For the most part, providers support the Direct Provider Contracting proposal put forward by the Centers for Medicare & Medicaid Services, with some stipulations and considerable tweaking.
Key stakeholders are mostly supportive of a Medicare Direct Provider Contracting proposal but urging the federal government to keep it simple and not overwhelm providers with paperwork.
"Burden reduction must be a priority for the Innovation Center when implementing the DPC model," the Medical Group Management Association said in a letter to the Centers for Medicare & Medicaid Services.
"Collecting and reporting quality metrics remain technically challenging, data intensive, and administratively burdensome," MGMA said. "Bureaucratic barriers to care, including prior authorization and appropriate use criteria, are at odds with care delivery and financial models in which participants are accountable for care outcomes."
That concern was echoed byThe American Geriatrics Society, which urged that "CMS take care not to add further administrative burdens that may negatively impact patient care."
The National Association of Accountable Care Organization supports the DPC concept, but urged CMS to limit participation to primary care providers for the rollout.
"Primary care is more appropriate for this type of model, and specialty DPC Models would be too similar to bundled payment programs," NAACOS said. "Further, it would be much more complicated to structure per beneficiary per month payments for specialty care which is typically more complex and can include episodes of care with greater variation in clinical conditions, treatment protocols and related costs."
NAACOS argued that starting with a primary care focus would allow CMS to test the concept while focusing on beneficiary protections without having to consider more complex specialty-focused DPC models.
"For purposes of beginning a DPC Model test, CMS would contract directly with primary care practices to establish the practice as the main source of primary care for services," NAACOS said.
'Yet Another Capitation Scheme'
The Association of American Physicians & Surgeons said it was "disappointed" with the proposal, which it said "turns the concept on its head."
"The title of the RFI itself signals an unfortunate transformation of DPC from Direct Patient Care into what CMS calls, 'Direct Provider Contracting,'" AAPS said in its letter to CMS.
"We are concerned that CMS is not encouraging direct arrangements between patients and physicians. The RFI explains that to CMS, DPC means "direct provider contracting (DPC), through which CMS would directly contract with Medicare providers,'" AAPS said.
"In addition, CMS asks for feedback on countless requirements and conditions it is considering imposing on physicians seeking to contract with CMS," AAPS said.
"To us and our members, this approach by CMS looks much more like yet another third-party-controlled ACO or capitation scheme than anything resembling the agreements Direct Primary Care practices are currently offering their patients," AAPS said.
Federal prosecutors say Sonja Emery fabricated her extensive credentials and professional experience in a scam that collected nearly $2 million in consulting fees over five years.
A healthcare consultant indicted in Michigan for allegedly falsifying her credentials and work experience was arrested this week in California, where she's collected more than $1 million in consulting fees over the past three years from a nonprofit health plan.
Sonja Emery, 52, who has been known to use a long list of aliases, was indicted by a federal grand jury in Detroit on 11 counts of fraud and tax evasion, for a scam that ran from 2011 through 2014. She's been accused of continuing to deceive her employers since.
Emery was arrested on Tuesday and appeared before a federal judge in Oakland, California, who authorized her release on $50,000 unsecured bond. Prosecutors have appealed the decision.
'Remarkable Ability'
In court documents urging Emery's detention without bond, federal prosecutors said she has "a long-established pattern dating back to at least 2006 of obtaining healthcare related employment using false names and work history."
"This past behavior reveals Emery's remarkable ability to obtain employment under false pretenses and her willingness to use false identities," prosecutors said.
A government investigation linked Emery to eight different Social Security numbers and three different names, which she gave to employers and law enforcement agencies in California, Connecticut, Georgia, Louisiana, Michigan, New York, and Wisconsin, according to court documents.
She also allegedly claimed to be a registered nurse licensed in two states, but an investigation showed that she used the licensure numbers of two other people.
Apparently, healthcare organizations weren't the only ones fooled by Emery.
