerned with is, can those people who have to know about things, or come in contact with knowledge, can they keep it confidential and can they keep it secure?

[00:03:53] Speaker 1: And I, I guess a lot of people understand and accept that when they go to the doctor's office now, there's really a team there. But your article this morning was really focusing on the other prong of that two-pronged issue.

[00:04:05] George Bussey: And, and that's correct. So we we see the rest of this clinical team, we see the nurses, the technicians, etc. What we don't see are the people behind the scenes who are involved in paying for the services or providing reimbursement for the services that your physicians and your hospitals, uh, and laboratories are are delivering to you. And, um, once we invited this third person if it were to the dance, uh, saying, we'd like you to be part of the dance and the part we'd like you to be is the payer, the one who has to foot the bill for this.

[00:04:45] George Bussey: They're going to have some questions and some issues about, well, exactly what am I paying for and do I like, you know, the tunes that are being played if you will. And I think that's, um, kind of the initial level at which, uh, health plans became involved in reviewing medical records. They have a contract with a, a patient or a member to pay for certain kinds of services and they have a contract with the physician to pay for services at a particular rate.

[00:05:16] George Bussey: And to make sure that the services are part of the contract and that the bill that's coming in is reflecting what was done, there needs to be some kind of access to records so that they're fulfilling their part of the contract.

[00:05:29] Speaker 1: Well, let me shift over to Arlene, as George has described it, Arlene, it seems perfectly reasonable to me that if we're going to, as he puts it, invite this third party to pay for all of this, that we've got to expect that they will review just what it is that's being done and whether it's being done right and priced properly, etc. And yet I know from your article in the paper this morning that you really have big concerns about the direction that things are going so far as confidentiality of medical records is concerned.

[00:05:58] Arleen Jouxson-Meyers: In my view, it largely boils down to a matter of balance. A balance between the insurer's need to know and the need for the doctor to have a confidential relationship with his or her patient. My opinion is that in our attempt to contain the cost of healthcare and to maintain premiums at affordable rates for employers, that we've really tipped that balance in favor of the insurance company and I would rather see that the balance got tipped the other way a little.

[00:06:35] Speaker 1: So you and George aren't necessarily arguing over what the law is today or the degree of confidentiality that exists today. You're simply saying that it needs to be changed, that society has somehow or another gone too far in the direction of trying to keep costs down and that's taken it away from some other values, like, for example, the relationship between the physician and the patient, which includes confidentiality.

[00:07:02] Arleen Jouxson-Meyers: Correct, and I do acknowledge that the insurance company does need to know. Fraud and abuse within the healthcare industry is harmful to every one of us. It's harmful to the physicians who are honest and practice honest medicine, and so the insurance company does need to know these things. But we need to look at other mechanisms to ensure security of the data that's transmitted.

[00:07:26] Speaker 1: Okay, George.

[00:07:27] George Bussey: Yeah, I think as a follow up to that, the the other role that has been placed on a health plan just in the last five to eight years, perhaps, is that of some kind of quality insurer as well as fiscal insurer. More and more people are demanding to have some information about the quality of care that they receive from their physicians or from a particular health plan that they sign up for. I know lots of people here in Hawaii were aware that several months ago, US News and World Report did a big article on HMOs.

[00:08:10] George Bussey: And I believe it was our local Kaiser that came out in the top ten or something like that across the country. Well, this information was compiled through reviewing data that had been collected in the process of receiving national Committee on quality Assurance accreditation. This process involves documenting how effective the care is that's being delivered by physicians, how well they follow preventative health guidelines, how well they follow treatment guidelines for common diseases where we have really good treatment protocols that we can follow, such as asthma. So health plans have actually been drawn into another whole role that's that's fairly new to them and requires information.

[00:09:00] Speaker 1: And what I hear you suggesting is that from the patient's point of view, that the fact that we don't have pure confidentiality is is good because among other things, it permits this sort of quality assurance process, it gives us, as consumers, a better sense for which organizations are doing a good job and which isn't.

[00:09:18] George Bussey: I think so and I think following up on Arlene's earlier point about balance, that's part of the debate that should go on, is do is that benefit worth the loss of some degree of privacy or confidentiality?

[00:09:34] Speaker 1: Well, speaking of balance, Arlene has suggested to me that there's something wrong with the way the insurance companies currently are getting all of the access that they have. For example, when I sign up for HMSA or whatever form of third party payment system is available to me, that there's some real fine print that basically is saying they can access my records for just about any purpose. And then also, as I understand it, when a physician wants to be a participating physician, that as a condition of that, they've got to basically agree to make all of their patient records available to that insurance company.

[00:10:18] Speaker 1: And then thirdly, as I understand it, there's there's an ongoing controversy right now, but seemingly at least, the argument is being made that even people who aren't part of an insurance plan, their records have to be made available to an insurance company so the insurance company can compare the service and cost to people who are a member of their plan to service and cost to people who aren't a member of their plan. Obviously, I don't know exactly what I'm talking about, but the impression I have, the overall impression I have, is that maybe we aren't in balance, that maybe this really has shifted over to the side of of little or no confidentiality.

[00:10:59] Speaker 1: What do you think?

[00:11:00] George Bussey: Well, I think that if I can take each one of those points one by one, I think that there are some improvements that can be made in the educational process to, um, individuals who sign up for health plans.

[00:11:15] Speaker 1: The technical term is bigger print?

