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MEDLIB-L  January 1996, Week 3

MEDLIB-L January 1996, Week 3

Subject:

Re: Time magazine managed care article

From:

Gilles Frydman <[log in to unmask]>

Reply-To:

Medical Libraries Discussion List <[log in to unmask]>

Date:

Thu, 18 Jan 1996 16:05:31 -0500

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (792 lines)

At 01:27 PM 1/18/96 -0800, Valerie Schultheiss wrote:
>On Thu, 18 Jan 1996, Lisa McCormick wrote:
>
>> The article is a
>> frightening tale:  big money, big money, big money being made and the=
 denial
>> of services to patients.  {I know I repeated big money, I'm=
 editorializing}
>
>I was going to alert you all to this myself until I saw Lisa's post.  So
>I'll second the motion; get the magazine (_Time_, January 22, 1996 issue;
>pp. 44-52.  I've got it on my desk even as we speak) -- it'll scare the
>socks right off you (even if you're not wearin' socks!)  I fear things
>will get worse before they get better.  Consumer health information
>services, anyone?
>
 
For those of you with web access the full text of the article is available
at
http://pathfinder.com/@@ckeMktGhpAEAQGV*/time/magazine/domestic/1996/960122/
cover.html
For the others here is the text:
----------------------------------------------------------------start
article--------------------------------------------------------------
 
THE SOUL OF AN HMO =20
 
MANAGED CARE IS CERTAINLY BRINGING DOWN AMERICA'S MEDICAL COSTS, BUT IT IS
ALSO RAISING THE QUESTION OF WHETHER PATIENTS, ESPECIALLY THOSE WITH SEVERE
ILLNESSES, CAN STILL TRUST THEIR DOCTORS=20
 
ERIK LARSON/LOS ANGELES=20
 
Alan Demeurers recalls it vividly as one bright moment in a succession of
dark days. "I remember exactly where we were sitting," he says. His wife
Christine had by then been found to have metastatic breast cancer and
believed her only hope was to undergo a costly new kind of therapy that
involves the harvest and retransplant of her own bone marrow--high-wire
medicine occupying what one of her physicians calls "the twilight zone
between promising and unproven treatments." =20
 
It is a measure of just how bleak those days were that this gleaming instant
came when Alan at last read the thick contract from their health plan,
Health Net of Woodland Hills, California. Like most Americans enrolled in
such plans, the couple had never studied the document. Now, however, the
specifics had become a matter of vital interest. "Good news," Alan announced
from his end of the family sofa in Murietta, California. "It's covered." =20
 
And so for the DeMeurerses began a three-year encounter with "managed health
care" and the powerful forces that are fast reshaping the culture and
practice of medicine in America--not just cutting costs but changing in a
fundamental way how doctors view patients, and perhaps how patients should
now view doctors. In a three-month investigation, TIME chronicled Christy
deMeurers' journey, but also the parallel, interlocking story of Health Net,
one very prosperous company in the Southern California market, a hotbed of
managed care that offers a living demonstration of what's likely to occur
everywhere else as the new medicine continues its rapid advance. Taken
together, the two stories provide a look deep inside the psyche of a
managed-care company that is typical of the hundreds blooming and merging
throughout the nation. These organizations have jettisoned the old Marcus
Welby-style medicine for something entirely new, in which doctors become
"gatekeepers," patients become "covered lives" and remote managers decide
who gets treatment and who doesn't. =20
 
"It's a paradigm shift," says William Popik, Health Net's chief medical
officer. "It's a shift that has taken place a lot more quickly than patients
are ready for--that's absolutely true. What's shifting is, patients can't
drive it anymore; patients can't decide, 'My ear hurts, so I'm going to go
to the doctor today.'" =20
 
Prodded by large companies fed up with rising medical costs, the new
medicine's entrepreneurs have turned health care into a corporate
battlefield increasingly governed by the promise of stock market wealth,
incentives that reward minimal care and a brand of aggressive competition
alien to front-line doctors for whom dressing for success still means
wearing khakis and a lab coat. =20
 
No one disputes that managed care has at last put the brakes on medical
spending, or that it has proved an effective vehicle for rationing health
care, a profoundly sensitive subject in a culture raised on the notion that
even the most expensive and esoteric treatments should be available to all.
At issue, rather, are the costs of the process itself--the effort and delay
inherent in acquiring care and the extent to which considerations other than
mere health are brought to bear by corporate managers who must approve even
such minor procedures as blood tests and mammograms. Yet the most
fundamental question raised by the new medicine is one largely missing from
public debate: Can you still trust your doctor? =20
 
"I think this system is robbing physicians of their essential goodness,"
says Dr. Roy B. Jones, a University of Colorado bone-marrow-transplant
specialist who saw Christy deMeurers during her journey. "I think physicians
are slanting the opinions they give based upon monetary considerations that
in many cases they wouldn't have allowed to influence them before." Vincent
Riccardi, a neurologist and expert on "Elephant Man" disease, says the issue
of trust in California is already moot. He has gone so far as to establish a
company, American Medical Consumers, that plans one day to dispatch
"personal medical advocates" to negotiate for care on behalf of patients.
People must be willing to confront their doctors, he says. "Since the trust
is already gone, why not? You've got nothing to lose." =20
 
The matter of trust becomes especially vital for patients such as Christy
deMeurers, unlucky enough to find themselves traveling the netherworld of
extreme illness, where hope and trust may be all a doctor has to offer. When
they're missing, "you feel just strangled," says Christy's mother, Joyce
Nesmith, who lives in Oregon. "It's a secret-society type of thing. What you
don't know, they don't want you to know." =20
 
Alan deMeurers became a Health Net subscriber in February 1989, when he
began teaching kindergarten in Lake Elsinore, California, southeast of Los
Angeles. Christy, formerly a K Mart manager, also became a teacher there in
July 1992 and also chose Health Net, the least expensive of three options.
They paid little attention to the nitty-gritty details of the plan. Alan
says he did not even receive a copy of the full contract until well after
signing. And when it did arrive, he says, "I just threw it in a pile with
all the other papers." =20
 
In choosing Health Net, the deMeurerses selected neither the best health
maintenance organization in America nor the worst, at least according to the
primitive "report cards" just now becoming available. Indeed, debate within
the industry and among consumer advocates rages over how even to define
quality, especially since no valid measure yet exists to show which plans
actually produce healthier people. Instead, companies tout their ability to
satisfy voluntary standards. Last month, for example, Health Net received a
one-year accreditation from the National Committee for Quality Assurance, an
industry group whose blessings are coveted by health plans around the=
 country. =20
 
Last year an N.C.Q.A. report card found that 86.7% of Health Net's members
rated the plan good to excellent, slightly below the mean for the 21 large
plans surveyed. On specific measures that the organization believes reflect
a plan's quality, such as how often it provides mammograms, Health Net
tended to rank at the mean or just below, but lagged sharply in providing
prenatal care for mothers and retinal screens for diabetics--the kind of
preventive care at which managed-care companies are supposed to excel. The
report card also showed that Health Net spent less on medical care than most
of the other plans surveyed and more on marketing, salaries and other
administrative expenses. The company is known among California doctors as
one of the most aggressively cost conscious in the state, a reputation that
stems in part from an earlier attempt to deny a bone-marrow transplant to a
subscriber named Nelene Fox, who by coincidence lived just minutes from the
deMeurerses. The jury in that case awarded the Fox family $89.1 million,
later negotiated down to an undisclosed sum. =20
 
