The UHC Situation

 

In Econ 101 in college, insurance is LITERALLY the textbook example of what economists call "market failure" (utilities are another example). Market failure refers to the fact that certain industries have unusual characteristics that make a competitive market impossible and they have to have government intervention on various levels. Our reality is exactly what the theory says would happen if you tried to run the insurance market with private companies competing. What this means is that our system isn't this way because of mistakes, or unforeseen problems, or because it's "broken". It's operating EXACTLY as it was set up and intended to run. They've always known it would be exactly as it is now.

You are witnessing the relief and gratitude of a population at seeing a predator, who has been terrorizing and killing them for fun and profit, brought down so that he can't harm any more of them. Brian Thompson was PERSONALLY responsible (he is the one who brought in the AI to deny claims with an error rate of 90%) for more death and torturous suffering of innocent people then all American serial killers and mass killers combined. Ossama Bin Laden had a family too. Ted Bundy was a great older brother. He forfeited his claim to "humanity" when he not only refused to stop killing us, he increased his killing. And stop shaming the public- the investors (who he defrauded billions of dollars from) went ahead and held their meeting anyway. They don't care about him any more than we do. Corporate media is spinning this story hard. The political and legal system in America has been taken over by the predator class, of who Brian Thompson was just one of them, so that those avenues are now closed for the rest of us as avenues to try to change the healthcare system. Our elected officials have almost unanimously sold us out and actively kept reforms from being undertaken.  They have eliminated every peaceful, lawful means we have of protecting ourselves from their insatiable and entitled greed. 

The corporate media is intentionally misrepresenting what the public is expressing to try to shame us for seeing the value of his life the same as he saw the value of our lives.  The corporate media is basically telling us to go back to shooting schoolchildren, or strangers at Walmart, and don’t even think about killing another person whose life actually MATTERED EVER AGAIN. Piers Morgan and MSNBC and FOX News and the rest of the corporate media- you have spent more than a year now justifying the rampant slaughter of children with sniper rounds en masse, the bombing and burning and utter destruction of hospitals with patients inside of them including preterm infants, the genocide of tens of thousands of civilians, so don't dare to lecture us about not being horrified by murder.  You are owned by the predator class and you think that if you do their bidding, that you are a member of their club.  You are just as expendable to them as we are.  They won’t hesitate to do to you what you are doing your best to convince us they aren’t actually doing to us.

Inside STAT's investigations of UnitedHealth Group

What United Healthcare Doesn’t Want You To Know
UnitedHealthcare began in 1977 with a new at the time model for providing healthcare- HMOs.  In 1973, the Health Maintenance Organization Act required employers to offer their employees an HMO option and provided federal grants ($375 million).  HMOs became highly profitable, but they completely failed in their ostensible mission to stop the escalating cost of health care in the US, which has obviously ballooned out of control since this time.  UnitedHealthcare was hired to run an HMO that was itself a non-profit, but the doctors in the HMO threatened to unionize because they were barely able to get by with what UHC was paying them.  It turns out that the same man who ran the non-profit hired his own for-profit company to run the non-profit creating a clear conflict of interest.  The man's name was Richard Burke.

UHC was built by acquiring federally-subsidized insurance HMOs, and it turns out that one of the people behind the 1973 HMO Act that created these subsidized insurers was Richard Burke.  Consolidation in the 90s reduced competition and prices for health insurance dramatically increased, as always happens with consolidation.  A major part of this consolidation was for-profit companies like UHC and Anthem buying up non-profits.  While markers of quality didn't improve and costs went up, another thing went up- denials of claims.  What used to be rare became so common that in 2021 nearly 50 million claims were denied.  

The denials are not just hurting patients, 41% of doctors now are taking out payday loans because of how hard it is for them to get paid.  BUT- of course- UHC also owns a payday lender to take advantage of this market that they created called OPTUM.  This isn't enough though- UHC (along with several other asset managers) are also buying up these distressed doctors practices at very low prices, furthering the consolidation.  UHC now employs over 70,000 doctors in America and is the largest employer.  UHC uses subsidiaries to appear as "outside influences" to reduce the rate that they are required to repay doctors or how to handle claims.  All of this is illegal and violated anti-trust laws.  UHC was allowed to acquire Change Healthcare, a company that gave them direct access to the information about what their competitors were paying for the same services and other proprietary information which they used to further undermine the market. 

How UnitedHealth’s Playbook for Limiting Mental Health Coverage Puts Countless Americans’ Treatment at Risk
"Around 2016, government officials began to pry open United’s black box. They found that the nation’s largest health insurance conglomerate had been using algorithms to identify providers it determined were giving too much therapy and patients it believed were receiving too much; then, the company scrutinized their cases and cut off reimbursements.

By the end of 2021, United’s algorithm program had been deemed illegal in three states.

But that has not stopped the company from continuing to police mental health care with arbitrary thresholds and cost-driven targets, ProPublica found, after reviewing what is effectively the company’s internal playbook for limiting and cutting therapy expenses. The insurer’s strategies are still very much alive, putting countless patients at risk of losing mental health care."

Insurers Continue to Rely on Doctors Whose Judgments Have Been Criticized by Courts
"United’s approach, the judge said, essentially boiled down to “We’ll just gamble with her life.”

"The cases, ProPublica found, expose in blunt terms how insurance companies can put their clients’ health in jeopardy, in ways that some judges have ruled “arbitrary and capricious.” To do so, court records reveal, the insurers have turned to a coterie of psychiatrists and have continued relying on them even after one or more of their decisions have been criticized or overturned in court.

In their rulings, judges have found that insurers, in part through their psychiatrists, have acted in ways that are “puzzling,” “disingenuous” and even “dishonest.” The companies have engaged in “selective readings” of the medical evidence, “shut their eyes” to medical opinions that opposed their conclusions and made “baseless arguments” in court. Doctors reviewing the same cases have even repeated nearly identical language in denial letters, casting “significant doubt” on whether they’re independent."

An important detail that is mentioned in this article is that doctors aren't considered to be practicing medicine when they work for insurance companies reviewing cases and making recommendations, so they can't be sued for malpractice or on medical grounds, so they can't be held accountable. "Insurers have tried to defend against lawsuits by pointing out that multiple doctors all reached the decision to deny coverage. But judges have criticized doctors for rubber-stamping denials and for “multiple levels of deficient arbitrary and capricious determinations.” Just last year, a judge wrote that “three deficient denials considered together does not amount to substantial evidence to save any one of them.”  

