Saturday, June 30, 2012

Docs vs Glocks

I have some good news to share with you. In the case Wollschlaeger vs. Farmer the federal judge today decided in our favor permanently baring the State of Florida to enforce the gag law preventing physicians to discuss firearm safety issues with their patients.Now we can continue educating our patients about the safe handling and storage of firearms, thereby preventing the accidental injury and death of children. I am very grateful for the opportunity to represent the Florida Academy of Family Physicians which supported our case all the way to victory. Wollschlaeger vs Farmer "The State is permanently enjoined from enforcing § 790.338(1), (2), (5), and (6). The State is also permanently enjoined from enforcing § 790.338(8), to the extent that it provides that violations of § 790.338(1) and (2) constitute grounds for disciplinary action. The State is further permanently enjoined from enforcing § 456.072(1)(mm), to the extent that it provides that violations of § 790.338(1), (2), (5), and (6) shall constitute grounds for which disciplinary actions specified under § 456.072(2) may be taken. A separate judgment will be issued forthwith pursuant to Rule 58 of the Federal Rules of Civil Procedure." Yours Bernd

Thursday, June 28, 2012

The Supreme Court Decision

Personally, I am very pleased about the Supreme Court decision upholding the Patient Protection and Affordable Care Act because it represents a step forward in creating a better and more equitable health care system for all Americans. I find it ironic that the two leading presidential candidates from both parties support(ed) an individual mandate. Unfortunately,during the election campaign the facts about health care will be drowned by ideologically driven rhetoric . Now should be the time to explain to the American people how we can create a sustainable high quality and efficient health care system. I do not give up the hope that this is possible. Yours Bernd

Tuesday, June 26, 2012

Waiting For The Supreme Court

Attached some of my thoughts and comments regarding the pending decision by the US Supreme Court. The court will have to answer four distinct legal questions raised by the challenge to the Patient Protection and Affordable Care Act (PPACA) Threshold Question: The threshold question is whether the court may decide the case now, or whether it must wait until 2015, when all of its provisions — including the individual mandate — have gone into effect. The judges, the plaintiffs and the defendant (US Department of Health and Human Services) during the hearing were uniformly inclined to decide the case now. Individual Mandate Question: Is the provision requiring virtually all Americans to have health insurance constitutional? The Supreme Court will have to determine whether Congress exceeded its powers to regulate commerce by creating a mandate that would force most Americans who aren't otherwise insured to buy coverage. The Commerce Clause, Article I Section 8 Clause 3 of the Constitution of the United States, grants the federal government specified powers, reserving the rest to the states and to the people. The two powers at issue in the case, set out in Article I, Section 8, concern the regulation of interstate commerce and the imposition of taxes. The administration’s primary argument is that the law is authorized by the commerce clause, which gives Congress the power to regulate commerce “among the several states.” The decision under review, from the United States Court of Appeals for the 11th Circuit, in Atlanta, said the health care law overstepped the limits imposed by the commerce clause by regulating inactivity and forcing people into the marketplace. Solicitor General Donald B. Verrilli Jr. argued that Uninsured Americans each year use $43 billion of health care they cannot pay for. Thereby, the effectively transfer those costs to other American families to the tune of about $1,000 per year, which constitutes a commercial activity. There is no question that f the court decides to strike down the individual mandate, then insurance companies cannot recoup the costs for those they have to enroll with preexisting conditions. Therefore, the health insurance premiums will substantially increase effective 2013, or even earlier! Medicaid Expansion Question: This expansion adds 17 million more people to the rolls. The states challenging the overhaul law have argued that even though the federal government will pay almost all of the cost, it is still impermissibly coercive. In my opinion Medicaid is a (poor) substitute for a failed Public Option for those who qualify: The expansion of Medicaid broadens that coverage to include all individuals and families with an income at or below 133% of the Federal Poverty Level (FPL) ($14,483.70) for an individual, and $29,725.50 for a family of 4. Additionally, applicants will no longer be required to complete an asset or resource test. Legislation also maintains eligibility limits (e.g., Medicaid limits as of March 23, 2010) through 2014 for adults and 2019 for children and provides states with the option for covering patients above 133% of the FPL. For individuals and families with an income ranging from 133% to 400% of the FPL, the expansion of insurance coverage will be in the form of state based health insurance exchanges where certain qualified patients will be eligible for premium or cost sharing assistance for private insurance. National guidelines will also govern a standard profile of benefits that will include among other things access to prescription drugs. The uniform coverage for Medicaid will also mirror the basic coverage package available to those purchasing coverage through the exchange. In an effort to empower patients, Enrollment information will be accessible on-line. States will be required to create a website for patients by January 1, 2014 where they can apply or renew Medicaid/CHIP or the State run insurance exchange. The problem with this approach is that it will create a class of Americans above 400 % FPL who CANNOT afford the expensive private health insurance premiums ( often > $20,000 per year) and therefore will have to stay uninsured WITH or WITHOUT penalty. This is already happening in Germany where the individual mandate without a viable public option has created a growing class of self-employed uninsured who do NOT qualify for the national health insurance plan for the poor. Separability Question: The Supreme Court will decide whether, if any part of the law is unconstitutional, it can be separated out, or whether the entire law has to be invalidated. Its important to understand that striking down a small component of the PPACA could have numerous consequences --both intended and unintended.For example, what will happen with the rule, already in place, that allows adult children to remain on their parents' insurance plans until age 26? Even though some of the biggest insurance companies have vowed to keep this provision in place, but if the court invalidates the law, those additional benefits might be taxable. The law waived a key tax provision to ensure that health insurance benefits are not taxed as income. But without the law, parents may have to pay income taxes on those benefits and employers could face higher payroll taxes. Personally, I consider the PPACA as leap forward in creating a better healthcare system for most Americans BUT it falls short to insure ALL Americans and to control the spiraling healthcare costs. As noted by President Obama, “Unless you have what’s called a single payer system in which everybody is automatically covered, then you’re probably not going to reach every single individual.” In other words, single payer is the only way to actually achieve universal coverage (White House press conference, July 22, 2009). In contrast to the PPACA, an improved Medicare for all would provide truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing our wasteful private health insurance industry with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout. Research shows the savings in administrative costs alone would amount to $400 billion annually, enough to provide quality coverage to everyone with no overall increase in U.S. health spending. The most rapid way to achieve universal coverage would be to improve upon the existing Medicare program by excluding private insurance participation (through so-called Medicare Advantage plans) and eliminating co-pays and deductibles, and then to expand the program to cover people of all ages. For more information see Yours Bernd

