The Role of Safety Net Providers

Attached a link to an article published in the recent edition of Health Affairs titled " Safety-Net Providers In Some US Communities Have Increasingly Embraced Coordinated Care Models." The findings of this study were also the focus of an article by John Dorschner published in the Miami Herald titled " Jackson Memorial Hospital too weak, county too divided to provide good safety net, study says." Here are some background information, facts and study findings excerpted from the article: FACTS: Safety-net providers play a crucial role in providing health services to uninsured and low-income people. Although the Affordable Care Act is expected to expand coverage to more than thirty million uninsured people, it is generally recognized that the safety net will still be needed to provide services to an estimated twenty million people who will remain uninsured. In addition, in all likelihood, many existing Medicaid and newly insured patients will continue to use safety-net providers rather than private mainstream providers because the safety net can better meet low-income people’s specialized needs related to language, culture, and transportation PROBLEM: Delivery of health services through the safety net historically has been fragmented. Usually hospitals, community health centers, and private physicians providing charity care have operated independently of each other, with little or no coordination of the care of a patient. Such fragmentation can result in severe gaps in the availability of services, reduce quality, lead to redundant use, and increase the costs to providers who typically operate with limited resources and thin margins. SOLUTIONS: During the past decade, however, a variety of community efforts to better coordinate care for the uninsured that reduce the use of emergency departments and increase the use of primary care providers have been documented. Most community initiatives focus on providers’ efforts to better manage care for their uninsured patients; stretch limited public and private funds; and address serious gaps in services, particularly the lack of access to specialty care. Often these programs improve access to care for the uninsured at a much lower cost than either private insurance or local Medicaid programs. STUDY DESIGN: The Community Tracking Study, conducted by the Center for Studying Health System Change, consists of in-depth tracking of health system changes in twelve randomly selected metropolitan areas from 1996 to 2010. Representative of US metropolitan areas, the communities are Boston, Massachusetts; Miami, Florida; Orange County, California; northern New Jersey; Cleveland, Ohio; Indianapolis, Indiana; Phoenix, Arizona; Seattle, Washington; Lansing, Michigan; Syracuse, New York; Greenville/Spartanburg, South Carolina; and Little Rock, Arkansas. The article describes safety-net coordination efforts in twelve randomly selected communities and illustrates how these efforts evolved during the past decade. In particular, we focus on initiatives that attempted to coordinate care across multiple providers and were often communitywide in scope. These initiatives were better able to manage the care of uninsured patients than a more fragmented system of care (for example, the initiatives used more outpatient primary care to reduce inpatient and emergency department use). Some evidence obtained from the twelve communities indicates that initiatives to coordinate care across providers reduce high levels of emergency department use and reduce the cost of providing care to the uninsured, but barriers to coordination remain. SELECTED KEY ASPECTS & FINDINGS OF THE STUDY : Nine of the twelve communities studied had some type of organized safety-net program in 2010, compared to only three communities in 2000 Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. Five of the six programs explicitly require patients to have a medical home that they use for all primary care needs. A primary care physician practice that serves as a medical home is generally responsible for authorizing referrals for specialty care. Generally, a single primary care physician serves as the medical home for program participants. An exception is HealthNet in Boston, which is organized around the fifteen participating federally qualified health centers that serve as medical homes for the patients who are referred to Boston Medical Center (the safety-net hospital that administers HealthNet) for specialty and inpatient care. Centralized referral networks are the most common type of community initiative and have grown most quickly during the past decade. They focus primarily on providing a centralized location where patients can receive referrals to physicians and schedule appointments with private practice physicians (mostly specialists) who agree to treat uninsured patients for free or at reduced costs. A few of the (MEDICAL HOME) programs use provider incentives, such as capitation or enhanced fees, to encourage appropriate utilization of services for patients. For instance, the Medical Services Initiative in Orange County offers financial incentives for physicians to join the network. The program also includes extra payments for medical homes to provide at least one visit for each patient per year (two for people with chronic conditions), pay-for-performance