State Medicaid pharmacy programs could save more than $30 billion over the next decade if they switched from fee-for-service programs to the more efficient approaches used by Medicare Part D plans, Medicaid managed care organizations, and commercial plans, claims a study from healthcare and human services consulting firm, TheLewin Group.
The study notes that Medicaid FFS pharmacy programs use fewer generic drugs and pay pharmacies higher dispensing fees and ingredient costs than other programs.
Lewin said the findings challenge the assumption that Medicaid pharmacy can reduce costs only by cutting benefits, limiting eligibility, demanding deeper manufacturer rebates, or paying drugstores higher dispensing fees in exchange for more pricing transparency.
"Medicaid is one of the few pharmacy benefit programs that still relies heavily upon a fee-for-service approach. By operating more like Medicare and commercial market plans, Medicaid could increase the use of generics and save billions without cutting benefits," said Pharmaceutical Care Management Association President/CEO Mark Merritt.
Three-fourths of Medicaid pharmacy dollars are administered using a fee-for-service approach in which public officials play a role in determining how much to pay drugstores for each prescription filled and ingredient costs.
The remaining one-fourth of Medicaid pharmacy dollars is managed more like pharmacy benefits in the commercial sector, where third-parties use management tools and negotiate pharmacy payments directly with chain drugstores and the drug wholesalers that represent independent pharmacies.
The Lewin study also found that although state Medicaid programs pay widely varying Medicaid dispensing fees, they are largely unrelated to the level of ingredient cost reimbursements a state pays, or the level of generic utilization a state achieves. For example, Texas pays the nation's highest dispensing fees ($7.50) and New Hampshire pays the lowest ($1.75), but they both pay about the same for ingredient costs and generate similar rates of generic drug utilization.
In addition, Lewin said the statutory and supplemental rebates paid to Medicaid by brand name drug makers are determined separately from pharmacy dispensing fees and ingredient costs. This means that manufacturer rebates have no impact on the savings that more active management of dispensing fees and ingredient costs could achieve. Likewise, these savings also do not assume any additional cost sharing for Medicaid beneficiaries.
Lewin identified four areas where pharmacy benefit management could improve:
Generic Drug Dispensing: Medicaid FFS is less effective at encouraging the use of generic drugs. The generic dispensing rate in Medicaid FFS averages 68%, compared to an average 80% generic dispensing rate in Medicaid MCOs.
Dispensing Fees: At $4.81 per prescription, the national average dispensing fee that Medicaid FFS programs pay to retail pharmacies per each prescription is more than doublethe average dispensing fees paid by Medicare Part D payers, Medicaid MCOs, or health plans in the commercial sector.
Ingredient Costs: The rate at which retail pharmacies are reimbursed for the pills, capsules, etc. is also higher, on average, in Medicaid FFS programs than in Medicare Part D or the commercial sector.
Drug Utilization: The number of prescriptions dispensed per person is typically higher in Medicaid FFS programs than in Medicaid MCOs due to less effective controls on polypharmacy, fraud, waste, abuse, and other factors in the FFS setting.
If all state Medicaid programs used a market-based approach with norms for Medicaid MCOs, Medicare Part D, and commercial payers, Lewin estimates that:
Combined federal and state savings to the Medicaid program would total $30.3 billion over the next decade.
Medicaid FFS prescription costs could be reduced by 14.8%.
Per member per month costs for Medicaid FFS pharmacy benefits could be reduced by $12 in 2011 under optimal management.
The Institute for Healthcare Improvement and Catholic Health Partners have announced that they have formed a partnership to reduce preventable harm throughout CHP's nine regional health systems.
Cambridge, MA-based IHI will work with CHP—the largest health system in Ohio, and with 34 hospitals in Ohio, Tennessee, Kentucky, Indiana and Pennsylvania—on a large-scale patient safety initiative in model hospitals to spread best practice improvements across the CHP organization.
The independent, not-for-profit IHI and CHP have already began the first phase of the partnership, which is based on the Institute of Medicine's six Aims for Improvement—healthcare that is safe, effective, patient-centered, timely, efficient and equitable.
