David Tuller / Trial by Error: Retired PACE Investigator Peter White and Swiss Re

[Jill]

If Peter White is 'advertising' a therapy that doesn't work (and has been based on bad science), can't we go to the advertising standards authority ? I heard a podcast and seem to remember they have some clout. For some reason I can't login in via disqus to comment directly on David's blog. Could someone suggest this to him after checking with ASA first . Thanks

 

[Jan]

David Marks has definitely joined the club of polite academics turned into angry PACE critics:



http://www.virology.ws/2017/08/07/t...-peter-white-and-swiss-re/#comment-3459075535

I love how they've been down graded from the sinking ship to a canoe with holes

It's looking increasing like they they are up shit creek without a paddle

 

[Woolie]

Insurance tends to be tightly regulated. I bet they're not allowed to declare ME to go under mental health when it's classified as neurological everywhere else. Hence the wriggling about with separate "fatigue" classifications in the UK.

Yes, but the question was not whether insurance companies can reclassify in this way, but whether offering CBT or GET will help them in that endeavour. I don't think it will.

The general theme of the discussion is whether offering CBT or GET has any advantage for the government bodies and insurance companies. Or whether these bodies are being duped just as much as we are.

 

[user9876]

Yes, but the question was not whether insurance companies can reclassify in this way, but whether offering CBT or GET will help them in that endeavour. I don't think it will.

The general theme of the discussion is whether offering CBT or GET has any advantage for the government bodies and insurance companies. Or whether these bodies are being duped just as much as we are.

I think insurance companies will end up hating people like White. They rely on having accurate information about patient numbers and likely success of treatments (they make money by pooling risk and taking a cut) so White misleads them about recovery and their costs increase beyond what is predicted. That is perhaps why White is so keen on pushing ME to the psychological category for insurance as it limits their risk and covers for his bad mistakes.

 

[A.B.]

It can be read in two ways.

The first is that White is misleading everyone, including insurance companies.

The other is that insurance companies don't care whether CBT/GET work or not, as long as they can claim that patients have been given the tools they need to cure themselves. That CBT/GET are actually harmful might even be desirable as patients will drop out of treatment and can then be labelled as not wanting to get better. Worse health also means worse ability to fight a legal battle.

 

[Valentijn]

What we have seen has not been particularly private or high-level, and in that context it makes more sense to feign belief in ME being an easily curable mental health condition. Lower level employees are happier to discriminate against patients and brainwash our doctors when they truly believe they are in the right - much like lower-level CBT practitioners. True believers make much better sales pitches. So I think the efforts of White & Co are aimed at helping the insurance industry in numerous ways, and we really aren't seeing what's going on behind the scenes there sufficiently to know what their real goals and awareness are.

First, public perception makes it easier to deny claims by ME patients. Peter White and other insurance lackeys do a good job in that regard with all of their militant patient claims, news coverage of ME being curable with CBT, and general implications that ME is a self-inflicted psychological disorder. This can prejudice tribunals who are assessing denial appeals, politicians who opt not to intervene, and the general public not to get up in arms about unfair and repugnant practices.

Second, re-classification of ME/CFS can save the insurance industry a lot of money in claims. And the psychobabblers seem to have been pushing very heavily for this behind the scenes. There's already a nation-wide fatigue categories added to some version of the ICD, where "chronic fatigue" lacks a neurological classification, and is even explicitly applicable to and synonymous with CFS. There are also indications that a similar move is underway with the global ICD codes, to reclassify CFS at least in a less biomedical manner, and bring ME with it if possible.

And then we have new codes regarding Bodily Distress Disorder or similar MUS concepts, where anyone having more symptoms than someone thinks they should is presumed to have a mental disorder. Which opens the door for saying "sure, you have a neurological disease, but part or all of your disability is due to BDD and not ME itself, so no payout for you."

And as to why they don't just list ME/CFS as an exclusion: because insurers make money by offering insurance, not by excluding insurance before it's even been bought. It's simply bad marketing to say they'll insure people - unless they come down with something debilitating and incurable. Bait and switch requires that the bait be tempting enough to attract people to sign up, to collect their premiums for years or decades, and to replace the product with a shittier one only when it's too late for the customer to switch to a different insurer.

It would be interesting to know how much of the ICD and NICE debacles the insurance industry is behind. But I doubt we'll ever be able to find out. Most of that would be down to private transactions between the insurers and their employees. At best we know that the people aiming for psychologization of ME/CFS have insurance ties - but we will never know the orders they've been given from the top, or have proof that their actions are the direct results of their bosses orders. Though perhaps it's best to assume that their actions are in their paid capacity as employees of the insurance companies.

