Universal Health Care – How We’ll Get There
Aug 14, 2015 12:57pm PDT by
Medicare Advantage plans padded charges on home visits, whistleblower says
Texas case latest in series of allegations against privately-run health plans
By Fred Schulte
Center for Public Integrity, August 12, 2015
Center for Public Integrity, August 12, 2015
A new whistleblower case accuses a Texas medical consulting firm and more than two dozen health plans for the elderly of ripping off Medicare by conducting in-home patient exams that allegedly overstated how much the plans should be paid.
The Texas litigation is just the latest of at least a half dozen whistleblower cases that have been filed in the past five years alleging billing fraud and lax government oversight of privately-run Medicare Advantage plans that have proven increasingly popular with senior citizens.
The latest lawsuit was filed in federal court in Dallas by Becky Ramsey-Ledesma, a medical billing coder, against her former employer, CenseoHealth, LLC. The Dallas-based firm has contracted with thousands of doctors who visit elderly people in their homes and evaluate their health on behalf of Medicare Advantage plans.
But the health assessments exaggerated how ill patients were, which in turn inflated Medicare payments to the health plans, according to the allegations in the suit. The suit names 30 Medicare Advantage plans in 15 states, including several Blue Cross plans and other industry stalwarts, such as Humana Inc. Humana has more than three million Medicare members.
The private insurance plans offer seniors an alternative to standard Medicare, which pays doctors for each service they render. Medicare Advantage plans receive a set fee monthly for each patient based on a risk score that pays higher rates for sicker people and less for those in good health. Medicare essentially trusts health plans to report these risk scores accurately. The Medicare Advantage plans have grown rapidly in recent years, and now cover almost 17 million people.
The Texas suit was filed last year, but stayed under court seal until mid-June. It is the second whistleblower action to target Medicare Advantage home visits, which account for billions of dollars in annual revenues for health plans.
A 2014 Center for Public Integrity investigation found that home visits skyrocketed as federal officials struggled to prevent health plans from overcharging Medicare by tens of billions of dollars every year. Federal officials as early as 2013 were concerned the home visits could be a factor in jacking up risk scores improperly and wasting tax dollars. But they backed off a proposal to limit their use when the industry objected, the investigation found.
CenseoHealth’s home visits collect data on the health status of patients, which the private health plans then use to bill Medicare. The company had no comment on the lawsuit.
The Centers for Medicare and Medicaid Services press office declined to answer written questions seeking comment on its home visit policy. The agency instead issued a statement that said the home exams can have “significant value.” That opinion is shared by the health insurance industry trade group, America’s Health Insurance Plans. A spokesperson for AHIP called the visits “an important component of disease management activities.”
Medicare Advantage is enjoying robust growth and firm political support in Congress. The industry has beaten back several attempts by the Obama administration to cut its rates as enrollment has grown to encompass about one in three people on Medicare. In June, the House passed a bill sponsored by Rep. Vern Buchanan, R-Florida, that appears to prevent federal officials from halting the home health assessments.
At the same time, the Centers for Medicare and Medicaid Services is drawing scrutiny over top manager Andy Slavitt’s former ties to UnitedHealth Group, which runs the nation’s biggest Medicare Advantage plan. Senate Finance Chairman Orrin Hatch criticized Slavitt’s “conflicted history” in a statement issued after President Obama nominated him for the top CMS job in July.
Bringing Back House Calls
CenseoHealth has emerged as a leader in a growing market for in-home health assessments.
Formed in 2009 by two Texans, CenseoHealth grew from four employees to 325 workers by 2013, according to its website. It has built a network of nearly 5,000 doctors whom it says are “uniquely qualified to identify and diagnose health conditions.” CenseoHealth-affiliated doctors have done more than a million home visits, and in 2013 forecast revenue would reach $120 million, according to its website.
CenseoHealth’s investors include private equity firm Health Evolution Partners, headed by David Brailer, a physician and former health information technology czar under President George W. Bush. In March, Brailer was named chairman of CenseoHealth’s board of directors. Brailer could not be reached for comment.
