Top hospitals vary in their HIPAA-mandated responses to patient records requests, and researchers suggest it may be time for the government to toughen penalties for noncompliance.
Many of the nation's top hospitals are doing an uneven job of following federal rules for providing patients with their medical records, a new "secret shopper" study in JAMAshows.
Researchers at Yale University Medical School faced obstacles when attempting to get patient records from 83 hospitals in 29 states that were named as among the nation's best by U.S. News & World Report.
The researchers were trying to determine if the hospitals were complying with federal Health Information Portability and Accountability Act mandates for accessing patient medical records.
Study senior author Harlan M. Krumholz, MD, a cardiologist and researcher at Yale University and Yale-New Haven Hospital, said the problem could be much worse nationwide because the "secret shopper" used to compile responses intentionally targeted well-resourced hospitals.
"This is going on at top hospitals that should be able to invest in these things," Krumholz says. "That's why we thought this was a good place to start, because this should be the best case scenario."
The study sought patient records two ways: using telephone calls, and filling out records request forms.
For the phone calls, a researcher reading from a script called the records departments at the hospitals over a three-month span last fall, asking for the entire medical record of a patient that included lab tests, medical history, physician exam results and discharge notes.
The researcher asked about if the cost and time it would take to obtain the records, and if the records could be picked up in person, mailed, emailed, faxed, placed on CDs or accessed through a patient portal.
"There was discordance between information provided on authorization forms and that obtained from the simulated patient telephone calls in terms of requestable information, formats of release, and costs," the study said.
"On the forms, as few as nine hospitals (11%) provided the option of selecting one of the categories of information and only 44 hospitals (53%) provided patients the option to acquire the entire medical record," the researchers said. "On telephone calls, all 83 hospitals stated that they were able to release entire medical records to patients."
Even then, there were discrepancies in the information provided by hospital records keepers in telephone calls versus what the hospitals' records request forms said. For example, 83% of the hospital administrators said on the telephone that the patient records could be picked up in person, while only 48% of hospital records request forms said that was the case.
HIPAA requires that patient records be supplied in the format requested by the patient.
"For some places it's a strategy," Krumholz says. "One health system told me that they didn't have an interest in making it easy for people get the records because then people might go to the place across town. I actually heard someone say that!"
"But for most places it's not part of a strategic effort. It's more benign neglect," he says. "The people in the records room don't necessarily seem up to date with the regulations that were instituted a decade ago and they haven't configured a system that makes it easy for people."
There was no accounting for the prices hospitals charged to access the records. The study found that 48 hospitals charged well above the federal recommendation of $6.50 for electronically maintained records. In one instance, a hospital charged $541.50 for a 200-page record.
Krumholz says the study findings on fees are consistent with many complaints he's heard from acquaintances trying to access medical records.
"I know someone whose mother was in a top New York hospital and she said 'I need to take her records back with me,'" Krumholz said. "They brought out a big box and said 'We can give you all these records, but it will be $600.' She said 'I'm not paying that much,' and they said 'How about $300?'"
Krumholz says federal and state regulators haven’t enforced existing laws on accessing patient records, but that may change.
"CMS Administrator Seema Verma has had her own experience of having trouble getting the medical records for her husband, and she's talked about this," Krumholz says. "She's going to get CMS behind improving this situation, either through better incentives or stronger penalties."
"I am hoping that the hospitals, once they realize what's going on, will want to address this themselves."
The five zones saw 40,000 additional ER visits, 18,562 fewer inpatient stays, and a net savings of $108 million over four years for a program that cost the state $15 million to implement.
Maryland's state-funded Health Enterprise Zones have seen large reductions in inpatient stays in the underserved communities where they provide care, a new study shows.
However, the study, published this week in Health Affairs, also found that emergency room visits rose dramatically within the HEZs.
Overall, researchers at the Johns Hopkins Bloomberg School of Public Health found that the zones saw a drop of more than 18,000 inpatient stays that generated about $108 million in net savings over four years.
"We see a large cost saving here from a relatively small investment," said study lead author Darrell J. Gaskin, director of the Hopkins Center for Health Disparities Solutions at the Bloomberg School.
Five years ago, Maryland created Health Enterprise Zones in Annapolis/Morris Blum, Capitol Heights, Caroline and Dorchester counties, Greater Lexington Park and West Baltimore, with goals to improve health and reduce unnecessary hospitalizations.