When families sue the insurance companies and their cases are sound, they often settle out of court with confidentiality clauses because they don't want to risk losing in court and getting nothing. The Employee Retirement Income Security Act governs a lot of insurance claims in court and doesn't allow for punitive damages, which means there's no real penalty or disincentive for insurance companies to stop their bad behavior.  One federal judge said “They might have to pay 10 claims,” the judge said, “but if they can avoid paying a thousand claims, then why would they change anything?”  ANother judge, after likening the fraudulent language used by UHC to deny coverage, said "that it sometimes appears the insurer’s only duty is to “preserve the plan’s financial assets rather than offering aid to the plan’s human assets (its members and beneficiaries).”  (Sometimes??  All the time)

Her Mental Health Treatment Was Helping. That’s Why Insurance Cut Off Her Coverage. 
Insurers use both a lack of progress and making progress by a patient as reasons to cut off intensive treatment and cover only a lower, less expensive level.  If the patient hasn't made adequate progress they may claim that the treatment isn't working, isn't appropriate, that the patient is sabotaging the care, or that the problem is chronic and that acute care won't help.  This is done without concern for the length of time needed for the treatment to work or the fact that some conditions, such as bipolar, require life-long care.  Paradoxically, when a patient is making care, they will then claim that the treatment has worked and is no longer needed.  It's a lose-lose scenario for a lot of patients.  In the case that this article focuses on, the woman was denied ongoing care that resulted in her needing far more care at a far higher cost and bringing on so much distress that it derailed her progress a number of times and placed in her serious danger many times.

Judges have found companies using guidelines as the sole basis for coverage, even though this goes against the law and the companies themselves deny it.  They have also found in a number of landmark cases that insurance companies were violating a federal law that requires them to cover mental health and behavioral treatment the same as they cover physical health problems.  Despite these rulings, the companies continue to follow the egregious practices.  One judge wrote “The mere incidence of some improvement does not mean treatment was no longer medically necessary,”

Denied (The following is a script from "Denied" which aired on Dec. 14, 2014. Scott Pelley is the correspondent. Michael Rey and Oriana Zill-de Granados, producers.)
The shooter at Sandy Hook Elementary School had been denied mental health treatment by his insurer, which spurred an investigation into the aggressive and sometimes illegal tactics used by insurance companies to deny mental health coverage- especially serious cases that require long-term or intensive care.  The investigation found that there are many instances in which this care is denied or cut off prematurely on little or no grounds, and that many of these cases end in tragedy that may have been avoidable if they had received the treatment that they needed.

These denials are made by doctors who haven't seen the patient and don't have knowledge of the case outside the case records.  They call and harass doctors, sometimes multiple times a day, lookling for ways to cut off services.  They go against the expert opinion of treating doctors, and in many cases, multiple treating doctors and facilities.  Cases were found in which an insurance company doctor left several messages for a treating doctor, but then denied care after waiting only 22 minutes for a return call.  

One person interviewed said "They're called managed care, but it's really managed cost."  When asked why the insurance company was so aggressive about getting people, even children, out of long-term care and sending them home early, he replied "well, it's a lot cheaper in the short run. And if you're managing costs on a quarterly basis, you can understand why from a business point of view for that quarter it makes sense. For the sake of the child, for the sake of our society, for the sake of the child's future it doesn't make any sense."  In speaking about a notorious doctor known as Dr Jack who earns $25,000 a month doing "reviews" at $45 each, he said "We spoke to 26 psychiatrists from across the country, and every one brought up Dr. Jack's name. Some called him "Dr. Denial."  Some of the insurance company doctors that the writer looked into had denial rates between 92% and 100%.

He wanted to live. After his insurance rejected coverage, he died of a fentanyl overdose
A young man had himself taken to a treatment center that knew how to treat his Fentanyl addiction, but after only 3 days his insurance company refused to pay and he was sent home, where he died soon after from an overdose.  The article finds that "the system for appealing mental health denials effectively remains broken."  They found several commonalities including that the cases that were appealed were often decided by insurance plan doctors who were not trained in the criteria required by law, that many "appear to deny almost every appeal for behavioral health treatment they review", that data regarding denials is not shown to regulators or even kept, and that when regulators do get involved, they routinely side with patients, indicating that the denials were not correct most of the time. 

Deny, Defend, Depose: UnitedHealthcare CEO’s Slaying Highlights Widespread Rage at Healthcare Industry
"there has been an outpouring of rage on social media directed at the health industry, with many sharing stories of having claims for vital care denied and losing precious time with loved ones during illness."  Juan Gonzales, one of the hosts, points out that there are an average of 75 murders each day in America, but this one killing of such a wealthy and powerful person shines a light on how some of our lives are treated as much more valuable than others.  One guest explains that the rage has been boiling just below the surface for many years, pointing out that "A hundred million Americans have medical — have medical debt, but most of those people have health insurance. But they can’t get their insurance companies to cover the care that they need."

"This company in particular (UHC) has a record of using prior authorization or refusing to pay for needed care far more than its competitors. But for-profit insurers, in general, have used this as a means of enriching their shareholders, of using fewer and fewer of our premium dollars to pay for the care that we need, so that more money can be made available to their shareholders."  Brian Thompson ran Medicare Advantage for UHC.  

Healthcare Is a Right: CEO’s Killing Ignites Calls for Reform Amid Trump’s Plan to Privatize Medicare
"Wendell Potter, now an advocate for reform, he says the murder of Thompson “was a horrible crime, but it is important to point out that violent crime is perpetuated by these companies in an anonymous way every single day when an untold number of Americans are told they are not going to get the care they need.” Some doctors have referred to this as a “moral injury” they face on the job. Potter urges lawmakers to seize the opportunity to move forward with far-reaching reforms."  (This is ludicrous, lawmakers have sold us out to these health care companies.  They work for the people who pay them, and that isn't us.  We, The People, cna't begin to pay them what the private sector does.  Reform has been proven to be no option at all.)

They discuss the case of 17-year-old Nataline Sarkisyan, who died when Cigna denied a necessary liver transplant.  The company eventually agreed to cover it, under extreme pressure, but it was too late and Nataline died because of the delay.  

Derrick Crowe, one of the guests, represents Care Over Cost (a campaign to help people get claims denials overturned).  Wendell Potter, the other guest, is a former executive for the health insurance companies Cigna and Humana, executive editor of HEALTH CARE un-covered, author of the book Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans and Nation on the Take.

