PNHP

PacifiCare's massive Medicare Advantage fraud

PacifiCare's massive Medicare Advantage fraud

Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

Department of Health and Human Services
Office of Inspector General, November 2012

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services(CMS) makes monthly capitated payments to MA organizations for beneficiaries enrolled in the organizations’ health care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security Act require that these payments be adjusted based on the health status of each beneficiary. CMS uses the Hierarchical Condition Category (HCC) model (the CMS model) to calculate these risk-adjusted payments.

The diagnoses that PacifiCare submitted to CMS for use in CMS’s risk score calculations did not always comply with Federal requirements. For 55 of the 100 beneficiaries in our sample, the risk scores calculated using the diagnoses that PacifiCare submitted were valid. The risk scores for the remaining 45 beneficiaries were invalid because the diagnoses were not supported by the documentation that PacifiCare provided.

As a result of these unsupported diagnoses, PacifiCare received $224,388 in overpayments from CMS. Based on our sample results, we estimated that PacifiCare was overpaid approximately $423,709,068 in CY 2007. The confidence interval for this estimate has a lower limit of $288 million and an upper limit of $559 million.

The following are examples of HCCs that were not supported by the documentation that PacifiCare submitted to us for medical review:

*  For one beneficiary, PacifiCare submitted the diagnosis code for “spinocerebellar disease, other cerebellar ataxia.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided described an evaluation for fever and cough. The documentation did not mention cerebellar ataxia or indicate that cerebellar ataxia had affected the care, treatment, or management provided during the encounter.

*  For a second beneficiary, PacifiCare submitted the diagnosis code for “malignant neoplasm of the prostate.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided appeared to describe suture removal and left shoulder bursitis/tendonitis. The documentation did not mention prostate cancer or indicate that prostate cancer had affected the care, treatment, or management provided during the encounter.

*  For a third beneficiary, PacifiCare submitted the diagnosis code for “unspecified septicemia” (commonly referred to as “blood poisoning”). CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided noted that the patient was admitted for a “left total knee revision arthroplasty.” The documentation did not mention blood poisoning or indicate that blood poisoning had affected the care, treatment, or management provided during the encounter.

http://www.scribd.com/doc/116760242/RISK-ADJUSTMENT-DATA-VALIDATION-OF-PAYMENTS-MADE-TO-PACIFICARE-OF-CALIFORNIA-FOR-CALENDAR-YEAR-2007

Comment:

By Don McCanne, MD

It has long been recognized that the private Medicare Advantage plans (offered as an option to the traditional Medicare program) have been cheating the taxpayers, initially by selectively enrolling the healthy while being paid at rates that include a mix of the sick, and, more recently, by gaming the process of risk adjustment (which seeks to correct for the health status of the beneficiaries actually enrolled by the private plans). This new report from the HHS Office of Inspector General is helpful because it provides a perspective of the enormity of the problem.

In one year alone (2007), one California insurer – PacifiCare (acquired by UnitedHealth Group in 2005) – used their Medicare Advantage program to cheat taxpayers out of almost half a billion dollars! Extrapolate that to all Medicare Advantage plans in all states for all years, and think of the impact this must have had on our Medicare budget.

The private insurers pride themselves on their innovations. Based on their past behavior, we can be assured that they will continue to innovate in opaque ways that cheat not only the taxpayers, but also the health professionals and institutions, and, most importantly, the patients. Without transparency, they will get away with it for extended periods of time, with new innovations introduced as they get tripped up on the old.

Although the Affordable Care Act calls for a reduction in overpayments to these plans, the legislation leaves them in place. That is a terrible mistake.

We need to shut down the Medicare Advantage plans, and, while we’re at it, shut down all private insurers and replace them with an improved Medicare for everyone. We may not be able to do that before we reach “The Cliff,” but we should start working on it immediately.

PacifiCare’s massive Medicare Advantage fraud

Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

Department of Health and Human Services
Office of Inspector General, November 2012

Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services(CMS) makes monthly capitated payments to MA organizations for beneficiaries enrolled in the organizations’ health care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security Act require that these payments be adjusted based on the health status of each beneficiary. CMS uses the Hierarchical Condition Category (HCC) model (the CMS model) to calculate these risk-adjusted payments.