The state brought in primary care physicians and other health workers to improve care access and promote healthier behaviors in the Zones, which had higher rates of Medicaid use, lower-than-average life expectancy and other poverty indicators.
Gaskin says the key to success for the five HEZs, which are led by local health departments or hospital authorities, is to understand the care needs for their particular zone.
In the Annapolis area, for example, the HEZ installed a primary care clinic in a senior citizens' center. In the Lexington Park area, the problem was a lack of reliable transportation to healthcare facilities. So, the HEZ bought vans to transport people to healthcare appointments.
"Each zone tailored their program to meet the needs of their particular population. The state didn't tell them what to do. They just held them responsible for the healthcare outcomes," Gaskin says.
To gauge the success of the HEZs, the Johns Hopkins researchers analyzed state data on hospital inpatient stays, readmissions, and ER visits between 2013—2016. They compared the metrics in 16 zip codes in the HEZs and in 94 zip codes that were not covered but had similar demographics.
The rate of inpatient stays per 1,000 people declined in both populations during the study period—but declined more in the population served by the HEZs.
Over the four-year study period there were 18,562 fewer inpatient stays than would otherwise have been expected. Relative declines were even greater for the chronic conditions, such as diabetes, hypertension and chronic obstructive pulmonary disorder, that the HEZ initiative was specifically meant to reduce.
Unexpectedly, the analysis also linked the HEZs to 40,488 extra ED visits during the study period, but Gaskin says that statistic should be put in context.
"Some of this is emergency physicians not admitting patients, which they normally would have done, because now they're comfortable with sending those patients home," he says.
"Now they know the patient has a care coordinator or primary care provider in that in the community who they can immediately connect that patient with to help them manage their care," he says. "So, what we would have seen in our data as an inpatient stay, instead we see an ED visit."
Gaskin says the 40,488 extra emergency room visits cost $60 million, but the reduction of 18,562 inpatient stays saved $168.4 million, for a net savings of $108.5 million in the HEZ program that cost $15 million over four years.
Stakeholders call the 340B program 'a tremendous success' as Congress considers legislation that would raise the eligibility threshold and cut the number of eligible hospitals in half.
CEOs representing more than 700 hospitals in the 340B drug pricing program are urging Congress to protect their discounts.
In a letter this week to U.S. House and Senate leaders, the CEOs said that recent proposals to cut back the 340B program would worsen the high prices charged for drugs.
"We are concerned about recent regulatory actions that have reduced the reach of this vital program and by legislative proposals that would undo more than two decades of bipartisan work to preserve the healthcare safety net," they said.
The 340B requires drug makers to provide discounts to hospitals and other healthcare providers that serve high volumes of low-income or rural patients.
The CEOs did not identify specific threats to the 340B program, but their letter was delivered as Congress considers legislation that would raise the eligibility threshold for 340B hospitals, which safety-net advocates say would cut participation in half.
They note that 340B hospitals represent 38% of all acute-care hospitals but account for 60% of all uncompensated care. In addition, they note that the program discounts represent less than 2% of drugmakers' revenues, and supports safety-net care at no cost to taxpayers.
"Because of the savings from 340B, we are able to offer vital but often money-losing services including obstetrics, trauma care, opioid addiction treatment and HIV/AIDS care," the letter said. "In many rural communities, 340B savings are the difference between hospitals staying open and closing."
Critics say the 340B program is deeply flawed, ultimately leads to higher drug costs for consumers, and creates perverse incentivizes for hospitals to drive up treatment costs and increase profits.
A June audit by the Government Accountability Office found lax oversight of the 340B program by the Department of Health and Human Services' Health Resources and Services Administration.
HHS Secretary Alex Azar told the 340B Coalition Summer Conference in July that reforms were coming for the program, but reassured the advocates that 340B-covered providers who responsibly invest their savings have nothing to fear.
An OIG audit found widespread noncompliance with IRF guidelines, with providers and CMS sharing the blame.
Medicare paid hospital-based inpatient rehabilitation facilities $5.7 billion in one year for care that was not reasonable and necessary, a new audit shows.
The review, done for the Office of the Inspector General at the Department of Health and Human Services by an independent auditor, examined $6.75 billion in Medicare payments to 1,139 IRFs nationwide for 370,872 IRF stays in 2013.