[00:11:17] George Bussey: The technical term is bigger, bolder print. There's a a second part of the problem though, and and Arlene and I have talked about this in another context, which is that you're also signing away the confidentiality of your family members, um, because you're usually the only one who signs that, um, uh, that form.

[00:11:36] George Bussey: And we've had a lot of discussions about the impact on employers when they're in the process of trying to get their employees and their employees' families covered onto a new plan of going and and in requiring the employee to get the spouse to sign for her and the two of them to sign for, uh, their children as guardians of their children and just the whole paperwork process of making sure that you truly have informed consent in the in the sense that that the person understands that the health plan is going to be accessing their records.

[00:12:13] Speaker 1: So I think both Arlene and I are in agreement that we need to do some work on that to make that better for everybody.

[00:12:17] Arleen Jouxson-Meyers: I wanted if I could intervene for one brief moment here. I have particular concern about one ramification of that process and that is that, um, whether you give up your confidentiality rights or not seems to be linked to, um, receipt of benefits or payment for a particular service. And that fails to address a whole, um, group of people who have particularly sensitive information that they don't wish to, um, release. Uh, for instance, um, uh, an AIDS suffer or, um, social problems within a family with the history of child abuse or something of that, uh, um type.

[00:12:58] Arleen Jouxson-Meyers: Um, with the present system, as long as the insurance company is paying for a particular service, the patient has no right to say, I don't want information to be released related to that particular service. The only way they can secure confidentiality in that, um, situation is to say, I will pay for the services myself and sometimes that precludes, um, their ability to secure the confidentiality of their record.

[00:13:26] Speaker 1: So one way or another, it gets in the way of the delivery of healthcare if either they worry that the information is going to be passed on, or they simply can't afford to go to the physician because they don't want to run the risk that the information would be passed on.

[00:13:42] Arleen Jouxson-Meyers: I I yes, it does, um, very definitely affect the delivery of healthcare, but in addition to that, um, even if they do go [unintelligible — audio glitch] get receive the healthcare, they are they've lost their privacy rights related to that particular situation if they want to get the the service paid for.

[00:14:01] Speaker 1: Well, [unintelligible — audio glitch] think the short blunt answer is yes, if you want somebody else to pay for the delivery of service related to that, you're going to have to, um, allow the payer to have reasonable access. I think the bigger issue though is one that that gets back to to where we started. And if I can digress for just a moment, we did an employee satisfaction survey of our own employees in our company. And one of the questions on that satisfaction survey, uh, was, um, in essence, do you consider yourself a caregiver? Do you see yourself as part of the healthcare delivery team? And the overwhelming answer to that was yes.

[00:14:48] Speaker 1: And I think that that's a reality that's now part of our whole healthcare delivery system, that the people who are managing the benefit, paying the claims, involved in intensive case management, um, and disease management activities now are as much a part of the healthcare delivery system as the the nurses and the technicians and the other people who were new to the system maybe 40 or 50 years ago. And this is I think a major educational process for people to understand this. The second part of that is that none of that eliminates the concept of confidentiality and security.

[00:15:34] Speaker 1: It does mean that the information is shared with a wider group of people, but those individuals still have a a legal and a moral and ethical duty to maintain the confidentiality of the information that they have to come across and deal with. It's just that the circle of people who have need to know is much bigger than it used to be. Yes. You know, George just used the expression bigger issue.

[00:16:05] Speaker 1: Arlene, as we take a couple giant steps backward from focusing just on confidentiality, there are a lot of change going on in the healthcare industry and I mentioned at the top of the hour that the Wall Street Journal had an article not long ago where it talked about the battle over the soul of medicine and and it suggested that on the one side, you've got the physicians and on the other side, you've got I think at one point in the article they call them the bean counters, the the MBAs, the administrators, let's say.

[00:16:35] Speaker 1: And that somehow or another, as society seeks a balance that's constantly evolving, that there are an awful lot of physicians who seem to feel as though they've lost more control over the delivery of healthcare than what is in the best interest of society. What do you think?

[00:16:53] Arleen Jouxson-Meyers: Well, in my my opinion, um, uh, intrusion into the doctor-patient relationship and into the practice of medicine by insurance companies has really escalated to an unacceptable degree. To the extent that, uh, insurance companies have, uh, clinical practice guidelines which mean that they, uh, manipulate and and, uh, influence how certain diseases are actually cared for. Uh, they have, um, profiling of physicians where they keep data on, uh, the cost of medicines that we prescribe, um, the cost of tests, how many times we send to specialists or hospitalize a particular patient.

[00:17:34] Speaker 1: So you're you're as a physician, you're punished for focusing on healing people as opposed to focusing on cost containment.

[00:17:41] Arleen Jouxson-Meyers: Correct, and not only am I, um, punished, but I am also rewarded. HMSA is in the process right now of introducing a, um, uh, physician quality, uh, recognition award system, which takes into account a whole scoring system, uh, and so, the physician, if he does everything that HMSA wants him to do, um, has the possibility of getting a $10,000 a year bonus. So they're also incentive, uh, rewards.

[00:18:11] Speaker 1: A a stick is and and a carrot both that didn't used to exist. In other words, as a physician, you're feeling as though the incentives and the disincentives are changing and in your opinion, they're changing in a way that ultimately hurts the patient.

[00:18:26] Arleen Jouxson-Meyers: I believe that.

[00:18:27] Speaker 1: George, couple thoughts on that and then we're going to invite some questions.