The diagnoses that PacifiCare submitted to CMS for use in CMS’s risk score calculations did not always comply with Federal requirements. For 55 of the 100 beneficiaries in our sample, the risk scores calculated using the diagnoses that PacifiCare submitted were valid. The risk scores for the remaining 45 beneficiaries were invalid because the diagnoses were not supported by the documentation that PacifiCare provided.

As a result of these unsupported diagnoses, PacifiCare received $224,388 in overpayments from CMS. Based on our sample results, we estimated that PacifiCare was overpaid approximately $423,709,068 in CY 2007. The confidence interval for this estimate has a lower limit of $288 million and an upper limit of $559 million.

The following are examples of HCCs that were not supported by the documentation that PacifiCare submitted to us for medical review:

*  For one beneficiary, PacifiCare submitted the diagnosis code for “spinocerebellar disease, other cerebellar ataxia.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided described an evaluation for fever and cough. The documentation did not mention cerebellar ataxia or indicate that cerebellar ataxia had affected the care, treatment, or management provided during the encounter.

*  For a second beneficiary, PacifiCare submitted the diagnosis code for “malignant neoplasm of the prostate.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided appeared to describe suture removal and left shoulder bursitis/tendonitis. The documentation did not mention prostate cancer or indicate that prostate cancer had affected the care, treatment, or management provided during the encounter.

*  For a third beneficiary, PacifiCare submitted the diagnosis code for “unspecified septicemia” (commonly referred to as “blood poisoning”). CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided noted that the patient was admitted for a “left total knee revision arthroplasty.” The documentation did not mention blood poisoning or indicate that blood poisoning had affected the care, treatment, or management provided during the encounter.

http://www.scribd.com/doc/116760242/RISK-ADJUSTMENT-DATA-VALIDATION-OF-PAYMENTS-MADE-TO-PACIFICARE-OF-CALIFORNIA-FOR-CALENDAR-YEAR-2007

Comment:

By Don McCanne, MD

It has long been recognized that the private Medicare Advantage plans (offered as an option to the traditional Medicare program) have been cheating the taxpayers, initially by selectively enrolling the healthy while being paid at rates that include a mix of the sick, and, more recently, by gaming the process of risk adjustment (which seeks to correct for the health status of the beneficiaries actually enrolled by the private plans). This new report from the HHS Office of Inspector General is helpful because it provides a perspective of the enormity of the problem.

In one year alone (2007), one California insurer – PacifiCare (acquired by UnitedHealth Group in 2005) – used their Medicare Advantage program to cheat taxpayers out of almost half a billion dollars! Extrapolate that to all Medicare Advantage plans in all states for all years, and think of the impact this must have had on our Medicare budget.

The private insurers pride themselves on their innovations. Based on their past behavior, we can be assured that they will continue to innovate in opaque ways that cheat not only the taxpayers, but also the health professionals and institutions, and, most importantly, the patients. Without transparency, they will get away with it for extended periods of time, with new innovations introduced as they get tripped up on the old.

Although the Affordable Care Act calls for a reduction in overpayments to these plans, the legislation leaves them in place. That is a terrible mistake.

We need to shut down the Medicare Advantage plans, and, while we’re at it, shut down all private insurers and replace them with an improved Medicare for everyone. We may not be able to do that before we reach “The Cliff,” but we should start working on it immediately.

True reform remains elusive

By Arthur J. Sutherland III, M.D.
The Commercial Appeal (Memphis, Tenn.), Letters, Dec. 17, 2012

Dr. Scott Morris’ Dec. 13 Viewpoint guest column “Jesus, prophets couldn’t get health care” was quite clever, but we need to look “upstream” at the roots of our problems to figure out why Jesus couldn’t get care in our current health care “system.” The Patient Protection and Affordable Care Act of 2010 was just another symptom of the chaotic, costly and dysfunctional delivery system that we have lived with since World War II. We are an outlier among developed nations who all have more efficient and less costly national health programs that do a better job of delivering quality health care to all their populations.

