Image of the Texas State Capitol courtesy of adpal3180 via Flickr

One of Tim Flynn’s first duties as the first full-time nurse for the Texas State Capitol was to give then-Governor Ann Richards a flu shot. He was nervous enough that he forgot to bring a band-aid, which led Gov. Richards to warn him that he better not let any blood sully her $300 silk blouse!

He did his job carefully and well and her blouse was safe. His job was safe too evidently, because he’s been the Capitol nurse for the two decades since then, according to this profile of Mr. Flynn in the New York Times.

Through the administrations of Ms. Richards, George W. Bush and Rick Perry, Mr. Flynn has been at the Capitol to dispense flu shots, treat sinus infections, and provide patient education to lawmakers.

Everyone in the Capitol knows him and trusts him. Representative Rick Hardcastle says, “He knows I have bad allergies because he’s seen me before. It’s like going to see your family doctor.”

Even though he loved his job, he did get frustrated that he wasn’t able to write prescriptions or diagnose illnesses. So he decided to go back to school and become a nurse practitioner, graduating from the University of Texas in 2002.

As a state employee, Mr. Flynn does not charge patients. His Capitol clinic operates on a first-come, first-served basis. When children on school trips fall down, they go to him. State employees drop by when they have headaches.

“I love my job,” he said. “After being here 20 years, I know most of the folks that work here. I know their medical histories, their idiosyncrasies. This is my community. That’s why I call it my Capitol.”

In emergencies, Mr. Flynn is one of the first on the scene, providing life support until paramedics arrive. In 1999, when a Capitol parking guard was found slumped over his desk and suffering from gastrointestinal bleeding, Mr. Flynn treated him for shock before paramedics arrived and saved the man’s life.

Responding to emergencies is the smallest part of his job, Mr. Flynn said. He spends most of his time on procedures like treating strep throat, saving patients a trip to their primary care providers.

His job takes on added importance during the biennial legislative sessions, when lawmakers convene for 140 days at the Capitol.

“When it’s crunch time, I don’t have to call a doctor; I can go down to Tim’s office,” Mr. Hardcastle said. “When you have the flu during the night and you’re working on legislation, you need treatment. His job is vital to what we do.”

Image courtesy of AMagill via Flickr

Debt collection agencies have been embedding debt collectors as employees who run interference in emergency rooms and visit patients’ bedsides to demand payment, among other aggressive tactics.

The Minnesota attorney general, Lori Swanson, revealed that Accretive Health, one of the nation’s largest collectors of medical debts, has been engaging in these tactics. The New York Times notes that this raises concerns that “such practices have become common at hospitals across the country.”

Hospitals are increasingly desperate to recoup payments as their unpaid debts mount. To patients, the debt collectors can blend right in with hospital employees, yet these staff members focus on demanding that patients pay outstanding bills and may even discourage them from seeking emergency care at all. For example, they will sometimes purposely “stall” a visitor to the emergency room in an attempt to get payment before the patient receives any treatment. Their focus is on getting money, not the patient’s health.

Additionally, these workers (who are not actually medical staff) sometimes have access to health information, possibly in violation of Hipaa (the Health Insurance Portability and Accountability Act). Accretive employees may also have broken the law by not clearly stating that they were debt collectors.

As hospitals struggle under a glut of unpaid bills, they are reaching out to companies like Accretive that specialize in collecting medical bills.

Hospitals have long hired outside collection agencies to pursue patients after they have left hospital facilities. But financial pressures are altering the collection landscape so that they are now letting collection firms in the front door, according to Don May, the policy adviser for the American Hospital Association, a trade group.

To achieve promised savings, hospitals turn over the management of their front-line staffing — like patient registration and scheduling — and their back-office collection activities.

Concerns are mounting that the cozy working relationships will undercut patient care and threaten privacy, said Anthony Wright, executive director of Health Access California, a consumer advocacy coalition. “The mission of these companies is in direct opposition to the supposed mission of these hospitals.”