Illness of that magnitude, however, was about the last thing the deMeurerses
worried about. Like the vast majority of Americans at any one moment, the
deMeurerses weren't sick and didn't expect to get sick. Alan signed at 27,
Christy at 32; their two children were young and healthy. This was
insurance, something for a rainy day. They selected a medical practice--the
Rancho Canyon Medical Group in Temecula, California--from a roster of those
in Health Net's network. "We just wanted some basic protection," Alan says.
"We were all very healthy people." =20
 
In late August, less than two months after she had signed with Health Net,
Christy discovered a lump in her left breast. =20
 
Health Net began life as an experiment that worked too well, much to the
delight of Roger Greaves, its chief from 1982 until last year. The company
was launched in 1979 by Blue Cross of Southern California, which dispatched
Greaves, a vice president, to run the company. In his first year Health Net
made $17,000; the next, $17 million. It was so prosperous that Blue Cross in
1984 tried to seize its bank accounts, forcing Greaves to file a lawsuit in
which he proved the company was a free-standing satellite. =20
 
Health Net is typical of "network-model" HMOs that contract with large
medical groups and networks of physicians--called Independent Practice
Associations--to provide the actual medical care. New subscribers choose or
are assigned to a particular medical group, and in turn choose a "primary
care provider" or "gatekeeper" who controls access to other services and
outside specialists. Even his or her recommendations often must be approved
by the group's own utilization-review managers or by Health Net. =20
 
Health Net collects premium dollars from employers and reserves money for
its own profit, salaries, bonuses, marketing and administrative costs, as
well as for two special reserve pools to pay for AIDS care and all
transplants, including bone-marrow transplants. Last year alone it collected
over $2 billion in monthly payments from 1.2 million subscribers. =20
 
The company pays its medical groups and some hospitals a set monthly fee for
every subscriber assigned to their practices or likely to be admitted to
their wards--a system known as capitation. Typically the doctors' groups
hold back a percentage of this revenue to cover their operating costs and
produce a profit. They in turn pay their primary-care physicians a set
capitation fee and further negotiate capitation contracts with an array of
specialists, such as cardiologists and ophthalmologists. Every time a
capitated doctor performs a service or admits a patient to the hospital, it
cuts into his income. If he spends less than the capitated rate, he pockets
the difference; if he spends more, he eats the losses or recoups them
through "reinsurance" policies sold by Health Net and others. =20
 
One result of widespread capitation in California is that specialists,
hospitals and research centers have found their incomes slashed--great news
for employers such as Chevron and Bank of America. A recent survey of 376
HMOs found that from 1994 to 1995 the premiums charged by HMOs actually
declined, with the number of days members spent in the hospital shrinking
nearly 13%, from 315 per 1,000 members to 275. The average last year in Los
Angeles was 204, clear evidence of how managed care now dominates the=
 region. =20
 
But consumer advocates say the new medicine has replaced the admittedly
flawed fee-for-service system with something even more perverse. Capitation
by definition places the interests of doctor and patient in conflict, they
argue. "Understand, every time a patient comes into the doctor's office it's
a liability, not an asset--because he's on a fixed income," says David
Robinson, hired in 1989 to serve as a primary-care physician for Rancho
Canyon, the deMeurerses' medical group. =20
 
The system troubled him, he says. He would request what he believed were
necessary tests and referrals, only to have them countermanded by
utilization-review managers. He recalls requesting a CAT scan for a boy who
had experienced seizures and occasional losses of consciousness, possible
warnings of a brain tumor, only to have his request denied. He grew so
dissatisfied that he left the practice two years later, resolving to see
only fee-for-service patients. =20
 
The year Robinson left, Health Net hired a new associate medical director,
Dr. Clifford Ossorio, ostensibly to develop quality-control systems. But the
job evolved into something Dr. Ossorio says he had not anticipated. He wound
up on the front lines, making coverage decisions on specific, sensitive
cases. "I hated that job," he says. "I didn't get hired for that job. I
never want to do it again." =20
 
Yet one of Health Net's managers, Janice Bosworth, learned firsthand how
vigilant Dr. Ossorio could be. She was 31 when she discovered that her
breast cancer had spread to her liver. Her oncologist, Gary Davidson,
suggested she consider an evaluation at Duke University, a leader in using
transplants to fight breast cancer. Even Bosworth, with her insider's
knowledge of company policies, believed transplants were covered. =20
 
When a coworker invited her upstairs to meet the new associate medical
director, she agreed, "so that he would look at me as a person and not just
a stat on a piece of paper," she testified, while serving as a witness in
the Nelene Fox civil suit. As Bosworth and her colleague waited outside
Ossorio's office, they overheard him speaking angrily on the phone. "How did
she find out about Duke? I'm going to have to call them...Maybe Gary told
her. I'm going to have to call him too." =20
 
That he was talking about her case was bad enough. But it was his voice,
cold and without compassion, that chilled her. "I was just shaking," she
testified. "I was so upset, I was just shaking." =20
 
HEALTH NET, YOU'VE GOT EVERYTHING.=20
 
At first things moved quickly for Christine deMeurers. She endured a radical
mastectomy, radiation therapy and a round of chemotherapy that ended in
March 1993, the month Health Net proposed five new billboards, including one
that showed a young mother holding her child, with the slogan WHEN YOU'VE
GOT YOUR =20
 
In May, Christy underwent a bone scan, which showed her cancer had spread;
her disease was now classified as Stage IV metastatic breast cancer. Given
the standard therapies available, it was a death sentence, but her
oncologist, Dr. Mahesh Gupta, warmly assured her there was hope. He
recommended she consider a bone-marrow transplant and, in a breach of Health
Net procedure, skipped the usual channels for making referrals and arranged
a consultation with a physician he knew, Dr. Robert McMillan, an oncologist
at the Scripps Clinic in La Jolla. Christy's sister, living in Colorado, had
urged her to see a leading bone-marrow transplanter at the University of
Colorado, Roy B. Jones, but the deMeurerses decided to play by the book.
They drove to La Jolla the following Monday. =20
 
Dr. Gupta, reviewing his notes on the case, says Dr. McMillan agreed Christy
was a candidate for a transplant but said she would first have to undergo
several cycles of chemotherapy to demonstrate that her tumor would respond
to the potent drugs used in bone-marrow therapy. In the deMeurerses' eyes,
however, it was a deeply troubling encounter. Dr. McMillan declined even to
describe what was involved in a bone-marrow transplant or give the family a
tour of the Scripps facilities, according to Alan deMeurers and Christy's
mother, Joyce Nesmith. "I believe he was told to send us away, make it as
discouraging as possible," Alan says. He found the doctor's reluctance to
provide even basic information "just unbelievable." =20
 
