The Richmond-based health system says it discovered the overcharges during an audit of patient files, notified federal officials, and helped with the investigation.
Virginia Commonwealth University Health System Authority will pay the federal government and Virginia $4.6 million to settle self-disclosed overbillings to government health plans for radiation oncology services, the Department of Justice announced.
Richmond-based VCU discovered the overbillings to Medicare, Tricare, and the Federal Employees Health Benefits Plan, which had occurred from 2009 through 2014, while auditing patient files and claims data, took corrective action, notified federal regulators, and helped investigators, DOJ said.
VCU Medical Center issued this statement on the overbilling:
"During a 2013 internal compliance review, VCU Health System identified possible concerns with its Department of Radiation Oncology billing and documentation."
"This prompted VCU Health System to have an extensive external review conducted. The external review identified inaccurate payments from governmental payers, which VCU Health System voluntarily self-reported. There was no evidence of fraudulent activities discovered."
"VCU Health System agreed to repay roughly $4 million to the federal government to resolve the inaccurate payments, and has taken corrective action to address its radiation oncology billing practices. In addition, the review indicated approximately $640,000 in inaccurate payments that will be repaid to the Commonwealth."
The Tennessee-based hospital chain has announced that COO David Dill will become the company's new CEO when the merger with RCCH HealthCare Partners is finalized later this year.
LifePoint Health Chairman and CEO Bill Carpenter III will retire this year, after the for-profit hospital chain completes its merger with RCCH HealthCare Partners.
David Dill, LifePoint's president and COO, will take over as CEO and Carpenter will join the merged organization’s Board of Directors, LifePoint announced Wednesday.
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.
"I believe that LifePoint is better positioned than ever to be the leader in non-urban healthcare, and to help define what the delivery of community-based healthcare looks like in the future," Dill said.
Dill joined LifePoint as CFO in 2007. He was named COO in 2009 and appointed president and COO in 2011.
During Dill's tenure, LifePoint said it grew its revenues from $2.6 billion in 2007 to more than $6 billion projected for 2018 with the launch of the company's National Quality Program collaborative with Duke University Health System.
The $5.6 billion merger creates for Dill an assets portfolio that includes 85 non-urban hospitals in 30 states, regional health systems, physician practices, outpatient centers and post-acute providers, many serving as sole providers in the communities they serve.
A new institute will integrate the university's health and social services colleges, with a focus on improving care access and outcomes in underserved areas.
Humana Inc. and the University of Houston have launched what they're calling a long-term strategic partnershipto promote population health and value-based payment models for the next generation of clinicians.
A $15 million gift from the Louisville-based health insurer will establish the Humana Integrated Health System Sciences Institute at the University of Houston, which will include the university's colleges of medicine, nursing, pharmacy, social work and optometry.
The collaboration will create a pipeline of physicians, nurses, pharmacists and other healthcare professionals trained in population health, with a focus on primary care and improving care access and outcomes in low-income communities.
Humana's funding, to be doled out over 10 years, will defray start-up and operational costs for the soon-to-open College of Medicine, and fund endowed chairs for each of the five colleges.
Humana Chief Medical Officer Roy Beveridge, MD, called the University of Houston "an ideal partner" because of their shared commitment to "caring for individuals in underserved communities with the greatest health needs."
"This is an investment in the future of our healthcare system, which depends on clinical leaders who understand concepts like population health, the importance of social determinants of health and the need to emphasize value over the volume of health care services provided," Beverage said.
The College of Medicine is scheduled to admit 30 students in its inaugural class but awaits state and national accreditation.
University of Houston President Renu Khator said the establishment of the Humana Institute demonstrates that the university is "serious about an interdisciplinary, integrated approach to health education that will make a life-changing difference in Houston and beyond."
"This transformative gift clearly positions that dream to become a reality," she said.
The two South Carolina health systems, which merged last year, say the rebranding under one name reflects a unified commitment to improve care delivery in the Palmetto State.
