Archive for the ‘Healthcare’ Category
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.
They continue walking the earth even after they have been completely exposed as counterfactual. As Maher says:
What they do is they pass a zombie lie down to dumber and dumber people, who believe it more and more.
Hank Paulson may be over the one about climate change being a hoax, but it’s still good enough for Sean Hannity. Who then gets quoted by Michele Bachmann. Who forms the intellectual core of the thinking of Victoria Jackson. And when you think the zombie lie has finally gone to die at the idea hospice of the absolutely stupidest people on Earth, there it is being retweeted by Donald Trump.
But that’s just the summation of a very good rant about all the zombie lies about Obamacare. Maher goes through the list—lies that have been solidly refuted but never acknowledged by the GOP, which simply moves on to the next round of lies, leaving their litter of lies to blow around and soil our daily lives.
The eruption of the VA scandals showed clearly that the government does a poor job of investigating its programs. And now Medicare has been found to simply accept large-scale fraud, seemingly making no effort whatsoever to detect and punish fraud—until newspapers write stories about it. Charles Ornstein has an infuriating article in ProPublica:
The fraud scheme began to unravel last fall, with the discovery of a misdirected stack of bogus prescriptions — and a suspicious spike in Medicare drug spending tied to a doctor in Key Biscayne, Fla.
Now it’s led to two guilty pleas, as well as an ongoing criminal case against a pharmacy owner.
Last year, ProPublica chronicled how lax oversight had led to rampant waste and fraud in Medicare’s prescription drug program, known as Part D. As part of that series, we wrote about Dr. Carmen Ortiz-Butcher, a kidney specialist whose Part D prescriptions soared from $282,000 in 2010 to $4 million the following year. The value of her prescriptions rose to nearly $5 million in 2012, the most recent year available.
But no one in Medicare bothered to ask her about the seemingly huge change in her practice, Ortiz-Butcher’s attorney said. She stumbled across a sign of trouble last September, after asking a staffer to mail a fanny pack to her brother. But instead of receiving the pack, he received a package of prescriptions purportedly signed by the doctor, lawyer Robert Mayer said last year. Ortiz-Butcher immediately alerted authorities.
Since then, investigators have uncovered a web of interrelated scams that, together, cost the federal government up to $7 million, documents show.
In February, the U.S. Attorney’s office for the Southern District of Florida charged Maria De Armas Suero, who had been a secretary at Ortiz-Butcher’s Island Clinic from March 2011 to September 2013, with 11 counts of conspiracy, fraud and aggravated identity theft.
Suero subsequently agreed to plead guilty to two counts of conspiracy and identity theft. In a recounting of her wrongdoing, called a factual proffer, she acknowledged using Ortiz-Butcher’s paper prescriptions to “create fraudulent scripts for numerous Medicare beneficiaries…The prescriptions falsely represented that the Medicare beneficiary was seen by [Ortiz-Butcher] and that the listed prescriptions were medically necessary.”
Suero acknowledged that she was paid $100 for each prescription she generated. . .
Paul Krugman has a good blog post with links to graphs and stats about Obamacare. From one of his links:
In the NY Times Adam Liptak points out the Catholic old boys on the Supreme Court have now expanded significantly the restricted Hobby Lobby ruling. That didn’t take long, did it?
In a decision that drew an unusually fierce dissent from the three female justices, the Supreme Court sided Thursday with religiously affiliated nonprofit groups in a clash between religious freedom and women’s rights.
The decision temporarily bars the government from enforcing against a Christian college part of the regulations that provide contraception coverage under the Affordable Care Act.
The court’s order was brief, provisional and unsigned, but it drew a furious reaction from the three female justices — Justices Sonia Sotomayor, Ruth Bader Ginsburg and Elena Kagan — who said the court had betrayed a promise it made on Monday in Burwell v. Hobby Lobby Stores, which involved for-profit corporations.
“Those who are bound by our decisions usually believe they can take us at our word,” the dissent, written by Justice Sotomayor, said. “Not so today.”
At issue in the order, involving Wheaton College in Illinois, are federal forms that groups must fill out and send to their insurers and plan administrators as an alternate way to deliver free contraception to be offered to female workers under the Affordable Care Act.
Monday’s majority opinion in the Hobby Lobby case, written by Justice Samuel A. Alito Jr., seemed to suggest that the accommodation in which the forms played a role was an acceptable alternative to having employers pay for the coverage. He referred to it when he said the government already “has at its disposal an approach that is less restrictive than requiring employers to fund contraception methods that violate their religious beliefs.”
The difference between a form sent to insurance companies and plan administrators on the one hand and a letter sent to the government on the other mattered, the college told the justices, “because it believes, as a religious matter, that signing the form would be impermissibly facilitating abortions and therefore forbidden,” the brief said.