Monday, June 18, 2012

Medicare and Cuba

Attached a link to an article published in today's Miami Herald titled "Feds in Miami: Millions stolen from Medicare wound up in Cuban banking system" which should belong in the world of fiction but instead represents the sad reality of healthcare in South Florida. According to the article federal prosecutors have charged a Miami man, Oscar Sanchez, 46, with engaging in a massive money-laundering scheme and identified him as a key leader in a group that funneled at least $31 million in stolen Medicare dollars into Cuban banks in Havana. While Sanchez was a target of the ongoing investigation, prosecutors say dozens of crooked Medicare providers — who offered HIV and medical equipment services — all took part in the laundering scheme set up for one reason: To hide the money.In all, 70 medical company owners in South Florida submitted more than $374 million in claims to Medicare, and were reimbursed about $70 million. Most of the money was laundered through foreign banks, including Cuba, and the Castro government also extorted Medicare bounty from criminals who are allowed to go travel freely between here and the island nation. I have asked my self the same questions over and over again: how could such a criminal enterprise fed with Medicare money flourish and thrive? Why do Medicare contractors only smell the rat when the rat already left the sinking ship? Why can we not utilize a similar approach applied successfully in Taiwan where all healthcare providers are connected to the Bureau of National Health Insurance through (BNHI) a Virtual Private Network (VPN) for e-claim purposes. Any suspicious claims could be detected in real-time and their payment stopped. Instead, in the US we are acting after the criminals already laundered the money and left the country. This case should serve as (another) example that we have to strengthen the accountability and increase the transparency of the Medicare payment process. Yours Bernd

Wellcare's Response

Attached a link to a letter to the editor by Wellcare's vice president of corporate communications published in today's Miami Herald. It contains Wellcare's official response to the ongoing criticism of their efforts to bid for the lucrative Medicaid contracts. The letter emphasizes that WellCare today represents a transformed company "sensitive to the concerns of those advocacy groups that share our mission of service – a mission to provide quality healthcare solutions to the most vulnerable and fragile populations in Florida" Well, I believe that individuals can change and turn their lives around. Nevertheless, they still have to do time for the crimes they committed. Why does a different standard apply to a corporation which engaged in truly despicable actions? Those include ending coverage for sick people and as a result, the company saved $20,000 for every one of the 425 prematurely delivered babies that were dropped from their plan. Employees were also removing certain patients from coverage because they cost too much money.When the goal was reached, the company hosted a celebratory dinner. Such egregious behavior should not be rewarded by allowing the fox back in the henhouse. Wellcare should operate instead under public oversight with an ombudsman (or woman) representing the interests of the public by investigating and addressing complaints reported by individuals. The ombudsman(or woman) should investigate constituent complaints and attempt to resolve them, usually through recommendations (binding or not) or mediation. Is that too much to ask for? Yours Bernd

