UPMC applauds the ruling, but the Pennsylvania Attorney General's Office says it will file an appeal with the state supreme court.
A state court has rejected the Pennsylvania Attorney General's attempt to modify and extend a five-year consent decree governing University of Pittsburgh Medical Center's dealings with rival Highmark.
Pennsylvania Commonwealth Judge Robert Simpson ruled Wednesday that the AG's office did not have the authority to modify the consent decree—which expires June 30—without the consent of both Highmark, which agreed with the modifications, and UPMC, which did not.
"Because the OAG does not plead fraud, accident or mistake, this court lacks the power or authority to modify the termination date of the consent decree without the consent of the parties, even if it were in the public interest to do so," Simpson wrote in a 45-page ruling.
UPMC Chief Communications Office Paul Wood said in prepared remarks that the health system "agrees with the Commonwealth Court ruling that the Consent Decrees end on June 30, 2019, which is exactly what the Pennsylvania Supreme Court unanimously decided last year."
Simpson declined to rule on UPMC's counterclaims that Pennsylvania Attorney General Josh Shapiro did not have the authority to regulate nonprofit organizations, nor did the judge rule on Shapiro's claim that UPMC was not meeting its charitable obligations.
Shapiro's office filed suit against UPMC in February, asking the court to allow for the modification and extension of the consent decree indefinitely, arguing that UPMC was violating its obligations as a nonprofit organization.
UPMC countersued two weeks later, claiming the AG's office lacks the legal authority to meddle in UPMC's negotiations with Highmark and other health plans.
Shapiro's spokesman Joe Grace said the AG will appeal the ruling with the Pennsylvania Supreme Court.
"Judge Simpson ruled that Commonwealth Court itself could not extend the date of the consent decrees—not that such a modification was barred," Grace said. "This enables our office to quickly appeal to the Supreme Court, which we will do in short order given the impending scheduled expiration date."
"As this complex legal process plays out, Attorney General Shapiro will continue fighting for the best interest of patients, payers and the public in Western Pennsylvania and uphold their access to the healthcare facilities they have contributed to building," Grace said.
The UPMC-Highmark feud has been long-running, as the payer-provider organizations have jockeyed for market dominance in western Pennsylvania.
State officials required the two to work together, imposing a consent decree in 2014 that required each health plan to cover services provided by the other organization. That decree is set to expire June 30.
A federal report found no generally accepted estimate of downstream healthcare costs associated with untreated behavioral health conditions.
Nearly 57 million adult Americans have a substance abuse or mental health condition, and nearly 40 million of them go untreated, according to data cited by the Government Accountability Office.
"Not treating behavioral health conditions can lead to other health care costs, such as the costs of emergency care for an overdose," GAO said in a recent report. "However, GAO found that research on such costs is limited and there is no generally accepted estimate of all the healthcare costs associated with untreated behavioral health conditions."
Citing 2017 survey data from the Substance Abuse and Mental Health Services Administration, more than 80% or respondents who reported a mental health or substance abuse problem said they did not perceive need treatment.
A further breakdown of SAMHSA survey results showed that:
Of the 18.7 million people with substance abuse disorders, 17.2 million are untreated.
Of the 11.2 million people with serious mental illness, 3.7 million are untreated.
Of the 35.4 million people with other mental illness, 22.9 million are untreated.
The SAMHSA survey found that people who perceived a need for behavioral health treatment but did not receive it blamed cost, stigma, and access challenges, such as not knowing where to go for treatment.
GAO said a review of existing literature on untreated substance abuse and behavioral health could not provide any downstream cost estimates.
"According to experts GAO met with, available research in this area is limited by methodological challenges, including determining which healthcare costs can be attributed to an untreated behavioral condition, and by limited data on the full prevalence of certain behavioral health conditions," the report said.
The 29 studies GAO reviewed for the report compared the healthcare costs associated with treating and not treating certain behavioral health conditions in adults focused more on specific behavioral health conditions and specific geographic areas.
