Category Archives: Uncategorized

Shared Savings Program ACOs Reduced Medicare Spending by $1 Billion

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ACOs under CMS’ largest alternative payment model outperformed fee-for-service providers in quality and cost savings within the first three years of program.

According to findings reported by the Department of Health and Human Services Office of Inspector General (OIG), accountable care organizations (ACOs) participating in the Shared Savings Program are learning how to achieve greater cost savings over time. The Medicare Shared Savings Program is one of the largest alternative payment models implemented by CMS to reward providers for the quality and value of their services in order to keep patients healthy and lower costs.

The OIG’s report suggests many positive outcomes of the program, including that one-third of the ACOs that reduced their spending lowered costs enough to receive a portion of the savings. CMS data on quality measures also shows that ACOs generally improved the quality of care they provided, with a rate of 82% performance improvement on the individual quality measures within the first three years of the program. ACOs also outperformed fee-for-service providers on 81% of the quality measures.

A small portion of ACOs are reported to have gone above expectations, reducing Medicare spending by an average of $673 per beneficiary, including spending reductions for high-cost services such as inpatient hospital care and skilled nursing facility care. The OIG reports that these high-performing ACOs’ frequent use of primary care services, which can lower utilization and costs for other care, and cost reductions for services such as emergency department visits, was a factor in their cost savings. These strategies are compared to other Shared Savings Program ACOs and the national average for fee‐for‐service providers, who showed an increase in per beneficiary spending for key Medicare services.

The OIG concluded that ACOs show promise in reducing Medicare spending while also improving quality. These improvements come at a critical time, as Medicare spending is predicted to grow to $1.4 trillion by 2027. A large portion of Medicare spending has been attributed to overbilling, with the Medicare program losing more money to this error than any other program government-wide.

Dallas lab company accused of paying kickbacks fights to keep its federal licenses

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https://www.dallasnews.com/news/crime/2017/09/04/dallas-lab-company-accused-paying-kickbacks-fights-keep-federal-licenses

Erik Bugen, defendant in medical kickback scam case.(Linkedin/Linkedin)

Erik Bugen, defendant in medical kickback scam case.

An embattled Dallas laboratory company accused of masterminding a $100 million fraud through bribes and kickbacks is fighting to keep its licenses to stay in business, according to a federal civil lawsuit.

Lawyers for Next Health and Medicus Laboratories filed a lawsuit on Aug. 18 against state and federal officials and agencies, seeking a temporary restraining order and injunction to stop them from suspending or revoking the company’s federal laboratory licenses.

Such a move would effectively put them out of business, the lawsuit says. Federal inspectors said they found regulatory violations without offering specifics, according to Next Health’s lawsuit.

That’s not the company’s only concern.

Two of Next Health’s principals, Andrew Hillman and Semyon Narosov, are currently facing federal bribery and kickback charges along with 19 others in connection with the former doctor-owned hospital chain Forest Park Medical Center. Prosecutors say the hospital paid about $40 million in bribes and kickbacks in exchange for patient referrals that generated $200 million in paid claims.

The $100 million fraud allegation against Next Health comes from a lawsuit UnitedHealthcare filed in February against the company, with allegations similar to those in the criminal case. The insurer alleges that Next Health paid bribes and kickbacks to doctors and other providers between 2011 and 2016 for overpriced and unnecessary drug and genetic tests.

Legal observers say laboratories are under intense federal scrutiny due to concerns that some are paying doctors to order genetic and drug tests that aren’t medically necessary.

Four Austin men, for example, were indicted in Dallas in July, accused of paying kickbacks to physicians for ordering bogus urine tests at North Texas labs. Another Texas lab company, Sky Toxicology, is fighting similar allegations from UnitedHealthcare in a lawsuit in San Antonio. Sky lawyer David Navarro said, “We intend to pursue our claims and vigorously defend against United’s counterclaims.”

Jeffrey Baird, a health care attorney in Amarillo, said many new testing labs have opened across the nation over the past two years. He said he advises his clients not to pay marketers any commissions to find specimens for testing due to the federal anti-kickback law.

“Anytime somebody figures out that a government program is paying money for something, you’re going to have folks try to figure out how to access that money,” he said.

