Should You Harness “Crowd Wisdom” to Solve Your Medical Mystery?

A new medical website is harnessing “crowd wisdom” to diagnose the medical conditions of patients that have eluded their personal physicians for years. “Crowd wisdom” is a concept that states that large groups of non-experts can often be smarter than individual experts, as long as the right mechanisms are in place to aggregate their collective wisdom. In fact, “crowd wisdom” has been used by Wikipedia to build their encyclopedia, and by Google to create their search engine. The concept was written about in detail by James Surowiecki in his book The Wisdom of Crowds.

The website, CrowdMed, was founded by Jared Heyman, who reportedly nearly lost his sister to a medical mystery that took three years, 24 doctors, and over $100,000 in medical bills to diagnose. Her condition was finally diagnosed by the collaboration of a large, interdisciplinary team of experts who reached a consensus-based diagnosis. This collaborative approach led to the development of CrowdMed, which connects patients to medical detectives who work together to solve these hard-to-diagnose medical mysteries.

According to CrowdMed, its medical detectives include medical students, retired physicians, nurses, physician assistants, chiropractors, scientists, naturopaths, and regular folks who enjoy solving medical mysteries. As of December 2014, CrowdMed’s medical detective community had the following characteristics: 52 percent male and 48 percent female; 66 percent work or study in medicine (across 32 job titles or specialties); an average age of 36; represent 22 countries; and 69 percent are from the United States.

The average CrowdMed patient has been sick more than eight years, has consulted at least eight doctors, and has incurred over $55,000 in medical bills. CrowdMed claims to bring these patients closer to a correct diagnosis in less than two months through the use of its patented prediction market algorithm which assigns probabilities to each diagnostic or solution suggestion offered by its medical detectives, based on their previous performance. CrowdMed contends that approximately 80 percent of their patients reported their top diagnostic or solution suggestion to be accurate, and over 50 percent say that CrowdMed results have brought them closer to correct diagnosis or cure. Compared to the traditional medical practice, CrowdMed claims that, on average, it produces helpful diagnostic or solution insights up to 50 times faster, and at 300 times less cost.

There are various reasons for its success, but CrowdMed believes that the success of their prediction market algorithm comes down a simple matter of incentives and engagement. Because their medical detectives have something to win or lose depending on their performance, this causes them to be more engaged and invested in their choices.

Here is how it works. When patients submit their case to CrowdMed, they can choose a free case submission option, or one of three pre-paid packages: Lite ($99), Standard ($299), or Premium ($499). Patients can also offer additional compensation to help attract the interest of more and higher quality medical detectives. The packages provide for 30, 60, or 90 days on the site, respectively. CrowdMed sends notifications to their patients at the end of the 30 to 90 day period, giving the patient the chance to extend the case for $99 per month.

Then, once their case is closed, the patient has 30 days to consult with his or her physician to select the best diagnostic and solution suggestions received from CrowdMed. CrowdMed then divides the compensation to those medical detectives who contributed to the best diagnosis or solution suggestion, as determined by the patient or their physician.

Medicaid Expansion has Positive Effect on Health Care for the Homeless

The Medicaid expansion option has not only increased access to health care for the homeless, but has had a positive impact on their health outcomes, and has given providers who treat homeless patients wider treatment options and increased revenue streams leading to operational improvements and additional staffing. These findings were part of a Kaiser Family Foundation (KFF) web briefing on December 15, 2014, which examined the early impacts of the Patient Protection and Affordable Care Act’s (ACA) (P.L. 111-148) Medicaid expansion on the homeless population, as well as opportunities and challenges looking forward.

The briefing, offered by KFF’s Commission on Medicaid and the Uninsured, highlighted key findings obtained from focus groups conducted with administrators, providers, and enrollment workers at four sites serving homeless individuals in states that have expanded Medicaid (Albuquerque, New Mexico; Baltimore, Maryland; Chicago, Illinois; and Portland, Oregon) and one site in a state that has not expanded (Jacksonville, Florida).