Denied: ProPublica Exposes UnitedHealth Profiteering OffLimiting Care for Children with Autism
Discusses ProPublica article exposing UHC/Optum for “strategically” moving to cut off ABA therapy for kids with autism, especially those on Medicaid.  UHC stands out as especially bad.  Company has “secret, internal cost-cutting strategy” – UHC/Optum calls it “the gold standard treatment”.  They have developed “market plans”, “special action plans” to limit access to care.  They are terminating contracts with existing providers and avoiding contracts with new ones. The Mental Health Parity Act was passed in 2008 that says that mental and behavioral health services must be offered at parity with physical health services.  This may also violate Medicaid laws. 

UHC took an old algorithm that was designed to identify patients at risk for suicide or substance abuse, they redesigned it to look for what they call “therapy overuse” and began aggressively targeting children with autism getting therapy.  The providers were being aggressively questioned about the medical necessity of the therapy.  They were investigated by 3 states and the Department of Labor for these practices, and told it was illegal and that they had to stop doing it in these jurisdictions.  The way our healthcare system is set up, they could continue to do this in other states.  

'Out of Control': Insurance Giant UnitedHealth Calls in Middle of Cancer Surgery to Question Necessity
This article discusses a video made by a doctor who was called out of surgery by UHC to justify the patient's inpatient status for the night following the surgery, to be questioned by someone who claimed not to know the patient's diagnosis or that she was in surgery, because that was a different department.  UHC later claimed that they wouldn't call a doctor out of surgery, but they have no credibility. 

OTHER HEALTHCARE COMPANIES
Debt in the dark: UCHealth sues patients daily and some have no idea why
UC Health, a Colorado company, claims that it's practice of suing patients who it claims "don't want to pay" is the industry norm- but an investigation showed that it is virtually the only health company in CO doing this.  It is suing patients who have already paid off their bills and can prove it, patients who have a zero balance on their account, and others for no reason anyone can figure out.  Two state legislators passed a law to try to stop this practice. 

The Predatory Financial Structure of the American Medical System

“Not Medically Necessary”: Inside the Company Helping America’s Biggest Health Insurers Deny Coverage for Care
"America’s largest insurers hire EviCore to make decisions on whether to pay for care for more than 100 million people.  “The Dial”: EviCore uses an algorithm that allows it to adjust the chances that company doctors will screen prior authorization requests, increasing the possibility of denials.
Lucrative Deals: Some EviCore contracts are based on how deeply the company can reduce spending on medical procedures. It tells insurers that it can provide a 3-to-1 return on investment.

"Over the years, medical groups have repeatedly complained that EviCore’s guidelines were outdated and rigid, resulting in inappropriate denials or delays in care."

"Known as risk contracts, EviCore takes on the responsibility for paying claims. As an example, say an insurer spends $10 million a year on MRIs. If EviCore keeps costs below that figure, it pockets the difference. In some cases, it splits the savings with the insurance company.  “Where you really made your money was on a risk model,” a former EviCore executive said. “Their margins were exponentially higher.  Insurers do not make explicit demands for more denials, a former EviCore sales executive said, Instead, they asked about “controlling the spend” — the amount of money paid out on certain procedures, he said. Nor would EviCore always use the word “denials” — they employed circumlocutions like “inappropriate determinations.”

"A 2023 academic study examined the criteria EviCore used to approve payment for imaging of the lower spine in cases of extreme pain. It found the guidelines deficient. Two of five medical experts who reviewed the guidelines even recommended not using them.  ( A critical appraisal of Evicore’s guidelines for advanced diagnostic imaging of the spine for lower extremity pain with neurological features ) "Nine months after starting at EviCore, Miller quit, disappointed by the attitudes of some of her colleagues. “Most of the physicians who work at these places just don’t care,” she said. “Any empathy they had is gone.”

Another way that EviCore reduces costs for insurers is that doctors make fewer reque4sts for procedures.  EviCore says this is because doctors make fewer inappropriate requests, doctors say they give up because fighting to get procedures for their patients is too time-consuming.  Cigna, who owns EviCore, claims that this effect (called the "sentinel effect") occurs because doctors are kept more up-to-date on current procedures.  "Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files."

"In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages. When doctors faxed prior authorization requests longer than the limit, company representatives would deny them for failing to have enough documentation. Carelon denied the allegations in court and admitted no fault."

"Lawsuits against employer-funded health plans, like the one Cupp had with United, must be tried in federal court, where case law favors insurance companies. For instance, insurers found at fault do not pay punitive damages, only the cost of treatment."

AMA survey finds prior authorization hurts patients and doctors
"Health systems should also expect higher drug costs. Hospital drug expenses are 12% higher than in 2020. Hospitals also need to get accustomed to patients shifting more toward outpatient facilities, Swanson said." from https://www.chiefhealthcareexecutive.com/view/hospitals-faring-better-than-last-year-but-a-difficult-path-lies-ahead 

Eat What You Kill
This report is about an oncologist named Dr. Thomas C. Weiner who practiced in Helena, MT and essentially built a kingdom there for himself at St Peter hospital.  He was eventually terminated for all kinds of fraud and harm to patients, including extremely excessive prescribing of opiate medications and the seemingly intentional killing of at least 10 patients but probably many, many more- all under the pretense of "providing comfort".  This man comes across as a psychopathic narcissist, essentially a cult leader who used all manner of coercive control and lying to maintain his powerful and extremely lucrative position in the community.  

This phrase refers to a reimbursal scheme at some hospitals in which providers are paid for the value of  the services they provide.  "Adding to a six-figure base salary, his pay was calculated by the number of relative value units, or RVUs, he billed on behalf of the hospital. The system compensates doctors using weighted values for certain types of visits or treatment. It works like this: A doctor might be paid $100 per RVU. A routine physical might be equal to 1 RVU, or $100; a more complicated and time-consuming procedure like radiation therapy might equal 8 RVUs, or $800. In other words, the more patient visits and treatments a doctor bills to insurance, the more that doctor and the hospital earn. Weiner described this system, which is common in American medicine, as “eat what you kill.”

