Archives for September 2012

Seniors Show Their Muscle in Fight Against Healthcare Fraud

Last year, the federal government ramped up its efforts to get seniors involved in the fight against Medicare fraud. One year later, the seniors have proven themselves worthy opponents against those attempting to defraud the government via Medicare schemes. This week, Kathleen Sebelius, Director of HHS, announced that seniors have become one of the most valuable resources when finding evidence of health care fraud, announcing that the Obama Administration is investing more than $7 million in new funding to support the Senior Medicare Patrol in various projects around the country.

 According to Sebelius, “seniors are paying attention and they are fighting back against the fraudsters who are trying to steal from Medicare.” It is often seniors who notice services they never received on their Medicare statements who provide the first tip that fraud is happening.  As a result, CMS has redesigned Medicare statements to make them easier to read and understand.  Senior Medicare Patrol (SMP) programs are educating seniors, family members, and caregivers around the country about the importance of reviewing their Medicare notices to identify errors and report potentially fraudulent activity.

 Sebelius noted stories such as one about a Medicare beneficiary in Texas who was asked to sign a work order for his diabetes supplies. According to Sebelius, the gentleman that, “normally he would have just signed and thrown the paper away.  But he had recently heard a presentation from the SMP at his adult day center, so he looked more closely and noticed that he was being charged $7,000 for one month’s supply. So he asked his home nurse to help him call the National Hispanic SMP and together they figured out that the supplier was going to charge Medicare for 100 boxes of diabetes test strips and 100 boxes of lancets, even though he’d received only one of each.  The SMP helped resolve the case and made sure that Medicare only paid for the supplies he actually needed and received.”

Cases like that are all too common. It is incredibly important to educate seniors on what to look for and how to pay attention. The SMP pays for many classes each year so that seniors may be trained to spot and report questionable items. In fact, much of the money coming in from the government is being allocated toward education. According to the stop Medicare fraud website, “educating and empowering health care consumers to prevent fraud is an essential strategy for protecting our citizens and their health benefits and strengthening Medicare and Medicaid.”And how are we sure? The OIG has reported that this program works. According to a recent OIG report released in June, in 2011, the SMP realized a 14-percent increase in the number of volunteers over the year before, bringing the total to almost 5,700. In just the past couple of years, the SMP saw a 45-percent increase in the number of Medicare beneficiaries who attended group education sessions, from 298,097 in 2010 to 431,128 in 2011.

 Although some of SMP’s efforts have experienced only modest results, about $19,283 in Medicare funds were recovered in 2011 and cost avoidance totaled $247,850, SMP members have also taken part in reporting two “large-dollar cases” to contractors. In one case, the Medicare contractor is seeking to recover $2.9 million in overpayments from a provider, the OIG report stated.

 To date, more than 1.5 million seniors have called SMP programs in cities around the country to ask questions and report potential fraud. And together they’ve saved Medicare and the federal government in excess of $100 million. And $100 million return on a $7 million investment isn’t too terrible.

An Obama Second Term Likely Will Benefit For-Profit Hospitals: Analysts

For-profit hospitals stand to gain a lot from a second Obama administration, according to a recent report from a financial analyst, because of the expanded Medicaid and private insurance coverage provided under the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148). Chris Rigg, an analyst with the Susquehanna Financial Group in Bala Cynwyd, PA, noted that, “the hospital industry will benefit significantly from [the health reform law’s] coverage expansions. The expansion of Medicaid and insurance subsidies more than fully offsets the commercial pricing pressure we expect in the individual and small group insurance segment.”

Under PPACA, the ranks of the uninsured have gone down already, according to a recent report from the U.S. Census Bureau. In 2011, the number of individuals without insurance fell to 48.6 million (15.7 percent of the population) from 50 million in 2010, the first drop in the uninsured since 2007.  The Census Bureau report–Income, Poverty, and Health Insurance Coverage in the United States: 2011–saw a corresponding increase in the number of individuals covered by health insurance, from 256.6 million in 2010 to 260.2 million in 2011.

The Census Bureau report noted that the percentage of individuals covered by private insurance or employment-based health insurance remained the same between 2010 and 2011. The percentage of individuals covered by government health insurance increased from 31.2 percent in 2010 to 32,2 percent in 2011. Medicaid coverage increased from 15.8 percent to 16.5 percent. Medicare coverage increased from 14.6 percent to 15.2 percent

Certain health insurance reforms went into effect in 2010, such as allowing adult children to remain on their parents’ health insurance until they turned 26. The uninsured rate among individuals age 19 to 25 dropped from 29.8 percent in 2010 to 27.7 percent in 2011. Expanded Medicaid coverage, as well as access to private insurance coverage through state health insurance exchanges, starts in 2014.

The current increase in the number of insured, coupled with the much larger increase expected starting in 2014, were the major contributing factors to the analysis that for-profit hospitals have better days ahead of them. According to Rigg, profit margins on earnings before income taxes, depreciation, and amortization (EBITDA) will increase more than 2 percent in 2014 for for-profit hospital operators Community Health Systems, Inc., Tenet Healthcare Corp., and Health Management Associates, Inc.