[00:18:30] George Bussey: Sure, I I think, uh, first of all, I'd like to respond to the issue of clinical practice guidelines. If you look at how those are developed, um, and the standards that are used, they are developed through nationally recognized, uh, groups of physician, um, organizations, uh, or research bodies, National Institutes of Health,

[00:18:55] Speaker 1: So it's not the MBAs that are saying, here's how you treat people, where their focus is on

[00:19:00] George Bussey: it's the physicians. It is a they are physician-developed guidelines in our health plan, they're run by a physician committee to determine whether due to any unique factors in Hawaii, they have to be adjusted to fit practice patterns here. and they are physician's best um thoughts on how to take care of disease, not an MBA's best thought on how to take care of disease.

[00:19:25] Arleen Jouxson-Meyers: the one problem with clinical practice guidelines, though, is that they fail to address the um or or in the ability to individualize care. um, it's a sort of global, this is how you take care of asthma.

[00:19:38] George Bussey: one size fits all type of problem.

[00:19:40] Arleen Jouxson-Meyers: Right, right.

[00:19:40] George Bussey: I think if they are used inappropriately, that's true. But but they are not clinical practice orders. They're clinical practice guidelines and they suggest how to organize your thinking and your interventions with a patient. obviously our patients do not read our textbooks and they do not follow the exact paths that our textbooks talk about, but they are um the guidelines are very good for for helping to remind physicians about what the science of medicine is as opposed to the art.

[00:20:16] Arleen Jouxson-Meyers: I would like to disagree with George a little bit on that point. Um, as early as, or as recently as just a few months ago, when we were discussing, um, a, a physician participation agreement with HMSA, uh, the clinical practice guidelines actually were orders. um, they had link to it in a in our contract that um we could be terminated or have reimbursements reduced if we did not, um, adhere to those guidelines.

[00:20:46] George Bussey: George, let me ask now they've softened. In in listening, Darlene, and in listening to other physicians and you're a physician, I get the the sense that physicians as a group are feeling a loss of control, that that even if maybe in theory they still have control, don't you think that there is this sense that somehow or another they're they're losing a an important degree of control? I I think I think the the accurate part of that is that physicians are having difficulty adjusting to the idea that they are no longer um individually autonomous that they are going to have to organize and and become part of larger groups.

[00:21:31] George Bussey: And I think it's also difficult um to begin having um some kind of external oversight, whether it's the federal government or the state government or a health plan. uh, speaking as a physician, I know that for a long time we've kind of figured that we know what's best. We're very um paternal and maternalistic uh about how we view our roles vis-a-vis our patients, and it's a real adjustment to uh to have other people say, well, you know, Dr. Bussie, maybe you could have done it better.

[00:22:05] George Bussey: I guess it's human nature to feel that we don't need to be accountable, that that we will do a good job without people watching over our shoulders. Uh, you're listening to the Price of Paradise radio show. My name is Randy Roth and we're talking specifically about confidentiality of medical records, but really the larger topic, the bigger topic, as George Bussie puts it, is um the the battle if you will that's going on over what the Wall Street Journal calls the soul of medicine, a tug of war if you will that we're observing over a relatively short period of time seems to be changing the way in which healthcare is provided in this country.

[00:22:41] George Bussey: If you'd like to ask a question or make a comment, our number is 955-8821. on a neighbor island the number is 1-800-955-8821. This is the first of a two-part series focusing on healthcare here in Hawaii. Today the guests are George Bussie, who's a physician and a lawyer who currently is medical director for Queen's Health Plans, and Arlene Jackson Myers, who's a pediatrician in Waialua, and in her third year of law school here at the University of Hawaii. She also is the founder and president of the Hawaii Coalition for Health, a group that advocates for patients' rights in healthcare. Next week we're going to be talking again about healthcare in Hawaii.

[00:23:25] George Bussey: Our guests will be HMSA's Fred Forton, UH, excuse me, UH ethics professor Ken Kipnis, and Hilo Hospital emergency physician and past president of the Hawaii Medical Association Fred Holshoe. Again if you'd like to ask a question or make a comment, our number is 955-8821. Well, let's start with Mark from Manoa. Good morning, Mark.

[00:23:50] Mark: Good morning. I just have a very quick question about a slightly related area, and that is the pharmacy. um, I recently was surprised to read in the very very fine print at the pharmacy that uh they reserve the right to uh tell my employer about the uh medication that I was getting. And I spoke with that pharmacy and they've they're now, I think, rewriting the form uh so that uh maybe it'll just be on an as-needed basis. But I'm curious, how far does it go uh in terms of uh who can be telling who about this sort of information, and what should consumers do about it?

[00:24:31] George Bussey: Okay, let's ask Let's start with George Bussie. I don't have a specific answer to the um the question that you uh presented, but I I think you demonstrated one of the things that that Arlene has learned, which is that when you present um information to folks indicating that you've actually read the fine print, sometimes they have a tendency to adjust it to make it more reasonable. Um, the the second part of that is I know for our health plan and I'm sure it's the same for HMSA and other health plans as well, uh, one of the real firewalls that we try to build into our systems is any individualized patient information getting back to employers.

[00:25:14] George Bussey: um, uh it's it's something that we recognize that needs to be uh uh protected with the utmost care uh and uh we have a number of of um policies and procedures in place to make sure that individualized healthcare information does not go back to employers. So I'm really surprised about that pharmacy language.