Still, hospitals are in a bind. The more than 5,000 community hospitals in the United States provided $39.3 billion in uncompensated care — predominately unpaid patient debts or charity care — in 2010, up 16 percent from 2007, the hospital association estimated.

Accretive is one of the few companies specializing in hospital debt collection that is publicly traded. Last year, it reported $29.2 million in profit, up 130 percent from a year earlier.

Late last month, Fairview Health Services, a Minnesota hospital group that Accretive provided services to, announced it was canceling its contract with Accretive for back-office debt collection. After Accretive informed investors, its stock plunged 19 percent in a day. On Tuesday, the company’s shares closed at $18.49, down 2.7 percent.

Accretive says that it trains its staff to focus on getting payment through “revenue cycle operations.” Accretive fostered a pressurized collection environment that included mandatory daily meetings at the hospitals in Minnesota, according to employees and the newly released documents. Employees with high collection tallies were rewarded with gift cards. Those who fell behind were threatened with termination.

“We’ve started firing people that aren’t getting with the program,” a member of Accretive’s staff wrote in an e-mail to his bosses in September 2010.

Collection activities extended from obstetrics to the emergency room. In July 2010, an Accretive manager told staff members at Fairview that they should “get cracking on labor and delivery,” since there is a “good chunk to be collected there,” according to company e-mails.

Employees were told to stall patients entering the emergency room until they had agreed to pay a previous balance, according to the documents. Employees in the emergency room, for example, were told to ask incoming patients first for a credit card payment. If that failed, employees were told to say, “If you have your checkbook in your car I will be happy to wait for you,” internal documents show.

Employees at Accretive’s client hospitals ask patients to make “point of service” payments before they receive treatment. Until she went to Fairview for her son Maxx’s ear tube surgery in November, Marcia Newton, a stay-at-home mother in Corcoran, Minn., said she had never been asked to pay for care before receiving it. “They were really aggressive about getting that money upfront,” she said in an interview.

Ms. Newton was shocked to learn that the employees were debt collectors. “You really feel hoodwinked,” she said.

While hospital collections at Fairview increased, patient care suffered, the employees said. “Patients are harassed mercilessly,” a hospital employee told Ms. Swanson.

Patients with outstanding balances were closely tracked by Accretive staff members, who listed them on “stop lists,” internal documents show. In March 2011, doctors at Fairview complained that such strong-arm tactics were discouraging patients from seeking lifesaving treatments, but Accretive officials dismissed the complaints as “country club talk,” the documents show.

Ms. Swanson said that the hounding of patients violated the Emergency Medical Treatment and Active Labor Act, a federal law requiring hospitals to provide emergency health care regardless of citizenship, legal status or ability to pay.

In the January lawsuit, Ms. Swanson said that by giving its collectors access to health records, Accretive violated the Health Insurance Portability and Accountability Act, known as Hipaa (pronounced HIP-ah). For example, an Accretive collection employee had access to records that showed a patient had bipolar disorder, Parkinson’s disease and a host of other conditions.

In addition, she said, the company broke state collections laws by failing to identify themselves as debt collectors when dealing with patients.

Late Tuesday afternoon, Accretive announced it won a contract to provide “revenue cycle operations” for Catholic Health East, which has hospitals in 11 states.

nebari – Fotolia.com

Dr. Otis Brawley is concerned how health care is currently consumed. He’s written a book called “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America” that examines and explains these concerns.

Tara Parker Pope of the NYT’s Well blog spoke to him about his book and how broken he considers the United States health care system to be. He states that “failure is in the system” — that no horror stories (and he has some doozies, like a woman with untreated breast cancer who brings in her breast for re-attachment after it falls off) should be dismissed as an aberration.

He doesn’t just blame hospitals, health care workers, or insurance companies though. He also thinks that patients demand overtreatment, and that this contributes to the bloat and inefficiency of the current health care system.