Greenville Health System and Palmetto Health will finalize a consolidation that began last year and rebrand as Prisma Health, the two South Carolina health systems said Tuesday.
Since late 2017, the two systems have been affiliates in the largest not-for-profit health system in the state, operating under a parent company with the interim name of SC Health Company.
That parent company is being rebranded as Prisma Health and both health systems will adopt the new name in early 2019. However, the 13 hospitals in the combined system will retain their core name identities, such as Baptist, Greenville Memorial, Laurens County, Richland and Tuomey.
The two health systems said in a joint media release that coming together under one new brand reflects their commitment to South Carolina.
"This is a once-in-a-lifetime moment for our organization," said Prisma Health Co-CEO Charles D. Beaman Jr.
"With a motivated 30,000-team-member workforce, we’re confident we will continue to make strides to improve clinical quality, access to care and the patient experience for South Carolinians, while addressing the rising cost of healthcare," said Beaman, the former CEO of Palmetto Health.
South Carolina has some of the nation's highest rates of obesity, diabetes, stroke, and cardiovascular and pulmonary disease. With the merger, Prisma Health says it now has the scale, scope and resources to address those population health issues, while continuing to be a not-for-profit, mission-driven organization.
When the two systems merged last year, no name changes were planned. However, Prisma Health Co-CEO Michael C. Riordan said plans changed when leadership realized that a single health company with a unified culture needed to unite under one name.
"We've already learned so much from each other," said Riordan, the former CEO at Greenville Health. "What we’re doing now will pave the way for transformative changes to health care in South Carolina. And through our efforts, we've already identified ways to achieve more together by operating as one organization under a single name and brand identity."
Brad Haller, director of West Monroe Partners' Mergers & Acquisitions practice, says the consolidation has made sense for two health systems with a healthy footprint in South Carolina.
"Combining the two under one umbrella is a good geographic play in that it connects the western part of the state with the central part of the state. While these are the two largest health systems in the state, there is still a healthy amount of 'competition' from other providers," Haller says.
The deal is representative of larger M&A trends in the healthcare sector, where Haller says "everything is about cost take-out and building scale against the payers," which he says is the primary strategic driver for most consolidations.
"Prisma" is a variation on the "prism," which Merriam-Webster defined as "a medium that distorts, slants, or colors whatever is viewed through it."
Prisma Health said the new name "reflects the diverse, multifaceted nature of the organization and its team members, as well as the bright future that lies ahead."
The health system says "the name and distinctive logodistinguish Prisma Health from traditional healthcare systems and signal its intent to look at health, and health care, in a completely new way.
The existing GHS and Palmetto Health brands, including their names and logos, will be retired in early 2019. Additionally, both affiliates have replaced their mission, vision and values statements with a new Purpose Statement."
Review period extended two weeks. CMS says discovering the 2017 scoring errors indicates its targeted review process 'worked exactly as intended.'
The Centers for Medicare & Medicaid Services says it is extending by two weeks the review period for the 2019 Merit-based Incentive Payment System (MIPS) adjustment calculation after it identified and fixed "a few errors in the scoring logic" used in the 2017 assessments.
As a result, CMS moved the 2019 payment adjustment from September 30 to October 15 at 8 p.m. Eastern Time.
"The requests that we received through targeted review caused us to take a closer look at a few prevailing concerns," CMS said in a post on its website.
CMS said the concerns include "the application of the 2017 Advancing Care Information (ACI) and Extreme and Uncontrollable Circumstances hardship exceptions, the awarding of Improvement Activity credit for successful participation in the Improvement Activities (IA) Burden Reduction Study, and the addition of the All-Cause Readmission (ACR) measure to the MIPS final score."
"Based on these requests, we reviewed the concerns, identified a few errors in the scoring logic, and implemented solutions," CMS said.
Errors remedied, CMS says it saw "a very high 91% participation rate" for the first year of MIPS in 2017, which provides individual clinicians, and physician groups participating in Alternative Payment Models access to feedback on their final 2017 MIPS score, and 2019 MIPS payment adjustment.
