Posts Tagged ‘Medicare’

Private Eyes Slow at Detecting Medicare Fraud

Monday, August 23rd, 2010

In 2007, private eyes identified $835 million in fraudulent Medicare payments, but recovered only $55 million.  Private detectives retained by Medicare required an average of six months to refer fraud cases to law enforcement officials, according to congressional investigators. The average lag time was 178 days - and by then, many cases are so cold that catching the perpetrators is virtually impossible, as is recovering taxpayer dollars. Recently, an inspector general report had questions about the contractors who play a leading role in Medicare’s efforts to rein in fraud.  In 2007, private contractors identified $835 million in problematic Medicare payments.  The government was able to recover only about $55 million or seven percent of the total, according to the report.

Medicare overpayments - which typically range from a billing error to a brazen swindle - totaled more than $36 billion in 2009, according to the Obama administration.  That’s why President Obama has placed a high priority on fighting fraud and waste in the hope that the savings will help fund the new healthcare law.  The opposition - in the form of Senator Charles Grassley (R-IA) - questions whether taxpayers are getting a good deal from Medicare’s private eyes.  His office is reviewing Medicare data from the last four years to determine why it took so long to refer fraud cases to law enforcement officials.  According to Grassley, “Medicare is already a pay-and-chase system when it comes to fraud, waste and abuse.  Providers are paid first; then questioned if there’s a problem.  Add to that mix contractors who sit on cases of ongoing fraud when they should be referring them to law enforcement, and you have a recipe for disaster.”

Medicare retains seven private companies - collectively known as “Program Safeguard Contractors” - at work to find fraud, a program that was started in the late 1990s.  These contractors, who oversee specific areas, investigate accusations of misconduct and work with the government’s criminal investigators.

Healthcare Reform Will Save Billions for Medicare

Monday, August 16th, 2010

Healthcare reform will save Medicare $418 billion over the next 10 years.

The healthcare reform bill is expected to save Medicare $7.8 billion through 2011 and $418 billion over the next decade, according to a report released by the Centers for Medicare and Medicaid Services (CMS).  Kathleen Sebelius, Health and Human Services Secretary, said “Because we began making changes right away, the savings from Medicare add up fast.”

The CMS report focuses largely on the measures that will change how healthcare is delivered and paid, which are at the heart of the historic legislation passed by Congress in spring.  Some of the programs are designed to cut the number of hospital re-admissions, find new ways to reimburse hospitals and physicians, and target fraud and abuse.  The last is expected to save Medicare billions.

Sebelius believes that Medicare will lead the private sector in reforming how healthcare is delivered.  Jonathan Blum, deputy administrator of CMS, said “I think when you look at the history of hospital and provider payments, when large payers like the Medicare program place continued financial pressure, hospitals become more productive.”

According to CMS estimates, changed to the Medicare Advantage programs and the ways in which the agency will reimburse providers will save $145 billion and $205 billion over the next decade respectively.  The report also highlighted several changes that affect care delivery.  As an example, actions to improve quality and simplify care are expected to save more than $15 billion.

Healthcare: Saving Lives or Prolonging Suffering?

Thursday, August 12th, 2010

There is a cacophony of voices in the media talking about healthcare reform, but it’s more heat than light.  That why Atul Gawande’s most recent article in The New Yorker is so important. Boston-based Brigham and Women’s Hospital general and endocrine surgeon Gawande examines how the trend to prolonging life is one of the reasons behind soaring healthcare costs.Is healthcare saving lives or prolonging suffering?  Everyone needs to read this.

According to Dr. Gawande in Letting Go, “Twenty-five percent of all Medicare spending is for the five percent of patients who are in the final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit.  Medical spending for a breast-cancer survivor, for example, averaged an estimated $54,000 in 2003, the vast majority of it for the initial diagnostic testing, surgery, and, where necessary, radiation and chemotherapy.  For a patient with a fatal version of the disease, though, the cost curve is U-shaped, rising again toward the end - to an average of $63,000 during the last six months of life with incurable breast cancer.

The big question Gawande poses is thus:  What are we getting in return?  “Patients who were put on a mechanical ventilator,” Dr. Gawande continues, “given electrical defibrillation or chest compressions, or admitted, near death, to intensive care, had a substantially worse quality of life in their last week than those who received no such interventions.  And, six months after their death, their caregivers were three times as likely to suffer major depression.”

Dr. Gawande notes that in one study, “Researchers followed 4,493 Medicare patients with either terminal cancer or congestive heart failure.  Surprisingly, they found no difference in survival time between hospice and non-hospice patients with breast cancer, prostate cancer, and colon cancer.  Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.  The lesson seems almost Zen:  you live longer only when you stop trying to live longer.”

