Auditors blame CMS for failing to establish a data-sharing agreement with the VA.
Medicare overpaid providers about $128 million over five years for medical care that the Veterans Administration had already paid for, federal watchdogs report.
The Department of Health and Human Services Office of the Inspector General determined that the "duplicate payments occurred because the Centers for Medicare & Medicaid Services did not implement controls to address duplicate payments for services provided to individuals with Medicare and VHA benefits."
"Specifically, CMS did not establish a data-sharing agreement with VHA for the ongoing sharing of data between the two agencies and did not develop an interagency process to include VHA enrollment, claims, and payment data in CMS's data repository," OIG says. "Inclusion of these data, which is required by federal law, would have allowed CMS to compare VHA claims data with existing Medicare claims data to identify duplicate claims paid for by both Medicare and VHA."
The audit covered $19.2 billion in Medicare Parts A and B payments for 36.3 million claims for Medicare and VHA benefits that received services from VA's community providers between January 2017 and December 2021. The auditors compared claims data from the VA and Medicare to match payments that had been claimed in both datasets.
"Because CMS did not develop an interagency process, CMS did not establish an internal process (such as claims processing system edits) to address duplicate payments for medical services authorized and paid for by VHA. Furthermore, CMS guidance to providers on VA’s responsibility to pay for medical services did not clarify that a provider should not bill Medicare for a medical service that was authorized by VHA," OIG says.
CMS Agrees
The OIG recommends that CMS: Create a data-sharing agreement with VHA; Build an interagency process to integrate VHA enrollment, claims, and payment data into the CMS Integrated Data Repository to identify pMedicare otential fraud, waste, and abuse under the Medicare; and establish an internal process to address duplicate payments made by Medicare for medical services authorized and paid for by VHA; and issue guidance to providers on not billing Medicare for a medical service that was authorized by VHA.
CMS agreed with the recommendations and said it was taking up the recommendations.
The findings highlight a critical need to improve medical treatment provided to women and make the workplace more supportive for women experiencing menopause.
Menopause-related symptoms such as hot flashes, night sweats, mood changes, sleep disturbances, joint aches and cognitive difficulties cost about $1.8 billion a year in lost work time, and another $26.6 billion for related medical expenses, a Mayo Clinic study reports.
Menopause occurs at a mean age of about 52 years, and because midlife women are a sizable proportion of the workforce, the effect of menopause symptoms on absenteeism, productivity, increased medical costs, and career setbacks is notable.
Mayo Clinic researchers invited 32,469 women aged 45 to 60 who are primary care patients Mayo to participate in the survey. Just over 5,200 women responded (16.1%) and of those, 4,440 were employed and included in the study.
The findings, published in Mayo Clinic Proceedings, linked menopause symptoms and adverse work outcomes, including lost work productivity, with the severity of the symptoms strongly predicting the odds of an adverse work outcome.
The study authors say the findings highlight the need to improve medical treatment for women and make the workplace more supportive for women in menopause.
"A full 13% of the women we surveyed experienced an adverse work outcome related to menopause symptoms, and about 11% were missing days of work because of these symptoms," Faubion says. "We also found some racial and ethnic differences on a sub-analysis of the results, though more research is needed in this area, in larger and more diverse groups of women."
The survey was conducted between March and June, 2021. The symptoms were assessed by the Menopause Rating Scale (MRS). The mean total MRS score was 12.1, a moderate menopause symptom burden. The mean age of the 4,440 participants was 54 years, with the majority being white (93%), married (76.5%) and educated (59.3% with college degree or more).
A total of 597 women (13.4%) reported at least one adverse work outcome due to menopause symptoms, and 485 women reported missing one or more days of work in the preceding year due to symptoms.
"Adding to the complexity of women's experience of menopause is that the topic has been taboo, particularly in the workplace, which potentially adds to the psychological burden of symptoms," says senior author Ekta Kapoor, M.B.B.S., assistant director of Mayo Clinic Women's Health.
"Women often fear bias, discrimination and stigmatization, and therefore may be reluctant to disclose their menopause symptoms to their workplace managers and others. Recognizing these concerns and creating a safe workplace environment for women to discuss their health care needs may help address this."
TBI and hip fracture were the two most common injuries among senior dog-walkers.
Walking the family dog is good exercise, but it also puts adult pet owners — particularly women and seniors — at risk of serious injuries such as bone fractures and traumatic brain injuries, according to a new study from Johns Hopkins University.
Using the National Electronic Injury Surveillance System database, the researchers examined 20 years of emergency department records and found that finger fractures, TBIs, and shoulder sprains were the most common injury among the approximately 422,659 adults who sought treatment related to walking a leashed dog between 2001 and 2020.