According to the suit, CenseoHealth used an algorithm to identify patients who might have undetected medical conditions that could raise their risk scores. The company uses marketers to contact patients and schedule doctor visits to their homes.
The suit alleges that the doctors don’t provide any medical treatment. Other than taking vital signs and weight, listening to heart and lungs and checking reflexes, no physical exam in involved and no lab tests are performed, according to the suit. The doctors ask the patient a series of questions on a checklist during the visit, which takes about an hour.
“In other words, the conditions reflected on the evaluation forms are not medical diagnoses derived from a medical examination, but instead, are self-reported conditions captured from the medical history and verbally confirmed” by the patient, according to the suit.
Some of the doctors lacked medical licenses, according to the suit, and others were assigned as many as ten visits a day for a flat fee of $100 each. Some faked results, according to the suit. The suit cited a test for Alzheimer’s disease in which each patient was asked to draw hands on a clock to indicate the correct time of day. “In some cases it was obvious that the same person had drawn the clock on multiple forms,” according to the suit.
Some of the diagnoses could not be made reliably through a home visit, according to the suit. Others were based on medications patients took, even when those medications could be taken for more than one condition, according to the suit.
These practices inflated risk scores, according to the suit, triggering “substantial overpayments” to the health plans.
Ramsey-Ledesma claims she was fired in August 2013, the day after she objected to the practices. According to the suit, her manager told her, “we can no longer trust you.”
The other whistleblower case that targeted home visits was unsealed in 2014. It was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services, Inc., or MedXM. The company, based in Santa Ana, Ca., has denied the allegations. The case is pending.
The Department of Justice declined to join either case, which may make it more difficult for the whistleblowers to proceed with their cases and collect a large award. However, lawyers who handle these cases say more of them are moving ahead without the government.
Other whistleblower cases involving Medicare Advantage have been filed in the past five years in California, Florida and South Carolina, among other locales. These cases also allege that Medicare Advantage plans inflated risk scores and as a result were overpaid by Medicare.
Friends in High Places
As early as 2013, CMS officials said they suspected home visits improperly raise risk scores and waste tax dollars. But as the visits became standard procedure for more and more health plans, CMS lost its appetite for tightening oversight.
Why did health spending rebound?
by Robert Samuelson
It was nice while it lasted, but it’s over and may not return for many years, if ever. The “it” is the slowdown in national health spending.
From 2008 to 2013, health spending grew roughly 4 percent a year, which was less than half the 9 percent average of the three decades before the Great Recession. Because the 4 percent rate matched the economy’s overall growth, health spending stabilized at 17.4 percent of gross domestic product (GDP). There was some hope that an era of sizable increases was over.
Robert J. Samuelson writes a weekly column on economics. View Archive
Forget it. Government actuaries from the Centers for Medicare and Medicaid Services (CMS) last week reported that health spending in 2014 rose 5.5 percent to $3.1 trillion. Worse, spending is projected to increase 5.8 percent annually between now and 2024. That’s faster than the economy’s expected growth, so health costs would rise to 19.6 percent of GDP by 2024. The gain in GDP share (from 17.4 percent to 19.6 percent) may seem small. Not so. It’s worth almost $400 billion a year. (All these dollar and GDP figures are unadjusted for inflation.)
So it’s back to the future. Health spending will silently shape the nation’s priorities. It will squeeze take-home pay, as employers devote more of their compensation to insurance and high deductibles raise workers’ out-of-pocket expenses. Government will spend more on Medicare (government insurance for the aged) and Medicaid (insurance for the poor). Other programs will compete for a smaller pot — or taxes will rise. The only good news, assuming the actuaries’ projections come true, is that spending has slowed from its pre-recession trajectory.
All this poses intriguing questions: What caused the spending slowdown? Why has it stopped?