By combining traditional medical data with self-reported SDOH data, the codes trigger referrals to social and government services to address people's unique needs.
UnitedHealthcare, and the American Medical Association have launched a collaboration to create nearly two dozen ICD-10 codes to better incorporate social determinants of health into healthcare delivery.
The collaborative wants to standardize how SDOH such as food, housing, transportation, employment, and financial means are collected, processed and used in patients' care plans, noting that there exists no consistent, organized method to capture that data.
By combining traditional medical data with self-reported SDOH data, the codes trigger referrals to social and government services to address people's unique needs, connecting them directly to local and national resources in their communities, the collaborative said in a media release.
Through this collaboration, UnitedHealthcare and the AMA's Integrated Health Model Initiative are supporting the creation of nearly two dozen new ICD-10 codes related to SDOH.
"The collaboration reinforces the importance of social and environmental factors in patient care, and will shape IHMI's efforts to support clinical decisions with useful and valid data to achieve broad improvements in health and greater health equity," said Tom Giannulli, MD, CMIO at IHMI.
Using its data model, UnitedHealthcare said it has made more than 700,000 social-service referrals for enrollees in its Medicare Advantage plans since 2017.
Increasingly, payers, providers, and state and federal governments are acknowledging the critical role that SDOH plays in proactive care delivery.
In 2016, CMS amended the Medicaid managed care rule to prompt Medicaid MCOs to help patients with nonmedical expenses that were considered crucial to achieving health outcomes and cutting costs.
Under the CMS Accountable Health Communities Initiative, many Medicaid MCOs assess patients' unmet social needs, including housing instability, food insecurity, utility needs, interpersonal violence, and transportation requirements.
An increasing number of states are requiring Medicaid MCOs to address social determinants of health as part of contractual agreements. In New York, The Empire State's Value Based Payment Roadmap requires MCOs to offer startup funds for partners in Value Based Payment agreements who are conducting social determinant of health interventions.
National and state hospitals groups warn that invalidating the Affordable Care Act would have 'disastrous' consequences for tens of millions of Americans and the nation's healthcare infrastructure.
The nation's largest hospital associations and 24 state hospital associations on Monday filed amicus briefs urging a federal appeals court to reject a Texas court's "judicial repeal" of the Affordable Care Act.
"If upheld, it will unwind eight years of progress under the ACA's broad set of reforms," read the joint amicus brief submitted by the American Hospital Association, Federation of American Hospitals, the Catholic Health Association of the United States, America's Essential Hospitals, and the Association of American Medical Colleges.
"And if upheld, it will cause tens of millions of patients to lose their health insurance, returning them to the ranks of the long-term uninsured and putting their health at risk," the associations said.
U.S. District Judge Reed O'Connor last December declared the entire ACA invalid, as the Texas-led coalition of plaintiff states had requested. The ruling was appealed to the 5th U.S. Circuit Court of Appeals by a California-led coalition of states intervening in defense of the ACA.
O'Connor's ruling invalidating the ACA went much further than what DOJ had urged. Last week, however, DOJ reversed course and notified the appeals court that it agrees with the plaintiffs' argument and O'Connor's ruling, and would entirely abandon its partial defense of the ACA.
The AHA-led amicus brief said that repealing the ACA only benefits the "plaintiffs' idiosyncratic health-policy preferences."
"But for the rest of the country, which has benefitted from expanded health-insurance coverage, the birth of a stable individual-insurance market, an expanded Medicaid safety net, and many other protections, it would be disastrous," the brief read.
"It would result in more Americans going without basic medical care and more Americans waiting to seek care until they are seriously ill, placing their health at greater risk and making it harder to treat their conditions successfully," the brief said.
In a separate amicus brief, also filed Monday, 24 state hospital associations also urged the appellate court to reverse O'Connor's ruling.