The KFF briefing draws upon the recent paper, Early Impacts of the Medicaid Expansion for the Homeless Population, co-authored by Barbara DiPietro, Director of Policy for the National Health Care for the Homeless Council; Samantha Artiga, Associate Director of the Kaiser Commission on Medicaid and the Uninsured; and Alexandra Gates, a Policy Analyst at the Commission. The paper provides an early look at the impact of the expansion for homeless providers and the patients they serve, building on an earlier KFF brief examining the potential role of Medicaid expansion for the homeless population.

Prior to Medicaid Expansion

According to Early Impacts of the Medicaid Expansion for the Homeless Population, prior to Medicaid expansion, homeless individuals were uninsured at high rates even when compared to other low-income groups. For example, of the 851,641 patients served by Health Care for the Homeless grantees in 2013, 57 percent were uninsured, compared to 35 percent uninsured patients served at all health centers and over four times the rate of the general population. In addition, the paper contends that people who are homeless have high rates of both chronic disease and acute illnesses, with many of these conditions associated with or exacerbated by their living situations.

Homeless Enrollment Levels

The Early Impacts paper indicates that Medicaid enrollment of the homeless has increased in all five of the study sites from January 2012 through July 2014:

  • Albuquerque, New Mexico increased from 5 percent to 31 percent.
  • Baltimore, Maryland increased from 51 percent to 87 percent.
  • Chicago, Illinois increased from 36 percent to 47 percent.
  • Portland, Oregon increased from 60 percent to 84 percent.
  • Jacksonville, Florida (despite no Medicaid expansion) increased from 0 percent to 3 percent.

Program Manager Viewpoint

During the briefing, Kascadare Causeya, a Program Manager at Central City Concern in Portland, Oregon, indicated that Medicare expansion resulted in the following challenges at his facility: (1) new Medicaid enrollment systems and requirements created confusion for frontline workers; (2) the lack of telephone numbers and email addresses for the homeless made follow-up contacts difficult; (3) the loss of year two funding created shortages in the enrollment workforce; and (4) the potential for Medicaid coverage loss upon annual renewal. From an enrollment worker’s perspective, however, Causeya found that their homeless clients were happy to enroll in Medicaid, willing to spread the word to other homeless persons, and their outward appearance was visibly improved after initial care.

Clinical Perspective

Nilesh Kalyanaraman, M.D., Chief Medical Officer for Health Care for the Homeless in Baltimore, Maryland, described the following clinical challenges in caring for the homeless: (1) the continued lack of reimbursement for key services (i.e., case management, outreach, and dental); (2) changing drug formularies and the need for prior authorization in managed care plans created delays in access; (3) the lack of housing; and (4) providers learning how to navigate the insurance landscape. Kalyanaraman, however, noted numerous improvements, including:

  • better access to comprehensive care (prevention services and specialty care);
  • increased availability and wider choices of medications (asthma, Hepatitis C, and arthritis drugs);
  • patients having greater control over their health (i.e., able to schedule appointments and obtain refills of medications on their own); and
  • the potential for improved health outcomes over the long term.

Administrator Viewpoint

Karen Batia, Executive Director of the Heartland Health Outreach in Chicago, Illinois, described the following challenges from the perspective of a program administrator:

  • the ongoing need for grant-based funding;
  • managed care plans require multiple provider contracts and significant increases in staff and infrastructure to fulfill compliance requirements;
  • homeless client data is fragmented and remains in silos;
  • increased demand for services stretches provider capacity and creates recruitment and retention issues; and
  • the cost of care for the homeless is initially high as clients access long-needed care.

Batia sees the following administrative opportunities: (1) increased revenue from Medicaid expansion will allow growth in staffing and infrastructure; (2) by treating the homeless, they will obtain better data on the population, which should result in a better understanding of their health needs and the associated costs; (3) the potential to establish risk stratified reimbursements based on the homeless population and appropriate outcomes; and (4) building a system of integrated services.