[00:25:34] Arleen Jouxson-Meyers: uh, Arlene. Um, I don't have any knowledge uh related to um what Mark is talking about in terms of pharmacy uh release of information, but I do know that um, uh, in the whole workman's comp arena, uh, employers um really have a very high level of ability of being to given individualized information about employees.

[00:25:58] George Bussey: Okay. Mark? Thank you very much. I I will say that the uh the pharmacy was flexible only when I called their headquarters. The local branch uh was uh surprised that I was even reading the fine print and telling me don't bother. Don't bother. Everybody signs it. So uh you have to I found that in I had to be aggressive to make it work. Good for you.

[00:26:18] Mark: Thanks a lot.

[00:26:19] George Bussey: Thank you, Mark. We go to David on Maui. Good morning, David.

[00:26:22] David: Aloha. Um, I would like you to ask your panelists what their opinion of medical marijuana is, relating to the legal and medicinal uh issue.

[00:26:32] George Bussey: Let's start with um Arlene.

[00:26:36] Arleen Jouxson-Meyers: Um, may I defer to George and to think about this for a moment? Yeah, what you say on this show is not confidential. So go ahead, George.

[00:26:46] George Bussey: You know, I I've seen the debates back and forth. I think the the big current argument against medical marijuana is that there are other um uh other pharmaceutical agents that are as or more effective than marijuana, and therefore we don't need to make any special um exceptions to allow it to be used uh in a medical context. I I think and I won't go into any details on it, but I think the bigger issue uh gets down to the country's whole philosophy about how it's going to deal uh with um substances that are used for hedonistic purposes and that may have addictive potential to them.

[00:27:29] George Bussey: And are we going to deal with that through uh criminal justice system, or are we going to deal with it through preventive health and uh treatment and education?

[00:27:38] Arleen Jouxson-Meyers: Arlene? I have somewhat more of a um uh liberal outlook um to uh choices than some of my physician members of the Hawaii Coalition for Health, and that was what led to my reluctance to speak out right at the moment. A number of our pediatric um members have real concerns that legalization of medical marijuana may actually um increase access to teenagers of of marijuana, and they have concerns related to that. Um, we have not reached a a position either way.

[00:28:13] George Bussey: Okay. David, thank you for your call.

[00:28:15] David: Uh, could I contact this in my own opinion? Uh, if you can do it real quickly. Okay. Well, I see it as another tyranny on the laity, as a one of the original professions, the physicians need to have sick people in order to uh keep their profession. So, therefore, they make laws against natural uh remedies which uh can can control the problem without having their um middleman intervention, and I think they're just nothing different than um illegal drug pushes, only they have the law on their side.

[00:28:49] George Bussey: Okay. Oh, Aloha. Thank you, David. Uh-huh. You're listening to the Price of Paradise radio show. We're talking about the healthcare industry in Hawaii in general, confidentiality of medical records in particular. I'm with George Bussie and Arlene Jackson Myers, and our phone lines are open. If you'd like to call us, we're at 955-8821, or from a neighbor island 1-800-955-8821.

[00:29:16] George Bussey: Arlene, I know in the past uh I've heard you comment that the healthcare industry, especially in Hawaii, has has gone awry, that somehow or another the focus used to be on total health for patients, and now the focus is on this uh cost containment and profit motivation that we were talking about a little bit earlier, and the in the terms of incentives and and disincentives. But you've commented that that somehow or another um things are worse in Hawaii than elsewhere. Why why so?

[00:31:58] Arleen Jouxson-Meyers: I I know I'm I'm correct in that uh opinion, and I could maybe be convinced otherwise, but um I feel like because Hawaii is a small uh isolated geographic uh uh island, um, and uh we have insurance carriers who have enormous power over the practice of medicine and uh power over how physicians behave. I think that escalates the problem. The other thing that's applicable to Hawaii is that we cannot get into a car and drive to the next state if our particular health uh care uh insurer is um refusing to pay for something.

[00:33:06] Arleen Jouxson-Meyers: We have to get on a plane at tremendous financial expenditure and try to go um to uh uh you know, another state somewhere.

[00:33:14] George Bussey: We're more of a uh uh captive audience than elsewhere.

[00:33:18] Arleen Jouxson-Meyers: Uh, yes.

[00:33:19] George Bussey: Um, George, any thoughts on that? Um, I'm not sure that it's any worse here or any better here than um than other places. What about what I think I heard Arlene say is that our market is structured a little bit differently here and as a consumer, I I'm under the impression that HMSA is is the real big player, and then folks like like your plan, the Queen's Health Plans, that that they're sizable, but more or less taking their lead from HMSA. Is is that accurate, inaccurate or somewhere in between? Well, actually, that's that's accurate in two different ways.

[00:34:16] George Bussey: First of all, it's accurate in the sense that HMSA, being the the market leader, has the power that uh 60 plus percent uh market share leader is going to have. I I think what it translates into is um defining what the community standard is. And no one can drift too far off the community standard for risk of of um uh some kind of of liability, whether it's market liability or legal liability. The other thing is the way um our laws are written, um new health plans as I understand them, have to have a number of things in them that exist in like 50% of the existing plans.

[00:35:52] George Bussey: And if HMSA has significantly over 50% of the market share, it basically means that your health plan has to come in with benefits at least matching that. So the the law in Hawaii made by our legislature ensures that there's going to be a certain degree of of similarity between the biggest plan and all the rest. That's correct and that has positives and and negatives to it. Okay, well we've got a bunch of people on the line. Let's start with Tim uh on a cellular from Hawaii Kai. Good morning, Tim.

