Tag Archives: Medicaid

Healthcare CEO faces life in prison for fraud that led to 2 patient deaths

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http://www.beckershospitalreview.com/legal-regulatory-issues/healthcare-ceo-faces-life-in-prison-for-fraud-that-led-to-2-patient-deaths.html

Fraud

The CEO and co-owner of a Maryland diagnostics company is facing life in prison after a federal jury convicted him of two counts of healthcare fraud that resulted in death, according to the Department of Justice.

On Wednesday, a federal jury found 67-year-old Rafael Chikvashvili, PhD, guilty of healthcare fraud. Dr. Chikvashvili was the co-owner and CEO of Owings Mills, Md.-based Alpha Diagnostics, which was a portable diagnostic services provider, principally of X-rays.

According to evidence presented at trial, Dr. Chikvashvili was involved in a scheme to defraud Medicare and Medicaid. He and others allegedly conspired to create false radiology, ultrasound and cardiologic interpretation reports. He also allegedly submitted insurance claims for medical examination interpretations that were never completed by licensed physicians, according to the DOJ.

Dr. Chikvashvili allegedly instructed his nonphysician employees to interpret X-rays, ultrasounds and cardiologic examinations, which, according to testimony provided at trial, resulted in two patient deaths.

Where’s the value in accountable care?

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Where’s the value in accountable care?

From left: Stephanie Baum of MedCity News, Christina Miles of Aon Hewitt, David Van Houtte of Aetna, Dr. Katherine Schneider of Delaware Valley ACO and Dr. Greg Carroll of GOHealth Urgent Care

Accountable care is supposed to be about paying for value. But six years after passage of the Affordable Care Act heralded the shift away from fee-for-service, Dr. Greg Carroll, corporate clinical leader of GOHealth Urgent Care, has an important question: “Where’s the value?”

Healthcare spending will make up 20% of U.S. economy within a decade

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http://www.fiercehealthcare.com/finance/healthcare-spending-will-make-up-20-u-s-economy-within-a-decade?utm_medium=nl&utm_source=internal&mrkid=959610&mkt_tok=eyJpIjoiTXpVMk1HRm1NRE5pWW1JMSIsInQiOiIrM3BwTVBRRXorTzl3NjQxOWNPOUh1UUxUT0ZcL2xNTGdleWQzKzRFRzIwZzhHYTg2T0c3TWlZV1BjUEsxd0JBRmNJaGk0WU9NMTRvWmFyZndPVit2SzZmUDFxM1dWSm1OV2l4Rnd1YlBMWTQ9In0%3D

Bar graph with arrow showing upward growth

Healthcare spending will comprise 20 percent of the U.S. economy by the middle of next decade, according to new data from the Office of the Actuary of the Centers for Medicare & Medicaid Services and published in Health Affairs.

Expenditures on healthcare services will grow at an average rate of 5.8 percent per year between 2015 and 2025, about 1.3 percent higher than projected annual growth in the U.S. gross domestic product, CMS concluded. By 2025, healthcare spending will comprise 20.1 percent of the U.S. economy, up from 17.5 percent in 2014. Expenditures totaled $3.2 trillion last year.

Despite the seemingly robust spending growth, it remains lower than the 8 percent annual growth clip that occurred in the two decades before the Great Recession of 2008, which helped to slow expenditures significantly. In 2015, spending grew at a 5.5 percent rate. This year, it is projected to be 4.8 percent, attributable in part to the slower expansion of newly insured under the Affordable Care Act.

“The Affordable Care Act continues to help keep overall health spending growth at a modest level and at a lower growth rate than the previous two decades. This progress is occurring while also helping more Americans get coverage, often for the first time,” said CMS Acting Administrator Andy Slavitt in a statement.

Drop in Percentage of Physicians Participating in Medi-Cal Raises Red Flags

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http://www.chcf.org/aca-411/insights/physician-participation?_cldee=aGVucnlrb3R1bGFAeWFob28uY29t

Physician Participation in Medi-Cal from 2013 to 2015

The share of physicians accepting new Medi-Cal patients is an indicator of the program’s capacity to meet demand. If a decreasing share of participating physicians are willing or able to take new Medi-Cal patients, beneficiaries in the program may have trouble getting the care they need. The proportion of physicians accepting new Medi-Cal patients has historically lagged behind the proportion accepting new patients covered by Medicare, which has a higher reimbursement rate, as well as behind the proportion accepting new patients with private health insurance.

New 2015 data now available on ACA 411 show the percentage of physicians participating in Medi-Cal has declined since 2013 — during the same period Medi-Cal enrollment skyrocketed by 39%. This raises serious concerns about whether the supply of physicians participating in Medi-Cal can meet the increased demand.

Physicians’ willingness to treat Medi-Cal beneficiaries is critical to ensuring Medi-Cal enrollees have adequate access to care. Without a sufficient number of doctors serving Medi-Cal beneficiaries, Medi-Cal enrollees may not be able to receive care in a timely manner. Beneficiaries may delay seeking needed care with disastrous effects or may end up receiving care in more costly settings.