incentives for medical homes to improve utilization of preventive services, and incentives for providers to reduce emergency department utilization. Health Advantage in Indianapolis pays capitated rates to primary care physicians to motivate physicians to encourage appropriate use of services and build relationships with their patients. It is unknown, however, whether these incentives are inadvertently discouraging the use of appropriate or necessary services. Formal evaluations of the six coordinated care programs have not been conducted or are not publicly available. One reason may be a lack of staff availability or other resources. However, available data show that Health Advantage in Indianapolis has been successful in decreasing inpatient use and emergency department use. In the first eighteen months after the program began, inpatient days for uninsured people decreased by 50 percent, and emergency department use decreased by 30 percent. In addition, in collaboration with researchers from the University of California, Los Angeles, the Medical Services Initiative in Orange County found that the ER Connect program reduced emergency department visits and increased the number of visits to primary care providers.Recent research on similar programs not included in the Community Tracking Study found that their patient costs were 25–50 percent lower than for patients enrolled in local Medicaid programs or through private insurance. What are the challenges and problems safety-net providers face? Many of the programs lack the capacity to serve all of the eligible uninsured. Providers’ practices are often full, and they have limited availability to see new patients, especially uninsured patients for whom they provide care for free or for reduced fees. Publicly subsidized programs are vulnerable to cuts in funding, especially given the strained local and state budgets of recent years. A major concern is the potential loss of funding for programs that have relied on Medicaid’s disproportionate-share hospital payments, extra payments to hospitals that serve a large number of Medicaid and uninsured patients, which are to be reduced under the Affordable Care Act. Health insurance coverage expansions in the Affordable Care Act may create the perception that the uninsured problem has been solved and these safety-net programs are no longer needed, potentially bringing an end to such efforts. Despite efforts at greater community collaboration, fragmentation and competition among safety-net providers remains. Competition among safety-net providers for Medicaid patients can inhibit closer cooperation. Most safety-net hospitals and federally qualified health centers depend on Medicaid patients for their financial viability both because reimbursements are based on the cost of care (and therefore are considerably higher than reimbursement rates to private physicians) and because grant revenue often doesn’t cover the full cost of care to the uninsured. Community health centers may be reluctant to participate in collaborative arrangements if they think that such cooperation could result in a loss of Medicaid patients. For example, interview respondents from Miami noted that some federally qualified health centers in the community were concerned that efforts by Jackson Health System (the main public hospital) to convert some of its primary care clinics to federally qualified health centers would increase competition for Medicaid patients, given the higher Medicaid rate that the hospital-based clinics receive. Safety-net hospitals are often the natural leaders for community integration efforts given their size and broad service area, not all safety-net hospitals are willing or able to assume that role. For example, Jackson Health System is the primary safety-net hospital for Miami-Dade County but generally does not provide a leadership role in coordinating care and services with other safety-net providers in the community. Part of this reflects Jackson’s financial troubles at the time of the site visit (Jackson lost about $240 million in 2009 and $100 million in 2010), which forced it to cut back on some services. But it also reflects the fragmented nature of Miami’s safety net, which respondents characterize as having more competition than coordination and collaboration among providers to provide care to low-income Medicaid and uninsured patients. Outlook & Opportunities: Safety-net providers—including health centers and hospitals—can form accountable care organizations to participate in Medicare’s Shared Savings Program, in which networks of providers that jointly take responsibility for the cost and quality of care provided to their patients can share in Medicare savings. New demonstration projects to test new payment and care delivery models have a potential impact on safety-net coordination.15 For instance, the bundled payment model involves a single payment to multiple providers for an episode of care, which motivates providers to coordinate and deliver care more efficiently. Safety-net coordination initiatives are also well poised to facilitate the insurance coverage expansions and health insurance exchanges created in the Affordable Care Act because of their established centralized enrollment systems that screen for eligibility for other public insurance. A MUST read article! Yours Bernd