The audit used a random sample of 220 IRF claims totaling $11.3 million in payments to 164 IRFs in calendar 2013, which is the most recent claims data available when the audit began.
The auditors were asked to determine if the medical records in the sample met federal coverage and documentation requirements for IRF fee-for-service claims in 2013.
According to the audit findings, may IRFs did not. Only 45 of the 220 sampled IRF stays complied with all Medicare coverage and documentation requirements.
"For 175 of the sampled stays, corresponding to 135 IRFs, medical record documentation did not support that IRF care was reasonable and necessary in accordance with Medicare's requirements," OIG said.
"On the basis of our sample results, we estimated that Medicare paid IRFs nationwide $5.7 billion for care to beneficiaries that was not reasonable and necessary," OIG said.
OIG noted a number of problems with the IRF program that led to the spotty regulation, such as:
Inadequate internal controls at IRFs that failed to identify and prevent inappropriate admissions.
Inadequate Medicare Part A FFS prepayment reviews for IRF admissions.
Ineffective educational efforts and post-payment reviews at Centers for Medicare & Medicaid Services that haven't controlled increasing improper payment rates reported by Comprehensive Error Rate Testing (CERT) since the 2013 audit.
Administrative hearings for IRF appeals that did not always include CMS to ensure that Medicare requirements were accurately interpreted.
A poorly designed IRF payment system that did not align cost with payments, which OIG said may have provided IRFs with a financial incentive to admit patients inappropriately.
While not calling for a return of the $5.7 billion, OIG did recommend that CMS:
Educate IRF clinical and billing personnel on Medicare coverage and documentation requirements and work with providers to develop best practices.
Increase oversight for IRFs, such as post-payment medical review.
Work with the Office of Medicare Hearings and Appeals to ensure that Medicare coverage and documentation requirements for IRF care are fairly represented at administrative hearings.
Re-evaluate the IRF payment system, which could include a demonstration project requiring preauthorization for Medicare Part A FFS IRF stays modeled on Medicare Advantage practices.
CMS agreed with the findings and recommendations in its written response to the audit, and said it was taking action to address the problem areas identified by OIG.
Molina CEO Joe Zubretsky says the deal gives the Long Beach-based managed care company 'flexibility to invest and refocus resources in our core health plan business.'
Molina Healthcare, Inc. has completed the previously announced $231 million sale of subsidiary Molina Medicaid Solutions to DXC Technology Company, the two companies said this week.
"The proceeds will provide additional resources and flexibility to invest in and focus on the Company's core health plan business and to continue executing on its margin recovery and sustainability plan," Molina said in a media release.
MMS provides technology platforms for Medicaid agencies in five states and the U.S. Virgin Islands to assist in claims processing, benefits management, administration and other business operations.
When the sale was announced in late June, Molina CEO Joe Zubretsky said the deal would give the Long Beach, California-based managed care company "flexibility to invest and refocus resources in our core health plan business."
DXC Technology provides IT services for government health agencies in 42 states.
"The combination of DXC and MMS significantly strengthens DXC's ability to provide the highest-quality services to state agencies in the administration of Medicaid programs, including what MMS now brings to the table—business processing, information technology development and administrative services," DXC Chairman, President, and CEO Mike Lawrie said in a media release.
Molina is still recoveringfrom a rocky 2017, which saw a companywide reorganization, top management turnover, and ultimately a $512 million loss for the year, which the company blamed on the cost of the restructuring and the federal government's refusal to pay subsidy payments.
So far, 2018 has been kinder to Molina, which posted Q2 net income of $202 million, compared to a net loss of $230 million in Q2 2017, and saw its net income per diluted share rise to $3.02 from $1.64 in Q1.
This week's civil settlement, and last year's separate $260 million criminal settlement, add up to $885 million in penalties for one of the nation's largest drug wholesalers.
AmerisourceBergen Corp. and its subsidiaries will pay $625 million to resolve civil claims that the drug wholesaler improperly repackaged cancer drugs into pre-filled syringes and sent them to physicians treating cancer patients, the Department of Justice said.
According to federal prosecutors, the drug wholesaling giant profiteered by skimming drug "overfill" contained in the original FDA-approved sterile vials and creating pre-filled syringes through a subsidiary, the now-shuttered Medical Initiatives Inc., that ABC claimed was a pharmacy.