[00:36:21] Tim: Good morning. How are you folks?

[00:36:22] George Bussey: Just fine. What do you have for this morning?

[00:36:25] Tim: My question is regarding cost containment and I'd like to get some response on the um the amount of money that hospitals and doctors have to spend on uh implementing government regulations and defending themselves against all kinds of legal uh matters that are brought up, even though they may not uh turn out to be uh pertinent.

[00:37:07] George Bussey: Good question. Thank you. Who wants to take a shot at it first?

[00:37:10] Arleen Jouxson-Meyers: Uh, I'm not sure whether this may um directly address the question being asked, but I I will start off here. Um, as a practicing physician and a primary care position that means that often times I'm settled with the duty of being a gatekeeper, uh, which means that my patients cannot go and see another specialist or be sent for a test or anything unless I, I okay that. Um, this process has created enormous, um, additional expenditures and staff needs um, in my office to address these issues. I sometimes spend many hours dealing with the the bean counters.

[00:38:29] George Bussey: When my father-in-law got out of the practice of medicine it was because he said he was doing less and less medicine and more and more paper.

[00:38:36] Arleen Jouxson-Meyers: Correct.

[00:38:38] George Bussey: I think there there is a lot of overhead that goes to, um, meeting a lot of different requirements, whether they be the requirements of uh, an insurance company, payer or the federal or the state government. Um, it's again it's one of those things that may have crossed a line but when you invite other people in to, um, help you pay your bills then they're going to start saying, well, okay, and and for me to do that, I want you to do this and I want you to do that and I want to check up on this other thing.

[00:39:13] George Bussey: And I think that, uh, to the degree that those things can be simplified so that it's one set of standards kind of across the board, we might be able to reduce some of the some of the overhead that people experience. So we live in a complicated world, but a big part of that, so far as today's topic is concerned, is that when you've got basically three players: the provider, the patient, and the payer, that that's going to dramatically increase the amount of paper pushing that has to go on.

[00:39:42] Arleen Jouxson-Meyers: And you didn't even mention the government.

[00:39:43] George Bussey: Didn't even mention the government. Let's go to Dick in Kailua. Good morning, Dick.

[00:39:47] Dick Miller: Uh, good morning, Randy.

[00:39:50] Arleen Jouxson-Meyers: Dick Miller my

[00:39:51] George Bussey: Yeah, recognize the voice. Former dean from the University of Hawaii School of Law and I know Dick doesn't mind my identifying him. Go ahead, Dick.

[00:39:58] Dick Miller: Not at all and uh, hi Arlene and hi George.

[00:40:00] Arleen Jouxson-Meyers: Hi Dick.

[00:40:02] Dick Miller: Uh, I guess we we all realize, and I think everyone recognizes that in order to uh, uh, provide uh, the medical care to the broadest number of of citizens, it's absolutely necessary to keep the cost of medicine as low as possible. So I think that there is consensus on that. I think where the consensus, uh, disappears is, uh, in the method uh, of achieving that goal.

[00:40:30] Dick Miller: And, uh, uh specifically, for example, uh uh my experience and I think that the coalitions in dealing with the uh, agreements that physicians have to enter into with their health plans suggests that the balance uh is heavily weighted in favor of the insurer and that the rights of physicians have really been uh uh almost eliminated. That is to say the physician has no real power uh to take on the health plan when the health plan does something that the physician and its uh, and his or her opinion believes is harmful to the patient or refuses coverage, etc., etc.

[00:41:12] Dick Miller: And the question is, uh, what specific steps can we take to uh strengthen the physician's role in uh fulfilling his or her professional responsibility to the patients? And let me just throw that one out and, uh, let let the two of you uh discuss that a bit if you would.

[00:41:34] Arleen Jouxson-Meyers: Well, um, just to recognize, uh, Dick's contribution to the activities of the Hawaii Coalition for Health. He is um, done an enormous amount of work for us and I I know that he and I share a common perspective.

[00:41:48] Arleen Jouxson-Meyers: Um, at the present time it's a daily struggle with, uh, health plans to um, equalize some of the terms in these physician, um, contracts. They are are often very onerous. And one of the things that we're experiencing is that we were able through, um, the threat of adverse publicity, uh, get HMSA last year to work with us on improving a lot of the contract and in fact they now probably have one of the better contracts available to physicians.

[00:42:21] Arleen Jouxson-Meyers: But a lot of the other smaller health plans, including Queen's healthcare plan, um, have not realized yet that the parade is going down a different street and they are continuing to attempt to implement really onerous provisions which deprofessionalize physicians and and take all the power away from them.

[00:42:41] George Bussey: George, I'm not sure, but I think I just saw an arrow go right by your left ear.

[00:42:46] Arleen Jouxson-Meyers: That that was a shot at you.

[00:42:48] George Bussey: Yeah, well I wear Kevlar so. What do you what do you think? I it's funny because my thoughts were were sort of the opposite in that as a small health plan, um, it is important for us to maintain good relationships with physicians. I know that Arlene has been working with our uh, provider services, uh, division, which is the area that works on physician contracting.

[00:43:12] George Bussey: Um, and you know, my understanding is that they are working in good faith with uh, Arlene and her group to try to work out differences. I know that for particular kinds of contracts and particular kinds of coverage, there are issues that um, really do uh, bring out some differences. For example, um, in a different context, Arlene was talking about workers' compensation, um, situation with confidentiality.