Once federal authorities shut down one abusive practice, fraudsters figure out another way to bill for unnecessary medical services, he added. “It’s whack-a-mole. It’s almost this cat-and-mouse game,” Baird said.

Next Health is the majority owner of Medicus, a clinical testing laboratory that became a Medicare provider in 2010, court records say. UnitedHealthcare says in its lawsuit that Hillman and Narosov control Next Health.

Medicus in 2014 paid $5 million to settle a federal civil complaint that it defrauded Medicare over urine testing services. Next Health says Medicus has stopped certain testing “out of an abundance of caution” and also ceased operations at four other labs it owns because of the latest controversy.

Government overreach?

Next Health and Medicus allege that state and federal officials have a “premeditated intent to shut down the plaintiff’s business operations” and are not following their own rules and procedures.

Company representatives could not be reached for comment. But in court documents, they say they were not given time to correct “alleged deficiencies.”

A team of state and federal inspectors arrived at Medicus’ laboratory in April for a five-day inspection, reportedly in response to an anonymous complaint, the lawsuit said. The team also inspected five other labs owned in part by Next Health, the lawsuit said.

Next Health’s chief compliance officer, who accompanied the inspectors, noticed a copy of an email left in plain sight from one team member to others, saying the labs had received ample media attention and that the inspectors needed to find a way to pursue a “complaint investigation,” the lawsuit said.

“Defendants’ employees and agents were instructed to make findings that would close down plaintiffs’ operations before they even went to plaintiff’s laboratories,” the suit says.

The email is proof, the lawsuit says, that the inspection was not due to a complaint but part of an effort to shut down Medicus’ lab and prevent Next Health from running any other labs “through a regulatory ban.”

A May 10 letter from the Centers for Medicare & Medicaid Services to Next Health and Medicus officials — appended in the lawsuit — said inspectors found problems with testing.

“Your laboratory demonstrated systemic and pervasive problems throughout the laboratory which has led to the findings of immediate jeopardy,” the letter says.

A finding of immediate jeopardy allows CMS to suspend, limit or revoke a laboratory’s license to operate without a hearing or opportunity for the lab to refute the allegations, the lawsuit says.

A CMS representative said the agency does not comment on pending lawsuits.

Federal charges

It’s not the first time Hillman has been in trouble with the law over alleged health care fraud.

In 2005, Hillman and his high school friend, Jason White, were indicted on mail fraud and health care fraud charges for an alleged scheme to defraud workers’ compensation insurance companies by getting them to pay for unnecessary medical equipment.

The following year, the U.S. attorney’s office in Dallas dropped the charges against Hillman after White took blame for the fraud and said Hillman had nothing to do with it, according to court records. That came after White had already pleaded guilty to conspiring with Hillman to commit the fraud, court records show.

Hillman was indicted for a second time in November — in the Forest Park Medical case — along with Narosov, a licensed physical therapist.

The indictment says the hospital paid Hillman and Narosov about $190,000 in kickbacks and bribes for referring patients to Forest Park Medical for surgeries and other procedures.

Both men have pleaded not guilty in that case and have filed a motion to dismiss the indictment. Attorneys for Hillman and Narosov said in court filings that their clients are not part of the alleged conspiracy and that the five-year statute of limitations bars charges against their clients in the case.

Narosov’s lawyer declined to comment. Hillman and Next Health and their lawyers could not be reached for comment.

Gift cards for urine

One of Next Health’s former marketing contractors was implicated in an unrelated criminal case involving an alleged laboratory kickback scheme.

Erik Bugen, of Austin, was indicted in July. Prosecutors say a company he co-founded, the ADAR Group, drummed up unnecessary tests for different labs and got the military’s health care system, Tricare, to pay for them. Soldiers were given Wal-Mart gift cards in exchange for providing saliva and urine, the criminal filing said.

Bugen has pleaded not guilty. He and his lawyer could not be reached.

The ADAR Group also found specimens for Next Health by giving people $50 gift cards to urinate in cups at Whataburger restrooms, according to the UnitedHealthcare lawsuit. Next Health labs conducted the tests under the guise of a “wellness study,” the lawsuit alleges.

Next Health lawyers have filed a motion to dismiss the lawsuit, saying UnitedHealthcare has failed to show any evidence of fraud.