Thursday, June 14, 2012

Floridians Deserve Protection

Attached a link to a great letter by Laura Goodhue, Executive Director Florida Community Health Action Information Network, which was published in today's Miami Herald. The letter was a response to Florida Insurance Commissioner Kevin McCarty's Other View article titled "Whoa — Don’t cash those rebate checks yet" in which he claims that the Medical Loss ration (MLR) requirements adversely affect the healthcare marketplace and are already creating unintended consequences that could lead to less competition, fewer products, and fewer opportunities for consumer choice. Laura Goodhue correctly points out that "the law says that insurers must limit the amount they spend on profit and overhead and spend a set minimum of premium dollars on direct medical expenses. If health insurers fail to meet that standard, they have to issue rebates for the difference. The Kaiser Family Foundation reported that Floridians would see $148 million in rebates that will be issued as refund checks or credited toward the portion of the premium that employees pay. Going forward, the MLR rule means that consumers will get a better deal from their health insurance company. These sound consumer protections must be embraced by our state — not dismissed.Ironically, Florida’s Office of Insurance Regulation has refused to accept funding to increase the agency’s ability to review proposed health insurer rate increases — a move that would help control the premiums faced by Floridians. To make matters worse, there’s no process for the public to weigh in on these same proposed rate increases. It doesn’t stop there: In the last year, the state also insisted that Florida get a partial exemption from the MLR requirements because, it claimed, it would lead to a mass exodus of insurers from our market. This request was rejected, and insurers didn’t flee after all." I absolutely agree that Floridian's deserve protection against corporate greed. Health insurance companies continue to enjoy " healthy" profit margins and will not leave Florida just because the Affordable Care Act requires adherence to the Medical Loss Ratio. There is still too much money to made from denying healthcare. Its irresponsible that the Florida Office of Insurance Regulation blocks all efforts to protect our fellow citizens but continues to shelter insurance companies. It makes me sick to my stomach!! Yours Bernd