[00:43:42] George Bussey: There are things about those contracts that might end up having language that's very difficult to uh, to work out. Um, in the area of new Medicare risk plans where uh, in insurance companies are being asked to take on significant financial risk because that's the only way you can do Medicare in the future.

[00:44:05] George Bussey: Um, health plans are trying to uh, encourage physicians to participate, uh, in that risk sharing and that's a new ball game for physicians and there's a lot of resistance on their part to, um, uh, to engage in in different kinds of contractual relationships. So I think there's going to be um, a lot of give and take and a lot of struggle until everyone gets a little more comfortable with what the new rules are. And speaking of struggle, I assume this is a relatively new phenomena that you'd have a a group of physicians that would band together and try to uh, to tug back when they sense that something's being pulled away from them.

[00:44:42] Arleen Jouxson-Meyers: Um, I I would like to correct that. We're not actually a group of physicians, we're a group of the public. Um, the majority of our membership are public members. In fact, we do have physician members and we also have other professionals as members, but it's not a a united organization of physicians.

[00:44:59] George Bussey: Well, all we see are physicians and and Professor Miller. So that's that's who we come in contact. And so in in a way what I what I think I hear is that each of you is basically uh, suggesting that you've got the moral high ground in the sense that each of you is really concerned about the quality of care and the cost of that care so far as the patient is concerned, but you've got different philosophies in terms of how we get from here to there.

[00:45:26] George Bussey: George? I think I think that's uh a pretty accurate statement. As I indicated, most of the employees in the company I work for consider themselves to be part of the health care delivery system.

[00:45:36] George Bussey: Um, I have a number of nurses who work um, in the division that that I oversee. And uh, they spend their days working with physicians and patients, uh, and other healthcare providers to coordinate care of very difficult and complex situations: transplants, um, services that require a lot of different uh, um, a lot of different people coming together and working together. And and I think we're all kind of learning some new roles in that, but we definitely see our responsibility as being keeping our members healthy.

[00:46:14] Arleen Jouxson-Meyers: Um our organization has two particular points of contention related to participating provider agreements and one of those is the fact that, um, the health plans have positioned them in such a way that they do not accept legal responsibility for uh the um, decisions, the medical decisions that they influence.

[00:46:35] Arleen Jouxson-Meyers: Uh, a number of them have provisions in their contract which require that the physician, uh, participate with utilization management programs. All of them have such a provision. And, uh, that participation, if if one doesn't participate, uh, one may uh lose membership or have reduced, uh, um, reimbursements. The some of the plans, and Queen's is not one of them, um, has a uh, a provision which says that, um, uh, the, uh, physician acknowledges that the plan, uh, does not practice medicine and that the physician takes sole responsibility, notwithstanding the fact that the plan is telling you what to do.

[00:47:19] Arleen Jouxson-Meyers: Okay. And some of them have a third provision, which is an indemnification clause. So we have a real problem with the fact that the health plans are manipulating care and influencing the practice of medicine and are shielding themselves from the the responsibility related to that.

[00:47:44] George Bussey: Dick, from Kailua, are you still there?

[00:47:46] Dick Miller: I'm still here.

[00:47:47] George Bussey: Uh brief comment from you and then we need to move on.

[00:47:49] Dick Miller: Yeah, I, uh, I I think, uh, Arlene has it. Uh, correct. The the problem is that the physician really doesn't feel, rightly so, that he or she has a role in the decision making that controls his or her practice. And and part of that is because of the termination provision in many of these contracts, which allows the the insurer to throw them out of the plan.

[00:48:06] Dick Miller: In some cases this would deprive them of any livelihood uh, without an appeal, without cause, without giving a reason. And therefore, they're not in a good position to take on uh, any, uh, real controversial issues against the health plan because they may lose their their position in the plan. I think that what we've got to move toward is one where the physicians, uh, by their representatives participate uh, much more deeply in the development of these utilization guidelines and quality control measures.

[00:48:39] Dick Miller: And when they feel that they're uh, they're represented in these, they may be and not threatened with immediate termination. If they disagree with the plan, they may uh, uh, begin to feel that they have more control over their own practice.

[00:48:52] George Bussey: Okay. Dick, thank you very much. I appreciate your call.

[00:48:55] Arleen Jouxson-Meyers: It's a pleasure.

[00:48:56] George Bussey: You're listening to the Price of Paradise Radio Show. My name is Randy Roth. We're talking about changes in the healthcare industry, especially in Hawaii and specifically about confidentiality and related issues. My guests are George Bussy, a physician and lawyer who currently is medical director for Queen's Health Plans and Arlene Jackson Myers, a pediatrician in Wahiwa who's about to finish law school and is the founder president of the Hawaii Coalition for Health, a group that advocates for patient's rights in healthcare. We've got, uh, some more callers on the line. Let's go to Alan in Lanakai. Good morning, Alan.

[00:49:29] Alan: Yes, good morning, Randy. Nice program. Quick two, quick questions. First one. Uh, I occasionally get, uh, letters in the mail, fundraising letters, that talk about those who are part of their coverage comes from Medicare, uh, do not have the right to get a second opinion, do not have a right to, [unintelligible — audio glitch] request, uh, medical treatment and and to pay for it themselves outside of the medical plan, and go further to state that if a doctor does offer them, or provide medical, uh, assistance to one of these patients who is paying for it himself and the federal government finds out, that doctor loses his ability to work uh, with Medicare patients for two years.

[00:50:15] Alan: Could you, uh, amplify that a little bit? What's this all about?