“UHC has failed to allege any facts demonstrating a ‘meeting of the minds’ necessary to establish a claim for ‘conspiracy to commit fraud,’” said Ernest Martin Jr., one of the Next Health’s attorneys, in the filing.

Martin said doctors referring specimens for testing at the Next Health labs “exercise independent professional judgment in determining what testing services are appropriate and necessary.”

Only 3.3% of ED Visits ‘Avoidable’

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The top three non-emergent ER diagnoses were identified by researchers as joint disorders, atopic dermatitis, and other soft tissue diseases.

What does “avoidable” mean?

Answer: It depends on who’s doing the study.

A study published Thursday in the peer-reviewed International Journal for Quality in Health Care found that only 3.3% of emergency room visits could be classified as “avoidable.” That stands in stark contrast, for example, with another study from Truven Health Analytics that found nearly 71% of emergency room visits are avoidable. What gives?

For its part, the more recent study, Avoidable Emergency Department Visits: A Starting Point, contends that it’s difficult to determine whether an ED visit was necessary until after the visit, which makes some sense, but severely limits the ability of triage to make a difference.

“Using chief complaints derived from diagnoses, which are determined post hoc, can be dangerous because visits that are eventually determined to be non-emergent after physician examination and diagnostic testing are virtually indistinguishable from emergent visits,” the study says.

So there’s that.

The 3.3% of visits the study’s authors do contend are actually avoidable include visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home, which is fairly restrictive. Further, a significant number of those avoidable visits, by their definition, included mental health and dental conditions, which emergency departments are ill-equipped to treat.

“This suggests a lack of access to healthcare rather than intentional inappropriate use is driving many of these ‘avoidable’ visits,” said study author Renee Hsia, MD, of the Department of Emergency Medicine at the University of California, San Francisco, in a press release. “These patients come to the ER because they need help and literally have no place else to go.”

To derive their results, study authors examined a total of 115,081 records, representing 424 million ED visits made by patients aged 18–64 years who were seen in the ED and discharged home.

By contrast, a separate study, which used data from emergency department visits of patients with employer-sponsored health plans, and examined insurance claims data for more than 6.5 million emergency room visits made by commercially insured individuals, under age 65, in calendar year 2010, found that just 29% of those patients required immediate attention in the emergency room.

The Truven study found that the top three non-emergent diagnoses were joint disorders, atopic dermatitis, and other soft tissue diseases.

Part of the controversy surrounding ED visits is, unsurprisingly, about money. ED care is expensive compared to non-emergency settings, and not only do insurance companies have an incentive to reduce unnecessary visits in favor of lower-cost settings of care, but with the rise of high deductible health plans, so do many patients. That is especially true for patients with employer-sponsored high-deductible plans, where the patient is responsible for all medical care costs up to a certain deductible, usually several thousand dollars, in a calendar year.

Medicaid patients, to use one example, do not generally have the same cost-sharing responsibilities, although that is changing.

Med School Grads Go to Work for Hedge Funds

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https://www.bloomberg.com/news/articles/2017-09-05/med-school-grads-go-to-work-for-hedge-funds

 

More are starting biotech companies or joining consulting or financial firms instead of practicing—all while the U.S. suffers a shortage of doctors.

Matthew Alkaitis, a third-year student at Harvard Medical School, is calm, friendly, and a good listener—the kind of qualities you’d want in a doctor. But though he spends 14 hours a day studying for his board exams, the 29-year-old isn’t sure how long he’ll be wearing a white coat. In September, Alkaitis, who also has a Ph.D. in biomedical sciences, will be starting a two-year fellowship at McKinsey & Co., where he’ll be advising clients in the health-care field. “I really hope that my career involves a period of dedicated time taking care of patients,” he says. “But I also have this competing goal to one day start or help build out a company that really adds something new and interesting and innovative to the medical system.”

