Medicare & Medicaid Fraud: Health Care’s Most Wanted Fugitives

For first time ever,  the Office of the Inspector General (OIG) for the U.S. Dept. of Health and Human Services (HHS) is publishing a list, complete with the mug shots below, of HealthCare’s “10 Most Wanted Fugitives,”   individuals who have allegedly defrauded taxpayers of more than $126.6 million.   These are just 10 of the more than 170 fugitives on OIG’s list, and it is asking the public to help:  “For OIG, tracking more than 170 health care fugitives is a challenge. If you have a tip about a featured most-wanted fugitive, send the information our way.”

If you go to the webpage of mug shots  and click on the photos, you’ll find a brief bio and details  of the fugitive’s crime.

For instance, consider Tarek Wehbe: Between January 2002 and January 2007, Wehbe, a physician, allegedly submitted fraudulent claims to Medicare, Medicaid, and private health insurance carriers in order to obtain reimbursement for services that were either not provided, medically unnecessary, and/or over-charged.

Reports From the Field: How Health Reform is Already Helping Families

To commemorate the one-year anniversary of the Patient Protection and Affordable Care Act, MomsRising, a five-year-old advocacy group dedicated to building "a more family friendly America," has produced an interactive map that provides stories from across the country about how health reform has helped or eventually will impact its members.

MomsRising advocates for such issues as paid sick time, removal of toxic substances from children’s products, fair pay for women and increasingly, supports the full roll-out of health reform. The map of personal stories they’ve produced is a powerful way to convey how the health law is spurring positive changes at the grassroots level.

Here are just a few snippets from stories members around the country have submitted:

“The changes in the health care law will allow my son, who is a full time student to be covered under the health insurance policy I have through my empolyer. He was dropped in December when he turned 23. He has been unable to afford individual health insurance…” (PA)

“My 9 year old son has seizures and is able to get his medication and continue to see his specialist because of health care reform. Since his pills and Dr. visits are so expensive - I won't have to worry about him reaching a lifetime maximum for coverage…” (CA)

"Closing the coverage gap for Medicare Part D Prescription coverage will make a huge difference in our lives. My 35-year-old husband has a pre-existing condition, for which he takes expensive prescription drugs. He's covered under Medicare, but we make too much money to qualify for any other assistance. He gets to the coverage gap in April, and we spend the rest of the year paying over $500/month for his medications. It's not easy, and we are very much looking forward to this cost going down." (WI)

"Though I have been in remission for over 10 years insurance companies still believe that covering me is too great of a risk, even for illnesses and accidents that have little or no relationship to my illness. Soon my husband will be eligible for Medicare and I will be without insurance for eight years. With the provision in the Health Care Reform Bill that preexisting conditions are covered I will be able to buy insurance at a reasonable rate.” (MI)

Click on this link to access the rest of these stories or view them by clicking on the interactive map below.

Source: MomsRising 2011

Life Is Sacred: Unless You’re An Illegal Immigrant

Recently, I wrote about Danielle Deaver, the Nebraska woman who was denied an abortion after her 22-week fetus was deemed unviable. Instead of being permitted to terminate her pregnancy, Deaver was forced by state law to endure “10 excruciating days” waiting for the extremely premature fetus to be born.

The Deavers were victims of Nebraska’s ill-conceived “fetal pain” law which prohibits abortions in the state after the 20th week of pregnancy. It is based on the discredited notion that a fetus may feel pain at that stage of development. Physicians who break the law face felony charges that could result in five years in prison and a $10,000 fine.

At the time, the author of the Nebraska law, Speaker Mike Flood, a Republican, said that even though the infant gasped and suffered for fifteen minutes before dying, he felt confident that the statute worked as planned in the Deaver case:

"Even in these situations where the baby has a terminal condition or there's not much chance of surviving outside of the womb, my point has been and remains that is still a life," Flood told the Des Moines Register.

Well, it turns out that the sanctity of life is not applicable in all cases in Nebraska. Last year the state passed a different law that eliminated Medicaid funding for prenatal care for about 1,600 low-income women, about half of whom were illegal immigrants. Doctors and health clinic administrators told the Lincoln Journal Star, that this cut in funding has had “dramatic effects.”

Woman on Staten Island Puts Together a Network of U.S. Doctors and Hospitals, Changing the Lives of Children Crippled by War

Fifty-seven year old Elissa Montati has little money and no training in humanitarian aid. All she has is “a computer and a phone” CBS correspondent Scott Pelley explained on 60 Minutes last night. Nevertheless, over the past 15 years, Montati, who lives alone on Staten Island, has transformed the lives of more than 100 children maimed, burned, and crippled in wars on five continents. She has done this by putting together a network of U.S. doctors and hospitals, one by one that agree to waive their fees and treat these children at no charge.

Montati runs her operation out of her former walk-in closet. “I added a window,” she explains. “And it works. I speak to the world right outta my walk-in closet.”

Asked where the 112 children she has helped come from, Montanti told Pelley, "Bosnia, El Salvador, Liberia, Niger, Sierra Leone, Iraq, China, Indonesia, Pakistan, Haiti. Did I say Nepal?"

The High Cost of Care in a Sellers Market

Below, a guest-post by David Spero, R.N.  Spero is the author of Diabetes: Sugar-Coated Crisis  -- Who Gets It, Who Profits and How to Stop It, a book that Thomas Bodenheimer MD, Professor of Family and Community Medicine, University of California, San Francisco describes as “a hard-hitting and beautifully written look at the social causes and cures of chronic illness... illuminates the true reality of diabetes and provides cutting-edge ideas on prevention and treatment.” (Bodenheimer’s recommendation puts it on my “to-read” list.)