Medicaid Expansion in the News

I case you missed those articles. Carol Gentry's great article titled Medicaid expansion could save over 5,000 lives was published in yesterdays Miami Herald " Other Views" section. In the article she referred to a recent New England Journal article titled Mortality and Access to Care among Adults after State Medicaid Expansions which concludes that State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health. Carol Gentry correctly argues that " If Medicaid expansion prevents 2,840 deaths/year for every 500,000, then Florida’s looking at 2,840 times 2, or about 5,680 a year. These are early deaths that are preventable. So when the debate begins about Medicaid expansion, remind those who control the state that they aren’t just talking about money. They’re talking about lives." She provided a factual contrast to Rick Scott's position whose "arguments" can be boiled down to a simple dogma: We need to help people get the skills and education they need to get a job, and help the private sector succeed so they have jobs to offer. Then you’ll have fewer people dependent on government programs because they’ll be pulling themselves out of poverty and financial distress. There is ONLY one problem! Even higher education and more skills won't get you better paid jobs anymore and no more unions are available to fight for workers rights, benefits and fair pay! Therefore, people need to work in two or three jobs to make ends meet which almost always is not enough to pay for expensive health insurance premiums. Rick Scott's line of argument reminds me of the statements made by communist party officials I encountered many years ago when I spent some time in communist East Germany and had to endure the ideological communism babble. Its almost the same tune: we need more .... ism to make people happy. Well, extreme right and left do meet each other at the fringes of extreme "thinking." But as of today at least I know that our rights come from nature and God, not from government. Guess, I have to do a bit more praying to get access to those rights fast because my health insurance premiums keep on rising. Yours Bernd

Back to the Future?

Attached a link http://online.wsj.com/article/SB10000872396390444840104577552823507551472.html to an article titled " Remember Managed Care? It's Quietly Coming Back" and video clip to the same topic http://live.wsj.com/video/health-insurers-erect-more-patient-hurdles/00207EE1-AEBD-4631-A6B8-78616EA417C1.html#!00207EE1-AEBD-4631-A6B8-78616EA417C1 highlighting the emergence of a new (old) policy by some of the U.S.'s biggest health insurers requiring doctors to get prior authorization before patients can get certain care. Managed care companies tried this in the 90's and quickly backed off responding to political pressure and the fact that employers switched away from restrictive health-maintenance organizations. So what will be different now? Health insurers say today's versions of 1990s strategies use new technology to focus closely on improving care as well as reining in expenses. UnitedHealth, for one, said it is using prior authorization "surgically" to counter "extreme variations in quality and cost." But doctors aren't sure how much things have changed. We must carefully monitor this new(old) development because it certainly will increase the workload in primary care practices WITHOUT receiving additional reimbursement. Yours Bernd

Healthcare in Israel

As a licensed Israeli physician and Israeli citizen I am grateful that Governor Romney praised the achievements of the Israeli healthcare system. He was quoted saying at a fundraiser in Jerusalem, “When our healthcare costs are completely out of control. Do you realize what healthcare spending is as a percentage of the GDP in Israel? 8 percent. You spend 8 percent of GDP on healthcare. And you’re a pretty healthy nation.” Yes, Israelis are enjoying superb healthcare because Israel requires all residents to carry insurance (mandatory insurance coverage) and puts caps on parts of the healthcare system (rationing of healthcare services). Israel created a national government controlled healthcare system in 1995 with compulsory participation. The system is funded through payroll and tax revenue and the government provides all citizens with health insurance.Health care coverage is administered by a small number of organizations, with funding from the government. People get to choose between four nonprofit plans, which have to accept all applicants including those with pre-existing conditions. All Israeli citizens are entitled to the same Uniform Benefits Package, regardless of which organization they are a member of, and treatment under this package is funded for all citizens regardless of their financial means. There are no life-time caps and nobody can be dumped off the insurance plan, The plans also must provide a list of government-mandated benefits. In the U.S. certain political groups call such a system a "socialist model" and any country that embraces such model a " socialist society." In Israel we call it a human right and cherish the accomplishment of our democratic society. Thank you Governor Romney for supporting Israels efforts to provide healthcare for all. I hope that Governor Romney will allow us to learn from Israel and to adopt their system. Yours Bernd

