New York City Agency and Vendor Bilked Medicaid, U.S. Says
Federal authorities have accused New York City officials of a five-year effort to defraud Medicaid, working with a contractor to exploit loopholes in Medicaid’s computerized billing system to collect reimbursements that amounted to tens of millions of dollars.
The office of Preet Bharara, the United States attorney for the Southern District of New York, said on Monday that the city’s Department of Health and Mental Hygiene and the contractor, Computer Sciences Corporation, created schemes from 2008 through 2012 that would produce reimbursements on tens of thousands of false claims for early intervention program services for infants and toddlers.
In one scheme, the city and the firm switched diagnosis codes on children, using a default code — 315.9, which designates an “unspecified delay in development” — that Medicaid would approve, the prosecutor’s office said.
Other schemes were intended to circumvent Medicaid rules that required the city and the computer firm to exhaust private insurance coverage before billing Medicaid, Mr. Bharara’s office said.
Activists Rally for Universal Healthcare
By Daphne C. Thompson
The Harvard Crimson, Oct. 27, 2014
Holding signs reading "Healthcare not warfare" and "Insurers deny, people die," more than 100 activists rallied at Boston Common Sunday to promote a single-payer healthcare system and an emergency global health fund.
The participants—including a Harvard contingent of around a dozen students and affiliates—marched the perimeter of the Common before arriving at the Parkman Bandstand, where they listened to several speakers describe the scale and severity of the global health crisis, in part due to the inequity of treatment.
Donald M. Berwick ’68, a health care policy lecturer at the Medical School who unsuccesfully ran for his party's nomination in the ongoing Massachusetts gubernatorial race, compared the magnitude of the health care campaign to the feminist and civil rights movements.
“A fight for a rational, humane, universal, sensible health care system which makes health care a human right—not just here, but anywhere—is a fight of that dimension,” he said. “We need to engage it.”
The Boston Rally for the Right to Health was one of many similar events taking place in 63 countries this weekend as part of the Article 25 “Global Day of Action” campaign, named for the section in the United Nation’s Universal Declaration of Human Rights that declares health as an inalienable right.
The activists gathered signatures to petition gubernatorial candidates Martha Coakley and Charles D. Baker ’79 to support a state-run, single-payer healthcare system in Massachusetts. A single-payer system would provide all citizens with comprehensive health care under a single, publicly-financed insurance plan.
“As cynical as it is, a lot of times it takes generational change for these kinds of ideas to become more ingrained,” said Frances Ding ’17, a member of Harvard Partners in Health, who attended the rally. “More and more people are looking to other countries and thinking, ‘why are they significantly happier with their health insurance?’ while we still can’t ensure health insurance for millions of Americans.”
Brook K. Baker, a law professor at Northeastern University who spoke at the rally, said that single-payer health care represents a more cost-efficient and equitable alternative to the current market-run system. Citing discriminatory insurance policies and pharmaceutical interests as tantamount to health rationing, he urged the protesters to pressure their representatives to invest in universal care.
On a global scale, the protesters advocated for a $20 billion Global Health Emergency Fund to combat epidemics like Ebola and strengthen medical systems in every nation.
“If those countries had access to healthcare to begin with, we wouldn’t be seeing this massive epidemic,” said Joia Mukherjee, an associate professor at Harvard Medical School who spoke on the Ebola crisis. “There is not healthcare anywhere until there’s healthcare everywhere.”
CORRECTION: STATE NO LONGER LOOKING TO ADMINISTER MEDICARE
ANNE GALLOWAY OCT. 26 2014, 8:27 PM
Two recent stories about the relationship between Medicare and Green Mountain Care, the state’s planned universal publicly financed health care program – often called single-payer – were inaccurate. The stories were based on statutes on the Legislature’s website that had not been updated.
Section (e) of chapter 18, Public Private Universal Health Care System, in Title 33, Human Services, still states online that, “The Agency shall seek permission from the Centers for Medicare and Medicaid Services to be the administrator for the Medicare program in Vermont. If the Agency is unsuccessful in obtaining such permission, Green Mountain Care shall be the secondary payer with respect to any health service that may be covered in whole or in part by Title XVIII of the Social Security Act (Medicare).”