Federal prosecutors said Emery convinced local prosecutors in fraud cases on at least two occasions that she suffered from "brain tumor surgery" and cancer that "left her blind," without memory, and incapacitated—none of which was true. The documents Emery used to support her medical claims were forgeries, federal prosecutors said.
Contra Costa Health Plan
Since the alleged events took place in Michigan, Emery has been a contract consultant at Contra Costa Health Plan, a county-owned, nonprofit health plan, for the past three years.
A review of Contra Costa County Board of Supervisors records found that "Sonja Robinson, RN," doing business as "Healthcare Solutions USA," was unanimously awarded annual contracts worth $384,000 each year from 2016through 2018"to provide consultation on utilization review, authorization and referral processes for the Contra Costa Health Plan."
Contra Costa Health Plan said Robinson was paid about $960,000 since January, 2016. A spokesperson said the health plan "first learned about the allegations against Sonja Robinson on May 22, 2018, and took immediate steps on that day to prevent her from providing further services to the department. Ms. Robinson's contract was terminated effective May 25, 2018, and she has not provided service to CCHP since May 22."
CCHP said Robinson was hired through a national healthcare consulting firm, and was contracted to provide services in the Utilization Management Unit, where she performed administrative duties and did not provide direct patient care.
Court records indicate Contra Costa is at least the eighth employer Emery has duped.
"The jobs that Emery has repeatedly sought also raise substantial concerns about Emery's ongoing danger to the community," prosecutors said, noting that Emery successfully obtained jobs with titles such as director of medical services and interim Chief Clinical Operations Improvement Officer.
"The government does not presently have evidence that anyone was physically harmed as a byproduct of Emery taking these positions. Nonetheless, if Emery were to flee, consistent with her prior pattern of criminal activity, she likely would attempt to obtain another health-care related position, which could endanger patient welfare and pose a danger to the community," prosecutors said.
Michigan Indictment
The Michigan indictment, unsealed this week, said that Emery allegedly told clients and employers that she was a registered nurse, had worked in healthcare management and consultation for 25 years, and held degrees including a bachelor of science in nursing, master's degrees in health administration, and a doctor of philosophy degree—none of which was true.
She allegedly provided employers and clients with extensive false or forged documents and references validating her fabricated background.
Emery used fake Social Security numbers, misstated her tax liabilities, filed bogus W4 forms with the IRS, and lied about her tax status in a multi-year effort to shake federal auditors, according to the indictment.
A federal review estimates that 5 million people have lost health insurance coverage in the past year, and the number of people with subsidized coverage through marketplaces has fallen by 3 million.
The average premium for a benchmark plan in the Nongroup Health Insurance Market—not including tax credits—grew by 34% in the past year and will continue to see double-digit growth in the near term before leveling off in the next decade, the Congressional Budget Office says.
CBO blames the cost growth on three factors:
Insurers are no longer reimbursed for the costs of cost-sharing reductions through a direct payment;
A larger percentage of the population lives in areas with only one insurer in the marketplace;
Some insurers expected less enforcement of the individual mandate in 2018—which would probably encourage healthier enrollees to leave the market.
As a result, CBO projects that the premiums for benchmark plans will increase about 15% from 2018 to 2019.
Despite those increases, CBO projects the market for nongroup health insurance will be stable in most areas of the country over the decade. Premiums for benchmark plans are expected to increase by about 7% per year between 2019 and 2028.
CBO also found that:
In an average month in 2018, about 244 million of those people will have health insurance, and about 29 million will not. By 2028, about 243 million are projected to have health insurance and 35 million won't.
Net federal subsidies for insured people in 2018 will total $685 billion. That amount is projected to reach $1.2 trillion in 2028.
Medicaid and CHIP account for about 40% of that, as do subsidies in the form of tax benefits for work-related insurance. Medicare accounts for about 10%, as do subsidies for coverage obtained through the marketplaces established by the Affordable Care Act or through the Basic Health Program.
Since CBO’s most recent report comparable to this one was published in September 2017, the projection of the number of people with subsidized coverage through the marketplaces in 2027 has fallen by 3 million, and the projection of the number of uninsured people in that year has risen by 5 million.