Dr. McMillan, in a written reply to questions faxed to him by TIME, stated
that rules governing patient-doctor confidentiality barred him from
discussing specifics of the encounter. He wrote, "At no time, either prior
to her visit or following her visit, did I discuss her case with Health=
 Net." =20
 
Whether justified or not in their fears, the deMeurerses by now had grown
deeply distrustful. They were keenly aware that Christy was dying and that
every day wasted was one more day in which the cancer cells in her body
could divide and spread. Just hours after their appointment with Dr.
McMillan, they flew to Denver; they saw Dr. Roy B. Jones the next day. =20
 
It is here in the realm of leading-edge medical technology that the culture
clash between the new medicine and the old becomes most evident. The new
medicine, by its nature, abhors complexity and innovation. Health Net, for
example, won't cover any treatment it deems to be experimental or
investigative, even though its contract with MediCal, California's Medicaid
program, does cover visits to acupuncturists and faith healers. Like other
HMOs, it spends nothing on research to hunt for new treatments for disease.
In fact, it feels bound by law and competition to avoid such research. =20
 
Recently, for instance, Health Net rejected a proposal to set aside money to
study ovarian cancer, arguing that such an investment might leave the
company vulnerable to a charge under the Americans with Disabilities Act
that it was discriminating against people with other diseases. "If we put
money into ovarian-cancer research and word gets out, then it isn't going to
be long before aids groups or prostate-cancer groups start having a field
day," says Lyle Swallow, Health Net's cheerful associate vice president for
legal services. "I didn't like having to give that advice, but it's another
rock and a hard place." =20
 
The company fears too that in a market such as California, spending on
research would create a competitive disadvantage. "One thing I have to
insist on as a company is a level playing field," says Health Net's Dr.
Popik. "I can't afford to pay for it if my competitors won't pay for it. If
you want to do it through a tax, that's fine." =20
 
Under the old medicine, research hospitals paid for clinical research
through billing surpluses; grants from the National Institutes of Health
tended to pay only for big-ticket basic science. Colorado's Dr. Jones
accuses HMOs of placing medicine in a double bind. "Is it reasonable," he
asks, "for an insurer to demand the gold standard of proof and
simultaneously refuse to pay for patients to enter a trial to get that level
of proof?" Dr. Jones is convinced that women who once would have come to him
for a transplant aren't coming because their doctors, operating under tight
managed-care cost guidelines, aren't telling them that transplants are a
medical option. "You put yourself in a position where you don't discuss it,
or else discuss it and, worse yet, indicate that all the data is negative or
that there is not a significant amount of data about this, I think you've
irreparably damaged the very thing that makes you as a physician so valuable
to patients." =20
 
Dr. Popik sees it a bit differently. "What should happen," he says, "is that
a physician shouldn't create an expectation for a patient. Because once that
expectation is completed, you start a process that is extremely difficult to
change." He adds, "There are other ways to give people hope. And that's the
paradigm shift." =20
 
When Dr. Jones examined Christy deMeurers, he believed a transplant could
help her. "The available proof for its efficacy in breast cancer was at
least equivalent to many other procedures that we do every day," he says. As
early as 1990, even Health Net had found evidence that bone-marrow
transplants might become a standard weapon against breast cancer. That year
the company's then chief medical officer, Dr. Leonard Knapp, ordered a study
by Technology Assessment Group of San Francisco to evaluate the treatment.
The report, however, didn't reach the conclusion he had hoped for. It found
that 3 out of 4 insurers paid for such treatments and, moreover, that by
1991 transplants would probably become "prevailing practice among
practitioners, providers and payers." =20
 
Dr. Knapp told TAG's project director, Janna Lee Smithey, he was "very
disappointed" in the report, she testified in the 1993 civil trial. When she
asked him why, he replied, "Because you didn't tell me it was experimental."
He said it in a joking way, but in fact the report had perturbed Dr. Knapp,
who stated in his own deposition that the report's data did not support its
conclusions; he recalled raising "a little hell about it." The report
apparently was never circulated very widely. In depositions last year, both
Dr. Ossorio and Dr. Sam Ho, by then Health Net's medical director, stated
that they had never seen it and knew nothing of its findings. =20
 
On June 8, 1993, the day the deMeurerses met with Dr. Jones in Denver,
Health Net, with Dr. Ossorio's support, formally decided the company would
not cover a transplant for Christy on grounds that it was excluded under the
investigational clause of her contract. =20
 
A week later, Christy, accompanied by her mother, returned to Dr. Gupta,
whom they still viewed as a beacon of warmth. "There's lots of hope, lots of
things to do," Nesmith recalls his saying. Christy, dissatisfied with her
reception at Scripps and reluctant to undergo months of treatment away from
home, wanted a referral for a second local evaluation, this time at UCLA.
Dr. Gupta agreed to make such a recommendation in writing, says Nesmith. He
told Christy and her mother to go somewhere for lunch and then come back;
the letter would be ready. =20
 
They returned to find a very different man. Suddenly, Nesmith recalls, "we
were like a piece of rock. There was a total 180=A1 turn." Dr. Gupta, his
demeanor gone cold, now said he was not qualified to make recommendations
for a transplant. =20
 
Christy insisted that he explain his change of heart. "And he became very
incensed and got up and walked out of the office without further commenting
or anything," Alan deMeurers said in a deposition last May. Says Nesmith:
"It was just such a devastating thing to know that he'd said yes, this was
the way to go, then two hours later have him change his mind." =20
 
Dr. Gupta confirms he saw Christy that day but says he does not recall this
aspect of their encounter. He did not in fact have the authority to make
such referrals, he says; these can only be made by a patient's primary-care
physician. Asked why, then, he felt empowered to make the first referral to
Dr. McMillan at Scripps, he says, "I knew those people one-to-one." =20
 
Christy petitioned her medical group, Rancho Canyon, for a different
oncologist. By now the deMeurerses had decided to get the treatment any way
they could. They made plans to begin raising money through appeals to
friends and the public. "As grateful as we were," Alan says, "it was
absolutely humiliating to have to ask for it." =20
 
Roger Greaves, Health Net's chief executive, was fighting a battle of his
own against what he calls the "cancer" of a tactical lawsuit. His company
had drawn the attention of Dr. Malik M. Hasan, founder and chief executive
officer of QualMed, a Pueblo, Colorado, managed-care company that owned an
HMO that competed against Health Net in Northern California. To best grasp
Hasan's delight in bold business maneuvers, one need only know that as a
young medical student in Pakistan in the late 1950s he made roughly $10
million selling land along the anticipated rights of way of new highways
revealed to him by a patient who happened to be a public-works surveyor. Dr.
Hasan, a neurologist, says he was once "rabidly anti-managed care." He built
his first HMO to counter a health plan that moved into Pueblo and sapped
revenue from the city's specialists. But suddenly he saw opportunity in the
new medicine. Over the next few years he created a robust managed-care
empire by acquiring ailing health plans--one company paid him $2.5 million
to take a plan off its hands--and, through tightfisted management, quickly
turning them into cash machines. =20
 