Monday’s “Hobby Lobby” decision was just the latest challenge to the Affordable Care Act. Details on the 5-4 decision and other challenges that could — if successful — have even deeper implications.
Video Credit By Carrie Halperin on Publish Date June 30, 2014. Image CreditDoug Mills/The New York Times
“To be sure, free citizens in a diverse nation will have different views about whether signing the form makes someone complicit,” the college’s brief said. “But that is a question of ‘religious and moral philosophy’ for Wheaton,” not the government. The quoted phrase came from the Hobby Lobby decision.
The court’s majority said Wheaton College need not fill out the forms. Instead, the order said, the college could just notify the government in writing. The government, it said, remains free “to facilitate the provision of full contraceptive coverage.” . . .
Once more we see expectations contradicted by experience. Paul Krugman notes in his blog:
For reference: I count at least six distinct predictions of Obamacare doom made by the usual suspects, not one of which has come true. Here they are:
1. Enrollment will be very low, and
2. Even if people sign up, they won’t pay their premiums.
Reality: Signups exceeded expectations, and the vast majority paid.
3. More people will lose coverage cancelled by Obamacare than gain it.
Reality: Sharp drop in the number of uninsured.
4. Rate shock.
Reality: Like it says, affordable care.
5. Young people not signing up, and death spiral.
Reality: Pretty good demographics.
Reality: Health costs are below anyone’s expectations.
It’s quite an impressive track record, actually. And what’s even more impressive is that none of the usual suspects will even consider admitting having been wrong.
Krugman has a good column today in the NY Times. From the column:
The goings-on at Veterans Affairs shouldn’t cause us to lose sight of a much bigger scandal: the almost surreal inefficiency and injustice of the American health care system as a whole. And it’s important to understand that the Veterans Affairs scandal, while real, is being hyped out of proportion by people whose real goal is to block reform of the larger system.
The essential, undeniable fact about American health care is how incredibly expensive it is — twice as costly per capita as the French system, two-and-a-half times as expensive as the British system. You might expect all that money to buy results, but the United States actually ranks low on basic measures of performance; we have low life expectancy and high infant mortality, and despite all that spending many people can’t get health care when they need it. What’s more, Americans seem to realize that they’re getting a bad deal: Surveys show a much smaller percentage of the population satisfied with the health system in America than in other countries.
And, in America, medical costs often cause financial distress to an extent that doesn’t happen in any other advanced nation.
How and why does health care in the United States manage to perform so badly? There have been many studies of the issue, identifying factors that range from high administrative costs, to high drug prices, to excessive testing. The details are fairly complicated, but if you had to identify a common theme behind America’s poor performance, it would be that we suffer from an excess of money-driven medicine. Vast amounts of costly paperwork are generated by for-profit insurers always looking for ways to deny payment; high spending on procedures of dubious medical efficacy is driven by the efforts of for-profit hospitals and providers to generate more revenue; high drug costs are driven by pharmaceutical companies who spend more on advertising and marketing than they do on research.
Other advanced countries don’t suffer from comparable problems because private gain is less of an issue. Outside the U.S., the government generally provides health insurance directly, or ensures that it’s available from tightly regulated nonprofit insurers; often, many hospitals are publicly owned, and many doctors are public employees.
As you might guess, conservatives don’t like the observation that American health care performs worse than other countries’ systems because it relies too much on the private sector and the profit motive. So whenever someone points out the obvious, there is a chorus of denial, of attempts to claim that America does, too, offer better care. It turns out, however, that such claims invariably end up relying on zombie arguments — that is, arguments that have been proved wrong, should be dead, but keep shambling along because they serve a political purpose.
The chart above, showing the US in its usual dead-last position for healthcare among developed countries, is from this report by The Commonwealth Fund. The first paragraph of the executive summary:
The United States health care system is the most expensive in the world, but this report and prior editions consistently show the U.S. underperforms relative to other countries on most dimensions of performance. Among the 11 nations studied in this report—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2010, 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last or near last on dimensions of access, efficiency, and equity. In this edition of Mirror, Mirror, the United Kingdom ranks first, followed closely by Switzerland (Exhibit ES-1).
Emphasis added. It’s too bad that Congress cannot get its act together to improve our national healthcare system. There’s much that needs to be done.
The report is well worth reading, and Lenny Bernstein has an article on it in the Washington Post:
A report released Monday by a respected think tank ranks the United States dead last in the quality of its health-care system when compared with 10 other western, industrialized nations, the same spot it occupied in four previous studies by the same organization. Not only did the U.S. fail to move up between 2004 and 2014 — as other nations did with concerted effort and significant reforms — it also has maintained this dubious distinction while spending far more per capita ($8,508) on health care than Norway ($5,669), which has the second most expensive system.