Projected net federal subsidies for health insurance from 2018 to 2027 have fallen by 5%.
A panel of policy experts offered the Senate Finance Committee their wish list of top priorities for rural healthcare in the coming years.
Sen. Ron Wyden, D-Oregon, asked a panel of rural health policy experts testifying before the Senate Finance Committee on Thursday what they'd do if they could "wave a magic wand" to create longer-term stability for rural providers and the seniors they serve.
Here's how they responded:
"We have talked to people in communities where rural hospitals have closed and almost always the first thing we hear is the disappearance of the emergency department. My top priority is maintaining access to emergency care."
—George H. Pink, deputy director of the Rural Health Research Program at the University of North Carolina
"Mine would be building that integrated system that would include beyond hospital-based services, particularly post-acute care after hospitalization and care for the elderly with chronic conditions which was in part addressed by the Chronic Care Act. We need to move forward with some of the innovations that are coming out of that."
—Keith J. Mueller, director, RUPRI Center for Rural Health Policy Analysis, University of Iowa
"The flexibility to develop a model in each rural committee that meets their needs so they can keep emergency care and other services. It would allow critical access hospitals to merge into a different model which would limit their need to have inpatient beds and be able to have emergency departments and do outpatient care to keep the financials healthy in that model." —Karen M. Murphy, RN, founding director of Glenn Steele Institute of Health Innovation at Geisinger, Danville, Pennsylvania
"My top priority would be recognition of the difficulty of acquiring and retaining providers in rural communities. Rural healthcare and rural communities create an environment that is unique. The opportunities that have been demonstrated in some of our ACO models create not only the integration of hospitals and physicians, but include all components of healthcare across the continuum. This environment is motivating and inspiring and it could create a platform for transforming healthcare." —Susan K. Thompson,RN, CEO, UnityPoint Accountable Care, West Des Moines, Iowa
A federal indictment alleges that a former fraud investigator for Anthem Blue Cross took bribes and provided coconspirators with billing codes that would bypass the insurer's fraud protection firewalls.
Five Californians—including a physician and a former fraud investigator—have been arrested and charged in a scheme that submitted bogus claims to health insurers and used some of the proceeds to provide patients with "free" cosmetic procedures, the Department of Justice said.
The arrest follows the unsealing of a federal indictment this week that details a multi-year scheme that lured patients into two San Fernando Valley clinics to receive free cosmetic procedures—including facials, laser hair removal and Botox injections—which were not covered by insurance.
The conspirators allegedly submitted at least $20 million in claims to the insurance companies, which paid approximately $8 million on those claims, the indictment said.
The scam used the patients' insurance information to fraudulently billed insurers for unnecessary medical services or for services that were never provided. In exchange, the alleged scammers calculated a "credit" that patients could use to receive "free" or discounted cosmetic procedures, the indictment said.
One of the coconspirators, Gary Jizmejian, 44, of Santa Clarita, was a former senior investigator at the Anthem Special Investigations Unit, the anti-fraud unit within Anthem.
The indictment alleges that Jizmejian took bribes in exchange for providing his coconspirators with confidential Anthem information that helped them submit fraudulent bills to Anthem.
In September 2012, Jizmejian gave his coconspirators insurance billing codes—CPT Codes—that Jizmejian knew could be used to submit fraudulent claims to Anthem without Anthem detecting the fraudulent claims, the indictment said.
Jizmejian also allegedly gave his coconspirators the billing code for an allergy-related lab test and told them to submit to Anthem large numbers of bills with this CPT code. The coconspirators used this billing code to submit approximately $1 million in fraudulent claims to Anthem, according to the indictment.
Jizmejian allegedly helped mask the fraud at the clinics by helping coconspirators avoid responding to inquiries from fraud investigators, diverting attention of other Anthem SIU investigators away from the clinics, and closing Anthem investigations into fraud at the clinics, the indictment said.
When reached for comment, Anthem Blue Cross issued the following response:
Mr. Jizmejian is no longer an Anthem employee.