Dr. Hasan offered to acquire Health Net, but Greaves wasn't interested. He
was about to convert Health Net into a for-profit company, a process that
under California law required Health Net to establish an independent,
nonprofit foundation and fund it with an amount equal to the company's fair
market value--a way of paying back the state for all the taxes the company
had avoided as a nonprofit. Conversion would pave the way for going public.
In a tactical maneuver, Dr. Hasan filed a lawsuit to block the conversion,
charging that Greaves had undervalued the company's net worth and cheated
the people of California. After all, Dr. Hasan himself was willing to bid
far more. =20
 
Dr. Hasan, in his Pueblo office--a cavern of polished wood, purple curtains
and gleaming chandeliers--concedes that his primary motivation was to force
Greaves into a merger, but second, if Greaves still refused, to force Health
Net to pay far more into its shadow foundation and thereby reduce the
capital it could deploy against QualMed's own California operations. As long
as Dr. Hasan pressed the lawsuit, Greaves knew, Health Net had no hope of
going public. "It was devastating to us," Greaves says. "My name was in the
paper every day as a bad guy, a villain." =20
 
Figuring he at least should hear Dr. Hasan's pitch, Greaves met him in April
1993. Health Net was thriving. The year before, Greaves had made a base
salary of $658,713 and a bonus of $815,000. Additional pay, including nearly
$300,000 from a long-term incentive plan, boosted his total compensation to
$1.9 million. =20
 
Yet Greaves began to like Hasan's plan. For one thing, it would allow Health
Net to go public instantly, using the already public QualMed as a vehicle.
The merger would also create an eight-state network and give both companies
an edge in the rush toward consolidation, a fundamental imperative of the
new medicine. =20
 
The merger also promised a more personal benefit. Under the old medicine,
says Dr. Hasan, "the idea was, you don't go into the health-care business to
get rich. But that system was very inefficient." Now the reverse is true, he
argues. When he took his company public, his holdings became worth $150
million. "We all got very rich," he says, his delight bubbling out in a
chuckle. The prospect of such wealth, Dr. Hasan argues, helped managed-care
companies draw the best executives, who in turn applied corporate stratagems
to compel doctors to become more efficient. "It's no longer a gentleman's
club," he says. "And I see that as a very positive development." A merger
with QualMed would make Greaves a very wealthy man. =20
 
Christy deMeurers at last won approval to see a new oncologist, Stanley
Schinke, and met him for the first time on June 21, 1993. She liked him
instantly. "He and Dr. Jones were the only physicians up to this point who
made us feel welcome," Alan deMeurers says. =20
 
Like virtually every doctor in California, Dr. Schinke has seen his practice
change rapidly. In 1990 he didn't have a single capitated contract with an
HMO. Today capitation governs half his practice. So far, he says, he has not
felt pressed to scrimp on care but is worried that managed care is eroding
satisfaction with the process of medicine, especially among patients with
complex and emotionally wrenching diseases such as cancer. The inability to
get things done quickly can be "horrendous," he says. Recently he needed
three or four weeks of effort--"I'm calling every few days, my receptionist
is calling, the family is getting nervous"--just to get a leukemia patient
an evaluation at an advanced research center. "That's a big difference now,"
he says. "Patients five years ago didn't have to jump up and down and scream
and say, 'I really want this treatment, please get me this referral, what's
taking so long?' That never happened. You had a patient advocate in your
doctor when you hit the doctor's door." =20
 
Dr. Schinke examined Christy and agreed she ought to consider a bone-marrow
transplant. At the least it might provide a period free of disease and
debilitating chemotherapy. He suggested she get an evaluation at the UCLA
Medical Center. To Dr. Schinke, whether Health Net would pay was a side
issue. "When the patient comes to me, I'm still going to tell them about
what I think may help," he says. "That's the ethical thing to do." =20
 
Health Net's Dr. Ho called Dr. Schinke, who in a deposition and interview
says he found the call coercive. "I didn't understand an administrator
calling up and in an abrupt tone saying, 'Why in the world, what was your
thinking, why are you recommending this patient consider such an option?'"
But Dr. Ho, now with another HMO, says the call was "simply to remind him"
that a transplant in a case like deMeurers' "is not indicated." =20
 
The deMeurerses, meanwhile, had grown so distrustful that they decided not
to tell UCLA that Christy was a Health Net subscriber. Says Alan: "We wanted
to find out what your average citizen would learn without insurance."
Christy got an appointment to see Dr. John Glaspy, an oncologist who prides
himself on being a fierce patient advocate. "They were suspicious, and they
were in pain. Psychic pain," says Dr. Glaspy. Still, he says, "the first
step in our relationship was a lie. There really isn't any other way to put
it." =20
 
Christy, in turn, had no way of knowing that Dr. Glaspy was a member of a
Health Net committee convened earlier that year to decide once and for all
when bone-marrow transplants would be covered--or that this committee
already had voted to deny payments for patients with Christy's level of
disease. Or that Dr. Glaspy had voted in favor of coverage but nonetheless
had agreed to uphold the committee guidelines. =20
 
The old medicine and the new were locked on a collision course. =20
 
One index of the angst stirred in California by the rapid advance of managed
care is the fact that a March 1995 visit to UCLA by Dr. Hasan has since
become legend, embellished with accounts of Dr. Hasan's pulling up in a vast
white limousine. The doctor insists that he arranged the visit merely to get
acquainted. But given that he controls the flow of 1.2 million patients, or
"covered lives," throughout California, perhaps UCLA officials can be
forgiven for reading between the lines. =20
 
With many hospitals in Southern California now losing money and desperate
for patients, HMOs possess great power, direct and implied, to dictate rates
and treatment policies. Health Net's contracts reinforce this sense of
vulnerability. The stated term of virtually all their contracts is one year.
The contracts do contain automatic-renewal clauses, but Health Net can also
cancel them at will simply by giving 90 to 120 days' notice. If Health Net
does decide to cancel a contract, it can exercise another clause that allows
it to reduce sharply the flow of capitation revenue well before the notice
period ends. =20
 
In reality, says Andrew B. Leeka, chief operating officer at City of Hope, a
major cancer center outside Los Angeles, "contracts with managed-care
companies aren't for a year or two years, they're for 30 days or 60 days."
Running afoul of a health plan's guidelines can be costly but necessary, he
says. "I can tell you from experience we have lost contracts because we act
as the patient's advocate." =20
 
Contract cancellations are rare--last year Health Net canceled only two
contracts with medical groups--but they stand as warnings to maverick
providers. On occasion UCLA has absorbed the cost of major treatments
disputed by an HMO simply to preserve contractual relations, says Francine
Chapman, in charge of negotiating its managed-care contracts. It could not
have been very reassuring, therefore, when one of Dr. Hasan's first remarks
at the UCLA meeting was, "I came here intending to give you hell, but I am
in too good a mood." (He attributed his mood to the then planned merger of
Health Net and the new for-profit incarnation of Blue Cross of California.
The merger collapsed last month. ) =20
 
UCLA.=20
 
"I said it with a smile," he says mildly. "It wasn't meant as a threat." He
simply hoped to convey his belief that the center could be far more
efficient. He told the group he did not buy UCLA's argument that because it
must train new doctors and handle more severe cases it should be paid more
than other hospitals. Perhaps, he mused, the center really ought to receive
less, given its pool of cheap labor: its interns and residents. "This is a
Darwinian world," he said. "Don't forget it." The meeting, especially the
Darwin remark, sent shock waves through =20
 