"This partnership with Catholic Health Partners provides an extraordinary opportunity to take evidence-based improvements to scale in the states served by Catholic Health Partners," said IHI President/CEO Maureen Bisognano. "We look forward to implementing this initiative and drawing on IHI's wealth of experience in spreading proven improvement practices across the United States and around the world."
CHP President/CEO Michael D. Connelly said the health system has worked over the last decade to improve clinical quality and patient safety. "Our objective is to harm no patient. Nothing exemplifies our mission better or is as foundational to our strategic direction and annual plans," he said. "Now, in partnership with IHI, our intention is to continue to reduce inpatient mortality, eliminate preventable harm, achieve nationally-designated quality measures and increase patient satisfaction."
The partnership will accelerate CHP's use of professionals equipped with enhanced improvement and safety knowledge; implement proven changes to improve patient safety within selected hospitals, to create exemplar hospitals that will spread improvement across the CHP system; and collaborate with leaders at all levels of CHP.
IHI designed the initiative and modeled it after its Safer Patients Initiative in the United Kingdom.
The National Labor Relations Board, which has leaned toward organized labor since President Obama took office two years ago, may soon ease restrictions against union worksite soliciting during organizing campaigns.
That's the opinion of Jay Krupin, a veteran labor relations attorney with the Washington, DC-based firm EpsteinBeckerGreen. Krupin says it's not clear exactly what will emerge early next year as NLRB examines issues related to union worksite access for organizing purposes. Given the new composition of the four-member board – which includes Obama's recess appointees Craig Becker and Mark G. Pearce, and Clinton appointee and Chair Wilma B. Leibman – Krupin anticipates that unions will be happier with the results than will management.
"We have a three-to-one supermajority of pro-union members of the board. They are implementing the parts of the (Employee Free Choice Act) that they couldn't get through the legislative process. The pro-labor leaning members of the board are taking that agenda and running with it," he says.
Krupin says he expects NLRB will hear arguments from organized labor that the no solicitation policy violates the National Labor Relations Act because it precludes unions from equal access to workers considering organizing. "Right now on the employers' premises you only hear from one side. The issue is the employers have a 'captive audience.' Our argument has always been the unions can meet with the employees any place else in the world," he says.
Improving union access to the worksite would be disruptive, and create an unfair and coercive environment, Krupin says. "The union doesn't represent the employees until the employees say they do. This is like having an insurance agent coming into your house until you sign the policy. If you want to sign the policy you will find them," he says.
Krupin predicts that NLRB will examine the parameters of the so-called 24-hour rule, which prohibits management from holding mandatory mass meetings with employees within 24 hours of a union vote. "Unions won't be able to speak to employees whenever they want, but I suspect it is going to be more of an equal access question," he says. "If an employer engages at any time, not just within 24 hours, with mass meetings with more than one employee on the premises, then the union should have the same access. It will be more equal access, rather than total access."
"The board's justification would be that since the employer has access to the employees, the unions should have the same access," Krupin says. "I'm making a supposition, but I'm pretty good at looking at this stuff and knowing the history. It's like the communications world, where stations have to give candidates equal access."
So what should hospitals do about it?
"They have to be aware of this and develop policies in anticipation of an equal access provision," Krupin says. "We are saying let's review what policies they have now to see where they sit. Then in anticipation of the changes in the rules, how would we change those policies, setting up a fire drill before the fire as to how we should change the policies."
It's also a good time to examine protocols. "If the union wants to come on the premises, and they have the right to come on the premises, how will they be escorted? What areas will they go to? What times can they come on the premises," Krupin says. "You have to establish preventive policies. Look at those issues in anticipation of the rules being changed. As the decisions come out of the board we can modify them, but we are getting a head start."
Healthcare unions have enjoyed tremendous success in the past few years, winning well over 70% of their organizing elections, but they are not invulnerable. Krupin says hospitals that interact effectively with employees have the best chance of defeating organizing efforts. "That means communicating with employees, comparing wages and benefits, making sure you deal with grievances and that other issues that employees have are handled effectively. If you do the things you are supposed to do and your employees understand the communication and the transparency, they may not like the decision but at least they know you are thinking about them and you are trying to do the right thing," Krupin says.
The problem, he says, is that hospitals wait too long to act. "There is a process to do this. Hospitals wait until their blood pressure is 190/140, their cholesterol is at 300, and they are 40 pounds overweight. Then they say 'Oh my goodness I will stop smoking then,'" he says. "Employees only go to unions when they feel the employer is not listening. Unions don't organize employees, managers do."
