Texas psych clinics take Medicare’s millions without oversight
Filed under: Health care reform, Health data, Health policy, Hospitals, Hot Health Headline
The Houston Chronicle’s Terri Langford reports that for-profit outpatient psychiatric clinics in the state, most located around Houston, are collecting millions in Medicare dollars yet “require no license to operate in Texas.”
She writes that, despite access to significant federal funds, the clinics are subject to little oversight from any level of government, especially when it comes to patient care.
…other than a one time inspection conducted by Medicare when clinics start operating - these programs have no detailed standards or “conditions of participation,” that must be met before filing claims and collecting taxpayer money.
…
The U.S. Department of Health and Human Services flagged the problem earlier this year, saying “no regulatory basis exists to ensure basic levels of quality and safety” for CMHC care.
The loopholes, including the lack of an established means to kick poorly performing centers out of the medicare system, apply nationwide, but their exploitation remains localized.
Records show that in 2009, Medicare paid $287 million on these programs nationwide, 74 percent of them located in the three states that have no state licensing requirements: Florida, Louisiana and Texas.
Medicare providers get reinstated when feds fail to attend hearings
Filed under: Health care reform, Health data, Health journalism, Health policy, Public records
Using data obtained through a public records request, Associated Press reporter Kelli Kennedy (@kkennedyap) reviewed federal Medicare fraud reports from between 2006 and 2009 and found that “Regulators fighting an estimated $60 billion to $90 billion a year in Medicare fraud frequently suspend Medicare providers, then quickly reinstate them after appeals hearings that government employees don’t even attend.”
Officials revoked the licenses of 3,702 medical equipment companies in the fraud hot spots of South Florida, Los Angeles, Baton Rouge, La., Houston, Brooklyn, N.Y., and Detroit between 2006 and 2009, according to data provided to the AP under a public records request. Those areas represent the highest concentrations of Medicare fraud in the country, according to federal authorities who have set up task forces there.
Of the providers who lost their licenses in those cities, about 37 percent, or 1,371, were eventually back in business, sometimes within days and often within months.
Furthermore, she writes, officials have not taken advantage of security bonds put in place two years ago to provide redress should a fraudulent provider vanish from the map. “Officials blame the delay on personnel changes,” she writes.
The gaps in the system grow out of poor communication between one set of contractors paid to inspect Medicare providers and alert officials to suspicious activity; a separate set of contractors that handles payments; and the agency that runs Medicare.
Kennedy’s report dives deep into the Medicare fraud reinstatement program, and reporters looking to better understand the system would be well served to read the full investigation.
Groups push for transparency in Joint Commission’s hospital accreditation surveys
Filed under: Health data, Health journalism, Hospitals, Hot Health Headline, Public records, Studies
The Lexington Herald-Leader’s Jim Warren reports that about 50 advocacy groups, including the Consumers Union and Mothers against Medical Error, have joined forces to ask Congress to make the survey data behind hospital accreditation freely available to the public.
Their main target is The Joint Commission, a non-profit group that sets performance standards and is hired by hospitals and other health-care organizations to measure whether they meet those standards. In many states, Joint Commission accreditation is the basis for hospital licensure. It conducts extensive surveys every three years or so, and funds its efforts by charging hospitals upward of $45,000 for the privilege of being evaluated.
The Joint Commission’s disclosure practices last made headlines in January when, in response to pressure from AHCJ’s Right to Know Committee, it made accreditation information more readily available online.
For help finding and understanding Joint Commission reports and similar sources, AHCJ members can check out board president Charles Ornstein’s latest guide to Deciphering Hospital Quality Data, in which he addresses the strengths and weaknesses of myriad data sources and provides pointers on how to access and utilize them.
Back-to-the-beat resources on health reform
Since so many of us are in storm (or non-storm) what-are-we-going-to-do-with-all-these-batteries cleanup and back-to-school mode, I thought I’d bring some resources and interesting studies to your attention to help bring your focus back on the beat.
Confusion still reigns
You probably saw the Kaiser poll reminding us once again how confused people remain about the health reform law - including the very people who would be most helped by it, the uninsured. It got a lot of coverage but if you missed it, it’s a must read. It ties into the theme of massive national confusion – and the frustration I feel that the confusion persists despite a fair amount of good reporting – that I wrote about in the first post I did for Covering Health. I think a lot of the confusion stems from the mandate . People hear that they will “have” to buy insurance, and they panic or get angry because they can’t afford it. They don’t hear that they may well qualify for subsidies to make it affordable-and they don’t have to be dirt poor to get the subsidies; many middle class people will also benefit.