In this post, Spero explains why “free market competition” doesn’t work to bring us affordable health care. Quite simply, the seller has too much power. Drug-makers and device-makers set their own prices, with little push-back from public-sector or private sector payers. Lobbyists have managed to push through a law stipulating that Medicare cannot negotiate for lower drug prices. As for private insurers, they have found that if they don’t cover all of the drugs advertised on TV, they lose customers. So for the past ten years they have been shelling out whatever the manufacturer demands, while passing the cost on in the form of higher premiums.

In the case of doctors and hospitals the situation is more complicated.  As I explain in a note following Spero’s post, total reimbursements to providers have been spiraling--though some physicians and medical centers have enjoyed the lion’s share of the gains, while others have watched their income drop.

High CEO Salaries at Nonprofit Hospitals Under Scrutiny…Once Again

Shock and outrage ensue every time the press gets wind of the million-dollar-plus salaries and other perks reaped by some CEOs at nonprofit hospitals. This year is no different—except that the ongoing recession that is forcing states to make painful budget cuts, especially by slashing Medicaid programs, is making the compensation reports especially hard to stomach.

In New York, for example, a state Medicaid-redesign commission recently recommended cuts to health care spending that total $2 billion. But while the proposal includes limiting home health care, increasing co-pays for Medicaid recipients, reducing their dental and mental health services, and putting a $250,000 cap on malpractice claims, there was no mention of limiting what the New York Times calls “lofty” salaries for CEOs at nonprofit hospitals.

Making Health IT Work in a Hospital: the CMIO Should Be a Doctor

A hospital’s Chief Medical Information Office (CMIO) should be a physician, says Pam Brier, president and CEO of Maimonides Medical Center “because nobody knows a doctor’s business like a doctor.” 
As a hospital’s information technology (IT) point person, a CMIO needs to be able to persuade physicians and other health care professionals that health information technology (HIT) can help them care for patients.

It is not that Brier believes that non-physician managers can’t talk to doctors. . . After all, she herself is not an M.D. Yet she runs Maimonides, a top-ranked 700- bed teaching hospital in Brooklyn, New York.

On the other hand, Brier is not an MBA either. She has a master’s in Health Administration, which means that, unlike many hospital CEOs who went to graduate school to study business, she understands that an organization that provides health care is not a “business” in any ordinary sense of the word. A hospital is a service organization: its raison d’etre is to meet the needs of a community and its patients.

The Dark Side of Industry-Funded Drug Trials

There are many serious problems with the current U.S. mental health system, the most glaring being the over-use or misuse of psychiatric drugs, the warehousing of the mentally ill to prisons and emergency rooms, and the unholy connection between academic researchers and pharmaceutical companies that can result in stilted clinical trials of already-approved drugs and misleading efficacy information that is used to boost sales.

I have written about these issues on HealthBeat before, but no single case demonstrates the convergence of these problems better than the tragic story of Dan Markingson, a young man who suffered his first bout of severe psychosis and schizophrenia in the summer of 2003. In November of that year, Markingson was taken to the University of Minnesota Medical Center in Fairview and against his mother’s wishes, was enrolled into an industry-sponsored drug trial being run by his psychiatrist, Dr. Stephen Olson. Six months later on May 8, 2004, mentally deteriorating and still enrolled in the study, Markingson, 27, committed suicide in the shower of his halfway house by violently stabbing himself in the neck, chest and abdomen.

Can Academic Medical Centers Become Accountable Care Organizations?

Below, an excerpt from a superb post by Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, that was originally published on Wachte'r's World. There, he questions whether academic medical centers (AMCs) will be able to turn themselves into the accountable care organizations (ACOs) that reform legislation favors. Or as Wachter, puts it: "Are Academic  Medical Centers Toast in a Post-Healthcare Reform World?”

I believe that some AMCs will be able to “re-vision” themselves, and that this will be the best thing that ever happened to them. Many AMCs need to re-set their priorities, putting less emphasis on money-driven research, while focusing more of  their resources on safe, patient-centered care. As  Wachter,observes, this will mean changing the keenly competitive and often wasteful medical culture traditional at many AMCs.

Robotic Medicine: A Surgeon Confesses That He Was Seduced By a Robot

U.S. healthcare is awash in medical technology, and recently, in an editorial published on Bloomberg.com, one surgeon suggested that we may be drowning. For as Dr. Craig D. Turner, a urologist in Portland, Oregon points out “what is different with the new wave of technological marvels is that many are heavily driven by marketing; here he links to an ad by GE Health touting wide-bore MRIs “Simply Powerful, Powerfully Simple.”

New technology always poses risks, he points out, because it “requires that physicians master arduous new skills” which means that while doctors climb a steep learning curve, some patients may be hurt.  Someone has to be one of the first hundred patients a doctor learns on. Meanwhile, often, the new, new thing “lacks clear benefits compared with established and less-costly technology.”

Innovation is proceeding at a pace that helps drive waste: “One health-care administrator told me the basement of the hospital is full of million-dollar machines collecting dust -- not because they didn’t work or because they were ineffective, but because they have been displaced by newer technology.”
“Now 10 years into surgical practice, I have learned some hard lessons related to new technologies,” Turner admits. “Patients often are put at greater risk as we physicians scale the learning curve. . . More things can go wrong.”