Act 144, which was enacted in 2014, repeals that section, though the statutes have not been updated online.
Section (f) of the same chapter now reads, “Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.”
State officials have said they are no longer seeking to administer Medicare as part of Green Mountain Care, and the law reflects that change.
Two recent stories contain inaccuracies that result from using the out-of-date online statutes:
Rep. Sarah Buxton, D-Tunbridge, is correct that Republican Senate candidate Bob Frenier’s campaign signs claiming the state wants to administer Medicare as part of single-payer are inaccurate.
Frenier’s other claim, that Vermont seniors on Medicare won’t have the same access to private supplemental coverage under Green Mountain Care remains a hypothetical. Most seniors have supplemental Medicare coverage, often known as Medi-gap plans.
It is currently unknown what Green Mountain Care will cover or what private supplemental health insurance policies will be offered once the program is in place.
Gov. Peter Shumlin has said there is no reason to expect that currently available supplemental coverage options for Medicare would change if the state moves forward with a single-payer health care system.
Partners chief met a trail of resistance
Questions linger over Gottlieb’s plans for change
By Robert Weisman and Priyanka Dayal McCluskey
| GLOBE STAFF OCTOBER 29, 2014
Speaking to investors early this year, Partners HealthCare chief executive Gary L. Gottlieb said his organization’s hospitals and doctors were creating a “new medical model” in a bid to “control our own destiny.”
But within months, parts of the plan started to fray. Regulators grew increasingly hostile toward Partners’ desire to expand, tens of millions of dollars in losses piled up at a new in-house health insurance arm, and some doctors and hospitals bristled at a push to standardize clinical practices.
When Gottlieb said last week that he would step away from Partners next summer — leaving four years of a five-year contract on the table — the news rippled through the state’s tight-knit health care industry, raising questions about the organization’s direction.
Partners remains the largest health system in Massachusetts and runs some of the nation’s most respected hospitals, including Massachusetts General and Brigham and Women’s. But health care industry insiders say Gottlieb’s aggressive push for change and hands-on management style alienated many people, from elected officials to labor leaders to executives at Partners’ own hospitals.
Others faulted Gottlieb for what they see as mismanaging a bid to acquire South Shore Hospital and two Hallmark Health hospitals north of Boston. A deal with the state’s attorney general, Martha Coakley, that would allow the acquisitions to go forward is mired in controversy. A loud chorus of critics, led by competing hospitals, say Partners already is too dominant and too expensive.
“This may mark Partners’ peak in its ability to grow without justification,” said Alan Sager, a professor at the Boston University School of Public Health and a longtime critic of hospital mergers he believes drive up medical expenses. “More and more people publicly question Partners’ ability to save money, lower its costs, and lower its prices.”
What ails Partners HealthCare?
by Shirley Leung
What ails Partners HealthCare?
People who work there have a reason to jump out of bed every morning. Doctors, nurses, and researchers walk the halls of some of the world’s greatest hospitals. They save lives, find cures for deadly diseases, and stand on the brink of other scientific breakthroughs.
But these days, there’s a growing strain of unhappiness infecting the state’s biggest hospital system, which has more than 60,000 employees.
Public criticism and a barrage of bad headlines about a planned expansion are weighing on once proud workers, some of whom are starting to ask themselves: How did our prestigious organization become the pariah of Boston?
Partners was formed in 1994 to save two struggling teaching hospitals, Massachusetts General and Brigham and Women’s. Today, they are stronger than ever, and while they remain the heart of the system, Partners has grown to 10 hospitals. The proposal that’s generating so much controversy would add three more.
At times, the mission can feel like it’s less about patients and more about growing the empire and containing the collateral damage that comes with claiming more territory.
Getting Partners’ chief executive, Gary Gottlieb, to go was seen as a way to ease the pain. Gottlieb, 59, said last week that he will leave next summer to run Partners in Health, a separate nonprofit aimed at providing medical care to impoverished countries. The former Brigham and Women’s president has led Partners HealthCare since 2010 and had four years left on a five-year contract.