The National Labor Relations Board, which has leaned toward organized labor since President Obama took office two years ago, may soon ease restrictions against union worksite soliciting during organizing campaigns.
That's the opinion of Jay Krupin, a veteran labor relations attorney with the Washington, DC-based firm EpsteinBeckerGreen. Krupin says it's not clear exactly what will emerge early next year as NLRB examines issues related to union worksite access for organizing purposes. Given the new composition of the four-member board—which includes Obama's recess appointees Craig Becker and Mark G. Pearce, and Clinton appointee and Chair Wilma B. Leibman—Krupin anticipates that unions will be happier with the results than will management.
"We have a three-to-one supermajority of pro-union members of the board. They are implementing the parts of the (Employee Free Choice Act) that they couldn't get through the legislative process. The pro-labor leaning members of the board are taking that agenda and running with it," he says.
Krupin says he expects NLRB will hear arguments from organized labor that the no solicitation policy violates the National Labor Relations Act because it precludes unions from equal access to workers considering organizing. "Right now on the employers' premises you only hear from one side. The issue is the employers have a 'captive audience.' Our argument has always been the unions can meet with the employees any place else in the world," he says.
Improving union access to the worksite would be disruptive, and create an unfair and coercive environment, Krupin says. "The union doesn't represent the employees until the employees say they do. This is like having an insurance agent coming into your house until you sign the policy. If you want to sign the policy you will find them," he says.
Krupin predicts that NLRB will examine the parameters of the so-called 24-hour rule, which prohibits management from holding mandatory mass meetings with employees within 24 hours of a union vote. "Unions won't be able to speak to employees whenever they want, but I suspect it is going to be more of an equal access question," he says. "If an employer engages at any time, not just within 24 hours, with mass meetings with more than one employee on the premises, then the union should have the same access. It will be more equal access, rather than total access."
"The board's justification would be that since the employer has access to the employees, the unions should have the same access," Krupin says. "I'm making a supposition, but I'm pretty good at looking at this stuff and knowing the history. It's like the communications world, where stations have to give candidates equal access."
So what should hospitals do about it?
"They have to be aware of this and develop policies in anticipation of an equal access provision," Krupin says. "We are saying let's review what policies they have now to see where they sit. Then in anticipation of the changes in the rules, how would we change those policies, setting up a fire drill before the fire as to how we should change the policies."
It's also a good time to examine protocols. "If the union wants to come on the premises, and they have the right to come on the premises, how will they be escorted? What areas will they go to? What times can they come on the premises," Krupin says. "You have to establish preventive policies. Look at those issues in anticipation of the rules being changed. As the decisions come out of the board we can modify them, but we are getting a head start."
Healthcare unions have enjoyed tremendous success in the past few years, winning well over 70% of their organizing elections, but they are not invulnerable. Krupin says hospitals that interact effectively with employees have the best chance of defeating organizing efforts. "That means communicating with employees, comparing wages and benefits, making sure you deal with grievances and that other issues that employees have are handled effectively. If you do the things you are supposed to do and your employees understand the communication and the transparency, they may not like the decision but at least they know you are thinking about them and you are trying to do the right thing," Krupin says.
The problem, he says, is that hospitals wait too long to act. "There is a process to do this. Hospitals wait until their blood pressure is 190/140, their cholesterol is at 300, and they are 40 pounds overweight. Then they say 'Oh my goodness I will stop smoking then,'" he says. "Employees only go to unions when they feel the employer is not listening. Unions don't organize employees, managers do."
While the nation's unemployment rate has increased to 9.8 percent, hospitals reported 8,000 payroll additions in November and 42,200 payroll additions so far this year. The growth in hospital jobs is nearly double the 21,700 jobs created in the first 11 months of 2009, but is still well off the pace of hospital job growth for most of the decade, data released Friday by the Bureau of Labor Statistics show.
After erratic hospital job growth in the first seven months of this year, hospitals have seen four straight months of growing employment, and have added 23,900 jobs since August. Overall, hospitals employed more than 4.7 million people in November.
BLS data from October and November is preliminary and may be considerably revised in the coming months.