Prosecutors said Alabama-based MII shipped millions of repackaged pre-filled syringes to oncology practices, with drugs that included Procrit, Aloxi, Kytril and its generic form granisetron, Anzemet and Neupogen.
As part of the scheme, ABC purchased original vials from manufacturers, broke their sterility, pooled the contents, and repackaged the drugs into pre-filled syringes, DOJ said.
All the while, ABC submitted no data to the FDA to show that it had ensured the safety and efficacy of the repackaged drugs, which prosecutors said were sometimes prepared in non-sterile conditions and contaminated.
ABC used the overfill to create more doses than it bought from the manufacturers. Federal prosecutors allege that ABC's scheme allowed it to bill multiple providers for the same vial of drug. Those providers then billed Medicare, Medicaid, TRICARE, the VA and other federal healthcare programs for the same vial.
The scheme also enabled ABC to boost its market share with product discounts, which it leveraged to lure new customers and to keep existing customers, DOJ said.
Last year, AmerisourceBergen Specialty Group, a subsidiary of AmerisourceBergen Corp., pled guilty to illegally distributing misbranded drugs and paid $260 million to resolve criminal charges for distributing drugs from a facility that was not registered with the FDA.
This week's settlement resolves ABC's civil liability under the False Claims Act for billing federal healthcare programs for the repackaged drugs. In total, the drug wholesaler will pay about $885 million in civil and criminal penalties.
"ABC placed corporate profits over patients’ needs, endangering the health of vulnerable cancer patients," said Richard P. Donoghue, U.S. Attorney for the Eastern District of New York.
ABC, one of the nation’s largest wholesale drug companies and ranked No. 11 on the Fortune 500 list, will pay the federal government $582 million, and will pay state Medicaid programs $43 million, plus accrued interest, as part of the civil settlement.
The deal with prosecutors resolves claims made in three whistleblower lawsuits, and those plaintiffs will receive $93 million of the federal recovery.
The settlement also resolves allegations that ABC paid kickbacks to physicians to induce them to purchase Procrit in pre-filled syringes. The kickbacks came as general pharmacy credits provided to customers, but which were not identifiable as specific to Procrit on invoices.
ABC on Monday issued the following statement: "By resolving this matter and entering into the Corporate Integrity Agreement, ABC acknowledged that some of its practices at MII were not consistent with AmerisourceBergen’s approach to corporate compliance."
"Medical Initiatives was voluntarily closed in 2014 and by entering into the corporate integrity agreement now, we are confirming both our commitment to compliance and to the continual evaluation and enhancement of our already robust compliance programs."
The average premium for employer-sponsored plans rose $267, or 4.4% between 2016 and 2017, which is twice the increase recorded between 2015 and 2016.
Employees who get their health insurance through their job are paying a lot more now than just a few years ago in premiums, co-pays and deductibles, a new study finds.
The average annual premium for an individual health insurance policy offered by employers rose $267, or 4.4%, to $6,368 between 2016 and 2017—nearly twice the increase recorded between 2015 and 2016 (2.3%), according to a new analysis from the University of Minnesota’s State Health Access Data Assistance Center.
In addition, the SHADAC researchers saw significant increases in workers' deductibles and co-pays in 2017.
"Attention has been focused on cost increases in the federal and state insurance marketplaces, but most people get coverage through their own or a family member's employer and face rising costs," Lynn Blewett, director of SHADAC, said in a media release.
"While employers continue to offer insurance benefits to their employees, they are increasing the worker share of rising costs," Blewett said.
SHADAC researchers analyzed employer-sponsored health insurance among private sector workers between 2016 and 2017 using the most recent data available from the Medical Expenditure Panel Survey.
Nationwide, the analysis shows that the percent of eligible workers receiving health coverage through their job held steady in 2017, at 73.5%, representing nearly 60 million employees.
The analysis shows:
Annual premiums for single coverage increased in 15 states in 2017, with increases ranging from 5.2% in Pennsylvania to 11.5% in Wyoming.
Nationwide, the average annual deductible for single coverage rose to $1,808 in 2017 an increase of $112 or 6.6%. Nearly half of workers enrolled in employer-sponsored plans (48.7%) had a deductible at or above $1,300 for an individual or $2,600 for a family.