Gottlieb championed ways to grow Partners. On his watch, the organization added Cooley Dickinson Hospital in Northampton and got into the insurance business with the acquisition of Neighborhood Health Plan.
Hit the brakes on Partners HealthCare deal
Before gobbling up South Shore and Hallmark, the medical behemoth must prove it can contain costs and return savings to Commonwealth
By Donald M. Berwick
| OCTOBER 19, 2014
The Partners Healthcare deal to acquire two Eastern Massachusetts health care systems — South Shore Hospital and Hallmark Health — is a very bad idea. It would make a behemoth even larger. You don’t have to be an antitrust lawyer to predict the consequences of even more market power: higher prices, less competition, and the squeezing out of smaller players.
Even without this merger, Partners accounts for about one-third of all hospital revenue and one-fourth of all physician revenue in the state. Partners’ prices hover around 30 percent higher than the state average, and its “total medical expenditures” — adjusted for the severity of the patients it cares for — are nearly 10 percent higher than the average.
So why then would the government let the acquisition happen?
The proposed terms negotiated by the Attorney General’s office, recently open for public comment and now under review in Suffolk Superior Court, purport to offer safeguards. The main ones are these: Partners agrees not to raise prices over a six-year period at a rate higher than general inflation, and it agrees that health plans can pick and chose components of the system to contract with, rather than having to take all of Partners or none.
So, the argument goes, the deal would offer more options for insurers and patients, and will slow the growth of health care costs. And, proponents say, the deal will stabilize two key Massachusetts systems that are vulnerable to failure if left on their own while also elevating the quality of care because Partners is so good at what it does.
The Health Policy Commission — the nearly toothless but highly competent independent oversight body established by the 2012 state health care cost containment law — does not concur. The commission has studied historical data from the Massachusetts Center for Health Information and Analysis, also known as CHIA, which is charged to monitor the costs and quality of care. From it, the commission predicts that the acquisitions will lead to higher prices and raise total costs to individuals and businesses in the state by tens of millions of dollars per year. What’s more, although quality metrics are limited, CHIA so far finds no objective evidence that Partners hospitals or physicians offer overall better care than the average. Finally, it suggests that neither South Shore nor Hallmark is anywhere near the brink of failure — they don’t need to be rescued by a deep-pocketed player like Partners.
The antitrust community consistently opposes as ineffective the kind of remedy that this deal proposes.
The following essay by Paul delespingasse is unpublished (therefore no hotline to the source), but I thought worth including in today's blog.
-SPC
Oregon Mess: Subsidies Key Defect In Obamacare
Paul F. deLespinasse, Ph.D.
Professor Emeritus of Political Science and Computer Science
Adrian College
Two medical stories are headlined in recent Oregon newspapers. One is local, but with national implications. The other is national, but with local implications. A common denominator lies beneath both stories.
In Oregon more than ten thousand people got inflated tax credits when buying insurance through the exchange set up under Obamacare. The excess credits may exceed $100 per month, so some people will have to pay substantial amounts back to the federal government.
The national news is the death of Thomas Duncan from Ebola and the infection of several people who treated him. Duncan was sent home, when he first visited a Dallas hospital’s emergency room, despite highly suspicious symptoms. After giving conflicting answers to embarrassing questions raised by this situation, the hospital has hired a public relations firm and allegedly has prohibited staff members from talking to the press.
Obamacare may have been a step in the right direction, but a common denominator underlying both of these stories is its inadequacy and poor design. Partly due to refusal by many states (including Texas) to expand Medicaid, tens of millions remain uninsured. And Obamacare excluded coverage for foreign visitors and undocumented aliens.
Thomas Duncan, visiting from Liberia, had no insurance. There is informed speculation that the Texas hospital had a policy of not admitting emergency room patients who lack insurance. If this is true, it is no wonder that the hospital would need to hire a P.R. firm and put a gag rule on its employees.