CMS said identifying and fixing the errors also indicated that its targeted review process "worked exactly as intended."
"The incoming requests quickly alerted us to these issues and allowed us to take immediate action," CMS said. "Addressing and correcting for the above elements resulted in changes to the 2017 MIPS final score and associated 2019 MIPS payment adjustment for the clinicians who were impacted by the identified issues."
A longitudinal study tracking students from medical school through residency suggests the grueling process leaves many young physicians questioning their career choice.
Resident physicians concentrating on certain specialties are particularly prone to burnout, a Mayo Clinic-led study shows.
The longitudinal study, which appeared this month in JAMA, found that 45% of second-year resident physicians reported experiencing at least one symptom of burnout, which can include exhaustion and depersonalization of patients.
Urology, neurology, emergency medicine and general surgery residents were at the highest risk of burnout, but the study authors don't know why.
"That is a great question for a separate research study," says Liselotte Dyrbye, MD, a Mayo Clinic researcher and first author of the article.
"We know that at the beginning of medical school, there isn't much burnout. But even in medical school we start to see burnout develop after a couple of years. It starts early and continues from training into practice," she said.
The years-long study, which involves 50 medical schools and 3,600 medical trainees, is the first national study to follow medical students from the beginning of medical school into residency to track predictors of burnout.
Residents were asked about their specialty, ethnicity, educational debt and other demographics, and completed surveys to measure anxiety, emotional social support, empathy and burnout. The survey found that residents with burnout were three times more likely to regret becoming a physician.
Dyrbye says she can only speculate on why some specialties are more prone to burnout, but she's spotted a trend.
"We see high rates of burnout in resident physicians in urology, neurology, ER and general surgery and that mirrors our previous findings of physicians in practice that we conducted with the AMA a few years ago," she says.
"There may be something unique in the particular work environments related to workload, practice efficiencies, autonomy, control, work life balance," she says. "Another possibility could be that the supervising physicians who are impacting the learning environment in such a way that these residents-in-training are impacted and at higher risk of burnout."
"Maybe there is more harassment or belittlement going on in these specialty training programs relative to other specialty training programs, which probably more reflects the practice environment," she says. "When a supervising physician is working in the same practice environment as the resident, then it's not so much of a surprise that they are both impacted by work-related stresses that drive burnout."
In an interesting wrinkle, the study found that self-identified minority students were more likely to regret their specialty choices, and the study authors suggest that one reason might be that these time-strapped minority physicians are being pressed to serve in their institutions' diversity programs.
"There are a lot of initiatives at academic medical centers across the country to really improve diversity, because that improves the science, patient care and research," Dyrbye says. "As a result, we have all of these diversity committees looking at retention and recruitment and various issues and people of diverse backgrounds get overtaxed when they're asked to be on those committees. In addition to the stress of being a resident, now you're worried about getting tapped on the shoulder 'Oh would you mind? Pretty please!'"
"There is nothing else that goes off that resident's plate to accommodate that institutional service," Dyrbye says. "We speculate that it could be a bit too much for those residents it could contribute to some of their specialty choice regrets."
Dyrbye takes some comfort in knowing that, given the rigors of physician training, more than 50% of the survey respondents say they were happy.
"But we should be concerned about the prevalence of burnout. It shouldn't be that high," she says. "We know that burnout is associated with suboptimal patient care. If these resident physicians continue to struggle with symptoms of burnout, they are also more likely to quit or not see as many patients and that impacts all of our ability to access care."
Critics say the 'draconian' proposed rule would prompt legal residents to forego medical care for fear of losing their green cards, with the higher costs of delayed care borne by taxpayers.
The Trump administration's proposal to expand public charge designations to Medicaid and Medicare Part D subsidies and other benefits will jeopardize the healthcare access of millions of legal residents, critics charge.
The 447-page proposed rule, which was unveiled Saturday by the Department of Homeland Security, would create "a strong disincentive to seek care," said Bruce Siegel, MD, president and CEO of America's Essential Hospitals.