[00:50:18] George Bussey: George, what's going on? Well, I'm not sure the most recent status, but for some time there had been a, uh, basically a, a provision that said that if you were going to treat someone who had Medicare, you had to, um, adhere to Medicare fee schedules, either as a participating provider which gave you one rate or a non-participating provider which gave you another rate. More recently and if you went outside of that, yes, you were guilty of breaking some kind of law. More recently, what has happened is that, uh, the federal government has allowed physicians to enter into what they call private contracts with, um, Medicare recipients.

[00:51:00] George Bussey: The first iteration of this had it set up so that if you were going to do that you had to do it for all of your Medicare patients and you had to do it for a set period of time. I don't know whether it was two years or what the rule was around that. I know that subsequent to that there had been a lot of, uh, negotiation and, and, um, uh debate and discussion about that black-white all or none rule that either all your Medicare patients are in or all your Medicare patients are out, and I don't know if that's been resolved, but that was the issue that he was talking about.

[00:51:34] Arleen Jouxson-Meyers: Um, I don't have anything to add, some to what George just said. I don't know either.

[00:51:40] Alan: Well, I guess, uh, it isn't quite as bad as some of these scare letters make it out to be, but uh, it sounded like, uh, a pretty heavy handed approach. Then a quick second question. Uh, are you aware of the fact that the Environmental Protection Agency is trying to ban my, uh, asthma inhaler?

[00:52:01] George Bussey: No. Yes, it is. Uh, I have all sorts of articles on this. Are you destroying the ozone or what? Not a fact. Is that the problem? Yeah, okay. CFC propellants. Yeah, and oh there's been all sorts of articles about it in the local papers and national magazines. And, uh, uh basically, uh, uh, the, uh, the amount of ultraviolet radiation, ultraviolet B, specifically hitting the deck is has not changed since 1980. And so this whole thing is a complete farce. And, uh, I have tried. There is one asthma inhaler, I have had asthma since age six, and, uh, some of them work better for me than others, which is a universal agreement.

[00:52:43] George Bussey: Uh, I've tried the one that's available. It is really ineffective for me and it is far and away the most expensive one available. And, uh, those little CFC propellant inhalers have completely solved my problem. They are a magnificent medication, and I deeply resent a distant bureaucracy trying to ban my access to them. Alan, was that your short question?

[00:53:06] Alan: Yeah. Thanks a lot for your call, Alan. Okay. Thanks for your program. Sure, George. You've got a comment?

[00:53:13] George Bussey: I just yeah one follow up thing related to the Medicare issue. Uh and this is one I'm sure that Arlene and I will agree on. Um, while she and I may have a lot of discussion about the, um, the nature of contracting with health plans and whether the contracts are slanted one way or another, at least in that situation, a physician does in fact have the ability to say, well, I'm not going to contract with you and I'm going to see this patient and they're going to pay me out of pocket and I will live with what I can collect for my patients.

[00:53:43] George Bussey: One of the problems with the old Medicare system and even the way they've changed it now is both physician and patient have lost that ability to say, thank you for your concern and your, your, uh, paternalistic, uh, interventions, but we'd prefer to do this on our own without any third party involved. And You can't even do that. It it's very hard to do that with Medicare right now, very hard. Interesting. And from Kaimuki, good morning.

[00:54:11] Caller: Good morning.

[00:54:12] George Bussey: You're on the air.

[00:54:13] Caller: I have one comment to make that everyone says that the employer pays for healthcare. They do write the check, but the employee pays for it by not having that much more money is my feeling and I feel that until patients get together, people power, and join Arlene because I think she's the one that's doing the most for helping patients do and get the care that they need.

[00:54:48] Arleen Jouxson-Meyers: Um, and I'm delighted to hear you say that. Um, I have felt for a long time that, uh, the employer paying for health care coverage is actually a benefit which the, uh, employee earns Yes. and it rightfully belongs to the employee.

[00:55:06] George Bussey: George Bussy. Well, [unintelligible — audio glitch] agree that the employee is the one that actually pays in one way or another. There's a lot of of uh economic analysis to demonstrate that, but I I do have to tell an interesting anecdote about this uh this whole issue because I was involved in a discussion with a physician who is both a participating provider and also an employer and also an employee of his own company and we went in the blink of an eye from him talking about how he wanted his reimbursement rates for his services increased to an immediate discussion about why our health plan rates for he and his employees were so high.

[00:55:58] George Bussey: and did not understand, did not see the disconnect between those two conversations. And I guess to put it in a different context, uh, we consumers of, um, health care services, we want high high quality, we want low low costs, uh, we want the best of everything and I think part of your article this morning was to suggest that there's some tough choices that have to be made.

[00:56:18] George Bussey: Yes, and I think yes, there are some tough choices, and I think we can deliver high quality at low cost, but that involves really getting in and looking at how individual providers and groups of providers deliver services and what the outcomes on their services are. The kind of changes that we're witnessing right now that are leaving a lot of physicians feeling as though they're losing something important. Yes. Arlene? I don't have anything to add, that's profound. Okay. And thanks for your call. We go to Frank, uh, from Saint Louis. Good morning, Frank. Aloha. Aloha. Comment about the call from a Noah, commenting about medical marijuana. I turn

[00:57:00] Speaker 1: to agree with him and in fact, doctors are being... But but uh it comes from the top, doesn't it, with the drug administration or whoever it is that okays medicine. We're seeing now a lot of recalls of new medicines lately. A few, anyway. But uh going on my question is uh do do we know [unintelligible — audio glitch] salaries of HMS administration, what what um percentage of of their income is administrative costs, and uh is it commensurate with other uh um similar uh organizations, especially their nonprofit, aren't they?