“Although the U.S. spends more on health care than any other country and has the highest proportion of specialist physicians, survey findings indicate that from the patients’ perspective, and based on outcome indicators, the performance of American health care is severely lacking,” the Commonwealth Fund, a New York-based foundation that promotes improved health care, concluded in its extensive analysis. The charts in this post are from the report.
The data for the 2014 report was collected before the Affordable Care Act (aka Obamacare) went into full effect, so that reform may eventually boost the U.S. out of last place by providing health insurance to some of the 50 million people who lacked it. But, according to the study, the problems of our health-care system remain so pervasive that it will take more than better access and equity to resolve them.
Karen Davis, a professor in the Bloomberg School of Public Health at Johns Hopkins University and lead author of the study, said overall improvement “is a matter of accountability, having information on your performance relative to your peers and being held accountable to achieving a kind of care that patients should expect to get.” . . .
This is why government is so important: the government is not profit-oriented, so it can provide products and services without those having to generate (ever-growing) profits, unlike private capitalism industry. Capitalism is no doubt good for some things, but it’s hardly a universal solution. (A moment of silence to allow Libertarians to catch their breath.)
Here’s an excellent example, in a Gizmodo article by Robert Sorokanich:
In the Soviet Union, western antibiotics couldn’t make it past the Iron Curtain. So Eastern Bloc doctors figured out how to use viruses to kill infectious bacteria. Now, with antibiotic-resistant bugs vexing doctors, that eerie yet effective method might come our way. In post-antibiotic world, infection cures you!
The technique actually dates back thousands of years, in a very rudimentary form: people observed that the water from certain rivers could cure infectious diseases like leprosy and cholera. In the early 20th century, scientists figured out that these waters contained very specific types of viruses, which killed the bacteria that caused the infections. No bacteria, no infection.
You already know this from high school biology (of course), but a virus works by injecting its DNA into a living cell, hijacking the cell’s replication machinery to make more viruses. When the cell can’t hold all those replicated viruses any more, it explodes, releasing the baby viruses to continue the cycle again—and of course, killing the cell.
Bacteriophages are a type of virus that targets, you guessed it, bacterial cells. Starting in the 1920s, scientists in both the U.S. and Georgia (the country, not the Peach State) began purifying bacteriophages and using them to treat bacterial infections. But right around WWII, western medicine latched on to the miraculous power of antibiotics, leaving the Soviet Union to perfect what’s now called “phage therapy.”
(Tip: pronounce “phage” to rhyme with “rage.” Or rhyme it with “lodge” if you’re fancy.)
Fast forward to today. Western medicine’s (over)reliance on antibiotics has led to the evolution of new superbugs that can resist even our most powerful bacteria killers. And as Nature reports, that’s got researchers looking into phage therapy:
In March, the US National Institute of Allergy and Infectious Diseases listed phage therapy as one of seven prongs in its plan to combat antibiotic resistance. And at the American Society for Microbiology (ASM) meeting in Boston last month, Grégory Resch of the University of Lausanne in Switzerland presented plans for Phagoburn: the first large, multi-centre clinical trial of phage therapy for human infections, funded by the European Commission.
And there are some serious benefits to phage therapy. While antibiotics work indiscriminately, killing both the disease causing bacteria and the healthy, necessary bacterial bystanders, each type of phage is precisely targeted to one very specific type of bacteria.
The downside is . . .
And the key paragraphs on how capitalism fails for this beneficial treatment:
There are, of course, drawbacks. Isolating, purifying, and storing phages is a much more finicky and time-consuming process than producing traditional antibiotics. And then there’s the most practical of concerns: money. Since phages occur naturally, and their therapeutic use is nearly a century old, it would be incredibly difficult for a drug company to patent a phage therapy cocktail as intellectual property.
Indeed, the U.S. Supreme Court ruled last year that naturally-occurring genes cannot be patented, a law which would likely extend to phages. Like it or not, pharmaceutical companies are unlikely to invest in a therapy when they cannot ensure they’ll make that money back with a patent-protected product that can’t be copied by the competition.
Emphasis added. One can readily understand why companies will not invest in offering treatments that can cure millions if they cannot guard against competition. Despite the name “free private enterprise,” most companies detest free private enterprise, because it leads to competition, which can cut profits. Thus “free private enterprise” turns to the government in order to secure protection against competition by, for example, getting the government to issue patents. (Capitalists rely on government a lot, despite their protestations to the contrary.)
In the case of these therapies, there is clearly a role for the government to develop and produce the phages, since (a) private enterprise will not, and (b) phages are desirable for the general public welfare.