"This court should reverse the district court’s order striking down the ACA," the brief read. "If the court holds the minimum coverage provision unconstitutional, it should sever that one provision and leave the rest of the law intact."
"Any other ruling would disrupt nine years of innovations that have become enmeshed in the health care landscape, wreak havoc in healthcare delivery in this country, and subvert the will of Congress," the 24 hospital associations wrote.
Prosecutors allege that CareWell executives developed schemes to create mandatory but unnecessary examinations that were billed to state and federal healthcare programs.
CareWell Urgent Care Centers will pay $2 million to settle whistleblower allegations that the company submitted inflated and upcoded claims to Medicare and to Medicaid programs in Massachusetts and Rhode Island, the Department of Justice said.
According to state and federal prosecutors, between 2013 and 2018, Quincy, Massachusetts-based CareWell filed false claims with Medicaid, MassHealth, GIC, and Rhode Island Medicaid after inflating evaluation and management services and failing to identify the clinicians providing the care.
CareWell allegedly used several schemes, including ordering clinicians to unnecessarily examine and document at least 13 body systems during medical history inquiries, and at least nine body systems during physical examinations.
This unnecessary documentation was compiled even if patients' medical complaints or symptoms did not warrant it, prosecutors said.
CareWell ordered clinicians to use patient encounter templates within the clinics' electronic medical records that used "yes or no" questions about specific body systems, even when such inquiries were not medically necessary, prosecutors said.
"Even if medical personnel failed to ask a patient every question in an encounter plan template, the template contained a default 'no' response to each inquiry," prosecutors alleged. "CareWell used the default 'no' responses to assert that the associated body systems had been examined and billed accordingly, even when no such examination had occurred."
CareWell managers also allegedly lied to clinicians and told them that examinations unrelated to a patient's specific medical complaints or symptoms were required by a malpractice insurance carrier.
Prosecutors also allege that CareWell failed to reduce the amounts of its claims for services performed by unsupervised nurse practitioners.
"The CareWell urgent care centers engaged in a calculated scheme to reap unjustified economic benefit for their own gain from precious government healthcare resources," said Andrew E. Lelling, U.S. Attorney for the District of Massachusetts.
The settlement resolves whistleblower allegations brought by former CareWell employee Aileen Cartier, who will collect about $340,000.
CareWell Responds
CareWell said in a media release that it reached the settlement "after fully cooperating with the inquiry."
"We believe it is crucial to be thorough with each patient's examination in order to provide the best possible care," the company said.
CareWell operates 16 urgent care centers in Massachusetts, and one in Rhode Island.
The pilot program will provide temporary housing, tenant support and other services to people who are homeless or at risk of homelessness because of their disability.
The Centers for Medicare & Medicaid Services has approved a Florida section 1115 pilot program that provides behavioral health services and housing to adult Medicaid beneficiaries with serious mental illness, substance abuse disorders, or both.
"We are committed to supporting states that seek to test policies that are likely to improvebeneficiary health because we believe that promoting independence and improving health outcomes is in the best interests of the beneficiary and advances the fundamental objectives of the Medicaid program," Chris Traylor, CMS's deputy administrator and director, said in a letter this week to Beth Kidder, Florida's deputy director of Medicaid.
"In its consideration of Florida's MMA (Managed Medical Assistance amendment), CMS examined whether the demonstration was likely to assist in improving health outcomes, whether it would address health determinants that influence health outcomes, and whether it would incentivize beneficiaries to engage in their own healthcare and achieve better health outcomes," Traylor said.
"CMS has determined the Florida MMA Demonstration is likely to promote Medicaid objectives, and the waiver and expenditure authorities sought are necessary and appropriate to carry out the demonstration," he said.
The Behavioral Health and Supportive Housing Assistance Pilot will provide transitional housing, tenancy support services, mobile crisis management and self- and peer-support, along with home and community-based services to people who are homeless or at risk of homelessness because of their disability.