“Comfort” was a word Weiner used often in our conversations. If a patient dies as a result of his treatment, he told me, it’s not unethical if his intent was to provide comfort. In medicine, this is called the principle of double effect. First developed by the Catholic saint and theologian Thomas Aquinas, it’s a set of criteria by which a person can morally justify ending someone’s life. It stipulates that a harmful consequence of a medical treatment, such as death, is permissible if it’s a secondary effect of beneficial treatment, such as alleviating pain with drugs. “It’s for their comfort,” Weiner told me. “It’s not that I euthanize them.”

Can the new CVS CEO handle the Aetna challenge?
This is an article about the replacement of one CVS Health CEO with another because stock value and profitability are the top priorities in how the health care company is run.  The stock price had fallen, due in part to their insurance arm Aetna "Health insurance companies typically aim to pay out about 80% of the premiums they collect for customer medical services. CVS said on Friday that the percentage of premiums spent on medical services had risen to 95%."

CVS Health slashes infusion services offerings, blaming industry headwinds
"More than 3.2 million Americans receive some type of infusion therapy each year, according to Bourne’s research. The figure is expected to grow over the upcoming years, as the population over 65 years old is projected to double in the next three decades, chronic disease continues to rise and the Food and Drug Administration green-lights new injection-based drugs."

"Nationwide nursing labor shortages have hit the infusion industry hard because infusion therapy can require a 1-to-1 nurse-to-patient ratio and must be performed by nurses with specialized training, according to Bourne Partners.

Training requirements can push compensation for infusion nurses up 10% to 20% higher than nonspecialized nurses, the consultancy said, straining provider budgets.

In 2022, CVS Health closed 36 of its 71 Coram clinics and laid off 2,000 employees including dietitians, nurses and pharmacists. A KFF News report attributed the closure to high overhead costs associated with providing infusion services, labor costs, reimbursement delays and supply shortages."

Parents Want Justice for Birth Injuries. Hospitals Want to Strip Them of the Right to Make That Decision.
A Florida program called NICA was set up to compensate families whose children experienced severe brain damage during delivery, with the condition that the parents can't sue for malpractice.  The program has been badly run, failing to provide the promised care, and parents who try to use the conditions that exist to avoid the program and sue for damages are now being thwarted with the appointment of guardians to make the choice to enroll in NICA on behalf of their children.  

Despite Persistent Warnings, Texas Rushed to Remove Millions From Medicaid. That Move Cost Eligible Residents Care.
"For three years during the coronavirus pandemic, the federal government gave Texas and other states billions of dollars in exchange for their promise not to exacerbate the public health crisis by kicking people off Medicaid.

When that agreement ended last year, Texas moved swiftly, kicking off more people faster than any other state.

Officials acknowledged some errors after they stripped Medicaid coverage from more than 2 million people, most of them children. Some people who believe they were wrongly removed are desperately trying to get back on the state and federally funded health care program, adding to a backlog of more than 200,000 applicants. A ProPublica and Texas Tribune review of dozens of public and private records, including memos, emails and legislative hearings, clearly shows that those and other mistakes were preventable and foreshadowed in persistent warnings from the federal government, whistleblowers and advocates."

We Reported on a Nonprofit Hospital System That Sues Poor Patients. It Just Freed Thousands From Debt.
Methodist Le Bonheur Healthcare filed more than 8,300 debt lawsuits from 2014 through 2018 against patients who owed money.  The hospital had a much less substantial financial assistance program than other hospitals in the area, owned it's own collection agency, and sued many people who owed money, even garnishing wages when it won.  Non-profit hospitals, such as Methodist, receive tax exemptions in exchange for providing community benefit- providing medical services to low-income patients and others who struggle to afford care.  After an expose by ProPublica and a local news source, the hospital forgave the debt of more than 6500 patients.

The Nonprofit Hospital That Makes Millions, Owns a Collection Agency and Relentlessly Sues the Poor
"Nonprofit hospitals pay virtually no local, state or federal income tax. In return, they provide community benefits, including charity care to low-income patients. In Memphis, Methodist Le Bonheur Healthcare has brought 8,300 lawsuits for unpaid medical bills in just five years." 

Low-Wage Workers Are Being Sued for Unpaid Medical Bills by a Nonprofit Christian Hospital That Employs Them
The same hospital mentioned above, Methodist Le Bonheur Healthcare, also sued it's own low-income employees for care they received.

The Growth of Private Equity in US Health Care: Impact and Outlook

Newsom sides with health care industry in rejecting rules for prescription drug middlemen, hedge funds

After private equity takes over hospitals, they are less able to care for patients, top medical researchers say

The Dangerous and Deadly Effects of For-Profit Health Care

Most Americans have a very simplistic understanding of how both our economic system and our medical system actually work, and so while there is widespread frustration and anger regarding the American health system, there is little agreement about what has caused the problems and what should be done to improve it.  The problems endemic to the US healthcare system seem innumerable, and even focusing on only those that are directly related to money and corruption doesn't seem to make the list much more manageable.  For starters, science done in the context of profit and business secrecy destroys its credibility.  Allowing the same people to give advice who have a vested interest in which advice you take further undermines reliability.  Insurance, including health insurance, is literally the textbook example of what economists call "market failure", a situation in which characteristics of an industry mean that a competitive market cannot operate in that industry and various forms of regulation are required.  Then there is just straight-up, old-fashioned corruption. 

Medical research has increasingly been funded by sources with vested interests in the outcome, calling into question the neutrality and validity of the results.  Research has become slewed towards drug development rather than other types of prevention and treatment which might be more effective and safer but are less profitable.  The encroachment of private investment into medicine has reached its peak destructiveness in the form of private equity investments that are doing little more than buying up hospitals, medical practices, pharmacies, insurance companies, and other medical businesses, raiding them for their assets, and then leaving the carcasses in bankruptcy.  This has jeopardized the safety of most Americans and led to more deaths and serious harm than we will ever know, just so that the already obscenely rich can become even more obscenely rich. 

The nature of the healthcare industry itself has had to change and adapt over time, complicating matters and obscuring some of the more harmful changes.  Large scale changes in the types of health problems facing the American public began in the 1960s with the recognition of auto-immunity and the meteoric rise in prevalence of auto-immune conditions, which remain poorly understood and for which treatments are not very effective or reliable.  A similar rise in prevalence in atopic diseases- diseases involving allergic and allergy-type responses- began not long afterwards, beginning in the 1980s.  Cancer rates have skyrocketed, and there has never been an area of research in which more money has been spent and yet so few advances have actually been made.  Many of what are claimed to be advances have more to do with playing with statistics and altering definitions than with actual improved patient outcomes.

