Archive for the ‘Healthcare’ Category
“Best medical system in the world”: ER physicians are now independent contractors and do not accept insurance
The US developed a medical system that uses the free market to resolve problems, rather than socialistic single-payer system (as in, say, France). The US approach has some serious problems if you need to go to the ER. But probably the invisible hand of the market will fix that. /sarcasm
UPDATE: Kevin Drum has a good post on this.
Once they’ve collected your insurance premiums, health insurance companies are loathe to spend that money
Basically, insurance companies love having the money come in as premiums, but they hate paying out settlements and in general do everything in their power to stall and reduce payments. Now they have adopted a new tactic, reported by Charles Ornstein at ProPublica:
Health insurance companies are no longer allowed to turn away patients because of their pre-existing conditions or charge them more because of those conditions. But some health policy experts say insurers may be doing so in a more subtle way: by forcing people with a variety of illnesses — including Parkinson’s disease, diabetes and epilepsy — to pay more for their drugs.
Insurers have long tried to steer their members away from more expensive brand name drugs, labeling them as “non-preferred” and charging higher co-payments. But according to an editorial to be published Thursday in the American Journal of Managed Care, several prominent health plans have taken it a step further, applying that same concept even to generic drugs.
The Affordable Care Act bans insurance companies from discriminating against patients with health problems, but that hasn’t stopped them from seeking new and creative ways to shift costs to consumers. In the process, the plans effectively may be rendering a variety of ailments “non-preferred,” according to the editorial.
“It is sometimes argued that patients should have ‘skin in the game’ to motivate them to become more prudent consumers,” the editorial says. “One must ask, however, what sort of consumer behavior is encouraged when all generic medicines for particular diseases are ‘non-preferred’ and subject to higher co-pays.”
I recently wrote about the confusion I faced with my infant son’s generic asthma and allergy medication, which switched cost tiers from one month to the next. Until then, I hadn’t known that my plan charged two different prices for generic drugs. If your health insurer does not use such a structure, odds are that it will before long.
The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Servicesclaiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs.
Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending.
“It seems that the plans are trying to find this wiggle room to design their benefits to prevent people who have high health needs from enrolling,” said Wayne Turner, a staff lawyer at the National Health Law Program, which filed the complaint alongside the AIDS Institute of Tampa, Fla.
Turner said he feared a “race to the bottom,” in which plans don’t want to be seen as the most attractive for sick patients. “Plans do not want that reputation.”
In July, more than 300 patient groups, covering a range of diseases, wrote to Sylvia Mathews Burwell, the secretary of health and human services, saying they were worried that health plans were trying to skirt the spirit of the law, including how they handled co-pays for drugs.
Generics, which come to the market after a name-brand drug loses its patent protection, used to have one low price in many insurance plans, typically $5 or $10. But as their prices have increased, sometimes sharply, many insurers have split the drugs into two cost groupings, as they have long done with name-brand drugs. “Non-preferred” generic drugs have higher co-pays, though they are still cheaper than brand-name drugs.
With brand names, there’s usually at least one preferred option in each disease category. Not so for generics, the authors of the editorial found.
One of the authors, Gerry Oster, a vice president at the consulting firm Policy Analysis, said he stumbled upon the issue much as I did. He went to his pharmacy to pick up a medication he had been taking for a couple of years. The prior month it cost him $5, but this time it was $20.
As he looked into it, he came to the conclusion that this phenomenon was unknown even to health policy experts. “It’s completely stealth,” he said. . .
Obviously some laws and regulations will be needed to prevent this sort of discriminatory price.
Greg Gordon reports for McClatchy:
During a meeting that was secretly recorded, a salesman for Reliance Medical Systems promised that within a month or two of joining its illicit kickback scheme, spinal surgeons could collect enough money to pay for their kids’ college educations, Justice Department lawyers charge.
Taxpayers were the multimillion-dollar sugar daddies in this plot, initially uncovered by two doctors-turned-whistle blowers who could collect a sizable reward under a law compensating those whose tips lead to federal financial recoveries.
In May 2010, a Michigan spinal surgeon bought into one of the schemes that aimed to circumvent a federal law barring device manufacturers from making payments to induce physicians to use their products, the government alleges in two suits filed under the federal False Claims Act.