I don’t think government production of phages will happen in the US, however. Corporations and oligarchs have enough control of the government to kill anything that might threaten their profits, regardless of the benefits to the public. Note that the countries that use this (highly effective) therapy are Poland, Russia, and Georgia, all of which are accustomed to a more vigorous government role that the US lately will allow.
This is quite similar to the strong resistance pharmaceutical companies have shown about using marijuana as a treatment for various disorders (epilepsy, MS, PTSD, and so on): although marijuana usage has been demonstrated to be an effective therapy, there’s no money to be made from it—anyone can grow marijuana plants. So Big Pharma really does not want this sort of treatment around because it deprives them of an income stream from selling expensive meds for the same ailments. (Interestingly, Big Pharma also does not allow the government to compare effectiveness of new medications: new medications have to shown to be better than a placebo, but they do not have to be shown to be better than current medications already on the market.)
Bribery and corruption are so much a part of US politics now that they are conducted in the open. Here’s an article by Jim Newell in Salon giving context for the latest example:
Since late 2009, it’s been an untouchable article of faith among Republicans that the Affordable Care Act was passed under such murky, corrupt circumstances that the law itself will never be fully legitimate and wasn’t passed in good faith. Indeed, there was some horse-trading in Congress in order to enact the law. And the most infamous of those side-deals with Democratic senators was the “Cornhusker Kickback.”
Nebraska Sen. Ben Nelson was one of the most difficult holdouts for majority leader Harry Reid in late December 2009, as the Senate was trying to pass the ACA. Nelson was demanding, especially over language regarding federal funding for abortion. Even after a deal was cut on that, he needed something else. And so he got it: a carve-out in the Senate legislation in which the government promised to cover 100% of Nebraska’s Medicaid expansion. In other states, the deal was that the government would cover 100% of the costs for the first few years of implementation and then gradually reduce its commitment to 90%. (Still a good deal!) This secured Nelson’s vote, and the Senate was able to break a Republican filibuster and pass the ACA on Christmas Eve.
The backlash against the “Cornhusker Kickback” — the term of art coined by a proud Senate minority leader Mitch McConnell – was swift. Republicans wielded it as an objection to the ACA as a whole. And Democratic members and governors from other states were upset that they’d be receiving fewer dollars from the federal government than Nebraska. The deal backfired on Nelson, too, who wasn’t greeted so much as a hero at home for his masterful negotiations so much as he was heckled at local pizza parlors for being terrible and corrupt.
That’s why the “Cornhusker Kickback” never made it past the final hurdle into law. After the House passed the Senate bill in March 2010, the Senate passed a package of “fixes” including the removal of the “Cornhusker Kickback.” Even though the provision was eliminated in the end, however, “Cornhusker Kickback” has still served as an opponents’ rallying cry against the law, and the Medicaid expansion, ever since.
But it appears that corruption surrounding the Medicaid expansion is coming full circle. Because for whatever deals the Democrats made (and then later eliminated) to secure the Medicaid expansion, you should see what the other side’s up to now to ensure it’s never implemented.
One of the country’s hottest state legislative battles is in Virginia, where new Gov. Terry McAuliffe is trying to fulfill a campaign pledge to expand Medicaid and bring coverage to a supposed 400,000 eligible citizens. He’s being met with stiff Republican opposition. If an agreement can’t be worked out and a budget deal isn’t cut by July 1, the state government will shut down. Key to McAuliffe and the Democrats’ plans was control of the state Senate, which is split 20-20 but controlled by Democrats since there’s a Democratic lieutenant governor.
But McAuliffe’s plan has suddenly, and shockingly, taken a turn for the worse. As the Washington Post reports, Republicans are poised to take control of the state Senate now through an act of quid pro quo corruption so brazen it would even make John Roberts blush: . .
And here is Laura Vozella’s story in the Washington Post:
Republicans appear to have outmaneuvered Gov. Terry McAuliffe in a state budget standoff by persuading a Democratic senator to resign his seat, at least temporarily giving the GOP control of the chamber and possibly dooming the governor’s push to expand Medicaid under the Affordable Care Act.
Sen. Phillip P. Puckett (D-Russell) will announce his resignation Monday, effective immediately, paving the way to appoint his daughter to a judgeship and Puckett to the job of deputy director of the state tobacco commission, three people familiar with the plan said Sunday. They spoke on the condition of anonymity because they were not authorized to discuss the matter.
The news prompted outrage among Democrats — and accusations that Republicans were trying to buy the Senate with job offers in order to thwart McAuliffe’s proposal to expand health coverage to 400,000 low-income Virginians.