Click to enlarge this graph from the Kaiser Family Foundation Data Note found at http://www.kff.org/kaiserpolls/8217.cfm.
Most of the coverage of the KFF poll I heard or saw centered on the uninsured, but there is also a related data note looking at knowledge and expectations of people who have employer-sponsored health insurance. Asked what they would be willing to do to lower health care costs, the answer could be summed up as “not much.” They are OK with participating in a wellness program (although not necessarily actually getting “weller”) but didn’t like the idea of more generic drugs, more restrictive networks of doctors, or higher copays and deductibles.
Eating away at the doughnut hole
An AHCJ member found this report by EBRI, the Employee Benefit Research Institute, useful so I’m sharing. It’s about how the health reform law will slowly (over a decade) close the “donut hole” for Medicare drug coverage, and how repealing the health law would create a savings hole for older Americans who use a lot of prescription drugs. (The doughnut hole is the gap after you use up the basic drug benefit but haven’t hit the “catastrophic” level. Beneficiaries pay monthly premiums through the gap, but don’t get benefits until they burn through the gap. ) EBRI studies health care and retirement issues and does periodic issue briefs.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Staff physicians on the rise
The Center for Health System Change has been tracking health care developments in 12 communities and found that hospitals are hiring more staff physicians. In policy circles, the talk has been that the staff-physician model is a tool in creating more clinical integration, care coordination, higher quality and lower cost – but this study found that the hospitals are in it primarily for market share. Physicians like it because it’s fewer hassles. It doesn’t necessarily bring down overall health care costs. Now, this is a snapshot in a fee-for-service world; new payment models being developed by private insurers, and Medicare and Medicaid may change the dynamic. But it’s an attention-worthy snapshot. The HSC Issue Brief, “Rising Hospital Employment of Physicians: Better Quality, Higher Costs?” is available online.
Who applied to be ACOs?
There was a lot of coverage a few months back about all the health systems that were not going to apply to become Medicare Accountable Care Organizations, at least not under the original shared savings model. We aren’t hearing as much about who is applying – worth checking in your community. Medicare also created an alternative, called the pioneer ACO, to attract more plans. We won’t know until around November how many applied to be pioneers, or who they are, but here’s the story of one plan that’s ready to go.
Behind the drug shortage
There was a lot of discussion on the AHCJ electronic discussion list recently about drug shortages, particularly chemotherapy shortages. I was out of town for a few days (helping care for a relative and learning, among other things, that Medicare pays for oxygen concentrators but not for the batteries) and I haven’t caught up with all of the messages, but this essay in the Sunday New York Times a few weeks ago by Ezekiel Emanuel taught me lots I didn’t know about generic chemo drugs, pricing and shortages, and proposed solutions.
Data, AHCJ article lead reporter to story on possible cuts at local hospital
Filed under: Government, Health journalism, Hospitals
St. Louis Post-Dispatch reporter Blythe Bernhard followed up on suggestions offered in Charles Ornstein’s recent AHCJ article about updated CMS data to produce an article about looming potential cuts in Medicare payments to St. Louis’ Barnes-Jewish Hospital.
The hospital’s problem? As Bernhard writes, Barnes-Jewish “is one of just three hospitals in the country to perform significantly worse than the national average in readmissions within 30 days for three conditions — heart attacks, heart failure and pneumonia — for each of the last three years.”
Medicare … plans to penalize hospitals with higher-than-expected readmission rates. Under health care reform, Barnes-Jewish and other hospitals could face up to a 3 percent reduction in Medicare payments, meaning millions of dollars, starting next year.
Reducing readmissions nationwide could save $26 billion over a decade, the government estimates.
Data shows disconnect between patient perception, hospital performance
Filed under: Health data, Hospitals, Hot Health Headline, Public records
Sifting through Medicare hospital rating data, USA Today reporters Steve Sternberg and Christopher Schnaars found an enlightening disconnect between patients’ subjective ratings of hospitals and hospital performance on quantitative measures such as death and readmission rates.