Misleading “Sprinkle, Eat, and Lose Weight” Claims Result in $26M Refund

The Federal Trade Commission (FTC) has announced that Epiq Systems, Inc., a redress administrator, will be mailing 477,083 refund checks totaling $26,023,329 to consumers who bought the sprinkle-on weight-loss supplement Sensa. The average refund each consumer will receive is $54, but that amount may differ based on how much he or she actually lost. The checks must be cashed within 60 days of their issuance date.

The refund announcement is the result of a January 2014 settlement with the national marketers of Sensa, who deceived consumers by claiming they could “sprinkle, eat, and lose weight” by using the supplement and by making misleading endorsements. The settlement imposed a $46.5 million judgment against the marketers, and required them to pay $26.5 million, with the rest suspended due to their inability to pay. However, if it is later determined that the financial information the marketers gave the FTC is untrue, the full amount of their judgment will become due.

FTC Complaint

The FTC charged that California-based Sensa Products, LLC, its parent company, Sensa, Inc., formerly Intelligent Beauty, Inc., Adam Goldberg, chief executive officer of Sensa, Inc., and Dr. Alan R. Hirsch, the creator of Sensa and a 10 percent owner of Sensa Products, LLC, deceptively advertised that the powdered food additive enhances food’s smell and taste, making users feel full faster, so they eat less and lose weight, without dieting, and without changing their exercise regime.

According to the FTC complaint: (1) the defendants typically charged $59 plus shipping and handling for a one-month supply of Sensa; (2) the powder was provided in twelve flavors, and marketed through radio and print advertisements, retail chains such as Costco and GNC, a promotional book, television ads and infomercials, the Home Shopping Network, ShopNBC, telemarketing, and the Internet; and (3) U.S. sales of Sensa totaled more than $364 million between 2008 and 2012.

The complaint further alleged that:

  • The defendants failed to disclose that some consumers were compensated for their endorsements of Sensa. In some instances, compensation included payments of $1,000 or $5,000, and trips to Los Angeles.
  • Hirsch, who conducted two of the studies cited in the ads and wrote a promotional book about Sensa, gave expert endorsements that were not supported by scientific evidence, and provided the means for the other defendants to deceive consumers.
  • The defendants falsely cited Dr. Hirsch’s studies as clinical proof that consumers could lose substantial weight without dieting or exercise.

Settlement

Under the January 2014 settlement, the defendants are barred from: (1) making weight-loss claims about dietary supplements, foods, or drugs, unless they have two adequate and well-controlled human clinical studies supporting the claims; (2) making any other health-related claim unless it is supported by competent and reliable scientific tests, analyses, research, or studies; and (3) misrepresenting any scientific evidence.

Dr. Hirsch is specifically barred from: (1) providing expert endorsements unless he relies on both competent and reliable scientific evidence and his own expertise; and (2) providing to others studies, promotional materials, endorsements, or other means for deceiving consumers.

The defendants also must disclose any material connections with the endorsers of a product or program, as well as with anyone conducting or participating in a study of the product or program.

Insolvency Reported

While consumers who purchased Sensa may still file a complaint with the FTC, no additional funds are presently available. Sensa, Inc. and Sensa Products, LLC have ceased operations. Sensa, Inc. and Sensa Products, LLC entered into Assignments for the Benefit of the Creditors under California state law on October 17, 2014. An Assignment for the Benefit of the Creditors is a form of insolvency under state law.

CMS Puts Off Incentive Reward Program Changes, Tightens Enrollment Rules

New rules designed to ensure that fraudulent entities and individuals do not enroll in or maintain their enrollment in the Medicare program have been finalized by CMS. The agency had also intended to increase the potential reward amount under the Incentive Reward Program (IRP) for information on individuals and entities engaging in sanctionable conduct in the Medicare program. However, based on adverse industry comments and the complexity of implementation, CMS chose not to finalize the proposed IRP provisions at this time. This Final rule will publish in the Federal Register on December 5, 2014.