16.1% of employer-sponsored plan enrollees nationwide had a separate deductible for prescription drugs in 2017. In 10 states, more than 20% of employees (including 47.3% in Mississippi) faced such a deductible.
Average annual out-of-pocket limits for single-coverage work-sponsored plans rose to $4,246 nationwide, an increase of $147, or 3.6%, between 2016 and 2017. Required co-pays for office visits rose 2.4% for primary care and 4.2% for specialist care.
"Cost increases at this level aren’t sustainable and require a renewed commitment to improving the effectiveness and value of healthcare services, so insurance can be more affordable for everyone," said Mona Shah, a program officer at Robert Wood Johnson Foundation, which sponsored the study.
America's Health Insurance Plans spokesperson Cathryn Donaldson did not dispute the findings, but said that "premiums and deductibles track directly with the underlying cost of health care, which continues to rise overall."
Over the past decade, Donaldson says, employer health costs have moved in a narrow band and premium growth has been modest.
Donaldson said employer-sponsored health plans are also offering employees more coverage options, including high deductible plans with lower monthly premiums that can be coupled with tax-deductible health savings accounts.
"High deductible plans with HSAs offer consumers more financial protection, control over their health care dollars, and greater peace of mind," she said. "In fact, more Americans are now choosing a HSA with a high deductible plan than ever beforebecause it empowers them to make affordable health care choices that aligns with their health care needs."
Kalispell Regional Healthcare System 'strongly disagrees with the allegations' brought forward by a former executive, but is 'relieved to put this issue behind us.'
Montana-based Kalispell Regional Healthcare System and six subsidiaries will pay the federal government $24 million to settle whistleblower allegations that it paid kickbacks to physicians to entice patient referrals, theDepartment of Justice said.
The government alleges that the False Claims Act and Stark Law violations occurred between 2010 and 2018, and that, among other illicit behavior, KRH paid excessive full-time compensation to more than 60 physician specialists—many of whom worked far less than full-time—as a means of securing referrals.
In addition, six KRH subsidiaries— HealthCenter Northwest LLC, Flathead Physicians Group LLC, Northwest Horizons LLC, Northwest Orthopedics & Sports Medicine LLC, and Applied Health Services Inc.—conspired to pay physicians employed at Kalispell Regional Medical Center to induce referrals to HealthCenter.
The subsidiaries also conspired to charge below fair market value for administrative services provided to HealthCenter, which unduly profited the physician investors at Flathead, who had an ownership stake in HealthCenter, DOJ said.
Under the settlement, KRH will pay $21.2 million, Flathead Physician Group will pay $2.8 million.
"Financial arrangements that improperly compensate physicians who make referrals to a hospital drive up the cost of healthcare services for everyone," Assistant Attorney General Joseph H. Hunt for the Department of Justice's Civil Division said in a media release.
The settlement resolves whistleblower claims brought in two lawsuits filed by Jon Mohatt, a former CFO for KRH's Physicians Network, who will pocket $5.4 million as his share of the recovery in the two consolidated cases.
Kalispell Regional Healthcare issued a statement detailing the settlement, adding that while the health system "continues to strongly disagree with the allegations, we are relieved to put this issue behind us."
"The Board of Trustees carefully considered the ongoing costs and distraction that litigation would impose upon the system, our employees, and the communities we serve," KRH said.
"We believe that a settlement allows our system to put this difficult matter behind us and allows our physicians and employees to move forward and focus on providing the excellent care that our community expects," KRH said.
"During the government’s review, the quality of care our physicians and staff provide was never questioned nor was overutilization an issue."
Shareholders will consider the compensation packages on Oct. 29, when they vote on the proposed merger with RCCH HealthCare Partners.
LifePoint Health CEO Bill Carpenter could descend gently into retirement strapped to a $70 million golden parachute, according to proxy statements filed Thursday with the federal government.
Carpenter and three other top executives at the Tennessee-based for-profit hospital chain will receive a total of $121 million in golden parachute compensation, according to the document, which was filed with the Securities and Exchange Commission this week.
LifePoint shareholders are expected to vote on the compensation package and the merger on Oct. 29 at LifePoint's Brentwood, Tennessee headquarters.
Carpenter's retirement was announced on Wednesday, and it will take effect after the merger with RCCH HealthCare Partners is finalized later this year.
His successor, David Dill, LifePoint's current president and COO, will also get a plush golden parachute compensation valued at $25.5 million, according to information posted on Page 125 of the proxy statement.