"This rule would force people to forgo medical visits and medications until they are sicker and costlier to treat. It would drive higher levels of uncompensated hospital care and, ultimately, higher costs for insured patients and taxpayers," Siegel said in a media release.
Rick Pollack, president and CEO of the American Hospital Association, echoed Siegel concerns about delayed care, and urged DHS "to rethink this policy that could affect the health of millions."
"America's hospitals and health systems have serious concerns that those legally in the country could choose to forgo health care benefits—and therefore delay accessing care—out of fear of repercussions for themselves and their families,"Pollack said.
In a statement on its website, DHS said it is "proposing to consider current and past receipt of designated public benefits above certain thresholds as a heavily weighed negative factor. The rule would also make nonimmigrants who receive or are likely to receive designated public benefits above the designated threshold generally ineligible for change of status and extension of stay."
DHS said it estimates that "about 382,264 aliens seeking adjustment of status annually would undergo review annually to determine whether they are ineligible on public charge grounds." The rule would not apply to families making less than 15% of the federal poverty designation.
Homeland Security Secretary Kirstjen Nielsen noted that the "public charge" dates back to the Immigration Act of 1882, and is designed to ensure that new immigrants are not a financial burden for the United States.
"Under long-standing federal law, those seeking to immigrate to the United States must show they can support themselves financially," Nielsen said. "This proposed rule will implement a law passed by Congress intended to promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers."
The proposed rule change does not require Congressional action, and DHS could impose the new rule after a 60-day public comment period is published in the Federal Registry, which is expected this week.
The Trump administration has made restrictions on immigration one of its top priorities, and the 60-day public comment period would extend through November's mid-term elections, likely making the proposed rule campaign fodder for Republicans and Democrats.
John Baackes, CEO of L.A. Care Health Plan, called the proposed changes politically motivated and said they could adversely affect more than 170,000 members of the nation's largest publicly operated health plan.
"The proposed change has already had a chilling effect, with anecdotal reports that people are choosing not to access benefits for which they currently qualify," Baackes says.
"The changes, once they become effective, are very likely to exacerbate serious problems that impact the health of the immigrant community," he says. "We are likely to see more hunger, child poverty, homelessness and a wide array of unmet health needs, as families may be unwilling to seek and maintain health care coverage, or enroll in other important programs, due to fear of the rule."
Frederick Isasi, executive director of Families USA, said the proposal was "cruel, shortsighted, and violates our nation’s values."
"Families should never be forced to choose between being able access the healthcare and medicine they need and being together," Isasi said.
"Under the administration's draconian proposal, lawfully-present immigrants who access lifesaving programs like Medicaid,or Low-Income Subsidies for the Medicare Prescription Drug benefit would be in jeopardy of losing their current legal status or attain permanent resident status," he said.
An Illinois law on tax exemptions for nonprofit hospitals was upheld by the state's high court, and hospital advocates there say the statute could be a model for other states.
The Illinois Supreme Court ruling upholding the constitutionality of a hospital tax exemption law is a win for nonprofit providers in other states too, Illinois stakeholders say.
"What our general assembly did in 2012, the statute that was upheld Thursday, potentially could be a model for other states that are grappling with the issue," Illinois Health and Hospital Association General Counsel Mark Deaton told HealthLeaders.
"Hospitals across the country are breathing a sigh of relief because, if this statute had been ruled unconstitutional, it had the potential for reopening a lot of chaos in Illinois. Our friends in other states are happy that the status quo is being maintained," Deaton says.
In Oswald v. Beard, the Illinois Supreme Court on Thursday unanimously upheld a lower court ruling that the law passed constitutional muster.
The Oswald case did not involve a hospital or an application for exemption or any decision by the state, and was based only on the language in the law. The plaintiff, Chicago resident Constance Oswald, said the law was unconstitutional because it did not expressly mention the constitutional requirements for exemption.
The seven justices on the Illinois Supreme Court rejected the argument.
