Fraud-busting contractors slow to refer cases
Despite recent high-profile busts, the private contractors hired by Medicare to sniff out fraud cases and refer them to law enforcement seem to be lagging, according to recent government reports. The Associated Press’ Ricardo Alonso-Zaldivar reported on investigations that found that contractors took an average of 178 to refer fraud cases, and that the government was only able to recover a small fraction of the money identified as lost to fraudsters (OIG report | Testimony).
As this letter summarizing the congressional investigation shows, Iowa Sen. Chuck Grassley is on the case. He’s looking to figure out how much the fraud hunters are paid ($102 million in 2005) and how that balances with their benefit to taxpayers ($55 million recovered by the feds in 2007). The numbers are tricky, Alonso-Zaldivar writes, because fraudulent claimants have a habit of closing up shop and disappearing as soon as they’re notified of the pending investigation. Thus, the fraudbusters can’t be blamed entirely for the collection failures, though their tardy referrals are at least partially responsible.
The contractors have widely different track records. One identified $266 million in overpayments in 2007, while another found just $2.5 million, the Health and Human Services inspector general said in May.
Earlier, the inspector general found gaping differences in the number of new cases the contractors generate for law enforcement. Some had hundreds of cases, while others were in the single digits. Most were doing a poor job at spotting new fraud trends, with “minimal results from proactive data analysis,” the inspector general concluded.
The Obama administration says it’s aware of the problem and is close to completing a reorganization of the contractors, to consolidate their work, define their jurisdictions more clearly, and help them coordinate better with claims processors and law enforcement.
The new “Zone Program Integrity Contractors” will cast a somewhat wider net, and be more closely monitored by federal health officials.
Related
- Investigating health care: Essential public records
- Duff Wilson: Investigating health care fraud
- Reporting on the business of health care
- Center for Public Integrity writer says listserv led to Medicare-fraud story
(Hat tip to Ricardo-Alonzo Zaldivar for providing a copy of the Grassley letter)
How reform will affect America, group by group
Filed under: Health care reform, Health policy, Hot Health Headline, Studies
In Health Affairs (AHCJ members get free access), economist Joseph Newhouse considers how health care reform will affect four major groups. They’re summarized below.
- Uninsured or on Medicaid or CHIP (30 percent)
- Insured individually or through a small business (10 percent)
- Insured through a mid-size or large business (45 percent)
- Recipient of Medicare (15 percent)
Medicaid expansion and broader subsidies are “major gains.”
This group will undergo the most change, with the individual mandate expanding their ranks to as much as 50 million people (16 percent of Americans). Health reform should “repair” this now-broken sector of the market.
A wash, as an insurance tax is balanced out by a reduced need to cover uncompensated care for the uninsured.
Complicated. The doughnut hole will close, but future financing sources are murky. Newhouse goes pretty deep into just how murky.
His conclusion is relatively upbeat. Newhouse writes that while reform “addressed many issues in health care financing, it left many others unresolved.” The system will need to be revised and updated throughout the foreseeable future, Newhouse writes, and effective implementation will “require persistence for many years to come.”
Waiting period affects 2 million disabled Americans
Filed under: Health care reform, Health policy, Hot Health Headline
Nearly 2 million disabled Americans “fall into a twilight with the first monthly Social Security disability payment, for they then must wait two years to become eligible for Medicare,” according to The Oregonian’s Anne Saker.
With at least 15,000 in that position in Oregon, Saker tells the story of Sue Sherman, diagnosed last year with pancreatic cancer, who discovered she must wait two years for Medicare to cover her. “Only 20 percent of pancreatic cancer patients live more than a year past diagnosis,” Saker reports.
Saker outlines the history of the waiting period, statistics about how many people in that situation go without insurance and the machinations in Washington, D.C., over the waiting period, but weaves it all into Sherman’s story, keeping a human face on the issue.
She looks at how Sherman’s illness and lack of coverage affects her family and includes an observation by Sherman’s daughter that the costs of her care will be passed on to everyone else.
As Trudy Lieberman says in her blog at CJR.org, “Her plight illustrates the traps that snare the disabled in every state.” Lieberman explains how people get caught in this waiting period and will be stuck with another waiting period with today’s launch of high-risk insurance pools.