In one case Dr. Gawande describes, “Aetna decided to let a group of policy-holders with a life expectancy of less than one year receive hospice services without forgoing other treatments.  A patient like Sara Monopoli (who was diagnosed with terminal lung cancer at the age of 34) could continue to try chemotherapy and radiation, and go to the hospital when she wished - but also have a hospice team at home focusing on what she needed for the best possible life now and for that morning when she might wake up unable to breathe.  A two-year study of this ‘concurrent care’ program found that enrolled patients were more likely to use hospice:  the figure leaped from 26 percent to 70 percent.  That was no surprise, since they weren’t forced to give up anything.  The surprising result was that they did give up things.  They visited the emergency room almost half as often as the control patients did.  Their use of hospitals and I.C.U.s dropped by more than two-thirds.  Overall costs fell by almost a quarter.”

Andy Griffith Tapped to Sell Healthcare Reform to Senior Citizens

Tuesday, August 10th, 2010

A new sheriff in town, Andy Griffith is promoting support for healthcare reform law.  A familiar face is hitting the airwaves to promote the Obama administration’s new healthcare law to the nation’s senior citizens. The pitchman is 84-year-old Andy Griffith, a lifelong Democrat whose role as Mayberry Sheriff Andy Taylor on The Andy Griffith Show made him a lasting symbol of small-town values.  Medicare is picking up the $700,000 tab for the advertisements.

In the commercials, which are airing on The Weather Channel, CNN, Hallmark and Lifetime, Griffith assures Americans that “good things are coming” as a result of the healthcare law.  He lists free preventive checkups and lower-cost prescriptions for Medicare patients as two of the benefits.  According to some polls, senior citizens are skeptical about the healthcare law because Medicare cuts will provide a significant share of the financing to cover the uninsured.

The ads come at a time when Medicare is celebrating its 45th anniversary. In the ad’s background is a photo of President Lyndon Johnson signing the Medicare bill into law. Griffith assures senior citizens that better protections are coming, thanks to the healthcare reform law.

Providers Will Be Held to Strict Standards on Electronic Health Records

Thursday, August 5th, 2010

HHS will allow hospitals to adopt electronic health records in multiple stages.  David Blumenthal, the Obama administration’s health information technology czar, recently told a House subcommittee that providers will be held to stricter standards over the adoption and use of electronic health records (EHR).   “We have every intent in the next rule-making, in 2013, to require much more robust exchange as a feature of meaningful use,” Blumenthal, the Department of Health and Human Services (HHS) national coordinator for health IT, said while testifying before a House Ways and Means Committee’s health subcommittee.

According to Blumenthal, the meaningful-use criteria allow providers to adopt EHR in multiple stages.  Each step is increasingly demanding.  “The fact is, we are going to make substantially higher demands of providers in the future,” Blumenthal said.  Representative Wally Herger (R-CA) said “The new HIT regulations are a step in the right direction and should put Medicare on a path to improved quality and efficiency.  However, by watering down the final regulations, we have missed an opportunity to advance healthcare delivery and ensure wise use of taxpayer money.”

CMS Issues Revised Guidelines for Electronic Medical Records Adoption

Thursday, July 29th, 2010

Physicians/hospitals could receive $27 billion to use electronic medical records.  The federal government has issued revised standards for the “meaningful use” of electronic medical records that will financially reward physicians and hospitals who adopt the new technology. According to the Department of Health and Human Services, physicians and hospitals could receive as much as $27 billion over the next decade if they put patients’ medical records on computer instead of paper.  Physicians can be paid up to $44,000 under Medicare and $63,750 for Medicaid.  Depending on their size, hospitals have the potential to receive millions of dollars.  In 2015, hospitals and physicians face financial penalties under Medicare if they fail to use electronic medical records by the deadline.

Dr. Donald Berwick, the new administrator of the Centers for Medicare and Medicaid Services (CMS) said electronic medical records will lead to “better, smoother care, more reliable care.”  Department of Health and Human Services (HHS) Secretary Kathleen Sebelius said “Only 20 percent of doctors and 10 percent of hospitals use even basic electronic health records.”  Taking a slightly different perspective, Richard J. Umbdenstock, president of the American Hospital Association (AHA), said the new standards are an improvement over the rules initially proposed but was not convinced that doctors or hospitals would adopt the new technology.

Some physicians believe that using electronic medical records will reduce errors and save patients’ lives.  The new standards are flexible and require physicians to meet 15 specific requirements, as well as another five selected from a list of 10 objectives.  To fulfill the new standards, physicians will have to submit 40 percent of prescriptions electronically.  “We are delaying some of the more ambitious requirements,” said Dr. David Blumenthal, the national coordinator for health information technology.

Finding the Right Line Between Healthcare Privacy and Accessibility

Tuesday, July 27th, 2010

Privacy versus accessibility duking it out in the healthcare arena.  One of healthcare’s biggest challenges is balancing the sharing of health information with the need to assure patient privacy.  Although privacy has been assured since the implementation of the 1996 HIPAA law, the issue of patient consent is now at the forefront because the American Recovery and Reinvestment Act’s (ARRA) financial support of electronic medical records has reignited interest in data-sharing and patient privacy rights.