The ENTIRE healthcare system is broken, not just health insurance companies
Dr Prasad points out, following the killing of the UHC CEO Brian Thompson, that out entire healthcare system is broken in many ways.  He discusses cases in which doctors prescribe experimental or unsupported treatments, such as a double lung transplant for someone with stage 4 lung cancer, the fact that the CDC and FDA have many times made decisions that benefit individuals who work there in their own careers but not the general public, and that pharma companies are not incentivized to produce real cures but to maximize revenue and market share.  "There is a lot of bad medicine".  A lot of providers do what they do because it's what they learned, but they don't have a good explanation.  

America’s Mental Barrier
"American insurance companies — quietly, and with little government pushback — have assumed an outsize role in mental health care. People in pain are paying the price."

Endo’s End Around: How One of the Nation’s Largest Opioid Makers Escaped a $7 Billion Federal Penalty
Reporting Highlights:
-Delayed Justice: After a whistleblower exposed the criminal behavior of Endo, a drug manufacturer, the Justice Department waited more than a decade to bring charges against the company.
-A Steep Discount: Federal agencies said Endo owed up to $7 billion in criminal fines, back taxes and other charges. The government settled this year for just $200 million.
 -Winners and Losers: Endo is still selling narcotics. Lawyers made $350 million. A few executives shared $95 million in bonuses. Thousands of opioid victims are to share $40 million. 

Please read this article.  There are so many ways that what Endo did, and how it avoided accountability, are so deeply wrong.  If you were horrified by the case of Purdue Pharma and the Sackler family, be prepared for the same but on a scale orders of magnitude more massive.  The complicity of the government (including the DOJ, DEA, CDC, FDA, Medicare, and more) shows a level of corruption and complicity that frankly cannot be remedied- it must be replaced, entirely, from the ground up.  You simply cannot reform something that is not broken, but rather working exactly as it was designed to work, by people who use their power to enrich themselves and make others pay the price at any cost. 

Sanders Says Senate Hearing Will Put 'Greed on Display' With or Without Healthcare CEO
A company called Steward Health Care has made massive profits, paid its private owners millions in dividends, and the CEO Dr. Ralph de la Torre paid himself $4 million and purchased a mega yacht thought to be worth $40 million, while incurring massive debt and driving all 31 of its hospitals into bankruptcy.  

Further, "On Thursday, CBS News reported that in 2017 Steward executives including de la Torre illegally conspired with Maltese officials in order to secure a hospital contract, according to a whistleblower.  While a spokesperson for the executive denied any wrongdoing, whistleblower Ram Tumuluri alleged in a complaint to the U.S. Congress that "in touting Steward's supposed competitive advantage in Malta... de la Torre boasted that he could issue 'brown bags' to government officials if necessary to close transactions."

Medicare Advantage is rife with corruption

Medicare Advantage plans 'intentionally using prior authorization to boost profits': Senate report

The Corrupting Influence of Money in Medicine

The influence of money has wormed its way into all aspects of the American medical system- research, practice, access, the guidelines and advice patients are given about their health, and even how diagnostic criteria are determined.  This money represents the domination of a few pharmaceutical companies that have twisted and tweaked the entire system to serve their profit motive.  The effects of what is called regulatory and institutional capture by economists has had a devastating effect on the health of Americans.  It has also led to an unprecedented amount of wealth consolidation at record speed.

In Minnesota, the Mayo Clinic Sometimes Called the Shots With Gov. Tim Walz
Tim Walz has a very close relationship with The Mayo Clinic, to the point that he has allowed them to re-write legislation that was passed by the Minnesota legislature.  The Mayo Clinic has costs that are 88% higher than average in Minnesota adjusted for medical complexity of patients.  Mayo has consistently fought and eliminated efforts to reduce the cost of health care, often emphasizing internal strategies instead such as AI programs to handle staffing.  They were instrumental in killing any "public option" or single payer healthcare including regarding the ACA under Obama. 

Industry's Influence in Medicine: Duped, Doped and Dying in America
Gwen Olsen, a former pharmaceutical drug rep, tells about her experiences seeing pharma companies from the inside.  She says that the system is predatory and was intentionally set up to control us by doping us up and dumbing us down for profit.  

It finally happened: Goldman Sachs asks 'Is curing patients a sustainable business model?

Mother’s death sparks concern about hospital investment
Private equity firms have bought hospitals and extract all the wealth they can from them, leaving them unable to properly care for patients, which can be deadly.

The healthcare system is a giant SCAM (that you pay for)

The average yearly cost of health insurance in the US is $7 K.  The US spends more on healthcare than any other country, but the quality of care is the lowest among all wealthy nations.  Patients are over0charged by billions of dollars every year.  "A handful of companies have turned healthcare into a trillion dollar scam".  Profits are valued over human lives.  In Canada, one vial of insulin costs $30 but here in America the same vial costs $300, and the price for one specific AIDS drug in the US is $2 K while it costs only $8 in Australia.  From the New York Times-"Among those who reported problems paying their bills despite having insurance, 63% said they used up all or most of their savings; 42% took on an extra job or more work hours; 14% moved or took in roommates; and 11% turned to charity."  A study found that 66.5% of all bankruptcies were tied to medical issues, which is about 500 K families going into bankruptcy each year. The US is the only developed country that doesn't have universal health care.  Many poorer countries, including Pakistan, Iran, and Rwanda, provide free medical care to their people.  

 

Insurance companies have tried to say that they offer a valuable service because they negotiate prices down so much, but it turns out that they start with a very inflated price, so they aren't really saving you money.  Hospitals and other providers won't negotiate their prices down so much with individuals because they say they don't have representation.  Another way of saying this is that hospitals penalize people without insurance by adding a charge of several hundred percent on your medical bill.  You could say that hospitals and insurance companies collude in a mafia-like scheme, where hospitals enforce penalties if you don't pay insurance companies for protection.  The rate of c-sections in America is more than double the world average and this is largely due to c-sections being much more lucrative.  There are even hospitals that charge you if you want to hold your baby after birth as "skin to skin contact".  

Blackstone is one of the largest investing firms on earth, and owns the biggest medical staffing company in America, called TeamHealth.  It came out in a deposition that TeamHealth's prices were "higher than those of 95% of other providers and 8 or 9 times more than what medicare would pay", and that "the actual costs of medical services are not a factor in setting TeamHealth's prices".  So if you've ever wondered where all the money you pay for medical care goes, it goes to investors.  Almost every publicly traded hospital, medical, and pharma company is at least partially owned by either BlackRock or Vanguard.  These two companies have almost total control over the American health care system and use their influence to bring in huge returns while more and more Americans can't afford healthcare at all.