Anthem fully cooperated with the government's investigation.
We have no further comment on pending government charges or activity.
The indicted coconspirators were identified as:
Roshanak Khadem, aka "Roxanne" and "Roxy" Khadem, 50, of Sherman Oaks. Khadem owned and operated the two clinics at the center of the alleged scheme—R&R Med Spa, which was located in Valley Village until early 2016, and its successor company, Nu-Me Aesthetic and Anti-Aging Center, which operated in Woodland Hills.
Roberto Mariano, MD, 59, of Rancho Cucamonga, a physician who helped operate the clinics;
Marina Sarkisyan, 49, of Panorama City, who was the office manager at the clinics;
Lucine Ilangezyan, 38, of North Hills, an employee and insurance biller for the clinics.
All five defendants are charged with one count of conspiracy to commit healthcare fraud and 13 counts of healthcare fraud. Each count charged in the indictment carries a statutory maximum sentence of 10 years in prison.
The not-for-profit, federal qualified health center has served Manhattanites for more than 50 years, and CEO Brian McIndoe says new name reflects its renewed emphasis on patient-centered care.
Manhattan's William F. Ryan Community Health Network has a new name.
The not-for-profit, federally qualified health center, with 19 sites across the Big Apple, is now Ryan Health.
"We just celebrated our 50th anniversary and healthcare has changed over those 50 years, and more so over the past several years," says Brian McIndoe, president and CEO of Ryan Health.
"After 50 years we felt we needed a clear direction going forward for the next 50 years. We wanted to change our name and logo because now we are focusing on our patient-centered care."
So far, Ryan Health has spent about $140,000 on the rebranding, mostly on internal signage and a website redesign. Total cost is expected to be between $270,000 and $300,000 when the rebranding is finalized in the coming months, McIndoe says.
The new name might also clear up some confusion with the clinic's more than 46,000 patients and other healthcare consumers.
"We have six major primary care sites but when you said 'William F. Ryan' the public thought of one site, our oldest site on West 97th St., which is also our largest site," McIndoe says. "They didn’t correlate the other five primary care sites as part of the network of William F. Ryan. We want people to think of our five other primary care sites."
McIndoe concedes that it's a challenge to gain attention in media- and advertising-saturated Manhattan.
"We've been in New York City for 50 years and we have a great reputation, so I don’t think we are going to get lost, but this is the Mecca, and we have to make sure that doesn’t happen," he says.
"We're always conscious about how we can reach our audience. We try to do that in a cost-effective manner. When our patients have a good service at Ryan, they reach out to friends and family and tell them how well we treated them with good clinical care and also with dignity and respect they deserve," he says.
Patients and potential patients will notice the difference when they go to the clinic's new website, and when the interact with the care teams, McIndoe says.
"That really means that, when a patient comes in, they are going to see the same patient service rep, the same nurse, the same provider. So, they get a comfort level with that care team," McIndoe says. "Our goal is that, if they feel more comfortable, they are more ready to share their concerns, and we can treat the patient as a whole, as opposed to piecemeal when they see different providers or nurses."
Ryan Health includes six community health centers, seven school-based health centers, four community outreach centers, a mobile medical van, and a staff of nearly 600 people.
The president has indicated he will sign the VA Mission Act, which makes access to private care easier for veterans, reviews the health system's infrastructure, and expands caregiver programs.
The Senate passed theVA Mission Actwith a 92-5 vote Wednesday and sent the sweeping $55 billion reforms legislation to President Donald Trump, who has said he will sign the bill.
Senate Majority Leader Mitch McConnell, R-Ky., said on the Senate floor Wednesday that the bill "removes those arbitrary time and distance requirements that limit eligibility for outside care."
"It replaces those one-size-fits-all policies with a conversation between veterans and their own doctors about what works best. This will empower more veterans to access the care they need—when and where they need it," McConnell said.
Tom Nickels, executive vice president of the American Hospital Association, praised Congress for passing the bill, saying it will ensure veterans have access to quality healthcare.