Medicaid Expansion in Florida

Attached a link to an editorial published in today's Miami Herald titled "Not so fast, Gov. Scott" focusing on Governor's Scott refusal to expand Medicaid. The editorial emphasizes that " for Floridians desperate to get basic healthcare the consequences could be dire. Train wreck, perfect storm, falling off the cliff — all of these phrases have been used to describe the impact of Mr. Scott’s decision unless the Legislature takes a more thoughtful approach. ....If Florida continues to ignore the “working poor” who can’t afford health insurance, these patients will have no recourse except to continue relying on public hospitals for unreimbursed care. But they will do so without the increased funding that the new law guarantees as compensation for the states, placing the burden on local taxpayers." The costs of uncompensated care will be passed down as a "hidden tax" to business that provide insurance for their employees, or to individual insurance policy holders. In 2008 this added an extra $1,017 to annual family health insurance premiums, and an additional $368 in individual premiums. The National Association of Public Hospitals estimates that about 4 million people who would have been eligible for Medicaid could go uninsured in states that have decided against expansion. In Florida, the move would expand coverage to an estimated one million more adults and children. Rejecting expansion will worsen the problem of uncompensated care in Florida, which already has the third highest percentage of uninsured patients in the country. But wait, it gets worse! Officials at the Jackson Health System are wary. They get $350 million in a special Medicaid appropriation from the Low Income Pool, far more than any other hospital in the state. They worry that if those funds are redistributed by Congress to cover Medicaid expansion nationwide, they could lose more than they gain in federal funds for new Medicaid patients. Without those funds Jackson Memorial Hospital and other hospitals in South Florida will be in dire financial straits. Lets remind ourselves why that is happening: Because the political leadership in this state is dominated by ideological "thinkers" who are refusing to acknowledge reality. Therefore, its of crucial importance that we act now using all available social networking tools at our disposal to educate and mobilize Floridians. Yours Bernd

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

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

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 http://www.pnhp.org/ Yours Bernd

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

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

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

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."

Healthcare Costs Analysis

Attached a link to an interesting article titled “Database to shed light on healthcare costs” reporting that researchers from the nonprofit, nonpartisan Health Care Cost Institute gained access to a database of 3 billion medical claims for more than 33 million individuals. The previously confidential information, scrubbed of identifying details, is being provided by three of the nation’s largest insurance companies: Aetna, Humana and United Healthcare, whose combined customers account for about 20 percent of Americans under age 65 who are insured through an employer. Until now, researchers have had to extrapolate from far smaller surveys of employers, or rely on government claims statistics from Medicare, which are almost exclusively limited to Americans over 65. The institute offered a first look at its findings, in a report that largely confirmed previously identified trends, but added intriguing details. The published results shed light on questions such as why healthcare costs are still rising faster than the inflation rate and why people seek less care. Attached a summary of the findings: Decline in healthcare utilization: According to the report, from 2009 to 2010 people with employer-sponsored insurance had 3.3 percent fewer admissions to hospitals and other medical facilities, 3.1 percent fewer “outpatient” visits to such facilities, and virtually no change in the number of procedures performed at doctor’s offices. In 2010, the average out-of-pocket payment for an admission to a hospital or other facility went up by more than 10 percent, to $700. The total charge for an outpatient visit including an emergency room visit or surgery that does not require an overnight stay also rose 10 percent, reaching $162. Reason: Cost-shifting to consumers of healthcare services. Many employers push more of the cost of care onto workers in the form of higher deductibles, co-pays and co-insurance. Prices grew at faster rates than the intensity of services: Increased spending by not just patients but employers was primarily caused by increases in the prices that hospitals, doctors and other providers charged for every category of service in 2010. The total price per outpatient visit, including the insurer and the out-of-pocket share, rose 10 percent, to $2,224. The increase was also significant for inpatient admissions, which went up 5.1 percent, to $14,662. Higher healthcare spending for younger patients: The growth in spending per patient in 2010 was as much as twice as high for those 18 and under than for any other age group. Does this mean that younger patients will have higher costs through their lives, which raises implications about bending the long-term cost curve? In my opinion we need more of those data to learn more about healthcare spending and how to contain rising healthcare costs.