The waiver request was sent to CMS after Florida lawmakers in 2016 directed the state's Agency for Healthcare Administration to seek federal approval to pay for "flexible services" such as temporary housing for people with severe mental illness or substance abuse disorders.
In exchange for the waiver approval, Florida must follow home and community-based services requirements for person-centered planning, conflict of interest, and home and community-based setting requirements.
The state must also develop performance measures within 90 days following the approval of the waiver to address the requirements of the pre-tenancy services, tenancy sustaining services, mobile crisis management and self-help/peer support, CMS said.
"By paying these costs, the Medicaid program helps vulnerable populations afford the medical care and services they need to attain and maintain health and well-being," Traylor said.
Showing a united front, the nation's largest hospital associations roundly condemned of the DOJ's decision to abandon its defense of the ACA.
The decision this week by the Department of Justice to drop any and all defense of the Affordable Care Act was met with scorn and dismay from the nation's hospital lobby.
American Hospital Association President and CEO Rick Pollack called the DOJ's about-face on the ACA defense "unprecedented and unsupported by the laws or the facts."
"America's hospitals and health systems oppose the Department of Justice's misguided decision calling on the courts to strike down the Affordable Care Act in its entirety," Pollack said in a media release.
"If courts were to adopt the DOJ position, Medicaid expansion would be reversed and protections for people with chronic and pre-existing conditions would cease to exist," Pollack said. "Millions of Americans would lose the coverage they have relied on for years. We have made too much progress in coverage and access to care for patients to go backwards."
The DOJ had argued in District Court proceedings last fall that most of the sprawling healthcare legislation should remain intact, even if the ACA's individual mandate were to be struck down in light of Congress zeroing out its tax penalty. Only the ACA's community-rating and guaranteed-issue provisions—which protect consumers with preexisting conditions—should fall with the mandate, the DOJ had argued.
District Judge Reed O'Connor's decision last December went much further than the DOJ had urged, declaring the entire ACA invalid, as the Texas-led coalition of plaintiff states had requested.
Now that an appeal is pending at the Fifth Circuit, however, the DOJ has decided that it agrees with the plaintiffs' argument and O'Connor's decision after all.
Federation of American Hospitals President and CEO Chip Kahn called the reversal "unfortunate but not unexpected considering (the Trump administration's) long-held views on the health law."
"Millions of Americans depend on the ACA to access healthcare and rely on the insurance protections afforded in the law," Kahnsaid. "We continue to believe the district court judge got it wrong and trust that this decision will be overturned in the appeals process."
Beth Feldpush, senior vice president of policy and advocacy at America's Essential Hospitals, called the Trump administration's position "untenable for our hospitals and their patients."
"It threatens to reverse important gains in health and healthcare access and take us back to a time when the emergency department was the only option for millions of people," Feldpush said. "That’s unsustainable and would push our hospitals to the breaking point as they struggle with the swelling costs of uncompensated care."
Sister Carol Keehan, DC, president and CEO of the Catholic Health Association of the United States, called the reversal "unconscionable and immoral."
"The Department of Justice, now backtracking from its prior legal stance to argue instead that the entire Affordable Care Act should be struck down, is stunning," Keehan said. "The time has come for our government to stop playing politics with people's health and livelihoods."
Keehan said the elimination of the ACA would bring back a litany of healthcare access and coverage problems that preceded the sweeping legislation, including the loss of guaranteed protections for 130 million people with pre-existing conditions and the elimination of Medicaid coverage for 17 million poor people.
"We would return to the era of insurance companies defining what they cover rather than being required to offer plans that provide true health security," she said. "The continuing innovation to shift the healthcare system toward providing more affordable and quality health care to people in this country would also be lost."
Keehan said the CHA would be filing a friend-of-the-court brief " to alert the Fifth Circuit to the dire consequences of upholding the District court's decision."
"If the last few years of debating the Affordable Care Act and all its provisions have taught us anything, it is that Americans value their healthcare," Keehan said.