The researchers also found that women, and all adults age 65 and older, were more likely to sustain serious injuries, such as fractures and TBIs, than people in other demographic groups.
TBI and hip fracture were the two most common injuries among adults age 65 and older, and women were 50% more likely than men to sustain a fracture. Older dog walkers were more than three times as likely to experience a fall, more than twice as likely to have a fracture and 60% more likely to sustain a TBI than younger dog walkers.
Across the 20-year study period, the estimated annual incidence of injuries due to leash-dependent dog walking more than quadrupled. The researchers say this may be due to concurrent rising dog ownership rates and promotion of dog walking to improve fitness.
The team hopes its findings will promote awareness among dog owners and encourage clinicians to discuss the injury potential of leash-dependent dog walking with their patients.
The study was published in Medicine & Science in Sports & Exercise.
"Dog ownership also increased significantly in recent years during the COVID-19 pandemic," says Ridge Maxson, the study's first author and a third-year medical student at The Johns Hopkins University.
"Although dog walking is a common daily activity for many adults, few studies have characterized its injury burden. We saw a need for more comprehensive information about these kinds of incidents." Edward McFarland, MD, the study's senior author and director of the Division of Shoulder and Elbow Surgery at Johns Hopkins Medicine, says "clinicians should be aware of these risks and convey them to patients, especially women and older adults."
"We encourage clinicians to screen for pet ownership, assess fracture and fall risk, and discuss safe dog walking practices at regular health maintenance visits for these vulnerable groups," McFarland says. "Despite our findings, we also strongly encourage people to leash their dogs wherever it is legally required."
Danville, PA-based Geisinger will be the first hospital to join Risant Health.
Megasystem Kaiser Permanente and Pennyslvania's Geisinger Health announced Wednesday that they plan to merge, with Geisinger to become the first hospital under KP's newly created but separate, value-based care affiliate, Risant Health.
Financial terms were not disclosed for the deal, which will have to clear daunting state and federal regulatory hurdles.
In a media release, the two systems describe Risant as a "nonprofit organization, created by Kaiser Foundation Hospitals, to expand and accelerate the adoption of value-based care in diverse, multi-payer, multi-provider, community-based health system environments."
"Risant Health's vision is to improve the health of millions of people by increasing access to value-based care and coverage and raising the bar for value-based approaches that prioritize patient quality outcomes," the health systems say. "In addition to Geisinger, Risant Health will grow its impact by acquiring and connecting a portfolio of like-minded, nonprofit, value-oriented community-based health systems anchored in their respective communities."
Geisinger will keep its name and mission, and will continue to work with other health plans, employed physicians, and independent providers. At the same time, Geisinger will tap Risant's value-based platform to maximize practices in care model design, pharmacy, consumer digital engagement, health plan product development, and purchasing.
As the first health system in Risant, Geisinger will help develop the system's strategy and operational model.
Geisinger President and CEO Jaewon Ryu, MD, JD, will be Risant's first CEO, transitioning from Geisinger when the deal closes.
"Geisinger will be able to accelerate our vision and continue to invest in new and existing capabilities and facilities, while charting a path for the future of American health care, through Risant Health," Ryu says. "Kaiser Permanente and Geisinger share a vision for the future of healthcare, and as the Risant Health name indicates, we believe by working together we will reach new heights in health care and raise the bar for better health for all communities."
Health systems that join Risant Health "will continue to operate as regional or community-based health systems serving and meeting the needs of their communities, providers and health plans while gaining expertise, resources, and support through Risant Health's value-based platform," KP says.
In addition, Risant Health will operate separately from KP's integrated care and coverage model while building on the mega-system's 80 years of expertise in value-based care.
"Our mission calls on us to find new ways to promote high-quality, affordable, and evidence-based care with equitable and improved health outcomes," says Greg A. Adams, KP chair and CEO.
"We know fully replicating KP's closed integrated care and coverage model is not viable in all communities. By helping other health systems achieve our value-based quality outcomes and savings in multi-payer, multi-provider environments, we believe Risant Health can deliver a transformative new solution to America's systemic health care problems."
The nation's big drug and health insurance lobbies are blaming each other for rising healthcare costs.
They're at it again!
The nation's largest drug and health insurance lobbies are blaming each other for rising healthcare costs that are footed ultimately by consumers.
The longstanding feud between the two powerful players reignited this week when America's Health Insurance Plans (AHIP) launched what it is calling "a major new advertising campaign" that "calls out how Big Pharma spends millions pointing fingers at others in the healthcare system to distract Americans from manufacturers' soaring drug prices – attempting to deflect blame, limit competition, and undermine patients' bargaining power.