Like Alkaitis, more people are coming out of medical school and choosing not to practice medicine. Instead, they’re going into business—starting biotech and medical device companies, working at private equity firms, or doing consulting. In a 2016 survey of more than 17,000 med school grads by the Physicians Foundation and health-care recruitment firm Merritt Hawkins, 13.5 percent said they planned to seek a nonclinical job within three years. That’s up from 9.9 percent in 2012. A separate Merritt Hawkins survey asks final-year residents: “If you were to begin your education again, would you study medicine or would you select another field?” In 2015, 25 percent answered “another field,” up from 8 percent in 2006. Among the reasons they cited: a lack of free time, educational debt, and the hassle of dealing with insurance companies and other third-party payers.

The trend is worrying, as the U.S. already suffers a shortage of doctors, especially in rural areas. “If you have a large number of people out training to see patients and taking care of people in our communities, then all of a sudden deciding not to, that’s a concern,” says Atul Grover, executive vice president of the Association of American Medical Colleges. The AAMC projects a nationwide deficit of as many as 100,000 doctors by 2030.

“I think that we are at a crossroads,” says Dr. Kevin Campbell, a cardiologist in Raleigh, N.C. “I trained in the early ’90s, and back then you definitely were thought of as a sellout or a second-class citizen if you weren’t going into clinical medicine.”

Medical students have more options nowadays. Medical and business schools are teaming up to offer joint degrees. There were 148 students enrolled in M.D.-MBA programs in 2016, up from 61 in 2003, according to the AAMC. At Harvard Medical School, in a class of about 160 students, about 14 will pursue the joint degree, and an additional 25 or 30 will do master’s in other areas, such as law and public policy. “We have some students who want to go back to the Midwest and practice in a community setting,” says Dr. Anthony D’Amico, a professor of radiation oncology at Harvard Medical School and an advisory dean. And then there are those “who want to implement skill sets they’ve been blessed with and apply them on a broader scale.”

Dr. Rodney Altman of San Francisco says the time he spends treating patients in the emergency room informs his work as a managing director at Spindletop Capital, a private equity firm that invests in health-care companies. “I really wanted to practice health care on a macro level,” says Altman. “For me the one-on-one interaction with patients, while important and rewarding, wouldn’t have been as rewarding as being able to impact a larger number of patients.”

Altman says his mentors and colleagues had mixed feelings when, after a decade of practicing full time, he decided to dial back his hours in the emergency room. “Most people were supportive, a lot were envious, and some appropriately cautioned me about the risks I would be taking,” he says. “Out in the business world, you’re subject to the whims of the capital markets and to a lot more that is out of one’s control. I think medicine is quite safe and secure in that way.”

Some consulting companies are also stepping up hiring of doctors. Steffi Langner, a spokeswoman for McKinsey, says her firm is actively recruiting doctors because the analytical skills necessary to be an M.D. are similar to the problem-solving skills a consultant needs.

Dr. Jon Bloom trained as an anesthesiologist and practiced for three months, then enrolled at Massachusetts Institute of Technology’s Sloan School of Management. He says he was inspired by other doctors he knew who were inventors and entrepreneurs. One reason more are choosing that path is that investors are willing to fund them. Figures compiled by the National Venture Capital Associationshow that investment in medical-related startups climbed from $9.4 billion in 2007 to $11.9 billion in 2016.

Bloom is co-founder and chief executive officer of Podimetrics, a startup in Somerville, Mass., that has developed a mat device that predicts and prevents diabetic foot ulcers. He says that even though his invention is now on the market after receiving approval from the U.S. Food and Drug Administration in 2015, he’s still living the startup life. “I definitely don’t make nearly as much as what a doctor makes. That wasn’t really important to me,” he says. “My friends who graduated residency many years ago, they have multiple cars, fabulous houses. They did OK. I still occasionally eat ramen noodles,” he chuckles.

BOTTOM LINE – A U.S. deficit of doctors may worsen as a growing minority of medical school grads are choosing other professions.

University Hospital boss talks changes after nurse arrest, says ‘this will not happen again’

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http://www.sltrib.com/news/health/2017/09/04/live-university-hospital-officials-discuss-arrest-of-nurse-who-refused-to-draw-blood/

University Hospital boss talks changes after nurse arrest, says ‘this will not happen again’

Administrators at University Hospital said Monday they have already changed policies so nurses, like the one who was arrested earlier this summer for refusing to draw a patient’s blood, no longer interact with police.

At a news conference Monday, Gordon Crabtree, the interim chief executive officer of University Hospital, said the nurse, Alex Wubbels, upheld hospital policy and patient privacy despite her July 26 arrest.

