"California regulators fined two insurance giants for overstating their Obamacare doctor networks and said the companies will pay millions of dollars in refunds to patients who paid too much for care.
The state’s Department of Managed Health Care levied fines of $350,000 against Blue Shield of California and $250,000 for Anthem Blue Cross. At issue were the companies’ error-riddled provider directories that frustrated many consumers statewide as they tried to find doctors during the rollout of the Affordable Care Act in 2014. As a result, some patients incurred big unforeseen medical bills because they unwittingly went out of network for care. In addition to the state's enforcement action, consumer lawsuits are still pending against both insurers." Read more at LA Times A pharmaceutical firm's recent decision to hike the cost of a prescription drug that treats foodborne illness from $18 to $750 per tablet outraged millions of Americans.
The move prompted Democratic presidential candidate Hillary Clinton to accuse the Swiss-American company Turing of "price gouging." The following day, Clinton unveiled her national plan to rein in drug prices -- and borrowed an idea from California: cap out-of-pocket costs for some prescriptions to save patients with chronic or serious health conditions thousands of dollars. The Golden State's effort to tackle the issue of skyrocketing drug prices is among the most aggressive in the nation, opening up a wider debate over an industry whose sales account for 10 percent of the nation's $3 trillion in annual health care costs. There seems little doubt that the controversy over rising drug prices will rage on and become a key issue in the presidential race. Though average generic drug prices have fallen by more than half since 2008, costs for the name-brand prescription drugs that treat chronic and life-threatening diseases have more than doubled over that period, up 127 percent, far more than the 11.24 percent inflation rate. Read more at San Jose Mercury News "Gov. Jerry Brown has signed legislation that requires weekly updates to health-service provider directories so people know what doctors and hospitals are in their network when they they shop for coverage or seek care.
Senate Bill 137 by West Covina Democrat Ed Hernandez responds to consumer complaints about inaccurate online directories. This has been a problem for years, but things got worse when thousands of consumers tried to pick a plan and provider after signing up for new insurance under the Affordable Care Act. The problem got so bad that Covered California took its provider search tool down in February 2014. It still isn’t up — consumers are directed to individual health plan websites instead. The Department of Managed Health Care slammed Anthem Blue Cross and Blue Shield of California last year for failing to provide accurate provider lists. The agency is preparing to do follow-up surveys to see if inaccuracies have been fixed, spokesman Rodger Butler said." Read more at Modern Healthcare Too many to post individually over the last few days:
Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid Bristol-Myers Squibb To Pay $14 Million To Settle Charges Of Bribery. "WASHINGTON (AP) -- Bristol-Myers Squibb will pay $14.6 million to settle charges from U.S. regulators that its joint venture in China gave cash and other benefits to government health care providers to boost drug sales. The Securities and Exchange Commission announced the settlement of civil charges Monday with the company, one of the largest drugmakers in the world. Bristol-Myers Squibb, based in New York, makes and sells prescription and over-the-counter medicines worldwide." Read more at AP California Woman Pleads Guilty In Medicare, Medicaid Fraud Scheme "LOS ANGELES – A Placentia woman pleaded guilty Monday to a federal charge stemming from the operation of a hospice that submitted millions of dollars in fraudulent bills to Medicare and Medi-Cal. Sharon Patrow, 44, entered her plea to a health care fraud count before U.S. District Judge S. James Otero, who set a May sentencing date. Patrow's mother, Priscilla Villabroza -- who is serving a 4 1/2-year term at a federal prison in Victorville for running a separate health care fraud scheme -- is also charged in the case. The mother and daughter, along with four others, were charged in December with 25 health care fraud and money laundering counts, each of which carries a potential multiple-year prison sentence, according to the U.S. Attorney's Office. The case involves the formerly Covina-based California Hospice Care, which Villabroza purchased in late 2007 while under investigation in the earlier case, prosecutors said. Officials allege that between March 2009 and June 2013, California Hospice submitted nearly $9 million in fraudulent bills to Medicare and Medi- Cal for purportedly providing end-of-life care to patients who were, in fact, not dying. The public health programs paid nearly $7.5 million on those allegedly bogus bills." Read more at OC Register Columbus Regional Agrees To Pay $35M Over Medicaid Fraud Claims "COLUMBUS — Last week, the hospital business in Georgia’s second-largest city received a double dose of financial misery. The first round of bad news centered on Columbus Regional Health. State Attorney General Sam Olens announced Friday that Columbus Regional and other related entities had agreed to pay Georgia and the United States up to $35 million to resolve allegations of false Medicaid claims. Then the Columbus Ledger-Enquirer reported Saturday that the other hospital organization in town, St. Francis, has been told by the feds that it must repay $21.4 million and make major changes in the way it does business. The federal audit report came 10 months after St. Francis said it could not account for about $30 million on its financial books." Read more at Albany Herald Atlanta Hospice Reaches $3 Million Settlement In Medicare Fraud Case "A Georgia hospice company has agreed to pay $3 million to resolve allegations it billed taxpayers for patients who were not terminally ill, the latest such settlement as federal officials target what they call a burgeoning number of abusive hospice schemes. Guardian Hospice set aggressive targets to recruit and enroll patients it knew were not in the last months of their lives so it could collect Medicare payments, the federal government alleged. In agreeing to the settlement, the for-profit company, which serves the Atlanta area, did not admit liability." Read more at AJC Government Accountability Office Report Highlights Improper Payments In Medicare, Medicaid WASHINGTON: Three health and safety net programs for the poor and elderly accounted for most of the federal government’s $124.7 billion in improper payments in fiscal 2014, the Government Accountability Office reported Thursday. "The figure, which represents improper payments across 124 federal programs, is up roughly 20 percent from $105.8 billion in fiscal 2013, according to a new GAO report. Most of the $19 billion increase resulted from erroneous payments under the Medicare, Medicaid and Earned Income Tax Credit programs. They account for more than 75 percent of the GAO’s government-wide improper payment estimate. Improper payments are those made in error or in an incorrect amount and can include duplicate payments, those made without proper documentation or to ineligible recipients, and payments for ineligible goods and services. They can result from fraud, unintentional clerical errors or a host of other reasons. Nearly $1 trillion in improper federal payments have been made since 2003, when a federal law began requiring certain agencies to report the amounts." Read more at McClacthyDC "When it comes to health care costs, it’s clear: Where you live matters. And in California, the gap is especially sharp between the north and south.