The job growth comes even as hospitals “mass layoffs” affecting 50 or more employees are keeping pace with the record 152 mass layoffs set in 2009. BLS data show that the nation's hospitals reported 16 mass layoffs in October —the latest figures available.
Hospitals shed 1,900 jobs in July, added 5,700 jobs in June, and shed 1,400 jobs in May, after creating 15,900 jobs in the first four months of the year. The sector reported 98,800 payroll additions in the first 11 months of 2008.
The healthcare sector—everything from hospitals, to chiropractors' offices, blood and organ donor banks, to walk-in clinics—added 19,200 jobs in November, and employed 13.8 million people that month. Healthcare has been one of the few areas of steady job growth during the recession and sputtering recovery, creating an average of 20,880 jobs each month, and 229,700 jobs in the first 11 months of 2010.
Healthcare created 215,300 jobs in 2009, and 763,400 jobs since the recession began in December 2007, BLS data show.
Job growth in the healthcare sector continues to be powered by ambulatory services, which accounted for 7,400 payroll additions in November, and 139,600 payroll additions in the first 11 months of 2010. Nursing and residential care facilities reported 3,800 payroll additions in November, and physicians' offices reported 500 payroll additions, BLS preliminary data show.
The larger economy gained 39,000 jobs in November, but the nation's jobless rate rose from 9.6% to 9.8% for the month. Since December 2009 nonfarm employment has increased by 946,000 jobs. However, 15.1 million people were unemployed in November, and 6.3 million of them were long-term unemployed who had been without a job for at least 27 weeks, BLS preliminary data show.
It's been 11 years since the Institute of Medicine reported in December 1999 that medical errors caused more than 98,000 deaths and injured more than 1 million people each year. Unfortunately, the results from two recent studies indicate that—despite a lot of focus and effort—the nation's hospitals have not significantly reduced medical errors, which still lead to tens of thousands of deaths each year.
Hospital advocates don't dispute the findings, but they also don't believe the last 10 years were a lost decade. They believe that progress has been made, even if it is not immediately apparent.
"It was discouraging not to see more evidence that the hard work that has gone on in the past decade has had as substantial an impact as we believe it has. But the studies are what the studies are," says Nancy Foster, vice president for quality at the American Hospital Association.
"There are enormous numbers of hospitals engaged in a number of activities directly addressing patient safety issues. Are we there yet? No. It is a multifaceted problem that requires a multifaceted approach," she says. "We have to keep hammering at it until we get to the level of safety that we expect of ourselves and the public rightfully expects of us. As these studies suggest, we have a ways to go."
The studies—one from Health and Human Services Office of Inspector General, the other from the New England Journal of Medicine—indicate that medical errors remain widespread, common, and deadly. The OIG study found that one in seven Medicare beneficiaries suffers an adverse event during a hospital stay, and those events, nearly half of them preventable, contributed to at least 15,000 deaths in a single month.
The second study, published in the Nov. 25 issue of The New England Journal of Medicine, examined 2,300 randomly selected patients' records at 10 hospitals in North Carolina from 2002-2007 and found 588 instances of "patient harm," including surgical errors, hospital falls, misdiagnoses, medication errors, and hospital-acquired infections. Fifty of the incidents were considered life threatening, and 14 people died, according to the study.
Ironically, North Carolina was chosen for the study because of that state's recent emphasis on reducing medical errors. "It's a fair study. It points out that there is much more work to be done despite the fact that we have had some very intense efforts in this state over the last five years," says Don Dalton, vice president and spokesman for the North Carolina Hospital Association. "A little to our disappointment, the years of the study didn't coincide with some of our years of greatest improvement. We created a quality center here in 2005 so we have done a lot in the last five years and three of those five years would not have been included in the study."
Dalton says NCHA and its member hospitals have worked hard to reduce central line bloodstream infections and surgical site infection. "More importantly we have done a lot of work with hospitals around the issue of creating just cultures, where hospitals are taking greater responsibility for changes in the system that would eliminate the opportunity for harm, and healthcare professionals continuing to take personal responsibility for their actions. We feel like it is the system work that has the greatest opportunity to improve the quality of care," Dalton says.
