Other than pharmacy benefit managers, which manage prescription drug plans, few other players in the health care market make decisions based on cost. When doctors write a prescription, they often fail to consider the price of the drug. And since many patients have prescription drug coverage, they also often ignore the cost. The situation can create a lucrative opening for some companies, especially in a low-profile corner of the industry like dermatology, where price increases might not attract broader notice.
The U.S. health-care system is vastly overspending for a single anemia drug because Medicare overestimates its use by hundreds of millions of dollars a year, according to an analysis of federal data. The overpayment to hospitals and clinics arises because Medicare reimburses them based on estimates rather than the actual use of the drug.
A draft report by a Justice Department scientific working group laments the nation's shortage of these specialists. Forensic pathologists' dwindling numbers have implications for the health care system. The national autopsy rate is down to a "miserably low" 8.5 percent, with only 4.3 percent of disease-caused deaths undergoing autopsy, the report says. That means there's less available data on whether medical procedures were performed properly.
A whistle-blower lawsuit based on insider information from a former Florida HospitalOrlando billing employee and a staff physician alleges that seven Adventist Health hospitals in Central Florida have overbilled the federal government for tens of millions of dollars in false or padded medical claims. The suit claims Florida Hospital used improper coding for more than a decade to overbill Medicare, Medicaid and Tricare, all federal government payors. In addition, it alleges, the hospital commonly overbilled for a drug used, for example, in MRI scans and billed for computer analyses that were never performed.
A 2011 study in the Journal of the American Medical Association found that only half of 144,000 nonemergency heart catheterizations—typically the use of tiny balloons and stents to clear blocked arteries—were appropriate; 38 percent were "uncertain" and 12 percent were "inappropriate." "It's presented in the media as if it's an aberrancy, when actually it's the rule," said Dr. David Brown, an interventional cardiologist and professor of medicine at SUNY-Stony Brook School of Medicine of the unnecessary heart procedures. "The medical system is addicted to the revenues that it generates." In 2011, Medicare alone spent nearly $1 billion on the procedures.
CMS released its first list of 27 qualified ACOs that meet the requirements of its Medicare Shared Savings plan. As of July 1, HHS announced that 89 new accountable care organizations have begun serving 1.2 million Medicare patients in 40 states and Washington, D.C. That's not to suggest that the feds have a monopoly in this space. In total, Leavitt Partners estimates there were 221 private and public ACOs in the U.S. as of the end of May 2012. This overview of how eight ACOs are treading these uncertain waters might help inform your own decision.