Dr. Hasan offers a contrite smile. "Maybe I should make it clearer to them
how patently I am devoted to those centers of excellence." And by the way,
he notes, "it was a Lincoln Town Car." =20
 
UCLA?=20
 
Nonetheless, within two months of Dr. Hasan's meeting, depositions taken in
the deMeurerses' legal battle against Health Net would raise the question,
Just how much power does the company truly possess? In the new medicine, can
a big HMO dictate medical decisions even at an institution as lofty as =20
 
When Dr. Glaspy met Christy for the first time on June 25, 1993, he found a
woman in reasonably good physical shape, except for the fact that she was
dying of breast cancer. The deMeurerses, in turn, saw Dr. Glaspy as warm,
confident and low key, and--unlike Dr. McMillan at Scripps--open with
information. =20
 
Dr. Glaspy, still unaware that Christy was a Health Net subscriber, agreed
that a transplant was an option. If she wanted it, he said, she could have
it. "In the part of medicine where there are uncertainties," Dr. Glaspy
says, "I think we have a sacred responsibility to explain those
uncertainties to patients, and we also should allow them to use their values
and where they're coming from to pick among the treatment options that are
rational." He could not wholeheartedly recommend a transplant in her case,
he says, but a transplant "was on the rational list." First, however, she
had to undergo the initial chemotherapy to test the responsiveness of her
cancer. Dr. Schinke, using drugs recommended by Dr. Glaspy, began the cycle.=
 =20
 
By now the deMeurerses had hired an attorney, Mark Hiepler, then preparing
for trial against Health Net on behalf of his client Nelene Fox--his sister.
For the deMeurerses, he mailed a detailed appeal to Health Net urging the
company to reconsider its denial and presenting evidence that the treatment
was widely accepted by cancer experts. =20
 
The appeal wound up on the desk of Dr. Ossorio, who again denied coverage.
The deMeurerses, committed now to getting the transplant by any means
necessary, launched a two-pronged attack: they authorized Hiepler to pursue
an injunction to compel Health Net to pay for the treatment: and they began
fund raising in earnest. Christy's sister organized a formal dinner in
Boulder, Colorado; friends and colleagues arranged a school talent show. The
deMeurerses' daughter Michelle, then eight years old, took a piece of
loose-leaf paper and with shaky precision wrote her own advertisement for a
yard sale. The sign said, MONEY GOES TO A MOTHER WITH BREAST CANCER. =20
 
On Aug. 28, Health Net's Greaves and QualMed's Hasan formally agreed to
merge their companies. The merger triggered a "termination agreement" under
which Greaves would receive a lump-sum payment of $1.1 million because
technically he had been terminated from his former positions--even though he
became cochairman and co-chief executive of the parent of the merged
companies, Health Systems International, a job that paid a base salary of
$865,000. "I gave up my sole authority as president, chairman and ceo," says
Greaves, "and my contract said if that happens you get paid out your
contract. So as any businessman would--anybody would--I exercised my
rights." In 1994, when the merger took effect, his income, including the
termination payment, bonuses and base salary, would total $3.2 million. =20
 
One week after the merger pact was signed, after a bone scan found that
Christy had indeed responded to the initial chemotherapy, the deMeurerses
signed an agreement of their own with UCLA, promising to pay up front the
full cost of the treatment: $92,000, an amount equal to 0.08% of the $11.7
million that Health Net had accumulated in its transplant pool by the end of
1993. =20
 
Suddenly Dr. Glaspy, who by now had learned that Christy was a Health Net
subscriber, found himself walking the fault line between the old medicine
and the new. The dimensions of his conflict became clear on Thursday, Sept.=
 9. =20
 
That morning, in his old-medicine role as advocate, he signed a legal
declaration "in support" of Christy's fight for an injunction. At 3 o'clock
that afternoon, wearing his new-medicine hat, he and two UCLA colleagues met
with other oncologists and Health Net officials at the Hyatt Hotel near Los
Angeles International Airport for another meeting of the company's
bone-marrow committee. =20
 
A tape recording of the meeting shows the extent to which business and
medicine have become entangled in California, and raises the question, When
does a patient's insurer determine the range of options a patient is allowed
to consider? The question was asked directly by one of Dr. Glaspy's
colleagues, Dr. Peter Rosen. "I guess I'm not quite understanding
something," he said, as the meeting gained heat. "If you know someone's a
Health Net patient, do you talk to them differently than if they're somebody
else?" =20
 
The talk at the meeting quickly turned to the matter of patient deception.
"The biggest problem," Glaspy told the Health Net officials present, "is
when they come to a center and they don't come with a pre-call from you, so
we don't know who they are, and we don't know they're from Health Net."
Alluding to Christine deMeurers, he said, "We had one of those where that
was the problem." =20
 
Ossorio argued that the best way to avoid the problem was to make sure all
Health Net oncologists received the "grid" that set out specifically what
the network would and would not cover. Most of the network's doctors were
"pretty comfortable" with it, he said. =20
 
But the fact was, some oncologists at the meeting had done transplants for
advanced breast cancer. "We have a protocol to treat breast cancer," UCLA's
Rosen said. The panel, he cautioned, had agreed only that such transplants
should not be covered as a general rule. "That didn't mean we necessarily
have all agreed that this is a worthless thing to be doing," he said. "I
think that could be a real problem." =20
 
At one point, Health Net's Dr. Ho seemed to lose patience with the doctors'
ambivalence. "Each of these issues--I just want to be clear about this. This
is not a Utopian society that everybody can be everything to all people and
paid for by somebody else. We have fiduciary responsibilities to our
employers to the tune of about $1.5 billion worth of premiums paid to us
every year to manage their health-care premium dollars responsibly . because
in general, insurance and payers and physicians have been ineffective in
holding that fiduciary responsibility." =20
 
But some doctors in the room clearly had been placed in an uncomfortable
position. "You must understand," Rosen said, "if insurance companies can
differ on this, and doctors can differ, and I can differ even when I look at
the data itself . I can't see how anybody can say, 'I've got it all figured
out: this is investigational; this is not investigational.'" An impassioned
Glaspy pointed one by one to other doctors in the room. "How can something
that he does, and he does, and he does, and he does be unreasonable?"
Neither Rosen's nor Glaspy's remarks were recorded in the official minutes
of the meeting. =20
 
Soon afterward, Health Net's Ossorio telephoned Glaspy's boss, Dr. Dennis
Slamon, the division chief of oncology at UCLA, in what the deMeurerses say
was an effort to influence whether the center would perform Christy's
transplant. Health Net's Lyle Swallow disputes this charge: "The idea that
Health Net could somehow muscle UCLA into doing anything, given their size,
given their reputation, given their budget, is really kind of laughable." =
=20
 
But last October an arbitration panel chosen by Health Net and the
deMeurerses found nothing to laugh at. Here is what happened next, as
reconstructed from depositions, court documents and direct interviews: =20
 
