Medicare/ Medicaid

CMS P4P project shows diabetes care savings

Wed, 11 Jul 2007 20:01:37 -0400

While the evidence for cost-savings seems a bit, well, ambiguous, CMS this week is trumpeting the results of the first year of its diabetes care P4P project. CMS has just completed the first year of a three-year demonstration project under which the agency is monitoring diabetes care provided by 10 large medical practices. Diabetes management is being measured by standards drawn from CMS's Doctor's Office Quality project. Under the terms of the demonstration, which was mandated by Congress, CMS is providing financial incentives to practices that save more than 2 percent over projected costs.

Based on these standards, Marshfield Clinic and the University of Michigan Faculty Group Practice, Ann Arbor, earned about $7.3 million, 80 percent of the $9.5 million they're thought to have saved Medicare. Meanwhile, all 10 participating practices met at least seven of 10 clinical benchmarks. Still, it's worth wondering why eight of 10 practices don't seem to have generated significant savings. Let's see what happens when Medicare begins measuring care for congestive heart failure and other conditions over the next few years.

To learn more about the project:
- read this Modern Healthcare article (reg. req.)

Related Articles:
Physicians question CMS P4P effort. Report
Trend: Medicaid programs offer P4P incentives. Report
Positive results for Medicare P4P pilot. Report
Exclusive: How to make P4P work. Interview

Study: When uninsured get Medicare, it's costly

Wed, 11 Jul 2007 20:01:34 -0400

A new study suggests that when chronically-ill uninsured adults age into Medicare eligibility, they're sicker than adults who had commercial insurance when they entered Medicare. The study, published in The New England Journal of Medicine, found formerly uninsured adults were hospitalized more often and had greater medical expenses through at least age 72.

The study, conducted by Dr. John Z. Ayanian of Harvard Medical School, looked at 9,760 adults who were 51- to 61-years-old in 1992. It found when uninsured people became eligible for Medicare, they had 13 percent higher levels of doctor visits, 20 percent more hospitalizations and 61 percent greater medical expenditures. The effects were strongest in people with cardiovascular disease and diabetes.

To learn more about the study:
- read this piece in The New York Times

Related Article:
Medicare funds at-home doctor visits for chronically ill. Report

Three more heart transplant programs in jeopardy

Wed, 04 Jul 2007 20:01:37 -0400

Continuing its ongoing investigation of heart transplant programs, CMS has threatened three more programs with decertification. CMS has given San Antonio, Texas-based Christus Santa Rosa Hospital-Medical Center, Abbott Northwestern Hospital in Minneapolis and St. Vincent Indianapolis Hospital 30 days to submit corrective action plans. Meanwhile, a fourth heart transplant program at the University of Kentucky Chandler Hospital has agreed to give up Medicare funding entirely, at least for the time being, following the lead of eight other programs that have made the same decision.

Among the key issues troubling CMS is the low volume of procedures performed annually by the cited hospitals. In both 2005 and 2006, each of the four performed less than the minimum 12 heart transplants.

To find out more about the warnings:
- read this Los Angeles Times article

Related Articles:
One in five transplant centers substandard. Report
Four more heart transplant centers could lose CMS funds. Report
Sutter heart transplant program decertified by Medi-Cal. Report
CA hospital faces transplant suit, again. Report

New HHS program targets Medicare fraud

Mon, 02 Jul 2007 20:01:37 -0400

HHS has launched a new pilot program hoping to catch dishonest medical equipment suppliers in the Los Angeles area and South Florida. If the pilot is successful, CMS plans to role out the program across the United States. The two-year effort, designed to ferret out Medicare fraud, will search for falsified bills and overcharges from suppliers of prosthetics, orthotics, diabetic supplies and DME.

CMS has targeted the two regions not only because they're rich with equipment suppliers, but also because they have a long history of Medicare fraud. Known scams include setting up fake companies who bill Medicare for non-existent services and products that never get delivered to anyone. Nationally, Medicare estimates such fraudsters are stealing several billion dollars a year.

To find out more about the program:
- read this Los Angeles Times article

Related Articles:
NJ hospital to pay $7.5 million Medicare fraud settlement. Report
Siemens execs convinced of $49M hospital fraud. Report
LA doctors named in $12M Medicare scam. Report

St. Barnabas racketeering suit dismissed

Wed, 27 Jun 2007 20:01:37 -0400

Despite its having engaged in a massive Medicare scam costing the federal government at least $630 million, St. Barnabas Health Care System did not prevent other hospitals from getting fair reimbursement.

That's the conclusion of a federal judge, who ruled that despite the fraud, St. Barnabas had not engaged in racketeering. Two small hospitals in Maine and Colorado filed the suit, alleging St. Barnabas' over billing was so extreme it distorted CMS's Medicare reimbursement formulas nationwide. (St. Barnabas had been involved in a scheme to inflate reported costs for its most expensive procedures and thereby increase billings.) The hospitals contended St. Barnabas' actions led to thousands of facilities losing more than $500 million in federal money. The judge, however, ruled the government was the only victim of the health system's actions. When St. Barnabas agreed to repay $265 million, even that damage was mitigated.

To find out more about the case:
- read this article in The New York Times (reg. req.)