Attempts to block implementation of the PPACA or opt out of parts of it just reflect the myopic vision our nation has in dealing with the cost and access issues in health care. The political rhetoric is one of fear and talk about the scarcity of wealth and other resources needed to transform our nation’s health care into one of the world’s best systems. That type of talk is just not true. We have an abundance of wealth, talent and medical resources, plus we already spend more than twice as much per capita as any other developed country. But we have the wrong system in place to get the job done.

Our current supply-driven health care market has no brakes on it. All the stakeholders have no incentives to control costs and improve quality. What we need is a well-thought-out and debated national health program with true national goals based on “best evidence” preventive and medical treatment standards, regional planning, and local implementation. We can best achieve these goals by improving and expanding Medicare for everyone in our country.

In a just society even those made poor have a right to health care. The PPACA will not cover everyone in America or make health care more affordable. The law just makes health insurance more affordable through a voucher system and supplements, but health insurance is not health care.

Even though the Church Health Center has done an outstanding job treating the working poor, we have a bigger problem than all the charity care in communities across the nation could possibly fix. It will require a national will to find the solution. Please look up H.R. 676, the Improved and Expanded Medicare for All Act.

Dr. Arthur J. Sutherland III resides in Memphis.

http://www.commercialappeal.com/news/2012/dec/17/letter-true-reform-remains-elusive/

Consider Medicare for everyone

By John Sytsma, M.D.
Sun Journal (Lewiston, Maine), Letters, Dec. 5, 2012

I am responding to a column by Matt Miller of the Washington Post, printed in the Sun Journal Nov. 30. He suggests that President Obama appoint a panel of experts, chaired by Mitt Romney, to solve the serious problems the nation faces in financing health care.

Rather than asking Romney to chair a panel, Obama should listen to the majority of U.S. physicians and many others who have studied the problem for years and come up with the only system that makes sense — a single-payer national health policy.

Yes, the U.S. health care system is extremely dysfunctional, with 20 to  30 percent of health care spending going into corporate pockets, while more and more dollars are being taken away from beneficiaries.

The U.S., with its profitized system of health care, is spending twice as much on health care as other industrialized countries, yet stands in 17th place in quality of care. The death toll is higher among the uninsured than among the insured. Medical bankruptcy abounds, even among the insured.

The U.S. needs to take a serious look around and consider Medicare for all — the most efficient, not-for-profit system, with administrative costs similar to those in other countries.

Dr. John Sytsma resides in Farmington.

http://www.sunjournal.com/news/letters/2012/12/05/j-sytsma-consider-medicare-everyone/1288823

PacifiCare's massive Medicare Advantage fraud

Risk Adjustment Data Validation of Payments Made to PacifiCare of California for Calendar Year 2007