Ossorio identified himself to Slamon and with little preamble asked whether
UCLA was still in accord with Health Net's guidelines. Slamon said yes. Then
why, Ossorio asked, was UCLA going to transplant a Health Net subscriber
named deMeurers? =20
 
The call struck Slamon as unusual. For one thing, he had never spoken to
Ossorio before. For another, he was not Christy's doctor, a fact Ossorio
must have known, given that Glaspy sat on Health Net's bone-marrow
committee. Slamon said he knew nothing about Christy's case, but he offered
to look into it. The following Friday, Slamon told Glaspy he had decided
UCLA should pay for the treatment. =20
 
"I got outraged," Glaspy recalls. He believed he still had room to work the
system and persuade Health Net to pay for the treatment. He felt guilty
about costing the unit so much money and resented Slamon's interference in
an area where he, Glaspy, was the expert. That night he wrote a letter of
resignation. Later, however, he reconsidered. "It took me four or five days
to cool off." =20
 
But Slamon says he made the decision to pay for the transplant after
discovering that Christy by then had already undergone the initial marrow
harvest. "We should not have taken her halfway into the stream without being
prepared to take her all the way across," he says. He insists that the
decision was his alone, and not the result of any coercion from Health Net. =
=20
 
Says Ossorio: "My intention was clearly that I wanted UCLA to follow the
policy we agreed to. Was that pressure? Yes. To fulfill an obligation we had
mutually agreed to." But he adds, "I swear to God, he volunteered to pay for
it." =20
 
Things got still more complicated when, a few days later, on Wednesday,
Sept. 22, Glaspy, at the request of Health Net's lawyers, signed a second
formal declaration, this time opposing Christy's motion for an injunction.
"I didn't view it as being against her," he said, in a deposition last
April. "They were all truths in that declaration that I had already told
Christine." And yet he knew, he said, that "this declaration could be used
legally to stand between her and the transplant." =20
 
The second declaration stunned the deMeurerses, who saw it as one more
violation of the doctor-patient relationship. "It felt like the same thing
we had gone through with Dr. Gupta," Alan says. Suddenly he and his wife
believed they had a new worry: Would UCLA really come through on its offer?
And would the care be as good as if someone else were paying? "Our first
inclination after we heard about Dr. Glaspy was, maybe we ought to go back
to Denver," Alan says. =20
 
At the last minute, UCLA put its promise to pay in writing, thus ending the
need for an injunction. On Sept. 23 Christy entered the medical center to
begin treatment. Whether the treatment worked or not depends on who is
speaking. Health Net officials are quick to point out how soon Christy
"expired" after the procedure. Glaspy says the transplant may actually have
shortened her life relative to what she might have expected with standard
therapy. But Alan deMeurers recalls how the day before she entered UCLA, she
could barely carry a sewing box from one room of their home to another.
Within several weeks of her discharge, Alan returned home from work to find
her mowing the lawn. She had four apparently disease-free months. "As hard
as it was to go through all that, it was worth it," Alan says. "That's one
thing Health Net never took into consideration at all, was quality of life."=
 =20
 
By spring 1994, she had fallen ill again. That summer the family took a
cross-country camping trip expressly with the goal of building happy
memories for the children. A friend arranged a behind-the-scenes tour of the
White House, and the kids got to play with Socks, the Clintons' cat. Christy
deMeurers spent one more Christmas with her family. She died on Friday
afternoon, March 10, 1995. =20
 
Soon afterward, most of Health Net's top executives left the company, seeing
little future for themselves in the coming merger with the WellPoint Health
Network. But in the new medicine, even leaving a company can prove immensely
profitable. =20
 
On March 31 Greaves signed a new severance deal that paid him a lump sum of
$2.8 million, plus assorted other payments, and guaranteed him and his wife
health care for the rest of their lives. The agreement also called for
Health Systems International to buy back as much as half of his common
stock, which brought him another $13.3 million. And Greaves signed a
generous three-year consulting deal. All told, his exit brought him $18.1
million, equivalent to the average monthly premiums paid by nearly 134,000
subscribers. =20
 
Last October the arbitration panel hearing Christy's case determined that
Health Net should indeed have paid for the transplant. It also found the
company had crossed the line in interfering with the doctor-patient
relationship, specifically when Health Net officials phoned Christy's local
oncologist and UCLA's Slamon. The latter call "was more heavy-handed" than
either man was willing to admit, the panel concluded, and had been made to
"influence or intimidate" UCLA and its doctors. Two of the three panelists
further saw this interference as constituting "intentional infliction of
emotional distress" on the deMeurerses because it triggered Glaspy's second
declaration opposing Christy's injunction. The panel awarded Alan deMeurers
$1.02 million. =20
 
It also declared that Health Net's interference in the doctor-patient
relationship fit the legal definition of "extreme and outrageous behavior
exceeding all bounds usually tolerated in a civilized society." =20
 
Or maybe it's just medicine on the far side of the paradigm shift. Says Dr.
Ho: "I'm sorry the panel didn't see that Health Net was doing what was best
for the patient, which was to deny the treatment as investigational, and
which in the end was proven the right decision."=20
 
 
Gilles Frydman<=3D>The Kosher Frog <=3D> [log in to unmask]      =20
                       ---------------------------------
                  The Internet Cancer Lists Archives
                  http://www.medinfo.org:=20
              ---------------------------------