Del. Scott A. Surovell (D-Fairfax) said Republicans were unable to win the policy argument about Medicaid expansion, so they have resorted to other means.
“It’s astounding to me. The House Republican caucus will do anything and everything to prevent low-income Virginians from getting health care. . . . They figure the only way they could win was to give a job to a state senator,” Surovell said. “At least they can’t offer Terry McAuliffe a job. I hope Terry continues to stand up to these bullies.”
Puckett, a senator since 1998, did not respond to calls seeking comment. Other Republicans denied that Puckett was offered the jobs in exchange for his resignation.
This story in the Austin-American is why I have so little patience with those who (like Obama) said that Edward Snowden should have gone through channels. Going through channels is designed to forestall bad information getting out. I am astonished that President Obama is unaware of this, but that does explain why he seems so out of touch. (Cf. Healthcare.gov rollout: they went through channels.) Jeremy Schwartz writes:
Brian Turner, a Department of Veterans Affairs employee who reported fraudulent scheduling practices in Austin and San Antonio, said Friday that VA officials attempted to stop him from speaking publicly, pinned blame on low-level scheduling clerks and conspired to cover up his allegations by falsely telling the media he had recanted.
Turner’s claims, first reported by the American-Statesman on May 6, quickly led to calls for investigations and were a key part of a wave of allegations that ultimately led to Friday’s resignation of VA Secretary Eric Shinseki.
Yet on a day when President Barack Obama called for a change in the culture within the VA, Turner detailed how San Antonio VA officials tried to discredit his allegations and intimidate him into silence.
According to a letter obtained exclusively by the American-Statesman, sent Friday by Turner’s attorney Eric Pines to the House Committee on Veterans Affairs, the problems began soon after he began reporting scheduling manipulation to his superiors in late April.
According to Turner, who works at San Antonio’s North Central Federal Clinic, scheduling clerks in Austin, San Antonio and Waco were regularly told to enter false scheduling information to make it appear that wait times for appointments were far shorter than they really were. In one scheme, he said, schedulers were told to “zero out” wait times by using the actual appointment date instead of the date requested by veterans or doctors.
On April 25, Turner says he was ordered by Marie Weldon, director of the South Texas Veterans Health Care System, through an intermediary to stop emailing or asking about VA scheduling practices.
On May 2, Turner says that Zachary Selover, chief of medical administrative service for the San Antonio VA, convened an unannounced meeting of scheduling clerks. “Mr. Selover forcefully placed pressure on the clerks to take responsibility for the VA’s improper scheduling practices, while claiming that he and other supervisors were unaware of the fraudulent practices,” the letter reads. When challenged by Turner, “Selover began yelling and screaming at Mr. Turner, causing him to incur an anxiety attack.” . . .
GOP members of Congress are, no surprise, that it’s not their fault for cutting funding for the VA. I imagine they were chanting, “Do more with less. Think outside the box. Work smarter not harder—oh, hell, work harder, too.” and so on.
Kevin Drum offers some good insights in the source of the problems and why they showed up in Phoenix first.
Once an organization goes bad, it becomes extremely difficult to eradicate the bad culture. In the VA, the corruption runs deep. David A. Fahrenthold writes in the Washington Post:
About two years ago, Brian Turner took a job as a scheduling clerk at a Veterans Affairs health clinic in Austin. A few weeks later, he said, a supervisor came by to instruct him how to cook the books.
“The first time I heard it was actually at my desk. They said, ‘You gotta zero out the date. The wait time has to be zeroed out,’ ” Turner recalled in a phone interview. He said “zeroing out” was a trick to fool the VA’s own accountability system, which the bosses up in Washington used to monitor how long patients waited to see the doctor.
This is how it worked: A patient asked for an appointment on a specific day. Turner found the next available time slot. But, often, it was many days later than the patient had wanted.
Would that later date work? If the patient said yes, Turner canceled the whole process and started over. This time, he typed in that the patient had wanted that later date all along. So now, the official wait time was . . . a perfect zero days.
It was a lie, of course. But it seemed to be a very important lie, one that the system depended on. “Two to three times a month, you would hear something about it,” Turner said — another reminder from supervisors to “zero out.” “It wasn’t a secret at all.”
But all this was apparently a secret to Secretary Eric K. Shinseki, perched 12 levels above Turner in the VA’s towering bureaucracy. Somewhere underneath Shinseki — among the undersecretaries and deputy undersecretaries and bosses and sub-bosses — the fact that clerks were cheating the system was lost.
On Friday, Shinseki resigned and was replaced by his deputy.
But his departure is unlikely to solve the VA’s broader problem — a bureaucracy that had been taught, over time, to hide its problems from Washington. Indeed, as President Obama said, one of the agency’s key failings was that bad news did not reach Shinseki’s level at all.