Pharmaceutical companies pay the most to lobby congress by far, which is twice as much as the next highest spender.  Life expectancy is dropping faster in America than anywhere else, and the maternal mortality rate is increasing.  Medical errors are the third leading cause of death in the country, 10% of all deaths each year.

The prices hospitals don't want you to see (NYT)   

How Profiteering and Corruption Harm Patients
A Place to Die’: For-Profit Health Care Crisis EXPOSED

Latest huge Big Pharma fraud settlement + shocking history of injury and death cover-ups

Drug Shortages Forcing Hard Decisions on Rationing Treatments
"In recent years, shortages of all sorts of drugs — anesthetics, painkillers,antibiotics, cancer treatments — have become the new normal in American medicine. The American Society of Health-System Pharmacists currently lists inadequate supplies of more than 150 drugs and therapeutics, for reasons ranging from manufacturing problems to federal safety crackdowns to drug makers abandoning low-profit products. But while such shortages have periodically drawn attention, the 
rationing that results from them has been largely hidden from patients and the public."

Medical Bills Leading Cause of Bankruptcy, Harvard Study Finds
"Illness and medical bills caused half of the 1,458,000 personal bankruptcies in 2001, according to a study published by the journal Health Affairs.  The study estimates that medical bankruptcies affect about 2 million Americans annually -- counting debtors and their dependents, including about 700,000 children.  Surprisingly, most of those bankrupted by illness had health insurance. More than three-quarters were insured at the start of the bankrupting illness. However, 38 percent had lost coverage at least temporarily by the time they filed for bankruptcy."

The High Cost of Drugs and Treatment and Paying Doctors to Prescribe Drugs
Transparency in medicine Dr Wen 

Leana Wen: What your doctor won’t disclose
TED talk by a doctor about issues of trust in the doctor-patient relationship, doctors resisting transparency about themselves and how they practice (including disclosing payments and perks from pharmaceutical companies). 

Docs on Pharma Payroll Have Blemished Records, Limited Credentials
"The implications are great for patients, who in the past have been exposed to such heavily marketed drugs as the painkiller Bextra and the diabetes drug Avandia — billion-dollar blockbusters until dangerous side effects emerged."
"A review of physician licensing records in the 15 most-populous states and three others found sanctions against more than 250 speakers, including some of the highest paid. Their misconduct included inappropriately prescribing drugs, providing poor care or having sex with patients. Some of the doctors had even lost their licenses.  More than 40 have received FDA warnings for research misconduct, lost hospital privileges or been convicted of crimes. And at least 20 more have had two or more malpractice judgments or settlements. This accounting is by no means complete; many state regulators don’t post these actions on their web sites.  Forty five who earned in excess of $100,000 did not have board certification in any specialty, suggesting they had not completed advanced training and passed a comprehensive exam. Some of those doctors and others also lacked published research, academic appointments or leadership roles in professional societies."

Lawsuits Say Pharma Illegally Paid Doctors to Push Their Drugs
"Pharma companies are being accused in lawsuits of paying doctors to push off-label uses of their drugs or financially rewarding doctors for prescribing their brand-name medications.  In the past three years alone, pharmaceutical companies have anteed up nearly $7 billion for settlements in cases such as one filed by Angela Maher, a former drug sales rep for Ortho-McNeil Pharmaceutical."

Despite improved transparency, conflicts of interest remain issue in medicine
“These conflicts undermine the reliability and credibility of the guidelines,” Nissen told Cardiology Today. “I don’t think that disclosure is the antidote here. The antidote is for physicians who are involved in public policy discussions not to accept money for promoting drugs.”

60 Minutes Episode Pharma execs used strip clubs, broke FDA laws to boost opioid sales

Forty-three percent of pediatricians receive industry payments "A significant proportion of pediatricians received payments from industry sources, such as pharmaceutical and device manufacturers, with the greatest amount of payments associated with attention-deficit/hyperactivity disorder treatments and vaccines, according to recent research in Pediatrics." 

Insulin should be cheap. Here’s why it's not

High Insulin Prices Drive Diabetics to Take Extreme Measures

Diabetics Are Hacking Their Own Insulin Pumps

Lawmakers grill Mylan CEO over EpiPen price hikes
"Jason Chaffetz (R-Utah), chairman of the House Committee on Oversight and Government Reform, held up an EpiPen to punctuate his point that epinephrine — “the juice” inside Mylan’s device — costs about $1 a dose. The list price of a two-pack of the pens is $608, up about 500 percent in a decade."

"You virtually have a monopoly, and you've used it to your advantage - but unfortunately, it's at the expense of people who need it," said Rep. Gerald E. Connolly (D-Va.). "I'm wondering what your sense of social responsibility is to those people."

FDA approves first generic version of EpiPen  The article discusses how the new generic version will help ease the chronic shortage of EpiPens that worsens near the end of the summer as kids need new prescriptions for school and other activities.  It also talks about how Mylan, the brand name version, actively fought the approval of the new generic
version out of self interest. 

Heather Bresch, the CEO of Mylan, testifies in front of congress about price gauging the epi pen 

Damning NEW Email Puts Joe Manchin’s Daughter At Center Of EpiPen Price-Fixing Scheme

Drug executives to testify before Congress about their role in U.S. opioid crisis "Current and former executives with the pharmaceutical distributors that are accused of flooding communities with powerful prescription painkillers have been summoned to testify before Congress about their role in the U.S. opioid epidemic."

"Since 2000, the epidemic has killed 200,000 people — more than three times the number of U.S. military deaths in the Vietnam War."

A Giant Pain in the Wallet
How an effort by the FDA to evaluate drugs that have been on the market since before testing was required has allowed pharmaceutical companies to price-gauge patients.

Pharmaceutical advertisements in leading medical journals: experts' assessments.
"In the opinion of the reviewers, many advertisements contained deficiencies in areas in which the FDA has established explicit standards of quality. New strategies are needed to ensure that advertisements comply with standards intended to promote proper use of the products and to protect the consumer."

