Is Your State Passing the Physician Information Test?

Physician quality data are only available for 16 percent of U.S. doctors, according to the second annual “State Report Card on Transparency of Physician Quality Information” report by the Health Care Incentives Improvement Institute, Inc. (HCI3). Only six states received a grade of “C” or better. This statistic shows why it can be difficult for consumers to make informed choices when searching for a doctor.

Background

HCI3 is a not-for-profit organization focused on improving the quality and affordability of health care through evidence-based incentive and payment reform programs.

Methods

In order to grade each state, HCI3 used scoring criteria that included the percentage of physicians and supporting health care professionals with publicly available quality information; the physicians’ provided information on outcomes, process, and patient experience; the accessibility of the information to consumers; and the recency of all quality information.

Scoring was based upon an attainable maximum of 100 points achieved with up to 65 points scored for the scope of transparency quality information; 20 points for scope of measures; and 15 points for accessibility of information.

HCI3 also examined the Robert Wood Johnson Foundation’s national directory for comparing health care quality. The directory lists public web-based resources and programs available in each state and is designed to help patients find information on the cost and quality of health care provided in their communities.

In examining the foundation’s national directory, HCI3 assessed physician quality in light of the following parameters:

  • whether the resource or program provided information on physician quality free of charge;
  • whether the information was disseminated by an independent and objective third party;
  • whether the information was specific to primary care physicians or specialists; and
  • whether the information on the website came from data that were captured and scored as of 2011 or later.

If any reporting program did not meet all of the criteria defined above, the state was assigned a grade of “F.”

Grades

Minnesota and Washington received an “A” for the second year in a row; Maine and California received a “B”; Massachusetts and Wisconsin received a “C.” States receiving a “D” grade included Missouri, New Mexico, Ohio, and Oregon, with the remaining 40 states and the District of Columbia receiving a failing grade.

All of the states receiving passing grades are states in which Aligning Forces for Quality (AF4Q) programs are present. AF4Q programs, along with HCI3’s Bridges to Excellence Clinician Recognition program, provide sources of public and objective quality information on physicians.

Francois de Brantes, HCI3 executive director, said, “Consumers are flying blind when it comes to selecting hospitals and physicians, and the overall quality and affordability of American health care won’t be improved until we find a way to solve this problem.” In fact, in another study conducted by the University of California San Francisco Department of Dermatology, results of an undercover dermatologist directory study showed that among 4,800 total physician listings, 45.5 percent were duplicates and only 48.9 percent of uniquely listed physicians were reachable.

With consumer-patients taking on more health care costs, HCI3 stressed that legislators should do more to enforce states to provide detailed, accurate physician information.

Highlight on Alaska: ‘Good Faith’ Medicaid Fraud Guilty Plea

An ongoing federal and state criminal investigation led to guilty pleas from three individuals and entities involved in a far-reaching scheme to defraud Medicaid, according to the Alaska Department of Law’s Medicaid Fraud Control Unit (MFCU).

Background

Good Faith Services, LLC (Good Faith), was an Anchorage personal care agency. Good Faith provided eligible Medicaid recipients with personal care, transportation, and care coordination services. A citizen complaint was filed against Good Faith, which led to a joint investigation by MFCU, the Alaska Department of Health and Social Services, the HHS Office of Inspector General (OIG), the Federal Bureau of Investigation (FBI), and Immigration and Customs Enforcement (ICE). The investigation revealed that 10 full-time Good Faith office employees billed Medicaid almost $400,000 for services they claimed to be providing while simultaneously working in the office; MFCU also alleges that Good Faith fraudulently billed Medicaid for more than $1 million in services provided in violation of Alaska Administrative Regulations by PCAs who had not yet received a valid background check.

In July 2013, 25 Anchorage-based personal care attendants (PCAs) and Medicaid recipients, all of whom were associated with Good Faith, were charged with criminal medical assistance fraud. An additional 53 individuals associated with Good Faith, including 13 of the company’s 16 office staff employees, have also been charged with criminal medical assistance fraud.

Plea Deals

On November 28, 2014, Good Faith pleaded guilty to a single count of medical assistance fraud, which is a class B felony. At the same time, one of Good Faith’s owners, Agnes Francisco, entered a guilty plea to a single count of attempted medical assistance fraud, a class C felony and a related entity, and Anchorage Adult Day Services entered a plea of guilty to a single count of class B misdemeanor medical assistance fraud.

Under its plea agreement, Good Faith will be required to pay a fine of $300,000 and restitution of $1.2 million. Further, Good Faith must permanently dissolve as a corporate entity and provide a declaration to the OIG that it will no longer provide Medicaid services. This follows the state suspending Good Faith’s billing privileges in November 2013. Anchorage Adult Day Services will pay a fine of $20,000 and is permanently suspended from providing Medicaid services.

Francisco, 55, will be sentenced by the court on March 31, 2015. Under the terms of her plea agreement, the court must find that Francisco’s conduct was designed to obtain a substantial pecuniary gain with a low risk of prosecution and punishment, which is an aggravating feature allowing the court to impose a longer period of incarceration. The presumptive range is zero to two years; with the aggravator, Francisco faces up to five years. She may also be fined up to $50,000.

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.

Some Lung Cancer Patients May Breathe Easier With Newly Approved Drug

On December 12, 2014, the FDA approved a new use for Cyramza® (ramucirumab), a cancer drug made by Eli Lilly Co. specifically for the treatment of metastatic nonsmall cell lung cancer (NSCLC). NSCLC is the most common form of lung cancer, occurring when cancer cells develop in lung tissue. Lung cancer is expected to kill about 159,000 people in the United States in 2014.

How it Works

Cyramza works by stopping blood flow to the tumor. It is intended to be used in conjunction with another drug, docetaxel, to treat patients whose tumors have continued to grow during or after treatment with a platinum-based chemotherapy.

Supporting Study

Cyramza was approved under the FDA’s priority review program based on a study of about 1,300 patients. Half the patients received docetaxel plus a placebo, while the other half received docetaxel plus Cyramza. The treatment continued until “disease progression” or the development of intolerable side effects. The study measured the length of time the patients survived after beginning treatment. The patients who received Cyramza lived an average of 10.5 weeks, while those who received the placebo survived an average of 9.1 weeks.

Prior Approvals

The FDA first approved Cyramza on April 21, 2014, as a single line treatment for advanced stomach cancer or gastroesophageal junction (GEJ) adenocarcinoma, which occurs in the region where the esophagus joins the stomach. On November 5, 2014, the FDA approved Cyramza for use with paclitaxel to treat advanced gastric cancer or GEJ adenocarcinoma.