"Over the past 20 years, pharmaceutical companies have earned more than $18.6 billion in total worldwide revenues on new prescription drugs that only cost them around $1.8 billion to develop," the ad says. "In fact, more than 22 cents of every premium dollar you pay goes into the pockets of Big Pharma to pay for prescription drugs—more than any other expense.
"And costs keep rising. The Wall Street Journalrecently reported on a new generation of therapies that cost patients as much as $3 million each year for treatment."
AHIP says ad campaign "will blanket broadcast, social media, and direct placements in targeted outlets in Washington, D.C.," AHIP says.
Robert Traynham, a spokesman for AHIP, alleges that "Big Pharma continues to deceive and divert attention from real solutions and the root cause of high drug prices – Pharma's anti-competitive, price-gouging tactics."
"Manufacturers keep prescription drug prices high and undermine the evidence-based, market-driven tools we use to lower prices and provide more choices in quality care for Americans. Consumers, businesses, and taxpayers are stuck paying excessively high costs. Big Pharma's dishonest distractions have to stop," Traynham says.
PHRMA Slaps Back
It took about one day for the Pharmaceutical Research and Manufacturers of America (PhRMA) to respond.
Spokesman Robby Zirkelbachsays the AHIP campaign comes as federal regulators are examining the role of pharmacy benefits managers in rising drug costs.
"If we needed any more proof that the health insurance and pharmacy benefit manager (PBM) industries are one and the same, look no further than a new ad campaign by AHIP," Zirkelback says. "With PBMs facing increasing scrutiny on Capitol Hill, AHIP is hitting the airwaves to deflect any responsibility for the high cost of medicine many people face.
Zirkelbach dismisses the payers' lobby claims that PBMs are negotiating for lower drug prices on behalf of patients.
"They claim that all they do is negotiate savings for patients, but if that were true, then why are they facing lawsuits, investigations and regulation by state attorneys general, state legislatures, the Federal Trade Commission and United States Congress for their role in rising healthcare costs?," Zirkelbach says.
"The fact is insurance companies don't want anyone to look under the hood at the broken PBM business model that now makes up the majority of their profits," Zirkelbach says. "That's right: big insurers now generate more profits from their PBM business than they do delivering insurance coverage. But that's not the only thing the insurance industry doesn't want the public to see.
PBMs charge fees tied to the price of medicines, which means they make more money when the price of medicine goes up. The FTC has warned this "may shift costs" and "ultimately increases patients' costs." They say they want lower prices, yet they often deny or limit coverage of lower-cost generics and biosimilars.
In 2021, the net price for medicines – the price after rebates, discounts, and other payments from manufacturers – grew just 1%. The government's inflation data reveals that the prices for medicines grew less than 3% over the last year.
"With so much to hide, it's not surprising AHIP is trying to avoid any responsibility for the high drug costs many people face," Zirkelbach says. "We hope lawmakers will hold insurers and middlemen accountable with real reforms that rein in abusive insurance tactics and lower out-of-pocket costs at the pharmacy for patients."
Tele-behavioral health was important to 95% of employers and 65% were satisfied around these services.
A new survey of more than 200 large employers finds near-universal recognition of the need for effective mental healthcare in their employee health plans, but also widespread dissatisfaction with the quality of and access to that care.
The survey, conducted in March by the National Alliance of Healthcare Purchaser Coalitions and HR Policy Association, found that while 99% of employers agreed that timely and effective access to mental healthcare is important, only 31% of the 221 respondents are satisfied with mental healthcare access in their company health plans, which combined cover 10 million people.
"Our study found a strong employer consensus on what is critical and significant variation in health plan and vendor performance," says Michael Thompson, National Alliance president and CEO.
"Many of the services provided, particularly in managing network access, continue to fall short of employer expectations. While there are bright spots, as an industry we still have a long way to go to meet the needs of employees and their families," he says.
The findings were presented Tuesday at a Path Forward mental healthcare meeting of employers, business health coalitions, mental and behavioral health service providers and health plans, and other stakeholders.
The survey asked employers to rank the importance in specific areas and their satisfaction with their service providers' performance.
The survey found that:
While 99% agreed that effective and timely access to in-network behavioral health is important; 31% were unhappy with efforts to identify and address gaps in network access.
Tele-behavioral health was important to 95% of employers and 65% were satisfied around these services.
Only 34% of employers agreed that their behavioral health directories were an accurate reflection of available providers.
While 54% were satisfied with the promotion of standardized measurement for behavioral health services, only 33% were satisfied with engagement and reporting of behavioral health outcomes.