Department of Health and Human Services
Office of Inspector General, November 2012
Under the Medicare Advantage (MA) program, the Centers for Medicare & Medicaid Services(CMS) makes monthly capitated payments to MA organizations for beneficiaries enrolled in the organizations’ health care plans. Subsections 1853(a)(1)(C) and (a)(3) of the Social Security Act require that these payments be adjusted based on the health status of each beneficiary. CMS uses the Hierarchical Condition Category (HCC) model (the CMS model) to calculate these risk-adjusted payments.
The diagnoses that PacifiCare submitted to CMS for use in CMS’s risk score calculations did not always comply with Federal requirements. For 55 of the 100 beneficiaries in our sample, the risk scores calculated using the diagnoses that PacifiCare submitted were valid. The risk scores for the remaining 45 beneficiaries were invalid because the diagnoses were not supported by the documentation that PacifiCare provided.
As a result of these unsupported diagnoses, PacifiCare received $224,388 in overpayments from CMS. Based on our sample results, we estimated that PacifiCare was overpaid approximately $423,709,068 in CY 2007. The confidence interval for this estimate has a lower limit of $288 million and an upper limit of $559 million.
The following are examples of HCCs that were not supported by the documentation that PacifiCare submitted to us for medical review:
*  For one beneficiary, PacifiCare submitted the diagnosis code for “spinocerebellar disease, other cerebellar ataxia.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided described an evaluation for fever and cough. The documentation did not mention cerebellar ataxia or indicate that cerebellar ataxia had affected the care, treatment, or management provided during the encounter.
*  For a second beneficiary, PacifiCare submitted the diagnosis code for “malignant neoplasm of the prostate.” CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided appeared to describe suture removal and left shoulder bursitis/tendonitis. The documentation did not mention prostate cancer or indicate that prostate cancer had affected the care, treatment, or management provided during the encounter.
*  For a third beneficiary, PacifiCare submitted the diagnosis code for “unspecified septicemia” (commonly referred to as “blood poisoning”). CMS used the HCC associated with this diagnosis in calculating the beneficiary’s risk score. However, the documentation that PacifiCare provided noted that the patient was admitted for a “left total knee revision arthroplasty.” The documentation did not mention blood poisoning or indicate that blood poisoning had affected the care, treatment, or management provided during the encounter.
http://www.scribd.com/doc/116760242/RISK-ADJUSTMENT-DATA-VALIDATION-OF-P…

It has long been recognized that the private Medicare Advantage plans (offered as an option to the traditional Medicare program) have been cheating the taxpayers, initially by selectively enrolling the healthy while being paid at rates that include a mix of the sick, and, more recently, by gaming the process of risk adjustment (which seeks to correct for the health status of the beneficiaries actually enrolled by the private plans). This new report from the HHS Office of Inspector General is helpful because it provides a perspective of the enormity of the problem.
In one year alone (2007), one California insurer – PacifiCare (acquired by UnitedHealth Group in 2005) – used their Medicare Advantage program to cheat taxpayers out of almost half a billion dollars! Extrapolate that to all Medicare Advantage plans in all states for all years, and think of the impact this must have had on our Medicare budget.
The private insurers pride themselves on their innovations. Based on their past behavior, we can be assured that they will continue to innovate in opaque ways that cheat not only the taxpayers, but also the health professionals and institutions, and, most importantly, the patients. Without transparency, they will get away with it for extended periods of time, with new innovations introduced as they get tripped up on the old.
Although the Affordable Care Act calls for a reduction in overpayments to these plans, the legislation leaves them in place. That is a terrible mistake.
We need to shut down the Medicare Advantage plans, and, while we’re at it, shut down all private insurers and replace them with an improved Medicare for everyone. We may not be able to do that before we reach “The Cliff,” but we should start working on it immediately.

Enough specialists for Medicare, but not Medicaid

Healthcare crisis: not enough specialists for the poor

By Anna Gorman
Los Angeles Times, December 15, 2012

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients moved up on waiting lists.

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

http://www.latimes.com/health/la-me-clinic-specialists-20121216,0,5422442,full.story

Comment:

By Don McCanne, MD

My career in private practice began with the introduction of Medicare and Medi-Cal (Medicaid). At that time, I had no problems referring Medicare and privately insured patients to specialists, but the majority of them refused to see my Medi-Cal patients. The stigma of “welfare patient” was there right from the beginning.

Quite a few years later, my Medicare patients continued to be accepted without question, but some of the managed care patients were rejected, and, of course, Medi-Cal patients continued to be rejected, except by a few very dedicated specialists. Eventually with EMTALA, at least I could force unwanted referrals for patients requiring specialized emergency services by sending them directly to the Emergency Department. What a terrible way to practice medicine.

As stated in my last message, there will be about 10,000,000 Medi-Cal patients in California, once the Affordable Care Act is fully implemented. Can you imagine the specialists suddenly opening their doors and welcoming these patients into their practices?

I’ll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.

Health care reform: the issue is equity

By Gabriel Edwards
The Pulse (OHSU Student Newsletter), Fall 2012 edition

The process of getting through medical school is fraught with uncertainty. What kind of residency will I apply to? Which lunch talks this week are offering free food? What innervates the palatoglossus muscle?