In some respects, Foster says, the two studies' results also reflect the improving quality of data collection and identification of hospital errors. "What I see in these two studies is that we have learned an enormous amount about safety and our risks to patients, what might constitute an error and new ways to identify them which are much more robust than the original methodology used in the Harvard Medical Practice study which was the foundation of the IOMs original estimate," Foster says.
"In addition we now see more things as potentially preventable than we did a decade ago," Foster says. "The biggest example is central line bloodstream infection. We used to think of them as having a certain level of inevitability and now we know we can get very close to zero with them. That's terrific news for patients but it does mean the count of things that are preventable has gone up."
Online ads for healthcare practitioners and technical workers rose by 12,400 listings to 555,500 in November, the largest increase of any job sector for the second consecutive month, and vacancies for the skilled providers outnumber qualified job seekers by almost 3 to 1, a report shows.
The Conference Board's Help Wanted Online Data Series, which tracks more than 1,000 online job boards across the United States, attributed the uptick to "advertised vacancies for family and general practitioners."
Healthcare support vacancy listings held steady with an increase of 600 listings to 112,600. There were 2.4 unemployed people for every advertised vacancy in healthcare support, The Conference Board reports.
The average wage advertised for healthcare practitioners and technical workers was $33.51 an hour, and the average wage for healthcare support occupations was $12.84 an hour, the report says.
The U.S. Bureau of Labor Statistics, which will release on Friday its employment statistics for November, has shown that the healthcare sector is one of the few areas in the economy that has seen monthly job growth throughout the recession, although that growth has slowed considerably since 2009.
In the overall economy, online advertised vacancies rose 47,400 in November to 4,457,200, following an increase of 113,700 in October, The Conference Board reports.
"In November, demand for workers continued to be positive, albeit moving at a disappointingly slow pace for the last few months," said June Shelp, vice president at The Conference Board. "November was a surprisingly quiet month throughout the nation, with most states posting small gains/losses in advertised vacancies. In this weak U.S. economic recovery, office help, construction jobs, and positions in business and finance continue to show very sluggish growth."
The nation's supply/demand rate stood at 3.27 unemployed for every advertised vacancy in October (the last available unemployment data), down from a peak of 4.73 in October 2009. Nationally, there are 10.4 million more unemployed than advertised vacancies, The Conference Board reports.
The Conference Board also reported a modest increase in demand for transportation and material sector jobs, and a decline in demand for sales and sales management positions.
"The simulator we can control. If it becomes too much, we can tone it down, make it literally a walk in the park if we need to."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Robert Neil McLay's story.
Public opinion polls show that the war in Afghanistan and the fragile peace in Iraq have fallen far down the list of concerns for most Americans, replaced by the economy and jobs, the federal budget deficit and spending, healthcare, and even immigration.
But there remains a dedicated group of medical professionals within the military that has not forgotten the wars, and the horrific impact they can have on the bodies and minds of the people who fight; nor have they forgotten the moral obligation this nation has to help these wounded warriors.
While it's hard to feel comfortable about medical advances that owe their development to the violence of war, that should not detract from the valiant work of people like U.S. Navy Reserve Commander Robert Neil McLay, MD, PhD, a psychiatrist and the research director in the Mental Health Directorate at Naval Medical Center San Diego.
McLay's field of expertise involves post traumatic stress disorder and the effects of combat-induced stress on the brain. He is a pioneer in the use of computer-based virtual reality simulators for treating PTSD. His treatment regimens, which include traditional therapy and consultation, have enjoyed success rates of up to 75%, even for patients with a history of treatment resistance.
"We see all types. PTSD can happen to just about anyone," says McLay, who spent seven months in Iraq in 2008. "We see the full range of people who had difficulties before they went and the trauma just made them worse, to at the other end of the spectrum, some Special Forces supermen who had never had any problems in their lives, who had always been the absolute best at anything they had ever done, and are now struggling with the very idea that, 'Hey! Why did this bother me?'"
Simulators create a variety of scenes with varying intensity. A routine patrol on a Fallujah street can be dialed up into a bloody firefight, if the patient is ready for it.
"The first time they tell that story is often the hardest part of therapy. The simulator we can control. If it becomes too much, we can tone it down, make it literally a walk in the park if we need to," McLay says. "But just coming forward and deciding to face your own demons, that can be tough for people. That is one reason why we introduced the simulator. It is to try to be able to put it slightly more in control between the doctor and the patient, and introduce people to it a little gradually."