Medicare Fraud and "Obamacare"

Attached an interesting article by Jay Weaver titled "Feds arrest more than 100 Medicare fraud suspects in South Florida, nationwide" reporting that several days ago, the feds charged 107 suspects with submitting $452 million in false bills to Medicare in seven U.S. cities. In the Miami area, 59 of those defendants were accused of trying to steal $137 million from the taxpayer-funded healthcare program.As a result of stepped-up law enforcement Medicare’s expenditures for a variety of medical services in South Florida decreased by a half-billion dollars over the past year alone! Its also important to emphasize that these successful efforts to curb Medicare fraud are part and parcel of the Patient Protection and Affordable Care Act (PPACA). The President has made a commitment to reduce Medicare fraud 50% by 2012. Therefore, the Affordable Care Act provides an additional $350 million over the next ten years to help fight fraud through the Health Care Fraud and Abuse Control Account (HCFAC) from FY 2011 through 2020. The Act also allows these funds to support the hiring of new officials and agents that can help prevent and identify fraud. Furthermore, the Affordable Care Act directs the Sentencing Commission to increase the Federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1,000,000 in losses. The law makes obstructing a fraud investigation a crime and makes it easier for the government to recapture any funds acquired through fraudulent practices. And the law makes it easier for the Department of Justice (DOJ) to investigate potential fraud or wrongdoing at facilities like nursing homes. Those "Obamacare" opponents who rail against the law should be reminded that they have failed to provide an alternative option on how to save half-billion dollars over the past year! Yours Bernd

Choose Wisely

Wednesday, April 18, 12 To The Editor of the Miami Herald RE: “Better health, fewer tests”, April 16th, 2012 As a board-certified family physician and addiction specialist I endorse the initiative, Choosing Wisely, of the ABIM Foundation supporting evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation. We must understand that health care costs are finite! We reached a tipping point that leaves only two options: health care rationing, or the efficient utilization of treatment resources. This requires a new health care delivery paradigm based on expanded primary care access, care coordination, utilization of information technology to measure quality and outcome of care, and the involvement of the patient as a partner and not the object of care. Such a Patient Centered Medical Home (PCMH) will not only contain and manage health care costs but, most importantly, will improve care. We also must shift from a volume to a value based payment system rewarding those health care providers who demonstrate accountable, efficient and safe quality medical care. We spent more than two-third of our health care resources on chronic disease management. We could stop the waste! Our patients need to understand that they have to share responsibility for their wellness care and treatment. Joint accountability implies that physicians and patients are partners in the healthcare delivery process. I am optimistic that we can succeed improving our country's health care system.

Healthcare and the Supreme Court

Attached a link to an interesting article "Is public option the last one?" emphasizing that IF the Supreme Court decides to strike down the entire health care law it might create a predicament for our legislators to resolve the healthcare quandary: Congress wouldn't be able to rely on the private market, because that would require a mechanism to force healthy people into the risk pool. And it would have trouble relying on a federal-state partnership, because that might be considered coercive. Ironically, striking down the individual mandate, or the entire law, would create an inevitable choice:a federal insurance program that would clearly pass constitutional muster. Medicare represents such a model, which currently covers the elderly and is run entirely by the federal government. Medicare gives no role to the states and therefore does not coerce them into anything. An expansion of this program to all Americans funded by a payroll tax would be a workable solution. In my opinion it would be fiscally and morally irresponsible to continue the status quo. Happy Passover and Happy Easter Yours Bernd