Take, for instance, common procedures like a cesarean section or a total knee replacement. The total average price tag for a typical C-section in the four-county Sacramento area is $28,828; in east Los Angeles County, it’s $17,567, according to a health care comparison tool unveiled last week by state officials and Consumer Reports magazine. And that knee replacement? It’s about $42,488 in the Sacramento Valley but drops to $27,276 in east Los Angeles County." Read more at Sacramento Bee "Medical giant Cedars-Sinai Health System said Tuesday it has acquired nearby Marina Del Rey Hospital, adding to a flurry of similar healthcare deals. Cedars-Sinai said it has purchased the 145-bed hospital and its neighboring medical office building. The price wasn't disclosed.
Marina Del Rey Hospital will operate as an affiliate of Cedars-Sinai and continue to provide its existing services, including a 24-hour emergency room. All 660 hospital employees will remain in place, according to Cedars-Sinai. Marina Del Rey Hospital was owned by a partnership led by Westridge Capital, a private investment firm based in Los Angeles. The deal fits in with Cedars-Sinai's ongoing efforts to expand and make care more convenient to patients in the community. It's also part of a larger consolidation trend among U.S. hospitals and, more recently, big health insurers." Read more at LA Times "Paramedic Jacob Modglin parks on a palm-lined street in Oxnard and jumps out of his ambulance. He is prepared for any kind of emergency.
But his patient is standing in the driveway of a one-story house, holding a thermos, and smiling. It's time for his 8 p.m. appointment. Modglin is part of a new cadre of "community paramedics" working in a dozen pilot programs across California. Their jobs are to treat patients before they get sick enough to need emergency care. The paramedics are still first responders, just deployed to prevent a crisis rather than react to one." Read more at The Los Angeles Times "Last year, 369 students graduated from Iowa medical schools, but at least 131 of them had to finish their training elsewhere because Iowa had only 238 residency positions available.
The story was the same for at least 186 students who graduated from Missouri medical schools and 200 who studied at Tennessee schools. States such as New York, California, Massachusetts, and Pennsylvania were happy to take them -- all four states took in more residents than students they trained. This is the world of medical resident matching. When states don't have enough residency positions for the medical students they've trained, they become resident exporters. When states have more residency positions than they have students to fill them, they become importers. Medical students have a strong interest in where they end up. But so do states. Many have a shortage of doctors, especially in primary care. And physicians who go to medical school and do their residency in a single state tend to stay. Sixty-eight percent of doctors who complete all their training in one state end up practicing there, according to the Association of American Medical Colleges (AAMC). So while some states spend tens or hundreds of millions of dollars to support medical schools and build new ones, a handful are recognizing that it's just as important to invest in residency programs -- to increase the number of doctors practicing within their borders." Read more at MedPage Today "Super-utilizers are the frequent fliers of the health care system, whose serious illnesses send them to the hospital multiple times every year and cost the system hundreds of thousands of dollars annually. Figuring out how best to address these patients’ needs and reduce their financial impact on the health care system is a subject of intense interest among policymakers. Now a new study has found that, in contrast to the notion that “once a super-utilizer, always a super-utilizer,” many patients who use health care services intensely do so for a relatively brief period of time.
Research and news reports often point out that super-utilizers are often uninsured or on Medicare and Medicaid and account for a large percentage of health care spending. Federal officials have suggested that their “large numbers of emergency department [ED] visits and hospital admissions … might have been prevented by relatively inexpensive early interventions and primary care.” Many of the programs that have been developed to reduce super-utilizer health care use have focused on the needs of people with multiple chronic conditions, ensuring they have a medical home through which their care is coordinated, for example, or addressing their social services needs." Read more on Kaiser Health News "Traditionally, medical students haven't been taught how to talk with their patients about the costs of treatments and medications. The thinking was that doctors should offer their best advice to all patients, regardless of their insurance or ability to pay.
But in a huge departure from the past, the vast majority of the country's medical schools now integrate discussions of cost, value and effectiveness into their curricula. It's "a dramatic change," says Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, which helps medical schools develop curricula." Find more at KPCC |
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March 2016
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