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August 2011, Week 2
August 2011, Week 1
July 2011, Week 5
July 2011, Week 4
July 2011, Week 3
July 2011, Week 2
July 2011, Week 1
June 2011, Week 5
June 2011, Week 4
June 2011, Week 3
June 2011, Week 2
June 2011, Week 1
May 2011, Week 5
May 2011, Week 4
May 2011, Week 3
May 2011, Week 2
May 2011, Week 1
April 2011, Week 5
April 2011, Week 4
April 2011, Week 3
April 2011, Week 2
April 2011, Week 1
March 2011, Week 5
March 2011, Week 4
March 2011, Week 3
March 2011, Week 2
March 2011, Week 1
February 2011, Week 4
February 2011, Week 3
February 2011, Week 2
February 2011, Week 1
January 2011, Week 5
January 2011, Week 4
January 2011, Week 3
January 2011, Week 2
January 2011, Week 1
December 2010, Week 5
December 2010, Week 4
December 2010, Week 3
December 2010, Week 2
December 2010, Week 1
November 2010, Week 5
November 2010, Week 4
November 2010, Week 3
November 2010, Week 2
November 2010, Week 1
October 2010, Week 5
October 2010, Week 4
October 2010, Week 3
October 2010, Week 2
October 2010, Week 1
September 2010, Week 5
September 2010, Week 4
September 2010, Week 3
September 2010, Week 2
September 2010, Week 1
August 2010, Week 5
August 2010, Week 4
August 2010, Week 3
August 2010, Week 2
August 2010, Week 1
July 2010, Week 5
July 2010, Week 4
July 2010, Week 3
July 2010, Week 2
July 2010, Week 1
June 2010, Week 5
June 2010, Week 4
June 2010, Week 3
June 2010, Week 2
June 2010, Week 1
May 2010, Week 5
May 2010, Week 4
May 2010, Week 3
May 2010, Week 2
May 2010, Week 1
April 2010, Week 5
April 2010, Week 4
April 2010, Week 3
April 2010, Week 2
April 2010, Week 1
March 2010, Week 5
March 2010, Week 4
March 2010, Week 3
March 2010, Week 2
March 2010, Week 1
February 2010, Week 4
February 2010, Week 3
February 2010, Week 2
February 2010, Week 1
January 2010, Week 5
January 2010, Week 4
January 2010, Week 3
January 2010, Week 2
January 2010, Week 1
December 2009, Week 5
December 2009, Week 4
December 2009, Week 3
December 2009, Week 2
December 2009, Week 1
November 2009, Week 5
November 2009, Week 4
November 2009, Week 3
November 2009, Week 2
November 2009, Week 1
October 2009, Week 5
October 2009, Week 4
October 2009, Week 3
October 2009, Week 2
October 2009, Week 1
September 2009, Week 5
September 2009, Week 4
September 2009, Week 3
September 2009, Week 2
September 2009, Week 1
August 2009, Week 5
August 2009, Week 4
August 2009, Week 3
August 2009, Week 2
August 2009, Week 1
July 2009, Week 5
July 2009, Week 4
July 2009, Week 3
July 2009, Week 2
July 2009, Week 1
June 2009, Week 5
June 2009, Week 4
June 2009, Week 3
June 2009, Week 2
June 2009, Week 1
May 2009, Week 5
May 2009, Week 4
May 2009, Week 3
May 2009, Week 2
May 2009, Week 1
April 2009, Week 5
April 2009, Week 4
April 2009, Week 3
April 2009, Week 2
April 2009, Week 1
March 2009, Week 5
March 2009, Week 4
March 2009, Week 3
March 2009, Week 2
March 2009, Week 1
February 2009, Week 4
February 2009, Week 3
February 2009, Week 2
February 2009, Week 1
January 2009, Week 5
January 2009, Week 4
January 2009, Week 3
January 2009, Week 2
January 2009, Week 1
December 2008, Week 5
December 2008, Week 4
December 2008, Week 3
December 2008, Week 2
December 2008, Week 1
November 2008, Week 5
November 2008, Week 4
November 2008, Week 3
November 2008, Week 2
November 2008, Week 1
October 2008, Week 5
October 2008, Week 4
October 2008, Week 3
October 2008, Week 2
October 2008, Week 1
September 2008, Week 5
September 2008, Week 4
September 2008, Week 3
September 2008, Week 2
September 2008, Week 1
August 2008, Week 5
August 2008, Week 4
August 2008, Week 3
August 2008, Week 2
August 2008, Week 1
July 2008, Week 5
July 2008, Week 4
July 2008, Week 3
July 2008, Week 2
July 2008, Week 1
June 2008, Week 5
June 2008, Week 4
June 2008, Week 3
June 2008, Week 2
June 2008, Week 1
May 2008, Week 5
May 2008, Week 4
May 2008, Week 3
May 2008, Week 2
May 2008, Week 1
April 2008, Week 5
April 2008, Week 4
April 2008, Week 3
April 2008, Week 2
April 2008, Week 1
March 2008, Week 5
March 2008, Week 4
March 2008, Week 3
March 2008, Week 2
March 2008, Week 1
February 2008, Week 5
February 2008, Week 4
February 2008, Week 3
February 2008, Week 2
February 2008, Week 1
January 2008, Week 5
January 2008, Week 4
January 2008, Week 3
January 2008, Week 2
January 2008, Week 1
December 2007, Week 5
December 2007, Week 4
December 2007, Week 3
December 2007, Week 2
December 2007, Week 1
November 2007, Week 5
November 2007, Week 4
November 2007, Week 3
November 2007, Week 2
November 2007, Week 1
October 2007, Week 5
October 2007, Week 4
October 2007, Week 3
October 2007, Week 2
October 2007, Week 1
September 2007, Week 5
September 2007, Week 4
September 2007, Week 3
September 2007, Week 2
September 2007, Week 1
August 2007, Week 5
August 2007, Week 4
August 2007, Week 3
August 2007, Week 2
August 2007, Week 1
July 2007, Week 5
July 2007, Week 4
July 2007, Week 3
July 2007, Week 2
July 2007, Week 1
June 2007, Week 5
June 2007, Week 4
June 2007, Week 3
June 2007, Week 2
June 2007, Week 1
May 2007, Week 5
May 2007, Week 4
May 2007, Week 3
May 2007, Week 2
May 2007, Week 1
April 2007, Week 4
April 2007, Week 3
April 2007, Week 2
April 2007, Week 1
March 2007, Week 5
March 2007, Week 4
March 2007, Week 3
March 2007, Week 2
March 2007, Week 1
February 2007, Week 4
February 2007, Week 3
February 2007, Week 2
February 2007, Week 1
January 2007, Week 5
January 2007, Week 4
January 2007, Week 3
January 2007, Week 2
January 2007, Week 1
December 2006, Week 5
December 2006, Week 4
December 2006, Week 3
December 2006, Week 2
December 2006, Week 1
November 2006, Week 5
November 2006, Week 4
November 2006, Week 3
November 2006, Week 2
November 2006, Week 1
October 2006, Week 5
October 2006, Week 4
October 2006, Week 3
October 2006, Week 2
October 2006, Week 1
September 2006, Week 5
September 2006, Week 4
September 2006, Week 3
September 2006, Week 2
September 2006, Week 1
August 2006, Week 5
August 2006, Week 4
August 2006, Week 3
August 2006, Week 2
August 2006, Week 1
July 2006, Week 5
July 2006, Week 4
July 2006, Week 3
July 2006, Week 2
July 2006, Week 1
June 2006, Week 5
June 2006, Week 4
June 2006, Week 3
June 2006, Week 2
June 2006, Week 1
May 2006, Week 5
May 2006, Week 4
May 2006, Week 3
May 2006, Week 2
May 2006, Week 1
April 2006, Week 4
April 2006, Week 3
April 2006, Week 2
April 2006, Week 1
March 2006, Week 5
March 2006, Week 4
March 2006, Week 3
March 2006, Week 2
March 2006, Week 1
February 2006, Week 4
February 2006, Week 3
February 2006, Week 2
February 2006, Week 1
January 2006, Week 5
January 2006, Week 4
January 2006, Week 3
January 2006, Week 2
January 2006, Week 1
December 2005, Week 5
December 2005, Week 4
December 2005, Week 3
December 2005, Week 2
December 2005, Week 1
November 2005, Week 5
November 2005, Week 4
November 2005, Week 3
November 2005, Week 2
November 2005, Week 1
October 2005, Week 5
October 2005, Week 4
October 2005, Week 3
October 2005, Week 2
October 2005, Week 1
September 2005, Week 5
September 2005, Week 4
September 2005, Week 3
September 2005, Week 2
September 2005, Week 1
August 2005, Week 5
August 2005, Week 4
August 2005, Week 3
August 2005, Week 2