84% agreed that it was important that plans support integration of behavioral health into primary care, but only 28% were satisfied.
64% agreed that early identification using tele-behavioral health can mitigate the severity of mental health issues.
Achieving high engagement in workplace behavioral health programs was important to 92%, but only 39% were satisfied.
Only 27% of employers were satisfied that their service providers evaluate and tailor behavioral health services to diverse communities.
Only 14% of employers were satisfied with service provider support of whole person program integration through data and process coordination.
The responses to this most-recent survey are depressingly similar to responses given in a similar survey five years ago, which found disparities for access to behavioral health when compared to physical health services. "While some progress is evident, many of the issues we cited in 2018 have persisted and we must double down on industry commitment and accountability to address these issues moving forward," Thompson says.
That figure does not include hundreds of millions of dollars spent for patients' months-long recovery costs.
Gun violence in the United States was responsible for nearly 49,000 deaths in 2021, about 30,000 inpatient hospital stays, and 50,000 emergency department visits, generating more than $1 billion in medical costs, according to a new report from the Urban Institute.
In addition, the report notes that gun deaths generated $290 million in costs, about $6,400 per patient, with Medicaid and other government payers picking up the cost. Survivors of gunshot wounds are left with huge medical bills that average about $2,495 per person per month in the year after the injury.
The Centers for Disease Control and Prevention says the 49,000 firearms death in 2021, in the midst of the coronavirus pandemic, was up from the 45,000 deaths reported in 2020. No other advanced industrialized country comes close. Firearms accounted for 10.4 deaths for every 100,000 people in the U.S. in 2019, five times greater than in the countries with the second- and third-highest death rates, France (2.2) and Switzerland (2.1).
The Urban Institute report also notes that:
Women are significantly more likely to be killed by a firearm in the U.S. than in other high-income countries.
The U.S. is the only high-income country where the number of civilian-owned guns exceeds the total number of people.
Medicaid, the program for low-income Americans that disproportionately enrolls people of color, pays most of the costs associated with hospital care for firearm injuries.
While Blacks comprise about 14% of the U.S. population, they accounted for 53% of firearms-related, inpatient hospital stays in 2016-17, and 50% of the hospital costs that year.
The ACP this week published a policy paper that recommends new evidence-based recommendations for audio and video telehealth.
As telehealth use increases, the American College of Physicians is calling for an evaluation of performance metrics used in virtual care,
"Over the course of the COVID-19 public health emergency we have seen a marked increase in telemedicine visits with our patients," says ACP President Ryan D. Mire, MD, MACP.
"Telemedicine can be a significant benefit to patients, increasing access to care and allowing care to be provided more efficiently," he says. "However, as we begin to develop performance measures to evaluate how physicians are doing in performing those services we need to make sure the measures are appropriate."
Mire's comments come as the ACP this week publishes a policy paper in the Annals of Internal Medicine that details new evidence-based recommendations for audio and video telehealth visits in ambulatory venues.
Specifically, ACP wants performance metrics used to evaluate telemedicine visits to adhere to the same criteria as in-person visits. In addition, the physicians' college calls for existing in-person metrics to be reexamined to determine if they're appropriate for telemedicine visits.
The policy paper stresses that telemedicine visits be incorporated into electronic health records, so that those visits do not become standalone encounters of fragmented care.
Before any care metrics are adopted, ACP calls for rigorous testing to ensure that the new metrics are reliable and valid for telehealth, and can be delivered at the appropriate clinical venue, whether that's an individual physician, group practice, health system or health plan.
Lastly, ACP wants to develop metrics that evaluate the effect of telehealth on poorer communities that may lack digital access.
"The same principles that we apply to quality measurement for in-person care should also be applied to the development of measures for telemedicine," Mire says. "The goal in all of our patient interactions is to provide high-quality care. Telemedicine can be an important tool in doing so and we need to make sure that measures encourage that high-quality without unnecessary burden, particularly for under-resourced communities and patients."
Two physicians allegedly involved in the scheme to defraud Medicare, Medicare, TRICARE and other government payers will also pay a combined $750,000.
Covenant Healthcare System paid $69 million in 2021 to resolve whistleblower allegations of a decade-long scheme that provided illegal kickbacks to physicians in exchange for referrals, a violation of the False Claims Act, federal prosecutors revealed this week.
The kickbacks, a violation of the Stark Law against physician self-referrals, went to eight physicians and the physician-owned Covenant Physician Investment Group between 2006 and 2016, and led to false claims submissions to Medicare, Medicaid, TRICARE, FECA, and other government programs, Dawn N. Ison, U.S. Attorney for Eastern Michigan, says in a media release.