There’s another question I’ve considered as I get through the first year. I wonder what our country’s health care system (the system in which I will practice medicine) will look like in the next few years. Embedded in this question is one thing I’m certain of: our health care system is broken.

We spend double the money of every other developed nation in the world, and our health is worse for it. We are fairly unique among developed countries in the degree to which our quality of health care depends on income or employment.

Wealthy Americans receive some of the best health care ever devised by humans. Less wealthy Americans are denied care because of lack of resources, succumbing to preventable illnesses at rates higher than our industrialized counterparts.

Both major political parties say that the health care system needs to be reformed, that costs need to be contained lest they eventually bankrupt the country.

During the latest battle of reforming health care there was talk about what would happen to various stakeholders in our current systems. What would reform mean for doctors? For private insurers? For patients? For President Obama’s political prospects? For the opposition’s political prospects?

Another question is asked far less frequently: What does it say about us as a society that, compared to other countries, so many more people are dying from preventable diseases or going bankrupt due to health care costs?

Our country has already decided that every American is entitled to education, police protection, and fire protection. Prisoners have a guaranteed right to health care. Right now there are tens of millions of Americans who don’t have the right to adequate health care.

Obamacare, fully implemented, would cut the number of uninsured only by half, leaving 23 million Americans without health insurance – 23 million who can’t afford all the health care necessary to ensure a high quality of life. And the problem doesn’t stop there. Insured individuals declare the majority of medically related bankruptcies. This is not a problem of insurance versus noninsurance. This is a problem of equity.

The solution to this problem, I believe, is to create a health care system that covers everyone, without exception. Obamacare will not do this, but a single-payer system could. I believe that this is the most moral solution.

Who is healthy and who becomes ill in life is not solely determined based upon personal merit; health care shouldn’t be awarded based on what one’s salary and job happen to be.

Everyone has a right to medically necessary care. I want to care for patients in a society that maintains that right. I strongly believe that we will get there together. Not because it’s easy, but because it’s the right thing to do.

Gabriel Edwards is a first-year medical student at Oregon Science & Health University in Portland, Ore. This article was originally published under the title, “Opinion: Health Care Reform.”

Enough specialists for Medicare, but not Medicaid

Healthcare crisis: not enough specialists for the poor

By Anna Gorman
Los Angeles Times, December 15, 2012
By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.
Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.
“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”
In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.
Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients moved up on waiting lists.
At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.
http://www.latimes.com/health/la-me-clinic-specialists-20121216,0,542244…

My career in private practice began with the introduction of Medicare and Medi-Cal (Medicaid). At that time, I had no problems referring Medicare and privately insured patients to specialists, but the majority of them refused to see my Medi-Cal patients. The stigma of “welfare patient” was there right from the beginning.
Quite a few years later, my Medicare patients continued to be accepted without question, but some of the managed care patients were rejected, and, of course, Medi-Cal patients continued to be rejected, except by a few very dedicated specialists. Eventually with EMTALA, at least I could force unwanted referrals for patients requiring specialized emergency services by sending them directly to the Emergency Department. What a terrible way to practice medicine.
As stated in my last message, there will be about 10,000,000 Medi-Cal patients in California, once the Affordable Care Act is fully implemented. Can you imagine the specialists suddenly opening their doors and welcoming these patients into their practices?
I’ll say it once again. If we had an improved Medicare single payer system that treated everyone equitably, we would not have this problem.

Medi-Cal could implode

Court ruling could cut California spending on Medi-Cal

By Maura Dolan and Chris Megerian
Los Angeles Times, December 13, 2012

A federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.

A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.

The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.

According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.

A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.

Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.

http://www.latimes.com/news/local/la-me-medi-cal-20121214,0,4784104,full.story

Comment:

By Don McCanne, MD

One of the major defects in the Affordable Care Act is that it perpetuates and expands the Medicaid program – a welfare program for low-income individuals. Because of political anti-welfare bias, it is vulnerable to budget cuts that would not be tolerated in a program like Medicare that benefits all of us.

