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Insurance official to Congress: ObamaCare not collapsing

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Insurance official to Congress: ObamaCare not collapsing

Insurance official to Congress: ObamaCare not collapsing

A Pennsylvania insurance official told Congress Wednesday that ObamaCare is not collapsing, as some Republicans have argued.

Speaking at a Senate Health Committee hearing on efforts to stabilize Affordable Care Act (ACA) markets, Teresa Miller, Pennsylvania’s acting Human Services secretary and former insurance commissioner, said that the notion is “just false.”

“I’m not going to sit here this morning and tell you that the ACA is perfect,” she said. “I think we all know that it’s not, but the narrative that the ACA is failing and imploding is just false.”

Miller, who works in the administration of Democratic Gov. Tom Wolf, noted that insurers in the state filed average premium increases of just 8.8 percent for next year, and that most enrollees receive government subsidies to help them afford premium costs.

While there have been “difficulties” in the market, she said, “our individual market is not collapsing.”

Other states have encountered more problems with their markets, but every state is on track to have at least one insurer offering ObamaCare coverage in every county next year, after some worries that there would be empty counties.

The insurance commissioners testifying largely called for efforts to further stabilize ObamaCare markets, for example by funding key payments known as cost-sharing reductions, which President Trump has threatened to cancel.

Multiple commissioners also called for a program called reinsurance that provides government funding to bring down premiums by paying for part of especially sick enrollees’ claims.

The Senate Health Committee is trying to reach a deal on a bipartisan stabilization bill by the end of next week, a tough task on such a polarizing issue.

Anthem Now Requiring Pre-approval for Hospital MRIs, CT Scans

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http://www.healthleadersmedia.com/finance/anthem-now-requiring-pre-approval-hospital-mris-ct-scans?spMailingID=11861186&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1240498373&spReportId=MTI0MDQ5ODM3MwS2

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The insurer no longer allows outpatient imaging in hospitals. Hospitals may feel the financial loss.

In a bid to cut costs, Anthem is now informing consumers that it must pre-approve any hospital-based MRIs and CT-scans, and that approval won’t come easily.

The insurer’s new policy forbids hospital imaging services on an outpatient basis and requires proof that inpatient imaging is medically necessary.

The Anthem change in policy is likely to be a financial blow to hospitals, which have seen outpatient imaging as a profit center in recent years.

Anthem announced recently that outpatient MRIs and CT scans must be performed at lower-priced facilities, citing its commitment to the Institute for Healthcare Improvement (IHI) Triple Aim Initiative, which calls for improving the patient experience, improving population health, and reducing costs.

The insurer says clinical research has shown the safety of imaging services in free-standing facilities, so the additional cost of a hospital setting is unnecessary.

“Anthem’s primary concern is to provide access to quality and safe healthcare for our members. We are also committed to reducing overall medical cost where possible when the safety of the member is not put at risk,” the company says.

Anthem notes that imaging costs can vary widely without any effect on quality of care, with scans costing as little as $350 and as much as $2,000.

The company also notified providers of the change in policy, explaining that physicians must obtain pre-certification approval for inpatient hospital imaging. Anthem told consumers that it will provide assistance in finding imaging facilities other than hospitals.

The change in policy could reduce a member’s out-of-pocket costs, Anthem notes.

“If the member has a benefit plan where he or she pays a percentage of the cost, it is possible that his or her percentage of out-of-pocket cost may be reduced,” Anthem says. “This is because the cost to undergo a CT or MRI scan administered in a freestanding imaging facility may be less than what a hospital-based facility would charge. If the member has a facility copay, there may not be a reduction in a member’s out of pocket cost.”

However, the policy still stands even if using a freestanding facility would not reduce the consumer’s out-of-pocket cost, the insurer explains. The approval or denial of the site of service is based only on medical necessity.

In the unlikely event that the physician ignores the policy and the patient receives imaging services in a hospital outpatient setting, the hospital would be responsible for the cost, Anthem says. The patient would not be held responsible unless he or she signed a statement acknowledging the deviation from Anthem policy and agreed to be financially responsible.

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.