Much of the thought behind the simulators comes from the older forms of exposure therapy that were developed decades ago, and which are based on the idea that fear naturally burns itself out.
"It is physiologically difficult to maintain an amped up state for long periods of time, which definitely happens in PTSD," McLay says. "If you actually really are under threat repeatedly, the system will stay ramped up. The brain stem?what keeps the physiology amped up?learns from the upper brain, the part that thinks. We learn to be afraid of what we avoid. Our brain stem learns that 'This really is a dangerous situation and I need to back away from it.' And when you are backing away from something that is inside your own head, we can't do that effectively."
The simulator allows patients to address their fears, to relive the source of anxiety and see that they no longer have to fear for their safety. "Your brain stem learns, 'Maybe I can be safe. If something reminds me about the trauma, I'm not going to be hurt this time around,'" McLay says.
Even with the simulator, and the new advances in therapy and medication, McLay says a big stumbling block remains the negative perceptions of mental illness, despite the military's efforts to remove the stigma. "We deal with some amazing people who have gone through some very difficult things, in some cases quite horrific things. The hardest step for most folks is coming forward and saying, 'I am going to talk about this,'" McLay says. "If you can get over that hurdle, it doesn?t mean the rest is easy but it does show the person has shown a certain amount of motivation and has overcome a huge hurdle just by coming in."
As much as he is an advocate for simulators, McLay also remains a healthy skeptic.
"It works but I'm not convinced it?s the best thing out there," he says. "I'm not absolutely convinced yet that the gizmo portion of it—the actual virtual reality—is the active component of treatment. It may be just meeting with the therapist as often as we are and providing the type of therapy that we are."
That's the question that McLay and his colleagues at NMCSD are now trying to answer. "Do you really need all these gizmos or can you do it with a still computer image without using the fancy simulators?" he says. "If you could, that might be good news. It would mean we were able to do this type of treatment in a lot more different clinics and with a lot more people."
“We have been able to bring back in the last year-and-a-half over $4 billion lost to healthcare fraud.”
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Tony West's story.
The settlement this year with Nashville-based FORBA Holdings LLC was far from the biggest fraud case that the Department of Justice has prosecuted.
But for Tony West, assistant attorney general for DOJ's civil division, the satisfaction he got with that dental management company case represents a big reason he left a thriving private law practice to return to the Department of Justice as a political appointee when President Obama took office in 2009.
"We found through our investigation not only were they cheating Medicaid, the way they were cheating Medicaid was by performing unnecessary procedures and surgeries on kids," West said. "They were pulling healthy teeth. They were giving kids unnecessary root canals; some really horrific things. We went after that company. Not only did we settle for a large amount of money, $24 million, but we also obtained the company's cooperation in our ongoing investigation of individual dentists."
It's hard to put a finger on the cost of Medicare and Medicaid fraud. Daniel R. Levinson, Inspector General at the Department of Health & Human Services, estimated for Congress this year that 7.8% of Medicare fee for service claims paid in 2009—roughly $24.1 billion—did not meet program requirements, although he stressed that the improper payments did not necessarily involve fraud.
A program as big as Medicare is ripe for fraud, which can take many forms. It could be a bogus durable medical equipment shop that's actually a post office box in Miami or Detroit. It could be a hospital using indigents to bill Medicare for unneeded services. It could be a multinational pharmaceutical company illegally marketing its medications for off-label uses not recognized by the Food and Drug Administration.
Regardless of the exact dollar amount, West concedes that fraud is a huge problem for Medicare and Medicaid, both in terms of lost money, and the corrosive effect on public confidence.
"It's been very damaging. Some people view Medicare fraud as a victimless crime because you don’t see it in the same way you would see street crime. But it really does damage the integrity of our public healthcare programs, which so many Americans depend upon for their care," West says.
"We lose so much of our hard-earned taxpayer dollars because of fraud. We have been able to bring back in the last year-and-a-half over $4 billion lost to healthcare fraud. While there is more than that that is being lost to fraud, it does represent an increase because we have been so aggressive cracking down on it."