Keep the Tax on High-End Health Plans
A study had found the product — prescription-grade omega-3 fatty acid —
useful in treating those with lower triglyceride levels, but the FDA
would not approve that use unless there was evidence that it would
actually reduce the risk of heart attacks for that population. Amarin
argued that it should be allowed to show doctors the study.It's legal, and often good for patients, for doctors to investigate and
try new uses of prescription drugs, and to share the results in journals
or online. But the FDA takes a dim view of pharmaceutical companies
using that information to market their products without the agency's
specific approval, and for good reason. The companies and their sales
staff have a strong financial incentive to expand the possible uses of
each drug, whether or not it's particularly helpful. Off-label uses can
also have as-yet-undiscovered risks.
The meaning of "truthful" and "not misleading" can easily become obscure when money is at stake. A drug rep could present a doctor with a small-scale study of a product or say that other doctors he deals with have had success with a specific off-label use, which might be true but is evidence of very little.
The meaning of "truthful" and "not misleading" can easily become obscure when money is at stake. A drug rep could present a doctor with a small-scale study of a product or say that other doctors he deals with have had success with a specific off-label use, which might be true but is evidence of very little.
The
FDA has been working on setting standards for the kinds of information
that pharmaceutical companies can promote to doctors. It might make
sense, for example, to allow drug reps to show doctors high-quality,
published studies whose results have been replicated. That's better than
restricting all promotion or allowing a marketing free-for-all.
What single-payer health care really is and how Obamacare compares
Posted Aug. 12, 2015, at 10:43 a.m.
Last modified Aug. 14, 2015, at 7:16 a.m.
Last modified Aug. 14, 2015, at 7:16 a.m.
During the debate about the Affordable Care Act (ACA, or “Obamacare”), you probably heard complaints about the U.S. heading toward socialized medicine and a single-payer health care arrangement similar to Canada’s system.
Is there a difference between socialized medicine and a single-payer system, and does the ACA truly take us down the path of socialized medicine? The answer is not always straightforward because people’s perceptions and definitions of the terms are blurred.
Generally, socialized medicine is a system where physicians work directly for the government. In a single-payer system, physicians have their own practices and are paid by a single insurer – which in this case is a government, using funds acquired through taxation.
In Canada, individual provinces set up their own health care systems and receive financial support from the federal government as long as they maintain certain standards of access. Funding (payment) is public, but care can be obtained through public or private options. That sounds a bit like the U.S. Medicare/Medicaid system, doesn’t it?
In fact, single-payer proposals in the U.S. have been referred to as “Medicare for all,” since they would extend the basic Medicare/Medicaid coverage to all Americans. The framework of this was outlined in the 2009 bill H.R. 676 (Expanded and Improved Medicare for All Act), among other resolutions.
Let’s contrast a few specific areas of the U.S. and Canadian systems.
Coverage – Canada’s system provides universal health care coverage that is portable and not tied to your job. Obamacare has increased the number of insured, but about 15 percent of Americans still do not have health coverage, and the majority of coverage is still provided as an employment benefit.
Benefits – Canadian benefits differ slightly from the Obamacare “essential health benefits” that define minimally qualified plans, but they are nevertheless quite similar. They include inpatient and outpatient hospital services, preventative treatment, and services deemed medically necessary. Each province has its own list of additional services.
Cost – Estimates are all over the map on the cost to individuals. In Canada, you do not pay co-pays and deductibles as in the U.S., but you are paying higher taxes to support it. In the U.S., you are paying co-pays and deductibles, insurance premiums, and some lesser amount of taxes. A direct cost-benefit analysis is difficult, if not impossible.
However, when comparing medical costs per capita using data from the Organization for Economic Co-operation and Development, we find that the U.S. spends far more than all other OECD countries. We spend $8,233 per person, more than 2.5 times the OECD average, almost $3,000 higher than the second place country (Norway), and significantly more than the $4,445 per capita spent by Canada.
Does the U.S. receive its money’s worth in care? Perhaps, but it is not necessarily apportioned fairly.
Appointments – Wait times are often cited as the problem with the Canadian system, but the U.S. is not far behind. Many nations with nationalized health care or single-payer variants fare better.