California’s Medicaid program, Medi-Cal, exemplifies this problem. It has one of the lowest payment rates in the nation, not even meeting the expenses of many of the physicians still willing to see these patients.

There are already over 7 million Californians on the program, and there will be almost a million children added as California shuts down its CHIP program (Medi-Cal pays less than CHIP). There will be about 2 million more individuals added in 2014 under the provisions of the Affordable Care Act. Further, low-income Medicare patients also eligible for Medi-Cal are being transferred into Medicaid managed care plans.

In spite of California being at the bottom in Medicaid payment rates, this 9th Circuit Court of Appeals decision upholds the additional 10 percent cut enacted because of California’s budget crisis. The reduction was challenged based on the fact that federal law requires that the state ensure that Medicaid patients have access to adequate health care services, and underpayment reduces the number of willing providers. That argument was rejected by the court, though it is difficult to see how California’s physicians will be able to care for over 10 million Medi-Cal patients when they are effectively donating their services plus subsidizing their losses resulting from overhead expenses that are greater than reimbursement rates. As more physicians turn them away, the crowd out of privately insured patients will threaten the solvency of the few remaining dedicated physicians.

This underpayment has real consequences. Access to primary care is impaired, and specialized services are especially difficult to obtain since most specialists are particularly resistant to allowing these patients in their practices, no matter how great the need. Outcomes for Medicaid patients are not as favorable as for those who have Medicare or private insurance. In some studies, the outcomes are as bad as the outcomes for the uninsured.

What good is a Medi-Cal card if it won’t provide access to health care?

If we had a single improved Medicare that covered everyone, this problem wouldn’t exist. Everyone would have the level of care that we should expect from a high-performance health care system. Are there too many politicians who still believe that we should offer only inferior health care to the poor because that is all they deserve? The rhetoric of the recent elections doesn’t bode well for a more egalitarian approach.

Single-payer activists screen film, discuss Canadian/American healthcare systems

State groups hope to raise support for a single-payer bill this winter

By Christen McCurdy
The Lund Report (Portland, Ore.), Dec. 13, 2012

Monday night a small crowd gathered at the Clinton Street Theater for a film screening of The Healthcare Movie (http://www.healthcaremovie.net/), a documentary about the history of the Canadian healthcare system that was produced by a Canadian/American couple Laurie Simons and Terry Sterrenberg to dispel myths and stereotypes about Canada’s healthcare system – specifically, that Canadian citizens dislike their healthcare system and frequently travel to the United States for care.

The film also showed interviews with Canadian activists who helped create Alberta’s single-payer system in the 1960s (before single-payer was adopted as a nationwide program). The activists interviewed in the film helped operated clinics, with the aid of British doctors (who were flown in to provide care for the province) after Alberta’s doctors went on strike.

According to the documentary, clinics occasionally had to be evacuated due to death threats from people opposed to the program (the documentary did not say from whom). Eventually, Alberta’s program became quite popular with the public as well as with doctors – due to cost savings, the lack of administrative concerns for doctors and increased access to care for the public.

Eric Lambert, who lived in Taiwan for seven years, said as a type one diabetic, he was better able to manage his health in Taiwan (which has a national healthcare program) because he was able to see doctors regularly and get medication with little out-of-pocket cost.

“I’m actually that person who’s kind of on the edge here in America,” Lambert said. “Being a diabetic is a twenty-dollar-a-day habit.”

Dr. Peter Mahr, from Physicians for a National Health Program, became involved with the movement for single-payer care after watching his patients wait too long to seek care. One patient – a man with hepatitis C – had a tumor growing out of his breast bone, which turned out to be metastatic cancer.

Richard Bruno, a medical student in his fourth year at OHSU, has been working on a video project of uninsured people talking about their experiences with the healthcare system. After showing the videos to 900 medical students, 86 percent said everyone should receive care regardless of ability to pay and 72 percent said they preferred the public system (i.e. taxes) of financing healthcare.