Personally I think any paycheck or other incentive received from insurers should disqualify the recipient's input in any government, regulatory, legal, or medical context. The conflict of interest isn't just potential - it's almost guaranteed that they will never act against the orders or best interests of their employers. Better safe than sorry, when it comes to public health.

 

[NelliePledge]

Personally I think any paycheck or other incentive received from insurers should disqualify the recipient's input in any government, regulatory, legal, or medical context. The conflict of interest isn't just potential - it's almost guaranteed that they will never act against the orders or best interests of their employers. Better safe than sorry, when it comes to public health.

absolutely agree

 

[Sbag]

Insurance tends to be tightly regulated. I bet they're not allowed to declare ME to go under mental health when it's classified as neurological everywhere else. Hence the wriggling about with separate "fatigue" classifications in the UK.

It seems that they are allowed but am still on the case with this

 

[Sean]

politicians who opt not to intervene,

Yes, they do like a convenient arse-covering excuse not to adequately fund proper research and support.

(Not all of them, there are good people everywhere. But in recent years their excuse seeking has become more extreme, especially on ME et al.)

 

[Snowdrop]

I think insurance companies will end up hating people like White. They rely on having accurate information about patient numbers and likely success of treatments (they make money by pooling risk and taking a cut) so White misleads them about recovery and their costs increase beyond what is predicted. That is perhaps why White is so keen on pushing ME to the psychological category for insurance as it limits their risk and covers for his bad mistakes.

That's the rational way of doing business. I think increasingly company leaders are prepared to go beyond the usual business practice to squeeze ever more profit much of which ends up directly benefiting them personally. In other words they seem more willing to take risks and that can become quite irrational. Their assessment changes from- is this an acceptable risk to take to can we get away with this. I can imagine this as a possible scenario in today's corporate climate.

 

[Valentijn]

I think increasingly company leaders are prepared to go beyond the usual business practice to squeeze ever more profit much of which ends up directly benefiting them personally. In other words they seem more willing to take risks and that can become quite irrational.

Large performance-based bonuses are a big problem in many industries, since they incentivize short-term personal gains over the long-term stability of the company.

 

[user9876]

That's the rational way of doing business. I think increasingly company leaders are prepared to go beyond the usual business practice to squeeze ever more profit much of which ends up directly benefiting them personally. In other words they seem more willing to take risks and that can become quite irrational. Their assessment changes from- is this an acceptable risk to take to can we get away with this. I can imagine this as a possible scenario in today's corporate climate.

So the insurance industry is regulated and they do risk assessments. There problem is that if they believe White they are not properly reflecting their risks back to investors or shareholders (which is considered a serious issue). Eventually these things show up in the profit and loss accounts.

When I talked with people about insurance (not medical) it was the underwriters who wanted to understand the risks they were taken on and economists building models. I suspect that insurers have issues if they go against the actuarial figures but if those are suppressed by bad doctor assessments then they simply don't have the right figures to work on. However, what we have seen from the banking industry is that regulation and internal/external audits are weak so good practice gets overridden for immediate profit. But I got the impression that internal regulation of lloyds syndicates was better.

 

[Seven7]

Yes, but the question was not whether insurance companies can reclassify in this way, but whether offering CBT or GET will help them in that endeavour. I don't think it will.

The general theme of the discussion is whether offering CBT or GET has any advantage for the government bodies and insurance companies. Or whether these bodies are being duped just as much as we are.

How can the insurance company being duped when it has been proven the data was manipulated by their plp to fit their needs???!!!!
I asked the question if this was insurance fraud but got deleted from page.

 

[Valentijn]

There problem is that if they believe White they are not properly reflecting their risks back to investors or shareholders (which is considered a serious issue).

Or they don't really take White's input into account when projecting current figures, but see him and others as more of an investment in creating future changes that are beneficial to insurers.

 

[Luther Blissett]

And as to why they don't just list ME/CFS as an exclusion: because insurers make money by offering insurance, not by excluding insurance before it's even been bought. It's simply bad marketing to say they'll insure people - unless they come down with something debilitating and incurable. Bait and switch requires that the bait be tempting enough to attract people to sign up, to collect their premiums for years or decades, and to replace the product with a shittier one only when it's too late for the customer to switch to a different insurer.

Yes, and at the same time, if they can influence the amount and quality of the social insurance on wider offer in society downwards, and increase stigma claiming it, it makes their product more attractive to potential customers.

The pitch and black propagands, goes something like this, but expressed in mostly unspoken terms:

You wouldn't want a chronic disease at your income level would you? Imagine living off such a low income! You might even be mistaken for one of them, the welfare dependents, the scroungers, the malingerers, the lazy, the workshy, the fatties, the druggies, the dregs.

It preys on people's keen understanding of which group they belong to and which groups they don't, along with status anxiety.