Enrollment Rule Changes

The Final rule implements the following changes regarding provider/supplier enrollment:

  • Denial based on Medicare debt. Denial of enrollment will be allowed if the provider, supplier, or owner was previously the owner of a provider or supplier that had a Medicare debt existing when its enrollment was voluntarily terminated, involuntarily terminated or revoked and (1) the owner left the provider or supplier that had the Medicare debt within one year of that provider or supplier’s voluntary termination, involuntary termination, or revocation; (2) the Medicare debt has not been fully repaid; and (3) CMS determines that the uncollected debt poses an undue risk of fraud, waste, or abuse. This denial based on Medicare debt can be averted if the enrolling provider, supplier, or owner satisfies the CMS claim collection criteria set forth in 42 C.F.R. §401.607 and agrees to a CMS-approved extended repayment schedule for the entire outstanding Medicare debt or repays the debt in full.
  • Felony conviction. Denial of enrollment or revocation of Medicare billing privileges will be allowed if, within the preceding 10 years, the provider or supplier, or any owner or managing employee, has been convicted of a federal or state felony offense that CMS determines to be detrimental to the best interests of the Medicare program and its beneficiaries.
  • Pattern or practice of bad claims. Revocation of Medicare billing privileges will be allowed if the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements.
  • Ambulance suppliers. The ability of ambulance companies to “back bill” for services furnished prior to enrollment will be limited. Currently, physicians, non-physician practitioners, physician and non-physician practitioner organizations, diagnostic testing facilities and suppliers of durable medical equipment, prosthetics, orthotics, and supplies cannot bill for services furnished prior to the later of the date the supplier filed a Medicare enrollment application or the date the supplier first began furnishing services at a new practice location. CMS is simply expanding this rule to include ambulance suppliers.
  • CAP limitation. The ability of revoked providers and suppliers to submit a corrective action plan (CAP) will be limited to situations where the revocation was based on 42 C.F.R. §424.535(a)(1), i.e., noncompliance with enrollment requirements, the enrollment application, or failure to pay user fees. The provider and supplier will have only one opportunity to correct all deficiencies through the CAP.
  • Submission of remaining claims. All revoked providers and suppliers will be required to submit all of their remaining claims within 60 days after the effective date of their revocation.

Incentive Reward Program

On April 29, 2013, CMS published a Proposed rule to revise the provider enrollment requirements and the IRP provisions (see CMS releases proposed rule on Medicare Incentive Program, provider enrollment, April 29, 2013). Under the Proposed rule, the reward would be increased from 10 percent of the overpayments recovered or $1,000, whichever is less, to 15 percent of the final amount collected applied to the first $66 million for the sanctionable conduct. The Proposed rule also specified that CMS would not will not give a reward for the same or substantially similar information that was the basis of a payment under the federal False Claims Act (31 U.S.C. sec. 3729 et seq.) or any state False Claims Act. The tip would need to provide sufficiently specific information to start a review or investigation by CMS, and the reward would go to the first person to give specific information on a provider or supplier.

CMS received a number of adverse comments regarding these proposed changes, including the following:

  • The significantly increased reward amount would lead to many reports containing irrelevant or erroneous information that would ultimately impose a heavy burden on CMS and its contractors.
  • The proposal to limit reward eligibility to the first reporter of information could create “shoot first, ask questions later” situations leading to tension between providers and patients.
  • The proposal would encourage whistleblowers to first report their concerns to CMS instead of using established internal compliance reporting methods created within Medicare provider organizations.
  • Does CMS have the resources in place to handle the large influx of tips and complaints that the proposal will generate?

In response to these concerns and due to the complexity of implementation, CMS chose not to finalize the proposed IRP provisions contained in its Proposed rule, but indicated that it may finalize them in the future.

Cost and Impact

According to CMS, savings from most of the finalized provider enrollment provisions cannot be quantified. However, with regards to the limitation on ambulance supplier back-billing, CMS believes that this provision will result in a transfer of $327.4 million per year from ambulance suppliers to the federal government. In addition, CMS believes that the requirement for revoked providers and suppliers to submit remaining claims within 60 days of revocation will limit Medicare’s vulnerability to fraudulent claims and allow for a more focused medical review. The agency believes this will likely lead to some future savings to the federal government.