The suit alleges that specialists at Wheeling Hospital were paid exorbitant salaries of more than $1 million per year because their referrals generated downstream revenue for the hospital.
Federal prosecutors have taken up a whistleblower lawsuit alleging that a West Virginia hospital, its management company, and CEO paid illegal kickbacks to physicians for patient referrals.
The Department of Justice alleges that nonprofit Wheeling Hospital Inc., violated the Stark Law and Anti-Kickback Statute, and that those violations were caused by R & V Associates Ltd., Wheeling's contracted management consultant, and Wheeling CEO Ronald Violi, who prosecutors allege had "dictatorial control" of the compensation agreements.
According to the suit, the 247-bed Wheeling Hospital had lost $50 million in the seven years before Violi and R&V took over management in 2005.
The managers quickly turned the hospital "into an extremely profitable venture. However, several of the arrangements that drove this newfound excessive profitability were illegal."
"Wheeling Hospital's dramatic revenue increase was accomplished by entering into lucrative but improper compensation arrangements with physicians that were well above fair market value, took into account the value or volume of services and/or were not commercially reasonable, in order to gain the physicians' referrals," the suit claims.
Prosecutors said that OB/GYNs, cardiologists, radiation oncologists and other specialists were overpaid exorbitant salaries—in some cases more than $1 million per year—because their referrals generated downstream revenue for the hospital.
Ultimately, some of those downstream revenues were reimbursed by Medicare or Medicaid.
The suit was filed in U.S. District Court for the Western District of Pennsylvania.
"Improper financial arrangements between hospitals and physicians can influence the type and amount of healthcare that is provided," said Assistant Attorney General Jody Hunt of the Department of Justice's Civil Division.
"The Department is committed to taking action to eliminate improper inducements that can corrupt the integrity of physician decision-making and drive up healthcare costs," he said.
The complaint is contained in a lawsuit filed under the whistleblower provisions of the False Claims Act that authorize private parties to sue on behalf of the federal government for false claims and share in any recovery. The whistleblower, Louis Longo, was an executive vice president at the hospital from 2011 to 2015.
The law permits the federal government to intervene and take over the lawsuit, as it did here in part.
Wheeling Hospital Responds
A Wheeling Hospital executive called the DOJ's suit an "unwarranted attack on what the hospital stands for and the ethics by which it operates."
"As we have said before, the allegations in this lawsuit are simply not true and an unfair attack on our hospital, our values and our dedicated physicians who partner with us to provide care to our community," said Gregg Warren, the hospital's vice president of marketing and public relations.
"We stand by our physicians and will aggressively defend against these baseless and unsubstantiated claims, while remaining fully committed to providing world-class care to the citizens of Wheeling and the Upper Ohio Valley every day," he said.
"We are particularly disappointed that the U.S. government chose to file its claims against our hospital in Pennsylvania rather than in Wheeling," Warren said. "Our community, our employees and loyal patients deserve to have the case litigated in West Virginia, where our hospital is located and our physicians provide care."
MedStar Health and two affiliates allegedly paid kickbacks to a cardiovascular surgeons group under the guise of professional services agreements.
MedStar Health Inc. and two affiliate hospitals will pay the federal government $35 million to resolve whistleblower allegations that the health system paid illegal kickbacks to a cardiology group in exchange for patient referrals, the Department of Justice said.
"Kickbacks give doctors an incentive to pursue unnecessary treatments that are costly and sometimes even dangerous to patients," Robert K. Hur, U.S. Attorney Robert for the District of Maryland.
"We will not tolerate medical care providers who put their patients at risk and waste taxpayers' dollars in order to line their own pockets," Hur said.
According to federal prosecutors, between 2006 and 2011 Columbia, Maryland-based MedStar Health, and Baltimore-based affiliates MedStar Union Memorial Hospital and MedStar Franklin Square Medical Center allegedly paid kickbacks to MidAtlantic Cardiovascular Associates under the guise of professional services agreements.