August 2005, Week 1
July 2005, Week 5
July 2005, Week 4
July 2005, Week 3
July 2005, Week 2
July 2005, Week 1
June 2005, Week 5
June 2005, Week 4
June 2005, Week 3
June 2005, Week 2
June 2005, Week 1
May 2005, Week 5
May 2005, Week 4
May 2005, Week 3
May 2005, Week 2
May 2005, Week 1
April 2005, Week 5
April 2005, Week 4
April 2005, Week 3
April 2005, Week 2
April 2005, Week 1
March 2005, Week 5
March 2005, Week 4
March 2005, Week 3
March 2005, Week 2
March 2005, Week 1
February 2005, Week 4
February 2005, Week 3
February 2005, Week 2
February 2005, Week 1
January 2005, Week 5
January 2005, Week 4
January 2005, Week 3
January 2005, Week 2
January 2005, Week 1
December 2004, Week 5
December 2004, Week 4
December 2004, Week 3
December 2004, Week 2
December 2004, Week 1
November 2004, Week 5
November 2004, Week 4
November 2004, Week 3
November 2004, Week 2
November 2004, Week 1
October 2004, Week 5
October 2004, Week 4
October 2004, Week 3
October 2004, Week 2
October 2004, Week 1
September 2004, Week 5
September 2004, Week 4
September 2004, Week 3
September 2004, Week 2
September 2004, Week 1
August 2004, Week 5
August 2004, Week 4
August 2004, Week 3
August 2004, Week 2
August 2004, Week 1
July 2004, Week 5
July 2004, Week 4
July 2004, Week 3
July 2004, Week 2
July 2004, Week 1
June 2004, Week 5
June 2004, Week 4
June 2004, Week 3
June 2004, Week 2
June 2004, Week 1
May 2004, Week 4
May 2004, Week 3
May 2004, Week 2
May 2004, Week 1
April 2004, Week 5
April 2004, Week 4
April 2004, Week 3
April 2004, Week 2
April 2004, Week 1
March 2004, Week 5
March 2004, Week 4
March 2004, Week 3
March 2004, Week 2
March 2004, Week 1
February 2004, Week 5
February 2004, Week 4
February 2004, Week 3
February 2004, Week 2
February 2004, Week 1
January 2004, Week 5
January 2004, Week 4
January 2004, Week 3
January 2004, Week 2
January 2004, Week 1
December 2003, Week 5
December 2003, Week 4
December 2003, Week 3
December 2003, Week 2
December 2003, Week 1
November 2003, Week 5
November 2003, Week 4
November 2003, Week 3
November 2003, Week 2
November 2003, Week 1
October 2003, Week 5
October 2003, Week 4
October 2003, Week 3
October 2003, Week 2
October 2003, Week 1
September 2003, Week 5
September 2003, Week 4
September 2003, Week 3
September 2003, Week 2
September 2003, Week 1
August 2003, Week 5
August 2003, Week 4
August 2003, Week 3
August 2003, Week 2
August 2003, Week 1
July 2003, Week 5
July 2003, Week 4
July 2003, Week 3
July 2003, Week 2
July 2003, Week 1
June 2003, Week 5
June 2003, Week 4
June 2003, Week 3
June 2003, Week 2
June 2003, Week 1
May 2003, Week 5
May 2003, Week 4
May 2003, Week 3
May 2003, Week 2
May 2003, Week 1
April 2003, Week 5
April 2003, Week 4
April 2003, Week 3
April 2003, Week 2
April 2003, Week 1
March 2003, Week 5
March 2003, Week 4
March 2003, Week 3
March 2003, Week 2
March 2003, Week 1
February 2003, Week 4
February 2003, Week 3
February 2003, Week 2
February 2003, Week 1
January 2003, Week 5
January 2003, Week 4
January 2003, Week 3
January 2003, Week 2
January 2003, Week 1
December 2002, Week 5
December 2002, Week 4
December 2002, Week 3
December 2002, Week 2
December 2002, Week 1
November 2002, Week 5
November 2002, Week 4
November 2002, Week 3
November 2002, Week 2
November 2002, Week 1
October 2002, Week 5
October 2002, Week 4
October 2002, Week 3
October 2002, Week 2
October 2002, Week 1
September 2002, Week 5
September 2002, Week 4
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September 2002, Week 1
August 2002, Week 5
August 2002, Week 4
August 2002, Week 3
August 2002, Week 2
August 2002, Week 1
July 2002, Week 5
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July 2002, Week 3
July 2002, Week 2
July 2002, Week 1
June 2002, Week 5
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June 2002, Week 3
June 2002, Week 2
June 2002, Week 1
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May 2002, Week 2
May 2002, Week 1
April 2002, Week 5
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April 2002, Week 3
April 2002, Week 2
April 2002, Week 1
March 2002, Week 5
March 2002, Week 4
March 2002, Week 3
March 2002, Week 2
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February 2002, Week 4
February 2002, Week 3
February 2002, Week 2
February 2002, Week 1
January 2002, Week 5
January 2002, Week 4
January 2002, Week 3
January 2002, Week 2
January 2002, Week 1
December 2001, Week 5
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December 2001, Week 3
December 2001, Week 2
December 2001, Week 1
November 2001, Week 5
November 2001, Week 4
November 2001, Week 3
November 2001, Week 2
November 2001, Week 1
October 2001, Week 5
October 2001, Week 4
October 2001, Week 3
October 2001, Week 2
October 2001, Week 1
September 2001, Week 5
September 2001, Week 4
September 2001, Week 3
September 2001, Week 2
September 2001, Week 1
August 2001, Week 5
August 2001, Week 4
August 2001, Week 3
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July 2001, Week 1
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June 2001, Week 3
June 2001, Week 2
June 2001, Week 1
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May 2001, Week 1
April 2001, Week 5
April 2001, Week 4
April 2001, Week 3
April 2001, Week 2
April 2001, Week 1
March 2001, Week 5
March 2001, Week 4
March 2001, Week 3
March 2001, Week 2
March 2001, Week 1
February 2001, Week 4
February 2001, Week 3
February 2001, Week 2
February 2001, Week 1
January 2001, Week 5
January 2001, Week 4
January 2001, Week 3
January 2001, Week 2
January 2001, Week 1
December 2000, Week 5
December 2000, Week 4
December 2000, Week 3
December 2000, Week 2
December 2000, Week 1
November 2000, Week 5
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November 2000, Week 3
November 2000, Week 2
November 2000, Week 1
October 2000, Week 5
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October 2000, Week 3
October 2000, Week 2
October 2000, Week 1
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December 1999, Week 5
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April 1999, Week 1
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March 1999, Week 3
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February 1999, Week 4
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February 1999, Week 2
February 1999, Week 1
January 1999, Week 5
January 1999, Week 4
January 1999, Week 3
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January 1999, Week 1
December 1998, Week 5
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December 1998, Week 3
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December 1998, Week 1
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March 1998, Week 1
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February 1998, Week 1
January 1998, Week 5
January 1998, Week 4
January 1998, Week 3
January 1998, Week 2
January 1998, Week 1
December 1997, Week 5
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December 1997, Week 3
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December 1996, Week 5
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December 1995, Week 5
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