In May 2009, HHS and DOJ joined forces to create HEAT, the Healthcare Fraud Prevention and Enforcement Action Team, and West says it's working.
"Every year, we have seen an increase in our ability to bring back taxpayer dollars lost to fraud," he said. "The cases do have a deterrent effect. If you look at the criminal side, you've seen an increase in our healthcare strike forces that we have set up around the country. We have seen an increase in the number of criminal defendants that have been arrested and are going to trial and are being held accountable."
West acknowledges that the crackdown on Medicare and Medicaid fraud is also highly symbolic now, as the Obama Administration begins implementing the complex healthcare reforms.
"When you look at the Medicare/Medicaid system, you are talking about trillions of dollars. It is just immense. The millions of Americans that rely on those two programs and the lives they touch is very far reaching and wide ranging," he says. "The fact that we can not only do the job of administering those two programs that help so many Americans, but at the same time crack down on waste fraud and abuse where we see it, and really step up the number of individuals and companies that we hold accountable for healthcare fraud is a testament to the work we have been doing over the past two years."
"If we have the same objective, we can find the common ground necessary to get there."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Jim Douglas' story.
Anyone who watched the deeply partisan, mean-spirited wrangling in Washington, DC, this past year during the healthcare reform debate would not be faulted for believing that the American political system is dysfunctional.
To find a working, bipartisan, political system that focuses on practical results within budgetary constraints, leave the Beltway and look to the states. In striking contrast to Congress, Vermont provides a great example of what Republicans and Democrats can achieve in healthcare when they agree upon a common goal. And perhaps no one better embodies that bipartisan spirit in the Green Mountain State than long-serving Republican Gov. Jim Douglas.
A career politician who has held various roles in state politics for three decades, Douglas is serving the last of his eight years in office, having been elected and reelected four times as a fiscal conservative and social moderate Republican in a state with a national reputation as a quirky hotbed for progressive politics.
In 2003, shortly after taking office, Douglas launched the Blueprint for Health in Vermont, with an emphasis on preventing illness and complications, rather than responding to health emergencies. Working with Democratic majorities in both chambers, he signed a package of healthcare reforms in 2006 to expand access to coverage, improve quality, and contain costs.
"If we have the same objective, we can find the common ground necessary to get there," Douglas says of his work with Democrats. "We found ways to make the progress here in a bipartisan basis that we can all be proud of. There are always advocates who will want to do more or something different, and that is a dynamic of our system. But the commonality of the interests in serving the people of Vermont and working toward a healthier population has allowed us to find that common ground."
Vermont's healthcare successes have not gone unnoticed. For the past three years, Vermont has been ranked the nation's No. 1 healthiest state by the United Health Foundation, the American Public Health Association, and Partnership for Prevention. The state ranked among the Top 10 states in 11 of 22 measures, including second-highest level of funding for public health, and ninth-lowest percentage of people without health insurance.
In March, Douglas was awarded the 2010 Health Quality Award from the National Committee for Quality Assurance for his work to improve Vermont's healthcare system through a focus on chronic disease prevention and management resources. Douglas, who was chairman of the National Governors Association during the healthcare reform debates this year, says the nation's governors share similar experiences, regardless of party affiliation.
"We have to deliver. We don't have the luxury of talking about things and letting deadlines pass. We have to balance budgets. Governors have to live within their limited resources, make tough decisions on a daily basis," Douglas says. "I spoke with a colleague—who I won't identify—who served in both the U.S. Senate and as a governor and he said the difference was striking. He said the Senate was a debating society where you talk about things and don't have to make a practical decision, whereas an executive has to make things happen and happen on time."
In this most recent election season that ended last month, the partisan gridlock and charred-earth tactics that has crippled Washington for years crept into a number of hotly contested state campaigns. Douglas, who will retire from state government at the end of his term, says he hopes the days of the moderate, consensus-building politician are not numbered.
"The American people like moderation. I don't think Americans are extremists at one end of the spectrum or the other. They want someone who is practical, gets the job done, who makes the trains run on time. On balance, it is going to be people who are more centrist who ultimately accomplish that," he says. "I hope I am not a breed that is dying. I think that is where most Americans are. Ultimately, it's not ideology. It's putting food on the family table that guides decisions and priorities of the people in our country."