Accuracy of pharmaceutical advertisements in medical journals.
"Doctors should be cautious in assessment of advertisements that claim a drug has greater efficacy, safety, or convenience, even though these claims are accompanied by bibliographical references to randomized clinical trials published in reputable medical journals and seem to be evidence-based."

What if all US health care costs were transparent? | Jeanne Pinder
How drug companies make you buy more medicine than you need
This video talks about how pharmaceutical drugs are packaged and sold in ways that deliberately lead to waste, which creates costs that are then borne by the consumer.  For some drugs such as chemotherapy drugs these costs can be very high.  This issue is not something that the FDA regulates. This article by ProPublica goes into more detail about this topic.

Frequency and Magnitude of Co-payments Exceeding Prescription Drug Costs
"A co-payment suggests sharing the total cost between patients and payers. However, drug co-payments sometimes exceed costs, with the insurer or pharmacy benefit manager (PBM) keeping the difference. Furthermore, some pharmacists are contractually prevented from alerting patients when their co-payment exceeds the drug’s cash price. Although some have argued that the practice is uncommon, a 2016 survey of independent pharmacists indicates otherwise."

The case of the $629 Band-Aid — and what it reveals about American health care
We have all experienced the bizarrely high prices charged for many medical services and devices, and I think we can all relate to the parent who wrote this article about the absurdity of medical pricing. 

Pharma Influence over Practice and Patient Care
Leana Wen: What your doctor won’t disclose
TED talk by a doctor about issues of trust in the doctor-patient relationship, doctors resisting transparency about themselves and how they practice (including disclosing payments and perks from pharmaceutical companies).

Conflicts of interest pervade US treatment guidelines, reports say
"Financial conflicts of interest are widespread among the authors of US clinical practice guidelines, according to two research letters and an editor’s note that were published in JAMA Internal Medicine.  Such conflicts are “an intractable problem in the United States,” write Robert Steinbrook, editor at large of JAMA Internal Medicine, and Colette DeJong of the University of San Francisco."

US Physician Societies are completely Corrupted

Dollars for Docs- How Industry Dollars Reached Your Doctors

We Found Over 700 Doctors Who Were Paid More Than a Million Dollars by Drug and Medical Device Companies
"Each year from 2014 to 2018, drug and medical device companies spent between $2.1 billion and $2.2 billion paying doctors for speaking and consulting, as well as on meals, travel and gifts for them."

Docs on Pharma Payroll Have Blemished Records, Limited Credentials

Now There’s Proof: Docs Who Get Company Cash Tend to Prescribe More Brand-Name Meds
"A ProPublica analysis has found for the first time that doctors who receive payments from the medical industry do indeed tend to prescribe drugs differently than their colleagues who don’t. And the more money they receive, on average, the more brand-name medications they prescribe."
"doctors who received industry payments were two to three times as likely to prescribe brand-name drugs at exceptionally high rates as others in their specialty."
"nearly nine in 10 cardiologists who wrote at least 1,000 prescriptions for Medicare patients received payments from a drug or device company in 2014, while seven in 10 internists and family practitioners did."

Matching Industry Payments to Medicare Prescribing Patterns: An Analysis
(this is mentioned in the above article)

Private equity ownership is killing people at nursing homes
"The researchers studied patients who stayed at a skilled nursing facility after an acute episode at a hospital, looking at deaths that fell within the 90-day period after they left the nursing home. They found that going to a private equity-owned nursing home increased mortality for patients by 10 percent against the overall average.  Or to put it another way: “This estimate implies about 20,150 Medicare lives lost due to [private equity] ownership of nursing homes during our sample period” of 12 years, the authors — Atul Gupta, Sabrina Howell, Constantine Yannelis, and Abhinav Gupta — wrote. That’s more than 1,000 deaths every year, on average."
This is the working paper behind this article:
DOES PRIVATE EQUITY INVESTMENT IN HEALTHCARE BENEFIT PATIENTS?  EVIDENCE FROM NURSING HOMES

Payments, Conflict of Interest, and Trustworthy Otolaryngology Clinical Practice Guidelines
"Clinical practice guidelines (CPGs) are the cornerstone of the evidence-based practice of otolaryngology–head and neck surgery. The American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) CPGs are widely distributed, as judged by frequency of downloads, webpage views, and CPG-related sessions at national meetings. Clinical practice guidelines are developed to reduce variation in care and to improve quality. They create debate and even controversy, with concerns expressed about restraints on clinician decision making as well as the medicolegal implications of recommendations. Clinical practice guidelines must be trustworthy, and the Institute of Medicine (IOM) and the Guideline International Network have provided standards for CPGs.1 A major threat to the creation of trustworthy guidelines is conflict of interest (COI) among the organizations and the committee members who create CPGs.

Influence Over Regulation and Policy
Why HEALTHCARE works the way it does: Look at these SHOCKING lobbying numbers

Third member of prestigious FDA panel resigns over approval of Biogen’s Alzheimer’s drug
"A third member of a key Food and Drug Administration advisory panel has resigned over the agency’s controversial decision to approve Biogen’s new Alzheimer’s drug, Aduhelm, CNBC has learned."

 "Dr. Aaron Kesselheim, a professor of medicine at Harvard Medical School, said the agency’s decision on Biogen “was probably the worst drug approval decision in recent U.S. history,” according to his resignation letter obtained by CNBC."

Secret Clinical Trial Data to Go Public: Drug companies have begun to share their clinical trial data. The long-overdue shift heralds a new era in medicine (from Scientific American)
"How well does a prescription drug work? It can be hard for even doctors to know. Pharmaceutical companies frequently withhold the results of negative or inconclusive trials. Without a full accounting, a physician who wants to counsel a patient about whether a drug works better than a sugar pill is frequently at a loss. Drug companies share only airbrushed versions of data on safety and usefulness.

As a consequence, regulators can approve drugs that have hidden health hazards. Clinical trials of GlaxoSmithKline's diabetes drug Avandia (rosiglitazone) and Merck's anti-inflammatory Vioxx (rofecoxib) revealed an elevated cardiac risk from the drugs, but relevant findings were held back from regulators or never published.* Far more drugs have gone to market with critical safety data kept secret. These scandals have tarnished the reputation of the pharmaceutical industry."

Bill Gates Almost Single-Handedly Derailed the Plan That Could Have Led to a 'People's Vaccine'
"But the inspiring plan devised by the scientists—which promised to create a vaccine essentially belonging to the world's people, not to corporate shareholders—was crushed fairly decisively when Bill Gates ventured into the fray."