One suit charges that Dr. Aria Sabit, who now lives in Birmingham, Mich., and Sean Xie, who was studying under Sabit, each paid $5,000 to become an investor in Apex Medical Technologies, a distributorship for Southern California-based Reliance. That month, the government alleges, each got back $20,117 from Apex – a return of more than 400 percent in 30 days’ time.
That was just the beginning.
Over the next nine months, Apex paid Sabit $264,957 while he repeatedly used Reliance products for spinal fusion surgeries, some of them unnecessary – and $483,570 before he stopped using Reliance equipment, the suit said. Sabit also presumably collected handsome physician fees for his services.
Meanwhile, Community Memorial Hospital in Ventura, Calif. paid Apex $1.4 million for the cost of the implants that Sabit used in his surgeries.
The hospital, in turn, billed Medicare – and federal taxpayers – for nearly all of those devices.
A second California-based Reliance distributorship, known as Kronos Spinal Technologies, made improper payments to two other physicians, Drs. Ali Mesiwala and Gowriharan Thaiyananthan, the suit said. Kronos was based at the same Jacksonville, Fla., address as Apex, it said. One of the distributorships’ owners allegedly was recorded as saying that the scheme was formed as part of a plan to “get around” the federal Anti-Kickback Statute, it said.
In July 2011, Mesiwala was recorded as stating that there was an “expectation” that doctors who bought into the distributorships would be using Reliance equipment, the suit said. He also was quoted as saying: “If you truly are in this to make money and you have a finite time limit to do it, I don’t know a better way to do it.”
Kronos paid its investor physicians $4.9 million from August 2007 through September 2012, the government said. . .
The South is alone in having a higher proportion of adults without health insurance after Obamacare than they did before. This is thanks to the GOP state governors and legislators who went to extraordinary lengths to make sure that the poor would not have access to healthcare. As I have observed, you can usually predict GOP policy if you assume the GOP hates the poor and will do everything they can to attack and undermine the poor. In this case, it required not extending Medicare in the states (which was essentially free), refusing to set up health exchanges (Kentucky is an exception—and indeed, the number of uninsured in Kentucky dropped sharply), and refusing to inform people about benefits under the Affordable Care Act.
The above chart is from this article, which attempted to identify the remaining uninsured as of June 2014.
The simple answer is that Medicare was not reviewing its billing data and seemed to have little interest in stopping fraud. Charles Ornstein reports in ProPublica:
A few years ago, Illinois’ Medicaid program for the poor noticed some odd trends in its billings for group psychotherapy sessions.
Nursing home residents were being taken several times a week to off-site locations, and Medicaid was picking up the tab for both the services and the transportation.
And then there was this: The sessions were often being performed by obstetrician/gynecologists, oncologists and urologists — “people who didn’t have any training really in psychiatry,” Medicaid director Theresa Eagleson recalled.
So Medicaid began cracking down, and spending plummeted after new rules were implemented. In July 2012 the program stopped paying for group psychotherapy altogether for residents of nursing homes.
Yet Illinois doctors are still billing the federal Medicare program for large numbers of the same services, a ProPublica analysis of federal data shows.
Medicare paid Illinois providers for more than 290,000 group psychotherapy sessions in 2012 — more than twice as many sessions as were reimbursed to providers in New York, the state with the second-highest total.
Among the highest billers for group psychotherapy in Illinois were three ob/gyns and a thoracic surgeon. The four combined for 37,864 sessions that year, more than the total for all providers in the state of California. They were reimbursed more than $730,000 by Medicare in 2012 just for psychotherapy sessions, according to an analysis of a separate Medicare data set released in April.
“That’s not good,” Eagleson said when told of the Medicare numbers.
Medicare’s recent data release has led to a string of analyses showing how waste and fraud is inflating the nation’s bill for health care. This work has echoed the findings of ProPublica’s investigation last year into Medicare’s prescription drug program known as Part D, which had fewer barriers to waste and fraud than other government health care programs – and was making less effective use of its own data.
Of the Illinois ob/gyns billing for group psychotherapy, . . .
Some of these physicians should face criminal charges for fraud and also lose their license to practice medicine.