Jackson Memorial Hospital in Crisis

Jackson Memorial Hospital, one of our finest teaching hospitals in the U.S., is stuck in a perpetual financial crisis caused, among other reason, by poor management. The proposed solutions do not follow surgical precision thinking but can only be compared with brute amputations threatening to destroy this great institution. The current management lacks strategic vision and obviously does not understand that the rapidly changing health care market demands flexibility and quick adaptation to evolving concepts of care delivery and reimbursement. This requires the development of team based care harvesting the creativity and experience of the highly skilled workforce. Therefore, it's counter-intuitive to reduce the number of experienced health care workers who are needed to develop and sustain new care delivery systems such as the Patient Centered Medical Home (PCMH). The Patient Centered Medical Home is a model of care where each patient has an ongoing relationship with a personal clinician who leads a team that, together, takes responsibility for patient care. The clinician-led care team is responsible for providing all the patient's health care needs and when needed, coordinating care across the health care system. The comprehensive care provided by the medical home leads to better health, longer lives, higher patient satisfaction and less expensive care. Other hospital systems in the U.S. are successfully pursuing such concepts and are being rewarded financially. For example, all 11 hospitals and six large community health centers of the New York City Health and Hospitals Corporation have received medical home designation for delivering accessible, comprehensive and family-centered primary care to New Yorkers that aims to reduce avoidable healthcare costs over time. The special designation was granted by the National Committee for Quality Assurance (NCQA) to 616 primary care physicians who collectively care for nearly 100 percent of HHC's primary care population of more than 477,000 adult and pediatric patients. All of the HHC facilities received "Level 3" designation, the highest ranking, which will qualify HHC for more than $15 million in Medicaid reimbursement rate increases every year. Jackson Memorial Hospital can lead the field in health care innovation and its not too late to implement changes. But we need a management team that can translate vision into reality. Yours Bernd

Supreme Court and Health Care

On Monday morning the Supreme Court will begin hearing arguments about whether the Individual Mandate is constitutional. On what case law the Supreme Court can base its decision? Lets look at the facts. In a recent New York Times article titled " At Heart of Health Law Clash, a 1942 Case of a Farmer’s Wheat" the author points out that a 1942 decision, Wickard v. Filburn, is the basis for the Supreme Court’s modern understanding of the scope of federal power. What was the core issue? The U.S. government had established limits on wheat production based on acreage owned by a farmer, in order to drive up wheat prices during the Great Depression, and one farmer, Roscoe Filburn, was growing more than the limits permitted. Filburn was ordered to destroy his crops and pay a fine, even though he was producing the excess wheat for his own use and had no intention of selling it. The Supreme Court interpreted the United States Constitution's Commerce Clause under Article 1 Section 8, which permits the United States Congress "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes". The Court decided that Filburn's wheat growing activities reduced the amount of wheat he would buy for chicken feed on the open market, and because wheat was traded nationally, Filburn's production of more wheat than he was allotted was affecting interstate commerce. Thus, Filburn's production could be regulated by the federal government. The Supreme Court issued a decision which included the following statement: "The power to regulate interstate commerce includes the power to regulate the prices at which commodities in that commerce are dealt in and practices affecting such prices." ( P. 128) And this is the issue we are dealing with today! The Filburn decision illustrates just how much leeway the federal government has under the Constitution’s commerce clause to regulate the choices individuals make in matters affecting the national economy. If the government can make farmers choose between growing crops on their own land and paying a penalty, the administration’s lawyers have said, it can surely tell people that they must obtain health insurance or pay a penalty. Now, if the Supreme Court decides that the individual mandates violates the commerce clause then insurance companies will face a quandary: on the one hand they have to offer health insurance coverage to each and every applicant regardless of his/her health status, but on the other hand they cannot sell enough insurance policies to healthy individuals to cover for those expenses because the individual mandate was declared unconstitutional. The health care law will still be valid BUT the financing will be on shaky grounds. Therefore, insurance companies already began to develop alternatives which will include steep premium increases for individual policies! Economists believe that the mandate, as envisioned by the law, will make a significant difference in reform’s impact. Some suggest that removing the mandate from the law would diminish the number of newly insured by nearly two-thirds and raise premiums overall by 30 percent. The Rand Institute researchers predict that eliminating the mandate would have little effect on premiums for individuals. But they, too, believe that health insurance coverage would fall dramatically — from 27 million additional people insured to just 15 million. Those are just projections, but the experts note that one state has managed to impose insurance reforms without weakening its insurance market. It’s Massachusetts, which happens to be the one state that also imposed an individual mandate. More than 98 percent of the state’s residents now have insurance, by far the highest percentage in the country. Premiums in the non-group market have fallen by 50 percent, relative to national trends, while premiums in the group market aren’t rising any faster than they were before the reforms began. Lets hope for the best and I predict the Supreme Court will uphold the individual mandate. Yours Bernd