With 2 million people affected, this is a story that should be told in every state. Lieberman wrote in 2008 about putting a human face on the proposed health reform plans. Reporters would be smart to heed that advice as they report on how the new law will be enacted.
Related
Health care reform has passed: What’s next?
Reading lists for health care journalists
In her column for Generations Beat Online, AHCJ member Eileen Beal offers a reading list for health journalists and focuses on two books in particular that she believes will help prepare reporters for the first wave of baby boomers, which will hit Medicare next year (scroll down to item 4, “Beal’s Beat”).
Photo by Beverly & Pack via Flickr.The subjects these books cover, doctors’ decisions and statistics, are broad enough to be useful to even those journalists not focused on aging coverage.
Her suggestions include “How Doctors Think,” by Harvard professor and oncologist Jerome Groopman, and “Know Your Chances: Understanding Health Statistics.
In an e-mail separate from her column, Beal pointed out that Covering Health readers also might be interested in an edited, ranked and extensive list of health resource books compiled by the Agency for Healthcare Research and Quality that includes general and specific offerings.
Lieberman: Joe’s looking out for folks at home
Sen. Joe Lieberman (I-Conn.) has been a vocal burr in the saddle of the Democrat majority’s push for health care reform. Writing for CJR.org, Trudy Lieberman seeks to explain why Joe Lieberman has so vigorously opposed measures like the “public option” and the long-term care CLASS Act. Trudy Lieberman says the senator’s position would seem to have something to do with his constituent base.
Independent Sen. Joe Lieberman at the 2008 Republican National Convention. Photo by NewsHour via Flickr.
Joe Lieberman comes from Connecticut, and Hartford is America’s insurance capital. It’s home base to Aetna, one of the country’s largest health insurers and a huge lobbying force this year, not to mention some lesser carriers that dabble in the health insurance business.
Trudy then goes down Lieberman’s reform stances issue-by-issue, pointing out exactly how vested interests in his constituency could have influenced each one.
There certainly seems to be some data to back Trudy Lieberman’s insights. OpenSecrets.org shows that the “Finance, Insurance & Real Estate” sector has been the largest donor to the senator.
We have public options now. Are they any good?
Filed under: Government, Health care reform, Hot Health Headline
ProPublica’s Sabrina Shankman reviews America’s existing “public options” for health care, finding mixed results and limited utility. In addition to Medicare and Medicaid, Shankman reviews a few less prominent institutions:
- The armed forces Tricare plan: Covers all active members of the military, retirees and their families, regardless of preexisting conditions. If you stick to military treatment facilities, it’s cheap.
- Veterans Health Administration: Veterans who meet its standards are guaranteed high quality care, but funding is tight at the VA right now.
- Indian Health Service: Allows American Indians and Alaska Natives free access to reservation clinics… until the service’s funding runs out, as it does about halfway through each year.
- Healthcare Group of Arizona: It was founded to provide afforable insurance to certain small businesses, but a lack of funds and climbing deductibles mean that many employers will be better off looking to the private market anyway.
Reuters has a handy summary of the key provisions of the latest bill likely to be considered by the House of Representatives.
Bundled payments may improve care, lower costs
Filed under: Health care reform, Health journalism, Health policy, Hospitals
Kaiser Health News’ Phil Galewitz looks at bundling hospital payments, a possible solution to the confusion and cost of separate billing. Under these programs (now in Tulsa and San Antonio, and coming soon to Denver, Albuquerque and Oklahoma City), “Medicare makes a single reimbursement for all the hospital and doctor care for heart and joint procedures, rather than making separate payments to the facility and physicians.”
In theory, the benefits are clear:
Bundling payments moves medical charges away from the traditional fee-for-service system that pays providers separately for individual services — an arrangement critics of the current system say leads to doctors and hospitals delivering more care, but not better care.
It looks like the program’s making a difference. A hospital executive admits the bundled payments make hospitals more reluctant to consult specialists (because the payment from Medicare remains the same and doesn’t rise to meet the cost of a specialist) but says the increased attention to quality brought by the bundling has improved patient care.