“Her actions are nothing less than exemplary,” Crabtree said. ”She handled the situation with utmost courage and integrity.”

The Labor Day news conference occurred on the same day Wubbels spoke on the ”TODAY Show.” She said while the discussions she’s had with the Salt Lake City Police Department have been progressive, she released the police body camera video Thursday because she felt University Hospital and the campus police force had not appropriately responded to the episode.

Crabtree took time Monday to praise Wubbels and to describe changes that have been implemented. Crabtree also said the University of Utah’s attorneys are considering whether to take action against Salt Lake City police and Jeff Payne, the detective who arrested Wubbels. Crabtree didn’t elaborate.

“His actions were out of line,” Crabtree said of Payne. “There’s absolutely no tolerance for that kind of behavior in our hospital.”

On July 26, Payne wanted Wubbels to draw the blood of 43-year-old William Gray, who was unconscious after being involved in a fiery crash earlier in the day in Logan. Wubbels refused, citing hospital policy against drawing the blood of someone without that person’s consent or without a warrant for arrest.

Thursday, bodycam video was released of Payne shouting at Wubbels and handcuffing and arresting her on suspicion of obstruction of justice. Police released her after about 20 minutes.

The video went viral and was picked up by many national news outlets. It drew nationwide criticism last week.

Payne has been placed on leave pending an internal investigation by Salt Lake City police and the city’s Civilian Review Board. Salt Lake County’s Unified Police Department has opened a criminal investigation at the request of District Attorney Sim Gill.

Crabtree said the hospital staffers are doing everything in their power to support Wubbels in the aftermath of the arrest.

“We have a traumatized nurse and a traumatized team,” Crabtree said referring to the burn unit.

Wubbels returned to the burn unit about a week-and-a-half after the arrest, said Margaret Pearce, chief of nursing. But her schedule is flexible so that she can take as much time as she needs.

“Alex took the time she needed,” Pearce said. “We’ve been playing it by ear with her.”

Nurses will no longer interact with police, Pearce said. That will be left to hospital administrators.

“We have to make sure this never, ever happens again,” Pearce said. “I was appalled at the events of July 26. She was advocating for the rights of her patient. She did this beautifully.”

The new policy, which was implemented in mid-August, will require police to interact with the hospital supervisor. It also will prevent law enforcement officials from entering the emergency room, burn unit or other patient areas in the hospital.

Crabtree and Pearce said the new policy began to be developed within hours of Wubbels’ arrest.

“As the CEO of this hospital, I take this very seriously,” Crabtree said. “We must stand together and make sure this is what it should be, a place for healing and a place for safety.”

Wubbels and her attorney, Karra Porter, said they released the video because police were not taking the event seriously. Porter has said her client does not necessarily want to file a lawsuit, but wants changes from both the Salt Lake City police force and police and security forces at the University of Utah.

University of Utah Police Chief Dale Brophy took an apologetic tone when he said he didn’t understand the gravity of the incident until he saw the body camera video.

“My reaction changed after viewing the video,” he said. “She shouldn’t have been hauled off in handcuffs.”

Apparently following protocol, two university police or security officers stood by during the arrest. Brophy said all of his officers will get training in de-escalation techniques. It remains unclear, however, whether university police will engage Salt Lake City officers differently in the future.

Nonetheless, Crabtree said that when it comes to University Hospital and its new policy, such an incident cannot take place again.

 

Paladin to buy 2 Tenet hospitals for $170M

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http://www.beckershospitalreview.com/hospital-transactions-and-valuation/paladin-to-buy-2-tenet-hospitals-for-170m.html

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Dallas-based Tenet Healthcare will sell its two Philadelphia hospitals to El Segundo, Calif.-based Paladin Healthcare for $170 million, to help lighten its debt burden of $15 billion.

The sale will transfer ownership of Hahnemann University Hospital, St. Christopher’s Hospital for Children and other related operations in Philadelphia to American Academic Health System, a new company formed by Paladin Healthcare.

“Paladin shares [Tenet’s] commitment to providing compassionate, exemplary care and service, and we believe that entrusting the stewardship of these institutions to its affiliate AAHS will benefit the patients, employees, physicians and community for years to come,” said Mike Halter, CEO for Tenet’s Philadelphia division and CEO of Hahnemann University Hospital.