Providers must be able to show that they are sharing information to improve patient care to be eligible to receive subsidies to acquire electronic healthcare records-keeping technology.  Conversely, the stimulus bill modifies HIPAA and allows patients to demand that their records for a treatment or service not be shared with their insurance company if they pay the full cost directly.  Also included in the stimulus bill is a ban on selling patient data.

Federal officials believe that protecting patient privacy is critical to developing a national health information exchange that patients trust.  Doug Fridsma, acting director of the Office of the National Coordinator for Health Information Technology (ONC) said “We always put in here that privacy and security is paramount.” The government “plays an integral role in assuring trust and ensuring privacy and security of health information.”  Because the ONC has come under criticism for being insincere about privacy, the organization is now under pressure to release privacy and security policies.

According to Fridsma, “It’s going to be an iterative, incremental approach.  We have a lot of moving parts.  I’ve been trying to do as much as I can to support the work that’s been going on and to at least keep the channels of communications open.”

CBO Warns That Healthcare Reform Will Increase Federal Spending

Monday, July 26th, 2010

Reform translates to more federal healthcare spending.  The federal government’s share of dollars spent on healthcare is expected to soar from five percent of the current GDP to approximately 10 percent by 2035.  The increases are likely to continue unabated after that.  These projections are based partly on the recently passed healthcare reform legislation, which is expected to increase federal spending in the next 20 years, according to the Congressional Budget Office’s (CBO) analysis, “The Long-Term Budget Outlook”.

“The retirement of the baby boom generation portends a significant and sustained increase in the share of the population receiving benefits from Social Security, Medical and Medicaid.  Moreover, per-capita spending for healthcare is likely to continue rising faster than spending per person on other goods and services for many years,” according to the report.  The CBO predicts that these factors will increase federal spending relative to the overall economy in the future.  Only a major change in government policy will reverse this trend.  Once all provisions of the new healthcare law are implemented in 2014, there is a strong possibility that federal spending will decrease by 2030.  According to the CBO, reform could yield reduced spending over time.

Peter Orszag, director of the White House Office of Management and Budget, notes “CBO reiterates that the Affordable Care Act will reduce the deficit by more than $100 billion in the current decade and more than $1 trillion in the decade after that - which represents the most deficit reduction enacted since the 1990s.”

President Obama Sneaks Dr. Donald Berwick Past Republican Opposition to Head CMS

Wednesday, July 14th, 2010

President Obama bypasses Senate to make Dr. Donald Berwick the head of Medicare and Medicaid.  Facing a hostile approval process from Republicans in the Senate, President Barack Obama is making a recess appointment of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS), the agency that oversees Medicare and Medicaid.

A sharp critic of the way healthcare is delivered in the United States, Berwick believes the system is inefficient and lacks an efficient information-sharing apparatus.  In addition to his practice and academic work, Berwick is the founder of the Institute for Health Care Improvement, a think tank that focuses on “cultivating promising concepts for improving patient care and turning those ideas into action.”

Berwick, a Harvard-educated pediatrician and Harvard Medical School professor, believes in improving the quality of healthcare so physicians are rewarded for better outcomes rather than on a per-procedure basis.  Although it’s unlikely that this idea could be applied to the whole medical profession, Medicare and Medicaid are large enough that changing the traditional way healthcare is delivered would echo throughout medicine.  Together, Medicare and Medicaid cover 100 million Americans - approximately one-third - and accounted for $750 billion of federal spending in 2009.  According to the Congressional Budget Office, that totals 20 percent of the federal budget.

“Many Republicans in Congress have made it clear in recent weeks that they were going to stall the nomination as long as they could, solely to score political points,” according to Dan Pfeiffer, White House Communications Director.  “But with the agency facing new responsibilities to protect seniors’ care under the Affordable Care Act, there’s no time to waste with Washington game-playing.”

White House Wants to Stop Medicare, Medicaid Billing Errors and Fraud

Tuesday, June 29th, 2010

Federal government to use payment recapture audits to fight Medicare, Medicaid fraud.  President Barack Obama is expanding payment recapture audits as a means of fighting waste and abuse in government programs such as Medicare and Medicaid.  The presidential memorandum will direct federal agencies to “expand and intensify” the use of audits, such as those performed by recovery audit contractors and Medicaid integrity contractors.  The initiative will extend the scope of such audits beyond fee-for-service payments into other government contracts.  The president also will support bipartisan legislation to expand the authority of government agencies to direct recaptured funds toward audits.

The announcement follows an executive order issued by President Obama in November, 2009, that directed the government to aggressively control improper payments, which were said to equal $98 billion.  Fully $54 billion of that was attributed to Medicare and Medicaid and reflect an estimate of payments made in error, duplicate billing and even fraud.

Aimed at the political middle and designed to rally support for healthcare reform, the proposal would employ private auditors whose sophisticated computer systems can scan Medicare and Medicaid billing records for patterns of false claims.  The auditors would get to keep some of the dollars recovered.  According to the White House, a Medicare pilot program recovered approximately $900 million for taxpayer between 2005 and 2008.