Two other top executives at the company, CFO Michael S. Coggin, and CAO John P. Bumpus, will receive golden parachute compensation valued at $13.4 million and $11.4 million, respectively, the proxy statement said.
Carpenter has a long history with LifePoint, which specializes in hospital operations in non-urban settings. He was a founding employee when the company was formed in 1999, and has served as CEO since 2006 and was appointed chairman of the board in 2010.
"It has been an absolute privilege to lead LifePoint for nearly 13 years, and to be a part of the team since the company’s inception almost 20 years ago. I am incredibly proud of all the organization has accomplished during that time," said Carpenter.
"We’ve grown from 23 hospitals in 9 states, to nearly 70 hospitals in 22 states today, to a footprint that will soon span coast to coast, pending completion of our merger with RCCH HealthCare Partners," he said.
LifePoint and RCCH, both of which are headquartered in Brentwood, Tennessee, announced their merger in July. Dill will be the first CEO of the merged company, which will keep the LifePoint Health name.
The CMS administrator says the Trump administration is committed to giving states the flexibility they need to contain their Medicaid costs, even as some critics suggest that regulating the work requirement will cost more money than it saves.
Centers for Medicare & Medicaid Services Administrator Seema Verma on Thursday offered a robust defense of the Trump administration's work requirements for "able-bodied adults" on Medicaid.
"There is dignity and pride that is derived from work—for paying one's own way—and I believe it is the desire of nearly every American to achieve financial independence," Verma said in remarks before the 2018 Medicaid Managed Care Summit.
"Let me be clear, there is no shame in receiving extra help when it’s needed—that's why we have a safety net to care for folks on hard times," Verma told the summit. "But our default position must always be to help and encourage those who are able to lift themselves up and find their footing again."
In January, CMS put forward guidelines for states seeking waivers for Medicaid work requirements. So Far, CMS has approved work-requirement waivers for Arkansas, Indiana, New Hampshire, and Kentucky, although that state's waiver was later vacated by a federal court. CMS is reviewing waiver proposals from seven other states.
Critics of the work requirements dismiss them largely as either a stunt or a back doorway to pare the Medicaid rolls.
The Centers on Budget and Policy Priorities has said the work requirements will kick many low-income adults off Medicaid "including people who are working or are unable to work due to mental illness, opioid or other substance use disorders, or serious chronic physical conditions, but who cannot overcome various bureaucratic hurdles to document that they either meet work requirements or qualify for an exemption from them."
Verma said Thursday she has heard the criticism and faced resistance to the work requirements.
"But I reject the premise, and here is why: it is not compassionate to trap people on government programs, or create greater dependency on public assistance as we expand programs like Medicaid," she said.
"Community engagement requirements are not some subversive attempt to just kick people off of Medicaid," Verma said. "Instead, their aim is to put beneficiaries in control with the right incentives to live healthier independent lives."
Verma said the policies used to determine work eligibility for Medicaid enrollees "are not blunt instruments."
"We’ve worked carefully to design important protections to ensure that states exempt individuals who have disabilities, are medically frail, serve as primary caregivers, or have an acute medical condition that prevent them from successfully meeting the requirement," she said.
It's not clear how many Medicaid enrollees would be affected by the work requirements. A study from the Kaiser Family Foundation suggested in June that the impact would be negligible because only 6% of Medicaid enrollees targeted by the work requirements aren't already working and are unlikely to qualify for an exemption.
"Most working Medicaid enrollees are working full-time for the full year and are working in low-wage service jobs with limited benefits such as sick time or health coverage," the Kaiser study said.
Verma rejected that assertion.
"Some have argued that these demonstrations are unnecessary because nearly all Medicaid beneficiaries are already working," she said. "To that I say—great. Then this policy won’t impact them."
In addition, Kaiser said work requirements for Medicaid would also require states to establish complex and potentially expensive verification processes to track enrollees which could not be paid for with federal Medicaid funds.
In other words, the work requirements could potentially cost states more money than they save.
Verma noted that federal spending on Medicaid grew by more than $100 billion between 2013 and 2016, and is a top budget expenditure for many states.
"We have a responsibility to make sure that taxpayer dollars are spent only on qualified services for those who are truly eligible, even as we return greater control of the Medicaid program to the states," she said.