This is an ironic development: Until recently, the VA had been seen as a Washington success story. In the 1990s, reformers had cut back on its middle management and started using performance data so managers at the top could keep abreast of problems at the bottom.
Then that success began to unravel.
As the VA’s caseload increased during two wars, the agency grew thick around the middle again. And then, when the people at the bottom started sending in fiction, the people at the top took it as fact.
“Shinseki goes up to Capitol Hill, and says, ‘I didn’t know anything.’ I find it perfectly believable,” said Paul C. Light, a professor at New York University who has studied the bureaucracy of the VA and others in Washington. “And that’s a real problem.”
For decades, the VA was a byword for bureaucracy itself, seen as Washington’s ultimate paper-pushing, mind-bending hierarchy. That reputation was rooted in the VA’s history: It came about because the agency’s first leader was an audacious crook.
Charles Forbes was chosen to head the Veterans Bureau by his poker buddy, President Warren G. Harding, in 1921. He was a poor choice. Forbes took kickbacks. He sold off federal supplies. He wildly misspent taxpayer money — once buying a 100-year supply of floor wax, enough to polish a floor the size of Indiana, for 25 times the regular price (apparently as a favor to a floor wax company).
Eventually, Forbes was caught. The president was unhappy. In 1923, a White House visitor opened the wrong door and found Harding choking Forbes with his bare hands.
“You yellow rat! You double-crossing bastard!” Harding was saying, according to historians. When he noticed the visitor, he let go of Forbes’s neck.
Forbes was eventually convicted of bribery and conspiracy. But afterward, the VA’s next leaders built in layers of bureaucracy and paperwork — to be sure that nobody would ever have the same freedom to steal.
Seventy years after Forbes was gone, the place was still wrapped in that red tape.
That was clear on the day that Kenneth Kizer — a reformer appointed by President Bill Clinton — arrived at the VA’s health service.
“I had to approve reimbursement of a secretary . . . purchasing a cable for her computer. I think it was something like $11 or $12,” Kizer said. There was a form. He had to sign it personally. “Here I’m running this multibillion dollar organization with — at that time — 200,000 employees. And I’m having to approve reimbursements for somebody.”
Kizer set out to change that. He cut back on staffing at VA headquarters in Washington and at regional headquarters. He cut out layers in the chain of command. And he embraced the idea that statistics could allow the agency’s leaders to peer around those middlemen and see the bottom from the top.
If patients at a certain hospital were waiting too long for appointments, they wouldn’t have to wait for the news to travel from a scheduling clerk to a supervisor, from the supervisor to a chief, from the chief to the hospital director, from the hospital director to the region, and from the region to Washington.
Instead, Washington could just watch the numbers and see for itself.
Today, 15 years after he left the VA, Kizer said he’s frustrated to see that one of his solutions — that numbers-based system — become the problem itself. Instead of alerting the bosses to problems in the field, it has been perverted to cover them up.
“The measures have become the end,” Kizer said in a phone interview from California, “As opposed to a means to an end.” . . .
Continue reading. It’s worth noting that the GOP forced Kizer out. Too bad.
The US is “special” (in the pejorative sense) in many ways: one of 3 nations in the world that refuse to use the metric system (the other two are Liberia and Myanmar), the nation that imprisons the highest proportion of its citizens (we really lead here: no other nation is even close), the only advanced nation that witnesses mass killings of its citizens as a part of daily life, and so on. Our healthcare system, though recently improved, lags far behind that of other advanced nations. And the US does not provide paid maternity leave. John Zarocostas reports in McClatchy:
The United States is the only Western country—and one of only three in the world—that does not provide some kind of monetary payment to new mothers who’ve taken maternity leave from their jobs, a new U.N. study reports.
Two other countries share the U.S. position of providing “no cash benefits during maternity leave,” according to the report, which was released Tuesday by the International Labor Organization: Oman, an absolute monarchy in the Persian Gulf; and Papua New Guinea, a South Pacific nation where the U.S. State Department says violence against women is so common that 60 percent of men in a U.N. study acknowledged having committed a rape.
The other 182 countries surveyed provide either a Social Security-like government payment to women who’ve recently given birth or adopted a child or require employers to continue at least a percentage of the worker’s pay. In 70 countries, paid leave is also provided for fathers, the report said, including Australia, which introduced 14 days of paid paternity leave last year, and Norway, which expanded its paternity leave from 12 to 14 weeks.
The United States also provides for fewer weeks of maternity leave than what other Western countries mandate, the report said. . .