 

[Woolie]

It feels like a conspiracy, with everyone complicit in it, including insurance and government. But if we go around saying that, we've already lost the argument because we sound like conspiracy theorists.

But what if we start with the assumption that government and insurers actually believe CBT and GET are effective? And that this belief forms part of their motivations for recommending it? Then there's somewhere to go advocacy-wise. I am not naive enough to think any of these organisations actually care about us, of course they don't. But I do think their own interests are only met if these treatments actually work.

Insurance companies can only make a win from CBT/GET if it reduces other types of claims, and I've argued above that there is no evidence for this. National health bodies would have similar motivations (reducing other types of costs), but on top of that, they also need to be "seen to be doing something".

According to this hypothesis, as soon as CBT and GET are no longer seen as effective, then they will cease to serve the purposes of insurers or government health agencies.

Again, this argument is about CBT and GET specifically, not about any other issues surrounding MECFS. Its about whether recommending and paying for CBT or GET will have sufficient benefits for these organisations to at least pay for itself. Moves to reclassify CFS as a mental disorder, that's a different issue.

 

[Valentijn]

It feels like a conspiracy, with everyone complicit in it, including insurance and government. But if we go around saying that, we've already lost the argument because we sound like conspiracy theorists.

Most people distrust insurance companies, at least in the US and even in the Netherlands. Maybe people are more trusting in the UK, but in the US insurers are generally seen as some of the worst villains, willing to let people suffer and die to try to squeeze out a few more cents of profit.

And I dare say governments aren't particularly trusted either, as they're driven by various ideologies rather than simply the public welfare. And with Atos scandals being a regular feature in mainstream media over the past couple years, I doubt even the UK public is giving them much benefit of the doubt.

But what if we start with the assumption that government and insurers actually believe CBT and GET are effective? And that this belief forms part of their motivations for recommending it? Then there's somewhere to go advocacy-wise.

Yeah, around in circles. Patients, charities, and other advocates have been pointing out the flaws with CBT/GET recommendations for years, if not decades, and it's gotten nowhere. NICE simply rates the evidence as is most beneficial for their interests. The attitude of NICE should leave no room for doubt - they are not interested in the science, they will pass the buck to unnamed experts when asked for a justification, and they will accuse patients of threatening the well-being of said experts solely on the basis of patients showing too much interest in NICE's processes.

Insurance companies can only make a win from CBT/GET if it reduces other types of claims, and I've argued above that there is no evidence for this. National health bodies would have similar motivations (reducing other types of costs), but on top of that, they also need to be "seen to be doing something".

They also win if they can deny claims and benefits, which we see plenty of happening with both insurers and the UK government. Appeals are often more productive, but many patients give up before getting that far - and that is a win for insurers, government agencies with a budget, and the profit-driven companies hired by government agencies.

 

[Chrisb]

and that is a win for insurers, government agencies with a budget, and the profit-driven companies hired by government agencies.

I would only add "and for that small group of people who pass freely between employment in government, administration, regulation and business."

 

[Jonathan Edwards]

But what if we start with the assumption that government and insurers actually believe CBT and GET are effective? And that this belief forms part of their motivations for recommending it? Then there's somewhere to go advocacy-wise. I am not naive enough to think any of these organisations actually care about us, of course they don't. But I do think their own interests are only met if these treatments actually work.

I think the problem is that CBT and GET are indeed effective in reducing costs because the alternative is ongoing supervision and support by a physician. A short course of therapists time will be cheaper.

The government itself is not interested in actual medical benefit. It is almost exclusively interested in finding ways of commercial outsourcing of NHS services because it believes that is best. Therapists can be subcontracted to through specialist commercial centres, doctors in clinics are more tricky.

And the insurance companies are not actually interested in reducing health care costs. The more health care costs the more they can make on insuring people. What they like is dependable risk. They also get into deals with the commercial suppliers. So CBT and GET suit them too.

As I see it the weak point in the system is the evaluation by Cochrane. That still has to appear to be unbiased scientific review. I doubt the political pressures can be brought to bear there in quite the same way. But the mental health section seems to be soft on quality of evidence. I am afraid the mental health professions are going to have to face up to the fact that evidence needs to be more reliable.

 

[Woolie]

I think the problem is that CBT and GET are indeed effective in reducing costs because the alternative is ongoing supervision and support by a physician. A short course of therapists time will be cheaper.

But no, the PACE data shows us that there is actually no reduction in health care utilisation following CBT or GET. From my post above:

This claim is untrue. The McCrone cost effectiveness paper showed that in PACE, healthcare-related costs were higher following GET and CBT than following medical care alone (SMC). See Table 3. There was no difference between SMC and CBT or GET with respect to receipt of illness/disability payments. See Table 4.

Maybe because when people don't get better, or when the benefit they thought they perceived doesn't pan out, they go back to their doctors to find out why?