Monday, June 11, 2012

Healthcare Fraud: The Ultimate Chutzpah

In his book, The Joys of Yiddish, the Jewish humorist Leo Rosten defines chutzpah as "gall, brazen nerve, effrontery, incredible 'guts,' presumption plus arrogance such as no other word and no other language can do justice to." In the same book, Rosten also defined the term as "that quality enshrined in a man who, having killed his mother and father, throws himself on the mercy of the court because he is an orphan." Chutzpah is not only restricted to individual misbehavior but includes corporate malfeasance, too. A great example of such behavior is being displayed by Wellcare, a Tampa-based health insurer with a checkered past, which is preparing to bid on billions of dollars in state government contracts to serve Florida's poor and disabled. But why does Chutzpah apply to this company? Well, lets review their checkered past. WellCare administers Medicaid benefits in Florida, Georgia, Hawaii, Illinois, Missouri, New York and Ohio and Medicare Advantage plans in 12 states. The company learned it was under federal investigation in 2008. Law enforcement agencies alleged that the company defrauded Florida's Health Kids program out of $40 million and subsequently made misleading earnings statements based on the ill-gotten gains. The company entered into a deferred prosecution agreement with the U.S. Attorney General's Office and the Florida Attorney General's Office in May 2009, agreeing to pay back $40 million in addition to a $40 million fine. It settled a class-action lawsuit with shareholders for $200 million in December 2010. On April 26, the Tampa, Fla.-based company signed a final settlement with the Civil Division of the U.S. Dept. of Justice, the Office of Inspector General of the U.S. Dept. of Health and Human Services, nine states and five whistle-blowers. The settlement terms were announced as a preliminary agreement in June 2010 and require the company to pay the Justice Dept. a $137.5 million fine. On the same date, WellCare signed a corporate integrity agreement with the HHS Office of the Inspector General. As part of the agreement, the company will hire a third-party observer to monitor its compliance with state and federal regulations, train its employees on compliance with those rules, retain a chief compliance officer and introduce an internal monitoring program. No further fine was required as part of the agreement. As part of various settlements with state and federal law enforcement, WellCare agreed it would neither admit nor deny the allegations against it. Critics also slam the federal settlement, finalized in April, which requires the company to repay less than half of the alleged $400 million to $600 million it siphoned from taxpayers.Five former executives — including CEO Todd Farha, CFO Paul Behrens and general counsel Thaddeus Bereday — were indicted in March 2011 and are awaiting trial. Evidence against them includes taped conversations between executives discussing how they could duplicate their bills to the state. The executives also discussed plans to save money by terminating coverage for neonatal babies and terminally ill patients, and throwing parties to reward employees who ousted expensive enrollees, according to whistle-blower documents. And what does Wellcare representatives have to say? "Most importantly, the corporate integrity agreement ends concern about our eligibility to participate in Medicare, Medicaid and other federal and state health care programs," WellCare General Counsel Tim Susanin triumphantly declared during the company's first-quarter earnings call May 6. That's chutzpah because it is apparent that two different standards of law seem to apply: one for companies and one for ALL others who dare to defraud the federal health program(s). For us mortals the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), takes a tough position regarding suspension or exclusion from the Medicare Program or revocation of Medicare provider numbers. There are some situations in which the law requires that the OIG to issue a mandatory exclusion from the Medicare Program, such as loss of the professional's license or conviction of health care fraud. There are other situations in which exclusion from the Medicare Program will only result in a possible "permissive exclusion," such as conviction of a nonhealth care related felony or discipline of a health professional's license. This gives leeway to the OIG to determine whether or not it will ultimately exclude or suspend the provider from the Medicare Program. Regardless, the consequences are long-lasting and much more devastating to a health provider than might be imagined until it is experienced. A person, organization or facility excluded from the Medicare Program will be placed on the List of Excluded Individuals and Entities (LIEE) maintained by HHS. All Medicare or Medicaid providers or contractors are required by law to check this before contracting with a health provider or employing a health provider. The law prohibits any Medicare, Medicaid or Federal Health Program from contracting with or employing in any way a person or organization that has been excluded. This even extends to any officer, director or shareholder of an organization that has been excluded. Lesser known is the fact that if a person or organization is excluded or suspended from the Medicare Program, then they are automatically placed on the Excluded Parties List System (EPLS) maintained by the government Services Administration (GSA) and they are also "debarred" or excluded form being able to contract with the federal government (or any contractor of the federal government) for anything. This even extends to any officer, director or shareholder of an organization that has been excluded or debarred.States have been required to become more aggressive in recovering fraudulent payments and overpayments in Medicaid cases, as well. A portion of the money they recover must be returned to the federal government since the federal government provides 55% of Medicaid funding. Many states have passed laws that require exclusion from the state's Medicaid Program if the health provider has been found to have committed Medicaid fraud. Exclusion form a state's Medicaid Program is also grounds for exclusion from the federal Medicare Program. Many state's have also passed laws that require revocation of the professional license of an individual who has been excluded from the state's Medicaid Program. For example, in 2009, the Florida Legislature passed SB 1986 which became effective July 1, 2009. It amended Chapter 456 of Florida Statutes. It prohibits the Florida Department of Health from issuing a license to or renewing a license of anyone excluded from the state's Medicaid Program until that person has been reinstated back into the Medicaid Program and has been delivering services in it for at least five (5) years. This would be difficult for any health provider to do. But all of the above mentioned facts do not apply for Wellcare because it has found a guaranteed absolution of all past sins: hire a former U.S. senator , who serves as a paid director on the company's board and chairs a committee to ensure the company is ethical and complies with regulations, and contribute lots of money to state political campaigns ( at least $2 million since 1997) What can we do faced with such ultimate Chutzpah? Don't give up fighting the corrupt political system. Start investigations, blow the whistle, file lawsuits and support a free and unbiased media. Otherwise, if left unchallenged, this system will metastasize and destroy us. Yours Bernd