“This is a very important finding,” says Donald Berwick, director of the Centers for Medicare & Medicaid Services, adding that though patient-survey data offer critical insights into how it feels to be a patient at different hospitals, patients’ perceptions don’t tell the whole story.
The story is packaged with an infographic that allows readers to look up ratings for local hospitals.
AHCJ resources
- Updated hospital data allows reporters to identify ongoing problems: The release this month of federal data on hospital quality is a good reminder for reporters to give their local hospitals a checkup. To give you a head start, Charles Ornstein, senior reporter at ProPublica and AHCJ’s president, has done some preliminary analysis and points out states in which hospitals fared well and the states where hospitals did poorly.
- Deciphering hospital quality data
- Sorting out hospital rankings
- Making sense of hospital quality reports
- Analyze patient satisfaction surveys to evaluate local hospitals
Uninsured face delays, increased risks en route to long-term care
Writing for Heart & Soul, Yanick Rice Lamb offers up a comprehensive take on the special challenges patients and hospitals face when it comes to long-term care for the uninsured.
… a growing number of uninsured people … need long-term care after hospital stays. They lack insurance because they can’t afford it, their employers don’t offer it or they were dropped by private carriers after taking out policies on their own. Consequently, these patients experience delays in moving on to the next step in their care once they are medically ready for discharge. They are stuck in the hospital, because it’s hard to place patients in long-term care facilities or send them home with a nurse when they have no coverage, especially when there are complications. Hospitals end up picking up the tab — sometimes even after patients leave. Those costs are ultimately passed on to everyone who pays taxes and anyone who has a medical bill.
Rice Lamb fleshes out this scenario not only with anecdotes, but with a raft of statistics and studies showing that the ranks of such patients are swelling rapidly, as is the financial toll they’re taking on the system. She ties it in with the hospital “frequent flyer” and charity care issues that have received so much ink in recent years. At the same time, she takes a deeper look at the issues faced by the patients themselves, from the difficulty of spending days and weeks away from family, to the lower levels of attention they may receive from hospital staff as their stays drag on, to the increased risk of hospital-acquired infections and lack of specialized rehab.
Some of the most surprising observations came in relation to undocumented immigrants, who present major challenges despite being a small part of the patient population.
In some cases, when community support can’t be found, Rice Lamb writes that hospitals “Often pay to transport immigrants back to their countries — if the patients agree — and sometimes cover medical bills in their homelands. This often costs less than absorbing the expense of continuous care in the United States.”
Furthermore, she says, “Even with U.S. citizenship, language barriers can contribute to discharge delays. When caregivers spoke little English, the length of stay increased to 6.1 days, compared to four days for the control group, according to a study published recently in the Archives of Pediatrics & Adolescent Medicine.”
Throughout her work, Rice Lamb takes advantage of sources which reporters around the country should find useful when localizing similar topics.
Rice Lamb completed this project while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund.
Report: Calif. hospital chain profited from ER admissions
Filed under: Health data, Health journalism, Hot Health Headline, Public records
After months of investigation and updates, California Watch reporters Christina Jewett and Stephen K. Doig have unleashed their full report on California hospital chain Prime Healthcare Services and its knack for turning around failing hospitals by apparently pushing for the admission of ER patients who are insured by Medicare or insurance giant Kaiser Permanente, then keeping them in the hospital.
The report includes hyperlink sourcing, a raft of related documents and a great explainer on how they assembled the numbers behind the story. The duo took advantage of court testimony, sources and reams of public records.
The reporters say that evidence points to “an orchestrated campaign of admitting Medicare and Kaiser patients – moving them from the emergency room to a hospital bed – in the interest of changing the fortune of a money-losing hospital.”
State data shows that after the hospital chain took over 11 hospitals beginning in 2005, the percentage of Medicare patients who were admitted from the emergency room to Prime hospital beds increased from about 45 to 63 percent.
That 40 percent increase contrasts with other California hospitals that saw an average 8 percent decline from 2005 to 2009 in Medicare patients moved from the emergency rooms to hospital beds, data shows.
And, as you’ll see throughout the story, the interviews and anecdotes back up the numbers.
Tina Buchanan, the hospital’s former chief nursing officer, testified that [Prime founder and chairman Dr. Prem Reddy] began to require emergency room staff to put a yellow sheet of paper on each patient record that listed their health insurance status.