"While [the statute] does not expressly provide that the hospital charitable property tax exemption is limited to applicants that satisfy the constitutional requirement of exclusive charitable use, section 6 of article IX of the Illinois Constitution does say so, and we presume that the legislature intended to comply with this constitutional limitation," Justice P. Scott Neville wrote.
"The legislature was certainly aware of section 6 of article IX of the constitution and its requirement of exclusive charitable use, and it intended to enact a constitutional hospital charitable property tax exemption," Neville wrote.
At its core, Deaton says the main contention in the case "was very simple."
"It was about the wording of the statute, and does this statute or any statute have to reference the Constitutional provision this grows out of," Deaton says. "In this statute, should they have said in addition to complying with the constitution, hospitals also have to do the following thing?' The Supreme Court said 'No.'"
Deaton says hospitals and local governments win with the ruling.
"The court decision benefits hospitals by maintaining property tax exemption in place," he says. "It benefits communities because now everyone knows what the rules are, what the test is, and it ensures that communities are getting value for the tax exemption they grant."
"This really maintains the stability and benefit of tax exemption that hospitals have enjoyed for over 100 years in Illinois. It stays the course," he says. "We had about seven or eight years of tumult in the early to mid-2000s around the question of property tax exemption, and the law that was upheld today was enacted in 2012 and worked to resolve that tumult."
While the constitutionality of the law is settled, Deaton says other challenges could emerge when hospitals apply for tax-exempt status.
"Someone could come in and say 'We don’t think St. Elsewhere satisfies the statute' or 'We don't like that the statute counts a certain type of service,' so you might see more granular focused challenges," Deaton says. "But the question of whether the whole statute is constitutional, yes, that is settled."
Post-recession spending growth is climbing towards pre-recession levels and is largely driven by brand-name drugs, ER visits, and outpatient surgeries.
Private-sector healthcare spending grew by 44% over the past decade, rising from $3,752 per person with employer-sponsored insurance in 2007 to $5,394 in 2016, according to a study by the Health Care Cost Institute.
The recession, the Affordable Care Act, and strategic shifts in care delivery slowed spending growth but it's since rebounded. Spending growth in 2015 and 2016 climb toward pre-recession levels seen in 2007 through 2009, according to the study, which was published online Wednesday in Health Affairs.
The study is the latest to suggest that healthcare spending is accelerating and straining budgets across the economy, from the federal government, to businesses and households.
HCCI researchers examined private employer-sponsored insurance claims for about 40 million people, and found the annual average growth rate was 4.1% over the decade, ranged from 6.3% in 2009 to 2.6% in 2014, and climbed to an average of 4.4% growth in 2015 and 2016.
"Retrospective studies like ours show that healthcare spending is cyclical," study co-authors Amanda Frost and Kevin Kennedy said in an email to HealthLeaders.
"We observed a period of fast spending growth, followed by a period of much slower growth during the Great Recession. More recently, healthcare spending is up, and NHE predicts that we may be entering a period of faster growth."
Adjusted for inflation, healthcare spending rose 23% from 2007 through 2016, the researchers said.
Brand-name prescriptions, ER visits, and outpatient surgery drove 48% of the per capita spending increase. Frost and Kennedy say these three high-cost growth areas "may be good targets for cost-saving measures."
"Though, we did find that spending grew across all four main categories of health services: inpatient, outpatient, professional, and prescriptions," they said.
The findings also provide more evidence of a fundamental shift by consumers away from inpatient settings in favor of lower-cost outpatient settings.
Per capita out-of-pocket spending on brand-name and generic prescription drugs declined, and researchers pointed to benefit design changes and patterns of service use.
"In the case of brand-name prescriptions, recent spending trends did not correlate with utilization trends," Frost and Kennedy say. "Use of brand prescriptions has been falling each year, while spending has been increasing—suggesting price increases drove spending."
In addition, per capita out-of-pocket spending increased by 43%, driven by outpatient and professional services. The largest increase was seen in spending for ER visits.
Frost and Kennedy conceded some limitations in their study. While the sample data represents more than 25% of the population with employer-sponsored insurance, they said it may not be representative of the larger employer-sponsored insured population.