The transaction is expected to be completed in early 2018. It will need regulatory approval.

The decision to sell the two hospitals comes a day after Tenet announced it would replace longtime CEO Trevor Fetter and “refresh” the composition of its board of directors.

A Glimmer of Bipartisanship on the ACA

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http://www.commonwealthfund.org/publications/blog/2017/sep/bipartisanship-on-the-aca?omnicid=EALERT1267321&mid=henrykotula@yahoo.com

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With the eclipse of Republican efforts to repeal and replace the Affordable Care Act (ACA), bipartisan approaches to improving the law are having a moment in the sun. This week, Senators Lamar Alexander (R-Tenn.) and Patti Murray (D-Wash.) are cosponsoring hearings before the Senate Health, Education, Labor and Pensions (HELP) committee on bipartisan solutions to stabilizing private health insurance markets. The Problem-Solvers — a new caucus of House Democrats and Republicans — are similarly at work on a cross-party package of reforms. Eight governors have released a bipartisan plan, as has a group of health policy experts with mixed party affiliations.

The value of bipartisanship is indisputable. The alternative — on excruciating display over the last seven months — is ongoing partisan warfare that destabilizes our health care system. Health care providers and insurers cannot function effectively when changes in party control at the federal level threaten to upend the health care system every two to four years. And the fear of health coverage loss is unquestionably stressful for the millions of Americans who depend upon the ACA.

But the growing apparent consensus on key elements for a short-term, cross-party package is encouraging. These proposals focus on strengthening individual insurance marketplaces by legislating cost-sharing reduction payments; helping private insurers manage the risk of very high-cost patients using reinsurance and other means; creating a source of backup coverage for “bare markets” that lack private insurers; and offering states greater flexibility in implementing federal regulations governing private insurance markets.

Different groups propose additional bells and whistles, and there is much room for disagreement on how to design and implement specific provisions. But at least both parties are at the table. Where there’s a will, there may be a way.

Still, important practical questions remain. One is whether the will really exists. Republican supporters of repeal and replace continue to divide the Senate Republican caucus. Conservatives in the House — including the Freedom Caucus — will likely oppose anything that threatens their hope that the ACA will collapse of its own weight. And it is possible that President Trump, still grumbling about the failure of repeal and replace, will veto any narrow package that he believes pours salt in his health care wound.

Ironically, the failure of ACA markets to self-destruct may also sap the will for bipartisan reforms. Deadlines and crisis drive congressional action and, until recently, the threat that some individual markets — admittedly, small in number and population — would lack any insurer was an important spur for Congress to act. Now, that threat has receded as the last of the bare markets has found a carrier.  Bipartisanship is the legislative equivalent of nuclear fusion; it needs major external pressure to push those mutually repelling atoms together.

Even if there were a will, there might not be a way to get an ACA package into the queue. The fall congressional calendar is packed with other high-profile, high-stakes, deadline- and crisis- driven legislation. By September 30, Congress must reauthorize the Children’s Health Insurance Program (CHIP), which has traditionally enjoyed bipartisan support and is vital to the health care of more than 9 million American children. To respond to Hurricane Harvey, Congress also needs to rapidly enact emergency aid for Texas and Louisiana, which will require the extension of previously controversial flood relief legislation.

And these measures are just the beginning. Congress has to fund the federal government by September 30 — with or without support for the border wall — or face a government shutdown. There is the need to pass a controversial increase in the federal debt ceiling by the same date. And to have any hope of enacting major tax reform before the 2018 election, work must accelerate right after Labor Day. Putting the tax project off until after January is dangerous for proponents, because passing controversial tax legislation is infinitely more difficult in an election year.

Bipartisanship on health care action could lay vital groundwork in the short term for bolstering the individual health insurance market. Longer term, bipartisanship is essential for the kind of fundamental change that is necessary to increase coverage and contain costs in our health care system. We should not, however, underestimate the huge political and procedural obstacles that lie in the way of current admirable efforts to bring the two parties together on health care. It will take all the skill of committed Senate and House leaders from both parties to make progress on health care this year — or thereafter.