"We are pleased that the legislation consolidates multiple VA community care programs into one permanent 'Veterans Community Care Program,'" Nickels said in a statement Wednesday. "This will provide continuity for veterans to access care outside of the VA’s medical network and decrease confusion about eligibility criteria and covered services."
Key components of the bill:
Streamlines the process by which the VA issues payments for private care. VA physicians will now be given the authority to determine whether a veteran would be better off visiting a private physician because a VA facility is too far away or has overly long wait times, as NPR reported.
Expands telemedicine and community health partnership options.
Starts a review of the VA's infrastructure with plans to close down underused facilities that aren't worth keeping open. Congress has vowed to provide close scrutiny for any proposal to close a VA hospital.
Expands afamily caregiver stipendto include Vietnam veterans within two years, and all veterans within four years, as the Associated Press reported.
Opponents of the legislation believe it moves the VA too far toward privatization.Sen. Bernie Sanders, I-Vt.,the former chairman of the Senate Veterans Affairs Committee, voted against the bill and said it provides no funding to fill more than 30,000 positions at the VA that the Trump administration has left vacant
The passage of the bill and Trump's signature will extend the life of theVA Choice program, which was set to run out of funding in June.
This spring marks 4yrs since the Phoenix VA crisis. We won't forget what happened to our GREAT VETS. Choice is vital, but the program needs work & is running out of $. Congress must fix Choice Program by Memorial Day so VETS can get the care they deserve. I will sign immediately!
Sonja Emery allegedly told employers and clients that she held a BSN, graduate degrees in health, business and philosophy, and 25 years of experience in leadership, none of which was true.
A healthcare consultant who allegedly fabricated her credentials and work experience to scam six-figure fees from her victims was indicted by a federal grand jury in Detroit for fraud and tax evasion.
According to an 11-count indictment unsealed this week, Sonja Emery allegedly told clients and employers that she was a registered nurse, had worked in healthcare management, and had various degrees, including a bachelor of science in nursing, master's degrees in health administration, and a doctor of philosophy degree.
The indictment alleges that Emery, also known as "Sonja Lee Robinson," "Sonjalee Emery-Robinson," "Sonjalee Emery," and other names, a resident of New York, New Jersey, and Georgia, earned six-figure salaries, failed to file timely tax returns, failed to pay income taxes on the scammed money, and lied to the Internal Revenue Service, from 2011 to 2014.
The employer and client victims of Emery's alleged fraud were not named in the 19-page indictment. However, the details of her four-year-long scam were in the document.
Among the alleged fabrications:
From 2011 through March, 2014, Emery was employed as a senior vice president by an Ann Arbor-based healthcare consulting firm that paid her $285,000 a year, which she did not report to the IRS.
In 2014, after leaving the Ann Arbor firm, Emery consulted for a Wisconsin-based "community health system" that paid her $267,000, which she did not report to the IRS.
In late 2014, Emery consulted for a Massachusetts-based healthcare employer that paid her $226,000, which she did not report to the IRS.
Emery claimed to be a registered nurse licensed in two states, but an investigation showed that she used the licensure numbers of two other people.
Emery falsely claimed to have a BSN, a master's degree in health administration, a master's in business administration, and a doctorate in philosophy.
Emery fabricated a 25-year career in healthcare, claiming executive experience at a major hospital and consulting firms in Atlanta and New York City. She provided employers and clients with extensive false or forged documents and references validating her fabricated background.
Emery used fake Social Security numbers, misstated her tax liabilities, filed bogus W4 forms with the IRS, and lied about her tax status in a multi-year effort to shake federal auditors.
If convicted, Emery faces a statutory maximum sentence of 20 years in prison for each mail and wire fraud count, five years in prison for each tax evasion count, and three years in prison for lying to the IRS. She also faces restitution and monetary penalties.
As healthcare prices escalate and the public looks for answers, America's Health Insurance Plans has launched a publicity campaign that it says breaks down how a premium dollar is spent.
Spending on hospitals, doctors and prescription drugs account for more than 82 cents of every premium dollar, according to statistics compiled by America's Health Insurance Plans.