Two of these physicians, neurosurgeon Mark Adams, MD, and electrophysiologist Asim Yunus, MD, will pay $406,551 and $345,987, respectively, to resolve allegations related to their role in the scheme, Ison says.
The settlement with Saginaw, Michigan-based Covenant was finalized in 2021 but held under seal until the settlement with Yunus and Adams was finalized, Ison says.
Covenant did not respond Thursday afternoon to a request for comment from HealthLeaders.
The federal government collected $67.1 million, the state of Michigan collected $1.8 million, and whistleblower Stacy Goldsholl, MD, received $12.3 million, DOJ says.
"Improper financial relationships and kickbacks undermine the integrity of federally funded healthcare programs by influencing physician decision making," Ison says. "This outcome emphasizes our commitment to pursuing justice against parties on both sides of those relationships—the hospital seeking to influence the physician via certain compensation schemes and the physician accepting the compensation."
According to DOJ:
Between 2006 and 2016 Covenant had contracts with Yunus, Kimiko Sugimoto, MD, Sujal Patel, MD, Sussan Bays, MD, Guy Boike, MD, and Thomas Damuth, MD, to serve as "medical directors," whose referrals did not meet the exemption requirements of the anti-kickback statute.
From June 1, 2006, to December 14, 2009, Covenant employed Adams in an improper financial relationship that did not meet Stark Law exemptions.
From January 21, 2009, through July 31, 2013, Covenant rented office space to Ernie Balcueva, MD. But didn’t charge him rent, which DOJ called an illegal kickback paid in exchange for referrals.
Covenant let Covenant Physician Investment Group buy medical equipment that the group would lease to Covenant "through non-arm’s-length negotiations" to induce referrals.
Billions of dollars at stake as high court takes up central tenets of the FCA.
In a rare, if not unprecedented, display of unity, the nation's largest payer, provider, medical device, and drug lobbies are aligned and urging the U.S. Supreme Court to uphold an appeals court's rulings that critics argue will defang the whistleblower penalties in the False Claims Act.
The high court on April 18 will hear arguments in the combined appeals of United States v. Supervalu Inc. and v. Safeway Inc., the main arguments for which SCOTUSblog describes as "whether and when a defendant's contemporaneous subjective understanding or beliefs about the lawfulness of its conduct are relevant to whether it 'knowingly' violated the False Claims Act."
In both cases, the whistleblowers alleged that the retail chains knowingly overcharged Medicare and Medicaid for the cost of prescription drugs that they sold to customers at a discount.
In split rulings, the U.S. 7th Circuit Court of Appeals in Chicago sided with retailers in both cases, noting that the "usual and customary price" definition in the law that was relied on by the plaintiffs was vague and subject to interpretation.
The high court's ruling is expected to have a profound effect on whistleblower suits. Violators could still be punished, but it could prove harder for prosecutors and whistleblowers to demonstrate that the defendants knowingly broke the law, and thus would be subject to triple damages lawyers' fees, and other court costs.
With billions of dollars at stake, heavy hitters on both sides of the case have taken notice and filed amicus briefs.
"The FCA is the government's primary civil anti-fraud tool, and it has been wildly successful, with more than $72 billion recovered on behalf of taxpayers since the statute was revamped in 1986," TAFEF writes in its brief. "The Seventh Circuit's rule threatens this success by giving defendants with subjective knowledge of their own wrongdoing a get-out-of-liability-free card, which they or their lawyers can play at any time."
"If adopted by this court, the rule would not only rewrite the FCA's knowledge standard, but would also severely hamstring the United States' ability to protect taxpayer dollars from fraud."
AHIP / AHA Moment
In their joint amicus brief, AHIP and the AHA acknowledge their unusual alliance, noting that they "may not always share the same opinion on matters of litigation and policy, (but) we agree that the current regulatory landscape and construction of the False Claims Act creates an untenable situation for healthcare providers and health insurance providers."
"Medicare and Medicaid are vital public health programs that can operate only with the participation of private parties like our members," AHA/AHIP write, "but participation in these programs also entails navigating some of the most complex statutory, regulatory, and sub-regulatory requirements in existence."
Because of that AHA/AHIP write that the government's argument "causes us great concern."
"The government would impose criminal or civil FCA liability even though it admits that it cannot 'feasibly address in advance every potential ambiguity' in its thousands of statutes of regulations. The rule it proposes would create a Wild West of ramifications for any well-intentioned and legitimate hospital or insurance provider that seeks to serve Americans in partnership with the government," AHA/AHIP write.
"If the government's argument is accepted, our members will be forced to spend more on litigation and less on patient care," the amicus brief states.