Obamacare’s basic problem is complexity. Complexity made creation of web-based portals very difficult, and complexity forces individuals and employers to make choices they are poorly equipped to make. Much of this complexity flows from government subsidies, which allow people to purchase insurance, and especially from the need to document and monitor each person’s continuing eligibility.
Subsidies are obviously needed. Otherwise poor people who aren’t eligible for Medicaid would be unable to comply with the Obamacare mandate. And it is obvious that the subsidy for each individual needs to be on a sliding scale based on that individual’s income. But incomes can change, thus changing how much subsidy someone is entitled to and sometimes causing loss of all eligibility. Furthermore, as people’s changing fortunes move them in and out of Medicaid, the doctors who are “in-network” for them can change, forcing them to find new providers.
All of these problems---the need to reimburse the government for excessive tax-credits, the “churn” as people drop in and out of eligibility for subsidies or for Medicaid, the lack of universal coverage which may have started an Ebola epidemic in the U.S.---could have been avoided by enactment of a single-payer insurance system covering all people in the U.S. and financed by general taxes.
If Mr. Duncan had been covered by such an insurance system, he might well be alive today and he might not have exposed so many other people to Ebola.
Under a single-payer system people would still receive implicit subsidies based on their income, but this would be taken care of by the existing income tax system under which lower income people pay less tax and higher income people pay more. The Supreme Court’s highly dubious reasoning by which it allowed states to opt-out of Medicaid expansion would become irrelevant, since with universal coverage Medicaid would no longer be needed. There would no longer be doctors who are “in-network” or “out-of network.”
A single-payer insurance system would not solve all our problems, but the problems with Obamacare and the even bigger problems prior to Obamacare suggest we need to enact one as soon as possible.
FDR said it all in 1944. We’re still fighting to make his 2nd Bill of Rights reality
By Jeffrey Evangelos, Special to the BDN
Posted Oct. 29, 2014, at 10:19 a.m.
On Jan. 11, 1944, President Franklin Delano Roosevelt, in his State of the Union address, urged Congress to draft legislation that would achieve a “Second Bill of Rights” for the American people.
Arguing that “America’s own rightful place in the world depends in large part upon how fully these and similar rights have been carried into practice for our citizens,” Roosevelt was determined to see a country where livable wages and affordable health care were adopted as universal and inalienable rights.
Roosevelt dealt with two of the greatest challenges ever faced by an American president. He was elected in 1932 at the height of the Great Depression. He also faced the challenge of right-wing fascism during World War II.
Roosevelt rose to the occasion, signed Social Security into law and defeated Hitler’s fascists in Europe. As a man from great wealth, Roosevelt was labeled a “traitor to his class” by his wealthy opponents, who opposed his New Deal for working people in our country, “regardless of station, race or creed.”
Roosevelt realized early in his administration that a country cannot prosper when a small percentage of people hold most of the wealth and all the political cards. His greatest quality is something he shared with Abraham Lincoln and John F. Kennedy — his empathy, a quality sorely lacking today in the vitriolic atmosphere of American attack politics.
Empathy is “the ability to understand the thoughts, feelings or emotions of someone else.” It’s a quality that allowed Lincoln to forgive the South at the close of the Civil War in his effort to heal the nation. It is critical for a statesman or stateswoman to possess this quality; it allows one to listen and understand what life’s experiences have done to our friends, neighbors and constituents. A world without empathy is a frightening place. Values become skewed toward material wealth at the expense of compassion and equality.
When I began my campaign to return to Augusta as a member of the Maine House of Representatives, it was with some trepidation that I approached my first doors to communicate with my voters. After all, with polls showing the American people with a highly negative opinion of our politics and politicians (and who can blame them?), I was worried that this anger would boil over as I knocked on doors.
I was wrong.
Far from being greeted with anger and hostility at the state of affairs in our country, my voters have been hungry to tell their stories. They sit me down at their kitchen tables; all they are asking for is for someone who will listen. None wants sympathy, but I believe the warm response I have been receiving has a lot to do with empathy.
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