In a 2013 survey by The Commonwealth Fund, Canada ranked the worst out of the 11 nations surveyed in the ability to get a same-day or next-day appointment (41 percent) and those who waited six days or more for an appointment (33 percent). The U.S. was the second worst in same-day/next-day (48 percent) and third worst for long waits (26 percent).
However, in wait times for specialists, the U.S. was third best in both categories, while Canada finished last again. That is an indication of both our specialized-care emphasis and our tiered system. Specialized procedures that make more money are addressed more rapidly.
Part of the U.S. problem is supply and demand: With many new uninsured people entering the system, there is almost certain to be an increasing physician shortage over the next few years, especially for general practitioners and those serving rural areas.
Choices – Single-payer systems do allow you to choose and keep your doctor, but you are more likely to wait longer for an appointment. Insurance networks and prohibitive out-of-network costs limit the choice of doctors in the U.S., but, in general, access time is quicker if you do not care which doctor you see.
It is reasonable to argue that Obamacare could be a preliminary step toward a single-payer system, through implementation by the states. Vermont has announced intentions to go down that path.
Should a single-payer system ever be established throughout the U.S., it will likely have different definitions of what constitutes basic care and is likely to contain additional private insurance tiers for procedures beyond the basic single-payer options.
In other words, it will be some sort of Frankenstein’s monster blend of systems – much like Obamacare is now – and by the best definition of the word, it will never be socialized medicine. However, your taxes will be paying for it.
50 years of Medicare, Medicaid, Older Americans Act benefits
Posted Aug. 12, 2015, at 10:28 a.m.
Mainers had a lot to celebrate this July.
Fifty years ago, President Lyndon B. Johnson signed into law legislation that created Medicare, Medicaid and the Older Americans Act. Since 1965, each has served to protect the health and well-being of millions of American families, providing preventive and life-saving health care and other services to help older people live in their homes and communities as long as possible. Each has helped to stabilize and improve the economic health and security of Mainers and our nation.
The Older Americans Act created networks and programs to help older Americans gain access to information, benefits counseling, home-delivered meals, legal services, family caregiving supports, advocacy and other critical community services to help them age at home. The Maine network includes five Area Agencies on Aging that have served older adults for more than 40 years. Each year, the AAAs provide assistance to more than 130,000 older Mainers, including help for more than 20,000 older and disabled adults so they could enroll in Medicare and Medicaid.
Medicare provides certain health care services to older adults and serves about 276,000 people in Maine, mostly age 65 or older and others with disabilities. Medicaid was created for adults with low income, the elderly and people with disabilities. Both served as basic health coverage programs but have evolved over time to improve access to affordable health care. It’s no surprise a recent Kaiser Family Foundation survey found a majority of the public and program beneficiaries view Medicare and Medicaid programs positively.
Medicare Part A covers hospital services and Part B covers outpatient services, including preventive care and visits to the doctor to treat medical conditions. Part D, the Medicare prescription drug benefit, went into effect in 2006. The Kaiser survey shows a strong majority of voters view Medicare as very important and working well for most seniors.
Medicaid, known here in Maine as MaineCare, also is a critically important program for older Mainers. MaineCare not only served more than 300,000 low-income Mainers last year, including working parents, children, pregnant women and disabled adults, but also paid for critical assisted living and nursing home care and helped tens of thousands more with their Medicare premiums or prescription drugs.
Each of these programs serves Americans well and keeps older adults, their caregivers and families healthier, enabling them to live at home and in their communities longer.
MaineCare and Medicare have evolved over the time. Medicare Part D, for example, was added to help address high prescription drug costs many seniors face. More recently, the Affordable Care Act set funding aside for states to provide health coverage to low-income people, most of whom work in food service, personal care services or in building maintenance positions. Providing coverage to these workers is important as Maine’s workforce ages and people work longer — and it would help keep our workforce healthier and reduce overall health care costs over the long run.
As we recognize the importance of these programs in meeting the needs of millions across the country, including thousands in Maine, we should keep in mind those who still struggle to get the health care and services they need. Like other states, we not only should celebrate but work to take advantage of opportunities these programs provide in helping meet those needs.
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