Continue reading. It’s too bad that the US simply cannot get its act together. The problem in part is due to an antiquated Congressional structure that doesn’t allow effective operation. In additional to structural problems, it seems that most in Congress operate in fear (of the next election) and greed and don’t have any sense of responsibility to the nation and its citizens. For example, those making the most noise about the breakdown of the VA healthcare system are the very same people who voted against providing the funding so the VA could do its work. They eagerly blame Shinseki and ignore the damage that they themselves have done by underfunding the agency—an attitude typical of Congress, and an attitude that results in the continuing decline of the US.
UPDATE: More on how Congress shafted the VA.
Everyone seems to be upset about the wait times that veterans have to endure to get healthcare from the Veterans Administration. And yet we seem unconcerned that the wait times for the poor in states that refused to expand Medicare is infinite: they will have to wait until they die.
This is worse than the VA scandal. Ezra Klein writes at Vox.com:
The investigation is ongoing, but as of now, it looks like overwhelmed VA hospitals shunted some veterans onto secret wait lists and delayed their care (read Vox’s explainer here). The revelations are correctly being treated by both parties as a national scandal: denying Americans health care to which they’re legally entitled doesn’t simply inconvenience them. It can kill them.
We don’t know how many veterans were hurt by the VA’s secret wait lists. The VA was aiming for waits of no more than 14 days for non-urgent appointments, but Timothy Noah cites “an internal VA estimate” based on more reliable data that puts the average wait closer to 21 days. The investigation is likely to find hospitals where the average wait was much longer, and individual cases where the waits were truly appalling — and perhaps fatal.
It’s a relief to see so much outrage over poor access to government-provided health-care benefits. But it would be nice to see bipartisan outrage extend to another unfolding health-care scandal in this country: the 4.8 million people living under the poverty line who are eligible for Medicaid but won’t get it because their state has refused Obamacare’s Medicaid expansion.
As appalling as the wait times are for VA care, the people living in states that refused the Medicaid expansion aren’t just waiting too long for care. They’re not getting it at all. They’re going completely uninsured when federal law grants them comprehensive coverage. Many of these people will get sick and find they can’t afford treatment and some of them will die. Many of the victims here, by the way, are also veterans. So here are 24 health-care scandals that critics of the VA should also be furious about:
Alabama: Obamacare’s Medicaid expansion would provide 272,000 poor Alabamans with comprehensive health insurance, including 13,000 veterans. But the state has refused to let the expansion go forward.
Alaska: Obamacare’s Medicaid expansion would provide 30,000 poor Alaskans with comprehensive health insurance, including 2,400 veterans. But the state has refused to let the expansion go forward.
Florida: Obamacare’s Medicaid expansion would provide 1,212,000 poor Floridians with comprehensive health insurance, including 41,200 veterans. But the state has refused to let the expansion go forward.
Georgia: Obamacare’s Medicaid expansion would provide 599,000 poor Georgians with comprehensive health insurance, including 24,900 veterans. But the state has refused to let the expansion go forward.
Idaho: Obamacare’s Medicaid expansion would provide 86,000 poor Idahoans with comprehensive health insurance, including 3,800 veterans. But the state has refused to let the expansion go forward. . . .
[complete list in the article - LG]
All in all, the Kaiser Family Foundation estimates that more than 7.5 million uninsured adults would be eligible for Medicaid but live in a state that has refused the expansion. Of that group, 4.8 million are too poor to be eligible for subsidies in Obamacare’s insurance exchanges. So they’re out of luck.
This is a problem that affects veterans, too: The Pew’s Stateline estimates that around 250,000 uninsured veterans would be eligible for Medicaid if their states accepted the expansion.
The point here isn’t to minimize the problems at the VA, which need to be fixed — and fast. But anyone who feels morally outraged over the extended wait times at the VA should be appalled by the literally endless wait times the poor are enduring in the states that are refusing to expand Medicaid.
The Affordable Care Act, to the GOP’s horror, seems to be working.
Steve Levitt has altogether too high a regard for himself, one who mistakes confidence for content. Krugman sets him straight:
Noah Smith isn’t very happy with Steve Levitt, who thinks he was being smart by telling David Cameron that he should scrap the NHS and let the magic of the marketplace deal with health care. Strangely, Cameron wasn’t impressed.
I think there are actually several things going on here. One is a Levitt-specific, or maybe Freakonomics-specific, effect: the belief that a smart guy can waltz into any subject and that his shoot-from-the-hip assertions are as good as the experts’. Remember, Levitt did this on climate in his last book, delivering such brilliant judgements as the assertion that because solar panels are black (which they actually aren’t), they’ll absorb heat and make global warming worse. So it’s true to form that he would consider it unnecessary to pay attention to the work of lots of health economists, or for that matter the insights of Ken Arrow, and assert that hey, I don’t see any reason not to trust markets here.