Wednesday, June 06, 2012

Oregon's Medicaid Experiment

A story on NPR titled "Oregon's Medicaid Experiment Represents A Defining Moment" summarized an ambitious efforts to efficiently manage health care costs. Gov. John Kitzhaber, a Democrat and a former emergency room doctor, has convinced the federal government that he has a way to make Medicaid treatment better, and cheaper, by completely changing the way the sickest people in Oregon get health care. Under this new system each city will have its own umbrella group for caring for the Medicaid population, known as a "coordinated care organization." These umbrellas will include hospitals, doctors, mental health providers and dentists. Kitzhaber's vision is that all those health care businesses will stop competing so directly and will be linked electronically so that the systems can talk to each other — and patients can go wherever they need to get the most cost effective and high quality care. The goal of creating local coordinated care organizations is to improve care and reduce costs so deeper reductions won’t be necessary. Providers would have more flexibility in treating their members. Metrics would allow for providers and CCO to be paid based on member outcomes, instead of by just the number of services provided. For example, by keeping members at their healthiest and out of high-cost emergency rooms, providers would be paid more than if their members’ health did not improve. There are opportunities for shared savings when members are healthy and not in need of high-cost care such as emergency room visits Under the current system, hospitals and doctors don't have a financial incentive to make people better. Quite the opposite: If a patient keeps coming back, they keep getting paid. But under the new system, the quicker a patient gets better, the more money the coordinated care organization can keep. Kitzhaber believes that over the next five years, Oregon will be able to save the feds every penny of the $2 billion the state's been promised. "We estimated that if every state Medicaid program in the country were to adopt this model, the net savings would be about $1.5 trillion over 10 years," he said The question remains why Florida legislators stubbornly pursue a failed experiment to privatize Medicaid and refuse to examine other options? In my opinion, Oregon has taken a bold step forward in challenging all participating healthcare providers to collaborate to manage the scarce healthcare resources for the benefit of the patients and our community. Yours Bernd Addendum: What are "coordinated care organizations" and what is being proposed? House Bill 3650 proposes organizations in Oregon that would administer the health care coverage for OHP (Oregon Health Plan) members through a collaborative network of service providers. The vision is that CCOs would be a community-based network of patient-centered care, driven by local need. The idea is to take the best thinking in Oregon and creating local organizations focused on one thing: reducing the barriers that stand between members and good health. Because each community is different, there may be different models for CCOs. The criteria for how CCOs would operate are being developed with input from members, providers, stakeholders and the public. Today more than 80 percent of Oregon Health Plan members receive physical and mental health through a type of managed care organization that receives a set rate per patient for health care. Under the CCO model, a couple of key things would change. First of all, a CCO in a community would be responsible for coordinating all of the mental, physical and dental care for OHP members through collaborative relationships. Under the proposal, a CCO also would be paid differently than MCOs are today. There would be a global budget for all care, rather than a set rate or a “capitated rate” for each different type of care. At the same time, the CCO would have more flexibility to manage dollars in a way that pays for improved health rather than having to rely on approved billed services. Performance measurements for CCOs would provide incentives for better care. And CCOs would be accountable for addressing avoidable population differences in health care outcomes. Under the proposal, local providers would have the means and incentive to work together for the population they serve. There would be more flexibility for preventive care, chronic disease management and culturally competent care. The CCO would manage a global budget and if performance standards were met, providers could share in the savings. Source: Coordinated Care Organizations

Hospitals and Patient Safety

A new report card from healthcare watchdog the Leapfrog Group ranks hospitals for patient safety – A through F. A blue ribbon panel of the nation’s top patient safety experts provided guidance to the Leapfrog Group, an independent national nonprofit run by employers and other large purchasers of health benefits, to develop the Hospital Safety Score. The Hospital Safety Score is calculated using publicly available data on patient injuries, medical and medication errors, and infections. For the first time, the Hospital Safety Score will highlight the country’s best hospitals and warn against the worst to save lives and bring attention to the nation’s silent safety epidemic. According to recent studies, one in four Medicare patients will leave a hospital with a potentially fatal issue they didn’t have prior to hospitalization. On average, one medication error per day occurs for each hospitalized patient, and more than 180,000 Americans die every year from hospital accidents, errors, and infections. The Hospital Safety Score website allows visitors to search hospital scores for free, and also provides information on how the public can protect themselves and loved ones during a hospital stay. In South Florida 25 of 49 hospitals scored an "A." The news for South Florida hospitals wasn't all good, though. Eight rated a mediocre "C," including Mount Sinai Medical Center in Miami beach, Delray Medical Center, Plantation General Hospital and Wellington Regional Medical Center. Worse, six Miami-Dade County hospitals, including Jackson Memorial and the University of Miami Hospital, would have scored a "D" or an "F" but got a "score pending" reprieve in this go-round. They'll have a chance to improve their grades before the next ranking comes out in the fall, according to a public relations executive working with Leapfrog. Ashish Jha, MD, of Harvard, a member of the blue ribbon expert panel was quoted in the press release stating that "Even hospitals with excellent programs for surgical and medical care, state-of-the-art diagnostic equipment, and dedicated physicians may still need this score as a reminder that patient safety should be a top priority."