Similarly, Galewitz writes that a similar program in the mid 1990s “saved $42.3 million over three years, with costs decreasing from 10% to 37% at the four hospitals participating in the test.”
Rural health costs: Lower, but just as uneven
Writing on the rural news site Daily Yonder, Bill Bishop and Julie Ardery take a look at the Dartmouth Atlas, using only cost data from the two-thirds of hospital service areas that have mostly rural or exurban populations. They found that only 27 percent of the rural HSAs had Medicare reimbursement costs above the national average, but that variations in spending between rural areas were just as pronounced as those among their urban counterparts.
Bonners Ferry, Idaho, a town of about 2,500 near the Canadian border that’s home to the lowest Medicare costs of any American majority-rural area. Photo by prentz via Flickr.
The accompanying map is particularly nifty, not just because of what it shows about rural health differences, but also about the coverage and costs of rural hospitals.
To learn more about the Dartmouth Atlas and how to use it to determine how medical resources are distributed and used in the United States, read AHCJ’s Covering Hospitals, a slim guide that focuses on how journalists can best use Dartmouth Atlas and Hospital Compare.
Related
- AHCJ Rural Health Journalism Workshop
- Covering Health: How hysterectomies spurred Dartmouth Atlas’ birth
- Covering Health: Poor, rural hospitals have higher death rates
- Covering Health: Students look at rural health care in north Ga.
- Covering Health: S. Dakota may be model of health-care efficiency
- Covering Health: Dartmouth Atlas: Powerful when used right
- Covering Health: Why health costs in McAllen, Texas, resonate
They gave us Part D, now protect it from reform
Filed under: Conflicts of interest, Government, Health care reform, Health journalism, Pharmaceuticals
ProPublica’s Olga Pierce reports that at least 25 of the folks who helped push through pharma-friendly Medicare Part D six years ago are back as lobbyists,and this time they’re fighting to make sure the plan isn’t reduced by reform-related budget cuts.
Pierce’s piece can be divided into three sections, each illuminating and alarming in its own way: How this crew of insiders pushed the envelope to force through Part D in 2003 (Hint: A legendary abuse of the legislative process helped), how they’ve returned and who’s paying them (see a nifty chart of those connections here), and what they’re up to this time around (more of the same, only this time they’re wealthier).
Alongside Pierce’s story, she and ProPublica have launched “Eye on the Health Care Reform,” a feature in which Pierce will keep up with the reform effort’s legislative journey.
Workshop explored issues of aging America
More than 70 people attended AHCJ’s Aging in the 21st Century workshop last weekend, where former HHS secretary Donna Shalala discussed the health reform proposals and former FDA commissioner David Kessler discussed the nation’s obesity epidemic.
Sam Grogg, dean of the University of Miami School of Communication, left, moderates a session with Thomas Prohaska of the Center for Research on Health and Aging at the University of Illinois at Chicago and Sara Czaja of the Center on Aging at the University of Miami. (Photo by Carla K. Johnson for AHCJ)
AHCJ treasurer Ivan Oransky live-tweeted from the workshop, which featured panels about the health care workforce, aging in ethnic communities, brain research, elder abuse and more.
Shalala said she is confident that health care reform will pass and that consensus is within reach. She says the biggest issue remains how to pay for reform and bring down health care costs.
The Miami Herald’s John Dorschner reports that “speaker after speaker laid out a grim scenario” for aging in the United States, with a smalller health care workforce available to care for a growing elderly population.
Presentations from the workshop will be available for members on the AHCJ Web site later this week. A slideshow from the event is now online.
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Spend a week at the CDC studying public health, meeting sources. Apply for the AHCJ-CDC Health Journalism Fellowships today!
- Reporting on the intersection of health, environment
- Tip sheet: Covering cuts to Medicare reimbursements
- Briefing: Reporting on health reform between now and 2014
- Covering high-risk insurance pools: Tips for reporters
- Health care reform has passed: What's next?
- Health and education: Covering these intersecting beats
- Reporting on the business of health care
- Health reporting resources for journalists on state and local government beats