The study also excludes spending trends for patients with public insurance, and does not track health insurance premiums paid by employers and employees or information on drug rebates and coupons.
A new working paper recommends that long-term care hospitals lose their special reimbursement schedules under Medicare and instead get paid like cheaper SNFs.
Long-term care hospitals are paid too much for the care they provide, and should be stripped of their special reimbursement schedules under Medicare, a new study says.
Academics from the University of Chicago, Stanford University, and MIT in the joint study say most patients in long-term care hospitals would get the same or better care at less-costly skilled nursing facilities.
The study, released as a National Bureau of Economic Research Working Paper, estimates that Medicare could save $4.6 billion a year—with no harm to patients—by eliminating reimbursement schedules for long-term care hospitals, and instead paying them the same as skilled nursing facilities.
"As a result, they can and do treat patients that a SNF (which are sub-acute providers and that do not have the clinical infrastructure or staffing of a hospital) would not and should not," Lane Koenig, NALTCH's director of research and policy, said in an email to HealthLeaders.
"Because of this failure to recognize these differences, they mischaracterize the findings of their study in the abstract, introduction, and elsewhere in the paper," Koenig said.
The study calls for the elimination of a carve out for LTC hospitals that Congress created in the early 1980s that exempted them from payment reforms. As a result, LTC hospitals receive a substantially higher reimbursement than traditional hospitals, the study says.
That loophole has prompted the growth in the number of LTC hospitals, from a few dozen in the 1980s, to more than 400 today, and they account for $5.4 billion in annual Medicare spending.
"They are unique to the U.S. healthcare system, and, to the best of our knowledge, do not exist in any other country," said study co-author Prof. Neale Mahoney with the University of Chicago Booth School of Business.
The researchers examined new LTC hospitals entering the market between 1998 and 2014, and tracked patients leaving acute-care hospitals for the new LTC hospital. That transition triggered "a significant increase in Medicare spending and out-of-pocket costs for patients," the study found.
LTC hospitals cost the federal government three times as much as cheaper venues, such as SNFs, the study found, noting that in 2014, LTC hospitals were reimbursed at about $1,400 per day compared to about $450 at SNFs that provided medically similar care.
Despite the increased costs, the study said there was no evidence that LTC hospitals improved outcomes or reduced 90-day readmissions.
Even with the higher cost, the researchers found no evidence that long-term care hospitals increased the probability of patients going home, or reduced the chances of the patients dying within the 90 days after being admitted.
The researchers said that LTC hospitals likely will do their best to hobble any reforms to their reimbursements.
"The $4.6 billion of incremental spending generated by long-term care hospitals every year may look like 'waste' to the health economist, but to the (largely for-profit) industry it might more accurately be referred to as 'rents,'" the study said.
"This suggests a large financial incentive on the part of long-term care hospitals to block major regulatory changes, and may help explain their continued survival."
LTC Hospitals Refute Study
Koenig says the study fails to take into consideration several key points that invalidate the findings.
Specifically:
The study data are outdated and do not reflect the LTC hospitals Medicare patients or policies. The study covers LTCH market entrants between 1998 and 2014. Most of the growth examined in the paper happened prior to 2007. Today, the LTC hospital population has even higher acuity due, in large part, to a 2013 law that established patient criteria.
The study fails to recognize that LTC hospitals are acute-care hospitals and, as a result, can and do treat patients that a SNF (which are sub-acute providers and that do not have the clinical infrastructure or staffing of a hospital) would not and should not.
The study does not allow for the possibility that the clinical impact of LTC hospitals varies across types of patients. For some patient groups that spend three or more days in an intensive care unit or have multiple organ failure, LTC hospitals generate Medicare savings and improve mortality.
The study does not report the effect of LTC hospital care on readmissions to acute-care hospitals. A close reading of tables in the appendices suggests the authors did find a noticeable decline in readmissions corresponding to LTC hospital care, which contradicts the study's claim that LTC hospital care is not associated with measurable clinical improvement.