There’s also the resurgence of faith-based free-market fundamentalism. I’ll write more on this soon, but I’m seeing on multiple fronts signs of an attempt to wave away everything that happened to the world these past seven years and go back to the notion that the market always knows best. Hey, it’s always about allocating scarce resources (never mind all those unemployed workers and zero interest rates), and why would you ever imagine that market prices are wrong (don’t mention the bubble).
And underlying all of this is a problem of methodology.
How should you use the perfectly competitive model, so beloved of economists? It is, of course, only a model, and we know that its underlying assumptions are untrue. There’s the Friedman dictum that this doesn’t matter as long as the model makes good predictions; that’s actually quite problematic, and there are good reasons to argue that the realism of the assumptions matters too.
But one thing you surely shouldn’t do — one thing that even Friedman would or at least should have said you shouldn’t do — is . . .
And do click the link in Krugman’s post and read that. Levitt is the epitome of unwarranted self-esteem.
And the comments to Krugman’s column (at the time I write) are interesting.
Kevin Drum takes a look at what we get by making sure private insurance companies are the center of the Affordable Care Act:
Here’s an excerpt of a recorded telephone conversation between David Cienfuegos’s wife and a rep from Anthem Blue Cross (“Howard”) prior to a surgery that Cienfuegos underwent:
Wife: So how can I find out if the doctor we’re working with is contracting with Anthem?
Howard: If you know the doctor’s name, I can look them up for you.
Wife: The doctor who is doing the procedure … is Dr. Werthman, W-e-r-t-h-m-a-n.
Howard: Philip?… Yes, that doctor is in-network.
Wife: Oh, OK. So when I submit my claim form, that goes towards the in-network deductible?
Howard: Correct…. That is correct.
Wife: I just wanted to then confirm that the procedure, veri — I’m sorry, what was it called again? I know I gave you the name.
Howard: Uh, varicocele. I am not quite sure how you pronounce it.
Wife: Varicocele. That’s covered by our insurance?
You’ve probably guessed the punchline already: After the surgery, Anthem denied Cienfuegos’s claim, saying his doctor was out of network and the procedure wasn’t covered. This is the kind of innovation and cost-cutting efficiency that makes it so important to keep private insurers at the core of our health care system.
The GOP healthcare plan for years has been, “Go to the Emergency Room.” In fact, George W. Bush specifically stated in 2007:
Bush spent a fair amount of time talking about health care yesterday, as well.
“The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America,” he said. “After all, you just go to an emergency room.”
Kevin Drum pointed out at the time:
And as long as we’re on the subject, it’s worth noting that emergency rooms have only been required to treat all patients regardless of ability to pay since the 1986 passage of the EMTALA Act. The Reagan and Bush Sr. administrations, unsurprisingly, did little to enforce it. Bill Clinton tried to step up enforcement in 1994, but in 2003, after Bush Jr. became president, he approved new rules that loosened EMTALA regulations. And of course Republicans routinely complain about EMTALA to this day, calling it a “hidden tax” on the insured and railing against the fact that it doesn’t allow hospitals to dump illegal immigrants with heart attacks in the gutter. Long story short, the GOP is not exactly a stronghold of support for emergency room care for the poor. Bush might want to keep that in mind.
And now look what’s happening. Kevin Drum has a post on how hospitals in states that expanded Medicare under the ACA have seen big drops in uninsured admissions and also increases in Medicare patients—and, of course, with health insurance many of the formerly uninsured can now just go see a physician instead of going to a hospital. His post is well worth reading, and in closing he notes:
This is why hospitals support Medicaid expansion so strongly. Medicaid may not pay a lot, but on average it pays a lot better than uninsured patients. A drop of around 30 percent in uninsured admissions is a big win for the patients, but it’s also a big win for the hospitals.
Normally, of course, that would be enough to gain Republican support all by itself, but not in the world of Obamacare. The fact that Medicaid expansion benefits the poor, benefits hospitals, probably benefits state finances, and is all but free to participating states—well, it’s just not enough. Demonstrating their tribal opposition to all things Obama is far more important.
I don’t really have a good understanding of how group loyalty can override obvious facts and evidence can be ignored. Perhaps I’m just not a group-loyal person.
Kevin Drum finds Jonathan Bernstein making an interesting point. The Congressional GOP apparently swallowed their own BS, hook, line, and sinker. This means that they really don’t read things outside of the WSJ nor watch anything other than Fox News. The errors they overlooked and that led to their embarrassment were widely discussed in the mainstream press.
This reminds me strongly of how gobsmacked the GOP was when Romney lost, although it was evident from reports in the mainstream press that Obama would win—and had been evident for quite a while.