MedStar also agreed to settle allegations that it received Medicare payments from Jan. 1, 2006, through Dec. 28, 2012, for medically unnecessary stents performed by John Wang, MD, a one-time employee of MACVA who was later employed by MedStar.
The settlement resolves a lawsuit brought by three whistleblowers physicians: Stephen D. Lincoln, MD; Peter Horneffer, MD; and Garth McDonald, MD, cardiac surgeons who practiced together as members of Cardiac Surgery Associates in Baltimore.
The settlement also resolves a lawsuit brought by former patients of Wang, who claimed that Wang, MedStar, and Union Memorial knowingly performed medically unnecessary percutaneous transluminal coronary angioplasty with stent placement procedures and submitted false claims to Medicare for those cardiac stent procedures.
Under the civil settlement, the whistleblowers will receive a portion of the federal share of the recovery.
MedStar Health Responds
MedStar Health issued a statement noting that it denied "all wrongdoing."
"We fully cooperated with the government's investigation of these matters and ultimately determined that it was best to settle these matters in order to avoid protracted and distracting litigation," MedStar said.
"Importantly, the two cases have been settled without any findings of liability. MedStar has full confidence in our quality assurance and compliance programs, and we remain fully focused on advancing our patient care mission."
But a new study shows people living in areas with only one or two plans pay significantly more for premiums than do people in more-competitive regions.
The Affordable Care Act's Marketplace plans got more competitive in 2019, but there are still more regions with only one or two plans to pick from, a new study suggests.
The number of people living in areas with five or more marketplace insurers increased by 8% in 2019, from 18.6% to 20.1%, according to the analysis by the Urban Institute and the Robert Wood Johnson Foundation.
At the same time, the analysis showed that the number of people living in areas with only one or two plans in 2019 dropped by 17%, from 45.1% to 37.5%, which the report said signals an increase in marketplace competition between 2018 and 2019.
However, the study found wide swings in plan availability depending upon geography.
More than 20% of Americans live in an area with five or more marketplace insurers, the 322 least competitive rating regions are disproportionately concentrated in less populated areas of the country, especially the South.
"It's encouraging to see signs of stabilization in the individual market," said Anne F. Weiss, managing director at the Robert Wood Johnson Foundation, in comments accompanying the study.
"However, geographic location still plays too great a role in consumers' coverage options and how much they cost. Everyone should have affordable health insurance options, regardless of where they live, given the impact of coverage on health," Weiss said.
Among the findings:
The Northeast leads the nation in marketplace insurer competition, with a little more than 40% of its population living in areas with five or more marketplace insurers.
In the South, only 4% of residents live in areas with five or more marketplace insurers, while a majority (just under 53%) live in areas with only one or two marketplace insurers.
Approximately 26% of the population in both the West and the Midwest live in areas with five or more insurers, with 19% and 40% living in areas with only one or two insurers, respectively.
Consumers in areas with fewer marketplace insurers typically pay higher premiums. In 2019, the median benchmark silver plan premium for a 40-year-old non-smoker in regions with one insurer cost $592 per month compared to $376 per month in regions with five or more insurers, a difference of more than 36%.
GAO Study Sees Market Concentration
A separate study issued this month by the Government Accountability Office found that enrollment in private health insurance plans continued to be concentrated among a small number of health insurers in 2015 and 2016.
In the large group market, small group market, and individual market, the three largest commercial health insurance plans held 80% of the market or more in at least 37 of 51 states. The findings are similar to what GAO reported for 2011 through 2014.
GAO also found that within the overall individual and small group markets in each state, the health insurance exchanges established by the ACA were also concentrated from 2015 to 2017.
For the individual market exchanges, in each year, three or fewer issuers held 80% or more of the market, on average, in at least 46 of the 49 state exchanges.
The largest insurers increased their market share in about two-thirds of exchanges.
For the small group market exchanges, in each year, three or fewer issuers held 80% or more of the market in at least 42 of 46 state exchanges.