She said he would go through the “goldenrods,” as the papers were called, and point out the Medicare or Kaiser patients and say, “Make sure you get this one admitted.”
“If it was … an uninsured patient, he would tell them, ‘Get them out of my hospital,’ ” Buchanan testified.
There’s plenty more where that came from, but I will just leave you with this editor’s note, which appears alongside the main story.
It came to our attention late Friday that Prime Healthcare had issued a press release saying it had taken legal action against California Watch. We have not been served and can’t fully comment until we have reviewed any legal filings. In our dealings with Prime over the course of the past several months, the company has yet to present to us a single factual error that has merited correction or clarification. We continue to stand by our reporting.
House calls on the rise as their economic benefits become clear
Filed under: Aging, Health policy, Hospitals, Public health
In The Miami Herald, Ana Veciana-Suarez looks into why doctor house calls are on the rise, especially among the Medicare set. Through her reporting, it becomes apparent that it’s primarily a function of economics, all driven by the fact that, while a house call may appear expensive when compared to a typical primary care visit, in many cases the real alternative to a house call and some preventative medicine is an emergency room visit and/or an overnight hospitalization, both of which are in another cost bracket entirely.
Veciana-Suarez writes that while the latest home care boom may have started with the growth of concierge medicine, especially in South Florida, it’s now being driven by the big guns — Medicare and major insurers.
House calls, once thought to be too time-consuming and not very cost-effective, are making a comeback as healthcare providers recognize that they’re actually the answer to good care for patients who can’t make it to a doctor’s office. Medicare-paid house calls have been steadily increasing, according to government figures, and doctors report the same for non-Medicare patients, according to the American Academy for Home Care Physicians. What’s more, technology has made accessibility to patients’ records and other medical information available at any time and any place, a boon to physicians on the go.
Now a three-year federal government pilot program called Independence at Home is encouraging doctors to pick up those black medical bags of yore and pay a visit to their sickest patients. As part of the new healthcare reform law, the demonstration project will cover 10,000 Medicare patients described as medically fragile. It is set to begin in January in locations yet to be decided.
The main targets for both the government and private insurance programs are the so-called “frequent fliers,” and others with chronic conditions that need to be managed to prevent repeat visits to the emergency room. To that end, some programs also include social workers and home health educators. Most programs are still in the experimental phase, but Veciana-Suarez paints a clear picture of a sector that’s poised to assume a growing role in the coming decade.
Effort to make Medicare data public advances
Filed under: Government, Health data, Public records
The Dow Jones Company’s efforts to make Medicare data public took a step forward yesterday with a U.S. magistrate recommending [PDF] that the 30-year-old case barring access to the data be reopened and its motion to intervene in the case be granted in U.S. district court.
Dow Jones filed a motion to intervene [PDF] in January in its attempt to have the courts overturn a 30-year-old injunction that blocks release of the data, which individually identifies medical providers. The case was placed in the court’s electronic system but its status was “closed.” The company filed an unopposed motion in February to reopen the case. Magistrate Monte C. Richardson recommended that U.S. District Judge Marcia Morales Howard grant the motions.
The injunction is the result of a 1979 lawsuit brought by the American Medical Association, which objects to the release of data that includes how much money individual doctors receive from Medicare.
Wall Street Journal reporters, who negotiated for eight years worth of data if they did not publish identities, wrote a series of stories about Medicare data, showing that the federal government isn’t taking advantage of the data it has to detect fraud.
The board of directors of the Association of Health Care Journalists released this statement when the suit was filed in January:
AHCJ strongly supports the release of Medicare payment data that can help journalists better cover both the quality of care provided to patients and the finances of this critical government program. Publicly available information should include physician names connected to these payments. We see little reason why information on payments to doctors should be subjected to greater secrecy than payments to hospitals and nursing homes. The Wall Street Journal’s coverage demonstrates that data linked to doctors would help inform the public and likely would expose fraud and abuse in the program.
Related
- WSJ exposes flaws of Medicare’s pay now, investigate later culture
- Secrets of the System: See the WSJ’s contest questionnaire about how the series was done and read the stories (AHCJ members only)
- WSJ sues for release of Medicare provider data
- Press kit about the suit
- Senators join fight to open Medicare claims data
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