"Plans use a meaningful part of premiums to make coverage more efficient and effective," Matt Eyles, incoming president and CEO of AHIP, said in a media release.
"But as prescription drug prices and medical costs continue to rise, it forces premiums higher for hardworking American families. Health plans work hard to negotiate lower costs and premiums for their members," he said.
AHIP based its findings on commissioned research from Milliman, which examine 2014-2016 data gathered from commercial health plans.
Here's the AHIP breakdown:
23.2 cents pays for prescription drugs.
22.2 cents pays doctors, and an additional 20.2 cents pays for all other costs at doctors' offices and clinics.
16.1 cents pays for hospital stays.
4.7 cents pays federal, state, and local taxes.
2.3 cents goes to health insurance provider profits.
1.8 cents pays for customer engagement, including customer service operations; another 1.6 cents pays for care management, including disease management and wellness programs.
1.6 cents pays for activities related to claims, including programs to battle fraud, waste and abuse.
Ashley Thompson, senior vice president of public policy analysis and development at the American Hospital Association, said she's not surprised that prescription drug costs account for a large part of the premium dollars.
"Even so, this study does not account for the amount hospitals and health systems spend on escalating drug prices, which continues to increase," she said.
Thompson pointed to a 2016 study conducted by the Non-Partisan and Objective Research Organization at the University of Chicago for AHA which found that inpatient drug spending per admission increased 38.7% from 2013 to 2015.
"It is clear that hospitals and health systems are feeling this pressure as they work to make care more affordable for patients," she said.
However, Holly Campbell, deputy vice president of public affairs at PhRMA, dismissed AHIP's study as a tired attempt to deflect blame for rising healthcare costs.
"AHIP continues to compare list prices for medicines to net prices for hospital and physician services to advance their same old rhetoric and exaggeration on medicine costs," Campbell said.
"We saw the slowest growth in medicine spending last year – just 0.6%. And prices for brand name medicines grew just 1.9% on average after discounts and rebates, below the rate of inflation. Not medical inflation, but overall inflation. Last year, these rebates and discounts totaled $130 billion," she said.
Despite the dramatic rise in the use of the use of liposomal bupivacaine, the local anesthetic was not associated with a decreased risk in patient opioid-related complications.
A sweeping review of the use of liposomal bupivacaine found no correlation with reduced in-hospital opioid prescriptions or opioid-related complications in patients, according to a study in Anesthesiology.
The local anesthetic is injected into tissues surrounding the surgical wound, and is designed to provide pain control for up to three days, with the hope of reducing the need for opioids.
"When we tested this hypothesis in a real-world setting where state of the art pain procedures such as peripheral nerve blocks were used, we were unable to show benefit," senior author Stavros G. Memtsoudis, MD, said in remarks accompanying the study.
"Local anesthesia is one mode that has been proposed as being part of a multimodal approach to reducing opioid consumption. But we found that adding liposomal bupivacaine to the mix did not add significant benefit," said Memtsoudis, director of critical care services in the Department of Anesthesiology at the Hospital for Special Surgery in New York.
The study looked at data from 88,830 total knee replacements performed between 2013 and 2016 with a peripheral nerve block. One group had a peripheral nerve block and general anesthesia, and another group had a peripheral nerve block and regional anesthesia.
Liposomal bupivacaine was used with a peripheral nerve block in 21% (18,817) of patients. Between 2013 and 2016, the use of liposomal bupivacaine increased from 7% to 26%.
The research showed that liposomal bupivacaine was not associated with a decrease in patients' risk for opioid-related complications including those affecting the respiratory, gastrointestinal and central nervous system. In addition, no clinically relevant decrease in inpatient opioid prescriptions, length of hospital stay, and no reduction in cost of hospitalization was seen.
"It does not seem to be the silver bullet physicians have been hoping for," Memtsoudis said. "We also need to look for other ways to try to combat the opioid crisis, including trying to change physician and patient behavior and expectations. We shouldn't necessarily look at a pharmacological solution for everything."