[00:57:50] Speaker 2: Does any either of you want to respond to that or or to talk general [unintelligible — audio glitch] neither of my guests are responding to the specific question, Frank, let me ask it a little bit more broadly. We've got the system of of third-party payors. Is it inherently inefficient, in other words does a significant chunk of every dollar that is paid to a third-party payer, does a significant chunk end up going to administration as opposed to providing of of healthcare?

[00:58:20] Speaker 1: costs for instance that building is just gorgeous you know, just gorgeous.

[00:58:24] Speaker 2: Well we don't want to pick on HMS, but uh but George is is that something inherently um problematic with insurance or or is that not a concern? Because Queen's health plans is a form of of insurance?

[00:58:41] George Bussey: Yes, [unintelligible — audio glitch] is a it is a a concern that that everybody uh in the healthcare business has whether they're a physician or hospital or health plan uh depending on the type of of uh coverage or health plan you're part of, uh those administrative costs, they can run, if you're [unintelligible — audio glitch] efficient maybe as low as seven or eight percent. Uh if you're running an organization um that's not as large as the

[00:59:13] Speaker 1: Who are you saying? Is he going to come uh get up for breakfast?

[00:59:18] George Bussey: Oh, I'm sorry, I'm I'm talking I I didn't realize it was on air. Okay, George is is finishing up, go ahead.

[00:59:25] Speaker 1: Who comes for breakfast?

[00:59:28] George Bussey: Yes, I'm having bacon and an egg.

[00:59:30] Speaker 2: Excellent. Um we'll talk to you about your cholesterol levels uh later.

[00:59:34] George Bussey: Um if you if you're a small plan and you're running an HMO, it may be more on the order of of uh 12% or even a little bit higher because of the different uh demands on services.

[00:59:47] Speaker 2: Okay, Frank, thanks for your call.

[00:59:49] Speaker 1: Oh thank you.

[00:59:50] Speaker 2: We're down to uh just a few minutes and before I ask for your closing comments real quickly, George, you're a lawyer uh graduated top of your class. Arlene, you're one of our star students at at the law school. Is this a sign of the times that um physicians are are going to law school? Is there a a need, if you will, to go to law school? How does how does that fit into um to the picture? Is that relevant to our topic this morning?

[01:00:17] Arleen Jouxson-Meyers: I think it is relevant. I think that physicians um uh have to learn to evaluate things on a totally different uh perspective now, and I think the more physicians who go to law school and seek answers uh and and understand the their legal theories, the better we're going to be as physicians.

[01:00:38] George Bussey: I want to answer that uh both personally and and more generically. I think on a on a generic level, yes it was, it's important for physicians to learn more and more about other aspects of healthcare, whether they be legal or business. Um I'm smiling because I chose law because I saw that as a more autonomous profession than being an MBA, and so I have a lot of sympathy for all of the issues related to physician autonomy that Arlene's been talking about. I think we as individuals do really um pride ourselves on that and want to maintain as much of it as possible.

[01:01:14] Speaker 2: You've each got one minute to uh give us your concluding thoughts on this uh topic the big topic again changes in the healthcare industry in Hawaii and the more focused one on confidentiality of medical records, Arlene?

[01:01:26] Arleen Jouxson-Meyers: Very quickly, I think Hawaii is a very exciting place in this arena, um right now, um because of our geographic isolation and the smallness of of physician population and so forth. I think exciting things are going to happen to shift the balance um more in favor of the public over the next couple of years.

[01:01:47] George Bussey: George Bussie, I think that um as it relates to confidentiality, we are uh entering a new era where we're going to understand that confidentiality is a concept that exists across the healthcare delivery system and what we need are uh better and clearer rules about how within that system we maintain confidential information in a secure manner so it doesn't get outside of of that system. I also think a lot of changes are going to continue to happen uh with healthcare delivery as we all learn how to dance some new dances. Some new dances, change is hard.

[01:02:23] George Bussey: That's George Bussie, physician, lawyer, and medical director of Queen's Health Plans and earlier you were listening to Arlene Joxon Myers, a pediatrician in Wahiwa who's about to finish law school and is the founder and president of the Hawaii Coalition for Health, a group that advocates for patient's rights in healthcare. Next week we're going to continue this conversation over what the Wall Street Journal called the soul of medicine. Our guests are going to be HMSA's Fred Forton, UH ethics professor Ken Kipnis, and Helo Hospital emergency physician Fred Holshu. Our producer is Susie Roth, our production chief Jeff Alardi. Our sponsor is the Hawaii Community Foundation. It's an organization that believes in the power of neighborhoods.

[01:03:06] George Bussey: That's why it provides grants to help neighbors work together on projects such as community policing, graffiti paint outs, clearing away debris and trash or holding community festivals that bring people together. Since this program was established in 1991, the foundation has given more than $1 million in grants to hundreds of neighborhoods across the state. This is just one of the many reasons that people who bring this radio show to you are proud to be sponsored by the Hawaii Community Foundation. I also want to mention that Walter Roth was on the phones this morning helping us out along with Matt Neilson and Cassie Roth.

[01:03:41] George Bussey: Oh a bunch of people were helping us this morning. You've been listening to Pop Radio. Aloha.