He says he decided to write the book after listening to the debate over the Affordable Care Act. He says, “The talk should not be about rationing health care but about rational health care. So much of what we do in health care is irrational.” When asked to describe an example of irrational health care, he says:

A.
There was a man with colon cancer who went to a wonderful hospital with a wonderful reputation. He got surgery and was referred to a medical oncologist who has a wonderful reputation as a doctor to the rich and famous in Atlanta. That medical oncologist started giving him chemotherapy and two other expensive drugs. When this man lost his insurance, the oncologist basically dropped him, and the guy ended up being seen by me at the county hospital. A doctor who is training with me to be an oncologist immediately realizes that this guy is getting a chemotherapy regimen for colon cancer that we stopped using about 15 years ago. His medical oncologist was practicing the best medicine of the late 1980s, but we were in 2006. The other drugs he was being prescribed were totally unnecessary. But the doctor could get a substantial markup and make a substantial amount of money by selling them. The oncologist had known just enough to be greedy and prescribe drugs he can make money off of, but he didn’t know enough to prescribe the chemotherapy that would have given the patient a much better chance of surviving his cancer.

I’ve seen that so many times, where doctors really have failed to evolve and failed to learn as the profession and the scientific evidence have changed over time.

Q.
But in reading the book, you don’t just blame doctors for being greedy. You blame patients for being gluttonous. Can you explain?

A.
Another patient of mine had early colon cancer. Three doctors had told her she should not get chemotherapy. She decided she wanted it, and she went doctor-shopping until she found a doctor who would give it to her. Her insurance had no way to object to her getting this inappropriate chemotherapy because privacy laws prevent disclosing the stage of the disease to the insurance company. She was referred to me by a relative who was concerned about what she was doing. She readily admitted that she had three different medical opinions that said she should not get chemotherapy, but she wanted chemotherapy. So a doctor made $10,000 off that six months of chemotherapy, and she got an increased risk of leukemia for the rest of her life, not to mention losing her hair and everything else, with no scientific evidence that the treatment reduced her risk of the colon cancer coming back.

I blame patients, I blame doctors, I blame hospitals, I blame drug companies, I blame insurance companies. Our health care system is messed up because the system is designed to fail, and everybody is responsible for health care failing as it is now.

Q.
The story about the woman whose breast fell off was horrible. What were you trying to tell us with that example?

A.
We so frequently talk about breast cancer almost as if it’s a boutique disease or trendy. I feel some people have forgotten how terrible this disease can be. This lady – I saw a lot of things in her background that were lessons for society about what we need to do if we want to defeat breast cancer. When she realized she had something growing in her breast, she had insurance, but logistics having to do with her job and child care and a little bit of denial kept her from going to the doctor and getting this thing diagnosed and treated when it was likely curable. Later on, when she wanted to see a doctor, she couldn’t because her insurance had gotten so expensive that she had to drop it. If she had come in when she first found this thing 9 or 10 years earlier, I probably could have cured it, and it would have cost about a tenth of what we spent when she was uninsured and receiving free care from the hospital. She lived for about two years after I met her. That’s a failure of medicine to educate people.

Q.
In the book, you talk about a conversation with a hospital marketing executive who talks about drumming up business with free prostate cancer screenings at a mall health fair. How did that affect you?

A.
That was the beginning of Otis Brawley becoming a loudmouth in the prostate cancer screening debate. We’re making promises to patients and making them think we know things we don’t know and making money off of them. There is a subtle little corruption in medicine. We’re selling chemo to people who don’t need it, giving prostate screening when it might save lives, but we make them think it definitely does, and then I see a lady whose breast is falling off who couldn’t afford to see a doctor when she wanted to see one.

Q.
Is there any hope that things might improve someday?

A.
I am trying to get folks, through this book, to talk a little more about rational use of health care and realize that we are actually hurting people with overtreatment. Health care needs to be consumed in a wiser way that is much more concerned about allegiance to the science. We need to be more concerned about the welfare of our patients. There was a recent report, the 45 tests we do too much, that I was thrilled to see. People are starting to realize that we need to be a little wiser in our use of health care.