 "Among other things, the vaccine tragedy highlights the danger posed by the extreme concentration of wealth and power that Bill Gates represents. It turns out that his mega-philanthropy comes with a hitch: it enables Gates to develop extraordinary influence over crucial matters, such as whether or not the world's poor will have a chance to survive the pandemic." 

 

How Bill Gates Impeded Global Access to Covid Vaccines: Through his hallowed foundation, the world’s de facto public health czar has been a stalwart defender of monopoly medicine.

Money in Medical Research
The Corruption of Evidence Based Medicine — Killing for Profit
"This has huge implications. Evidence based medicine is completely worthless if the evidence base is false or corrupted. It’s like building a wooden house knowing the wood is termite infested. What caused this sorry state of affairs? Well, Dr. Relman another former editor in chief of the NEJM said this in 2002  “The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research. The academic institutions of this country are allowing themselves to be the paid agents of the pharmaceutical industry. I think it’s disgraceful”

The people in charge of the system — the editors of the most important medical journals in the world, gradually learn over a few decades that their life’s work is being slowly and steadily corrupted. Physicians and universities have allowed themselves to be bribed."

This Is The Sickening Amount Pharmaceutical Companies Pay Top Journal Editors

"The medical profession is being bought by the pharmaceutical industry, not only in terms of the practice of medicine, but also in terms of teaching and research," said the late Arnold Relman, a former editor-in-chief of the New England Journal of Medicine (NEJM) in 2002. He passed away in 2014.

"The academic institutions of this country are allowing themselves to be the paid agents of the pharmaceutical industry. I think it's disgraceful."

Undisclosed payments in research

Payments by US pharmaceutical and medical device manufacturers to US medical journal editors: retrospective observational study

"Industry payments to journal editors are common and often large, particularly for certain sub-specialties. Journals should consider the potential impact of such payments on public trust in published research."

Oncology trial authors don’t fully disclose financial conflicts of interests, analysis finds "A substantial proportion of US oncologists involved in clinical trials used to gain marketing authorization for cancer drugs do not fully disclose financial conflicts of interest when the trial is published, research in JAMA Oncology shows.  The analysis, published as a research letter,1 found that a of third of oncologist authors failed to completely disclose payments from the drug company sponsor of the trial when the trial was published."

Leading US cancer researcher failed to disclose industry ties in dozens of articles
"One of America’s most prominent breast cancer doctors failed to disclose pharmaceutical industry ties worth millions of dollars in authoring dozens of articles in major journals, according to a report by the New York Times and ProPublica.  José Baselga, physician-in-chief at Memorial Sloan Kettering Cancer Center in New York City, neglected to mention multiple directorships and consultancy fees when completing conflict of interest disclosure forms for leading publications including the New England Journal of Medicine and the Lancet, the report found.  Baselga also left out his industry payments when writing for Cancer Discovery, the journal of the American Association for Cancer Research (AACR), even though he was the joint editor-in-chief and president of the association."

Corruption and Profiteering in Medical Insurance and Medicare
Medicare Privatization Scheme Faced Legal Questions About Profiteering
"Diane Archer, founder of Just Care and a health policy expert, described a similar scenario in an email to The Intercept. “The way they make money is by spending as little as possible on patient care, while ensuring as best they can that they have all diagnoses possible for their enrollees in order to maximize government payments. The more diagnoses, the higher the government payments. Government payments are set upfront and unrelated to the cost or number of services people receive.

“And, yes, the incentive is to deny as much care as possible,” she continued, “it’s also to delay as much care as possible and to create administrative and financial barriers that make it hard for enrollees to get care"

 

Why I Left the Network
Extremely well done article about how insurance companies are avoiding coverage of mental health services, despite the ACA's requirement that they cover mental health services the same as they cover physical health services.  They create what are called "ghost networks", meaning that they will list providers who they know are deceased, retired, or not in their network in order to give the appearance that they have adequate coverage for services when in fact they don't.  They also keep reducing the amount that they reimburse providers, make it harder and harder for providers to get reimbursed, and challenge the legitimacy of provider's qualifications and treatments, all in an attempt to get providers to drop out of their network.  When they do drop out, their names are kept in the listings, and the companies find ways to make consumers work hard and take a long time to establish that care isn't available.

Health Insurance Whistleblower: Medicare Advantage Is "Heist" by Private Firms to Defraud the Public

The Reason Health Care Is So Expensive: Insurance Companies
"But the thing that few people talk about, and that no serious policy proposal attempts to fix—the arrangement that accounts for much of the difference between health spending in the U.S. and other places—is the enormous administrative overhead costs that come from lodging health-care reimbursement in the hands of insurance companies that have no incentive to perform their role efficiently as payment intermediaries."

"Because insurers are paid a fixed percentage of the claims they administer, they have no incentive to hold down costs. Worse than that, they have no incentives to do their jobs with even a modicum of competence."

CNN Exclusive: California launches investigation following stunning admission by Aetna medical director "California's insurance commissioner has launched an investigation into Aetna after learning a former medical director for the insurer admitted under oath he never looked at patients' records when deciding whether to approve or deny care."

Inside America’s ‘GoFundMe’ Health Crisis

Koch-backed study finds ‘Medicare for All’ would save U.S. trillions

Stability, Not Crisis: Medical Malpractice Claim Outcomes in Texas, 1988–2002

"Using a comprehensive database of closed claims maintained by the Texas Department of Insurance since 1988, this study provides evidence on a range of issues involving medical malpractice litigation, including claim frequency, payout frequency, payment amounts, defense costs, and jury verdicts. The data present a picture of stability in most respects and moderate change in others. We do not find evidence in claim outcomes of the medical malpractice insurance crisis that produced headlines over the last several years and led to legal reform in Texas and other states. Controlling for population growth, the number of large paid claims (over $25,000 in real 1988 dollars) was roughly constant from 1990–2002. The number of smaller paid claims declined. Controlling for inflation, payout per large paid claim increased over 1988–2002 by an estimated 0.1 percent (insignificant) to 0.5 percent (marginally significant) per year, depending on the data set we use. Jury awards increased by an estimated 2.5 percent (insignificant) to 3.6 percent (marginally significant) per year, depending on the data set, but actual payouts in tried cases showed little or no time trend. Real defense costs per large paid claim rose by 4.2–4.5 percent per year. Real total cost per large paid claim, including defense costs, rose by 0.8–1.2 percent per year."