Related Articles:
NY hospitals sue UnitedHealth, claim racketeering. Report
UConn Health Center settles Medicare charges. Report
Pediatrix settles over-billing claim for $25M. Report
Medicare fraud costs CMS billions. Report

UConn Health Center settles Medicare charges

Tue, 26 Jun 2007 20:01:35 -0400

The University of Connecticut Health Center will pay more than $475,000 to settle Medicare over-billing charges. The hospital was accused of overcharging Medicare for cancer treatments, including chemotherapy and infusion therapy, from 2002 to 2004. The feds had charged that instead of billing Medicare on a per-patient basis, the Center's John Dempsey Hospital charged Medicare for the hours it spent in patient care, resulting in bills that were two- to seven-times larger than allowed. The hospital also settled charges it had billed improperly for the breast-cancer drug Herceptin.

To learn more about the case:
- read this Hartford Courant article

Related Articles:
California hospitals accused of over billing Medicare. Report
Pediatrix settles over-billing claim for $25M. Report
Medicare fraud costs CMS billions. Report

King-Harbor restructuring in jeopardy

Mon, 18 Jun 2007 20:01:36 -0400

When Harbor-UCLA Medical Center took over operations of troubled Los Angeles hospital King-Drew, the idea was that Harbor would purge much of the facility's staff and upgrade their skills. However, it appears this isn't happening, despite the fact that the hospital promised these changes to CMS after it threatened to pull its accreditation. Yesterday, county health officials told the Board of Supervisors that they had only reassigned one-third of the hospital's 1,200 employees. For example, two-thirds of 388 registered nurses on King-Harbor's staff, including two with previous suspensions, were still on staff as of late May. This comes despite the fact that 60 percent of registered and licensed vocation nurses failed one or more parts of basic clinical competency tests, along with 60 percent of nurses working in specialized environments such as operating rooms, ICUs and post-anesthesia care.

Harbor officials told the Board that they can only do so much to manage the former King/Drew, given that the two facilities are separately licensed. In reality, what this means is that Harbor-UCLA, whose reputation for care is strong, really isn't running King-Harbor on a day-to-day basis, critics say. This certainly doesn't bode well for King-Harbor keeping its CMS certification in the future.

To find out more about King-Harbor's problems:
- read this Los Angeles Times article

Related Articles:
After death, LA hospital faces training demand. Report
LA officials grapple with King-Harbor hospital death. Report
Senator questions CMS on King-Harbor. Report

Senator questions CMS on King-Harbor

Sun, 17 Jun 2007 20:01:36 -0400

High-profile troubles at Martin Luther King Jr.-Harbor Hospital are bringing the wrath of Congress down on CMS. Senate Finance Committee Chairman Max Baucus (D-MT) has written a letter to CMS Acting Administrator Leslie Norwalk demanding to know how CMS will make sure that the hospital meets Medicare standards in the future. The facility, formerly known as King-Drew, has faced scrutiny over alleged care lapses for some time now. In its prior incarnation as King-Drew, the hospital had lost its CMS accreditation entirely, winning it back only when it agreed to reorganize and scale back services. Now, that accreditation is on the rocks again, after the well-publicized death of 43-year-old Edith Rodriguez in its emergency department lobby. The hospital will announce a plan to address care deficiencies shortly. In the mean time, it has kicked out its chief medical officer and begun screening its nurses to assure they have adequate skills.

To learn more about CMS scrutiny:
- read this Modern Healthcare article (sub. req.)

Related Articles:
After death, LA hospital faces training demand. Report
LA officials grapple with hospital death. Report
Drew U. plans to close residency program. Report
King/Drew patients may be scattered. Report

IL suit says private clinics diverted poor to EDs

Thu, 14 Jun 2007 20:01:38 -0400

Illinois Attorney General Lisa Madigan has filed a lawsuit against two Chicago-area medical practices, contending that the two refused primary care to Medicaid patients in an effort to get them into their higher-priced affiliated emergency departments. The suit also charges that the clinics, Carle Clinic Association of Urbana, IL, and Christie Clinic of Champaign, IL, wanted to discourage Medicaid patients from visiting their facilities. According to the suit, the two clinics now employ more than 90 percent of physicians in their region, Champaign County. The Attorney General's office argues that any limits on Medicaid patients' access by such a powerful group of providers could prove particularly harmful.

To learn more about the suit:
- read this Chicago Tribune piece

Related Articles:
AMA cites antitrust activity among insurers. Report
Physicians drop out of new Medicaid plan. Report

PA releases hospital-specific cardiac surgery costs

Thu, 14 Jun 2007 20:01:37 -0400

The state of Pennsylvania has released a new cardiac surgery performance report which for the first time includes hospital-specific payment data. According to the report, which was issued by the Pennsylvania Health Care Cost Containment Council, the average payment for heart bypass procedures by commercial health plans was $30,247, and for valve-only procedures $41,651 during 2005. Medicare paid $29,175 for bypasses and $42, 433 for valve-only procedures. The state's hospital association praised the report, though it suggested that in the future, the data should be risk-adjusted to account for differences in a patient's health status.

To find out more about the report:
- read this Philadelphia Business Journal item

ALSO: According to one analysis, the PA study proves that higher prices don't necessarily translate to higher-quality care. Article

Related Article:
PA first to report hospital-specific infection rates. Report
Report card on CA doctors coming. Report
OH hospitals debate quality ratings. Report