 

Balancing the Books: How Affordable Is Health Insurance Through Covered California When Local Cost of Living Is Taken Into Account?

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Click to access PDF%20BalancingAffordableCoveredCa.pdf

http://www.chcf.org/publications/2016/06/balancing-affordable-covered-ca?_cldee=aGVucnlrb3R1bGFAeWFob28uY29t

Subsidies offered through the health insurance marketplaces established under the Affordable Care Act (ACA) have reduced the cost of health insurance for millions of Californians. Subsidy amounts, however, are set nationally and do not take into account the local cost of living, which varies dramatically across the state.

Even with the help of subsidies, many Californians struggle to afford coverage through Covered California, the state’s health insurance marketplace, especially those living in areas where a high cost of living already strains household budgets.

In this analysis, researchers identified an affordability threshold — the minimum amount a typical household would need to earn to have sufficient funds to cover their basic needs and Covered California premiums and out-of-pocket costs after federal subsidies.

The affordability threshold varied widely by county, mostly due to the local cost of living, but in every county it fell above the maximum income to qualify for Medi-Cal as an adult (138% of the federal poverty level or $33,543 for a family of four or $16,395 for one person). This suggests that in every California county, there are families and individuals — specifically those earning above 138% of FPL and below the local affordability threshold — who are falling into an affordability gap. They earn too much for Medi-Cal but not enough to afford health insurance through Covered California, even with subsidies.

 

13 recent healthcare industry lawsuits, settlements

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http://www.beckershospitalreview.com/legal-regulatory-issues/13-recent-healthcare-industry-lawsuits-settlements-july8.html

Money and Scale

Medicaid plans can now pay mental health institutions. Most won’t until 2017

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http://www.modernhealthcare.com/article/20160705/NEWS/160639991

A policy that lifts a 50-year ban on Medicaid pay for mental health institutions kicked in Tuesday, but it may be months before many enrollees can take advantage of the new coverage

Since the creation of Medicaid in 1965, the program has excluded payment for institutions of mental disease (IMDs) for beneficiaries 21 and over. Most residential treatment facilities for mental health and substance-use disorders with more than 16 beds did not qualify for Medicaid reimbursement.

Medicaid Expansion: Driving Innovation In Behavioral Health Integration

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http://healthaffairs.org/blog/2016/07/05/medicaid-expansion-driving-innovation-in-behavioral-health-integration/

Blog_DoctorPatientConvo

Safety-net providers in states that have accepted the federal funding available for Medicaid expansion under the Affordable Care Act (ACA) are experiencing a positive ripple effect, where increased insurance coverage rates among patients and thus greater financial security for safety-net institutions are translating into better care. We found that safety-net providers in states that expand Medicaid are delivering more services and better-coordinated care than what is available in states rejecting the expansion.

Of particular interest is the effect of Medicaid expansion on attempts to integrate behavioral health services with primary health care — long a thorny issue for safety-net providers. Research has shown that the Affordable Care Act (ACA) has increased access to behavioral health services. We present case studies from two provider systems that illustrate some of the innovative approaches that are improving the quality of behavioral health care at safety-net institutions.

The Fundamentally Different Goals of the Affordable Care Act and Republican ‘Replacement’ Plans

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http://blogs.wsj.com/washwire/2016/06/07/the-fundamentally-different-goals-of-the-affordable-care-act-and-republican-replacement-plans/?utm_campaign=KFF-2016-June-Drew-ACA-GOP-alternatives&utm_medium=email&_hsenc=p2ANqtz-9Uqf60gdSQ_FC57uSLNkYvFicHfqEALEVvadSgR8xY01bL5QFOrYsCgcl6KB_N5PVHy5G8fwynf8MEywb7m1kUxPljFQ&_hsmi=30331935&utm_content=30331935&utm_source=hs_email&hsCtaTracking=7825060e-e865-4738-ba5a-68a31a8904b6%7C192993c0-5763-4c2a-b289-c32fd7a5274a

Rep. Pete Sessions and Sen. Bill Cassidy introduced legislation last month calling for replacing elements of the Affordable Care Act. A House task force established by SpeakerPaul Ryan is expected to follow with more health-care proposals. These Republican health plans are generally referred to as “replacements” for the ACA–in the spirit of “repeal and replace”–as though they would accomplish the same objectives in ways that conservatives prefer. But the proposals are better understood as alternatives with very different goals, trade-offs, and consequences. Whether they are “better” or “worse” depends on your perspective.

To boil down to the most basic differences: The central focus of the Affordable Care Act is expanding coverage and strengthening consumer protections in the health insurance marketplace through government regulation. By contrast, the primary objective of Republican plans is to try to reduce health-care spending by giving people incentives to purchase less costly insurance with more “skin in the game,” with the expectation that they will become more prudent consumers of health services. They also aim to reduce federal spending on Medicare and Medicaid and the federal government’s role in both programs. Elements of the ACA were designed to reduce costs, such as the law’s Medicare payment reforms, and elements of Republican plans such as tax credits aim to expand access to insurance, but the primary aims of the ACA and the Republican plans differ.