IOM: Substance Use Disorders Among Active Duty Military

Due to serious reports of rising rates of alcohol and prescription drug abuse in the military, the Institute of Medicine (IOM) was asked by the Department of Defense (DoD) to analyze policies related to screening, prevention, diagnosis, and treatment of substance use disorders (SUDs) for active duty services members of all branches of the military, i.e., the Air Force, Army, Marine Corps, Navy, members of the National Guard and Reserve, and their military families. The IOM report, entitled “Substance Use Disorders in the U.S. Armed Forces,” was released on September 17, 2012.

History of Alcohol and Substance Abuse

The U.S. military has a long history of alcohol and drug abuse.  According to the IOM report, in 1998, 15 percent of active duty members admitted to heaving drinking and 35 percent to binge drinking.  As of 2008, those figures had increased substantially, with 20 percent admitting to heavy drinking and 47 percent to binge drinking.  The IOM further reports that military doctors “wrote nearly 3.8 million prescriptions for pain medication in 2009, more than quadruple the number of such prescriptions written in 2001.”

A Public Health Crisis

The IOM analysis concludes that “alcohol and other drug use in the armed forces remain unacceptably high, constitute a public health crisis, and both are detrimental to force readiness and psychological fitness.”  The IOM believes that these facts must be acknowledged at the highest level of the military leadership and must be addressed through a variety of strategies, including limiting access to alcohol and drugs.  Additional structural recommendations by IOM include:

  • a routine check by prescribers of local prescription drug monitoring programs before dispensing;
  • training health care professionals to recognize patterns of prescription drug use and medication-seeking behaviors;
  • routine screening for unhealthy alcohol use and mechanisms to support interventions; and
  • placing interventions within the context of primary care.

Environmental changes recommended by IOM include reducing the number of outlets that sell alcohol, restricting their hours of operation, and reducing the type and amount of alcohol available.

Use of Evidence-Based Practices

The IOM report recommends that DoD fully implement its evidence-based guideline, entitled “VA[Veterans Affairs]/DoD Clinical Practice Guideline for Management of Substance Abuse Disorders,” which has already been developed by DoD. Implementation of this guideline, according to IOM, would help facilitate their recommendations regarding routine screening and effective treatment. 

Expanding TRICARE Benefits

The IOM concedes that the military health care system presently provides SUD treatment directly and through TRICARE insurance. TRICARE, however, does not cover intensive outpatient services, office-based outpatient services, and certain evidence-based pharmacological therapies which are standard SUD components of care.  The IOM, therefore, recommends that TRICARE SUD benefits be expanded to include care in intensive outpatient and office-based settings, which would increase access to care.  IOM further recommends that should the DoD fail to timely implement these TRICARE SUD changes, that Congress should consider legislation mandating these changes to DoD.


FDA Urged by Consumer Advocates to Set Standards for Arsenic in Rice

A Consumer Reports study of 223 rice and rice products finding that the average serving of rice contained up to 8.7 micrograms of inorganic arsenic has prompted consumer food advocacy groups to urge the FDA to set standards on allowable levels of arsenic found in rice and rice products. Although citing that no evidence is available to suggest that rice is unsafe to eat, the agency is currently in the process of studying 1,200 samples of store-bought rice and rice products, including short and long-grain rice, cereals, and drinks to measure arsenic levels.

The Consumer Reports study also found that there was higher levels of arsenic in brown rice than white rice, possibly because of how the two types are processed. Additionally, rice produced in the southern United States had higher levels of arsenic than rice from California or imported from Asia.

Arsenic is naturally present in water, air, food, and soil in both organic and inorganic forms. Organic arsenic passes through the body quickly and is considered harmless. However, inorganic arsenic is toxic and poses a cancer risk if consumed at high levels or extended periods of time. Inorganic arsenic is found in some pesticides and insecticides.

The FDA released data on 200 of the 1,200 samples in its study, noting that the study will not be completed until year’s end and that the agency would not draw conclusions until the completion of the study. However, the agency noted that based on its preliminary review of rice and rice products, the results from Consumer Reports appear to be consistent with those the agency is observing in its initial testing. The FDA also stressed that there are many different types of rice and rice products from different parts of the world, grown very differently, and the conditions under which they are grown may vary the levels of arsenic from year to year, lot by lot.

The FDA was unaware of any data that differentiated the amount of arsenic found in organic rice versus non-organic rice. Arsenic is present naturally as well in soil and water; thus it is absorbed by plants regardless of whether they are grown under conventional or organic farming practices. 

Consumer Reports used New Jersey’s drinking water standard of a maximum 5 micrograms per liter of water as its touchpoint, because there is no federal benchmark. Although the state’s standard is one of the strictest in the country, it is still unclear whether the levels of arsenic in water and levels in rice should be set with the same standard, because people consume more water than rice.