Mahr said he was campaigning for single-payer care because the Affordable Care Act will leave too many people uninsured and drive up costs. He also said 41 percent of Massachusetts doctors support a single-payer program, up a few points from polls conducted before the state’s current system (which is similar to what the ACA proposes) was adopted.

“What we’re talking about here is access to insurance, not access to care,” Mahr said.

Responding to an audience question about whether innovation and competition could continue in a system without a profit motive, Bruno said a lot of innovation (in the form of new treatments, drugs and devices) comes from research funded by the National Institutes of Health. As far as competition, he said: “They’ve [the insurance companies] been doing it for a few decades and it hasn’t gotten any cheaper. It’s gotten more expensive.”

Lindsay Caron, who worked on the documentary, said of insurance companies, “They’re not innovating. They’re not creating anything. They’re the ones profiting.”

Ross Lampert, an organizer with Healthcare for All Oregon, said his organization is forming chapters across the state, including eastern Oregon and in coastal communities, to raise support for a single-payer healthcare bill during the upcoming legislative session.

http://www.thelundreport.org/resource/single_payer_activists_screen_film_discuss_canadianamerican_healthcare_systems

Making the case for efficient health care

By Robert S. Levine, M.D.
The Grand Rapids (Mich.) Press, Letters, Dec. 5, 2012

Matt Miller’s column “The Business Man – Obama should use Romney to make health care more efficient” was right on target (The Press, Dec. 2). His suggestion that we “identify the major lessons and best practices” of other nations was totally ignored by Congress during the debate on the Affordable Care Act of 2010.

One feature of the health care systems in ALL other industrialized democracies is the non-profit status of the basic benefit package sold by insurers. This doesn’t mean that the government expropriates these companies, but it does define how the insurance industry must sell health care coverage products. T.R. Reid has clearly covered how this is done worldwide in his book “The Healing Of America” wherein he showed that it’s not all socialized medicine out there.

Dr. Steffie Woolhandler, a co-founder and board member of Physicians for a National Health Program, has identified six important principles for health care delivery system reform:

• Nonprofit.
• All capitation payments must be used for patient care. Surpluses are not
retained.
• Separate capital funding is based on regional planning. (eg., was a heart transplant program essential in Grand Rapids or simply approved to satisfy the growth agenda of one institution?)
• Eliminate insurance middlemen.
• Rich and poor in the same plan.
• Quality data used for improvement not financial reward.

Now we’re talking real efficiency and truly affordable universal care.

Robert S. Levine, M.D., retired, lives in Grand Rapids.

http://www.mlive.com/opinion/grand-rapids/index.ssf/2012/12/west_michigan_ceos_letter_list.html

Medi-Cal could implode

Court ruling could cut California spending on Medi-Cal

By Maura Dolan and Chris Megerian
Los Angeles Times, December 13, 2012
A federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.
A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.
The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.
According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.
A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.
Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.
http://www.latimes.com/news/local/la-me-medi-cal-20121214,0,4784104,full…

One of the major defects in the Affordable Care Act is that it perpetuates and expands the Medicaid program – a welfare program for low-income individuals. Because of political anti-welfare bias, it is vulnerable to budget cuts that would not be tolerated in a program like Medicare that benefits all of us.
California’s Medicaid program, Medi-Cal, exemplifies this problem. It has one of the lowest payment rates in the nation, not even meeting the expenses of many of the physicians still willing to see these patients.
There are already over 7 million Californians on the program, and there will be almost a million children added as California shuts down its CHIP program (Medi-Cal pays less than CHIP). There will be about 2 million more individuals added in 2014 under the provisions of the Affordable Care Act. Further, low-income Medicare patients also eligible for Medi-Cal are being transferred into Medicaid managed care plans.
In spite of California being at the bottom in Medicaid payment rates, this 9th Circuit Court of Appeals decision upholds the additional 10 percent cut enacted because of California’s budget crisis. The reduction was challenged based on the fact that federal law requires that the state ensure that Medicaid patients have access to adequate health care services, and underpayment reduces the number of willing providers. That argument was rejected by the court, though it is difficult to see how California’s physicians will be able to care for over 10 million Medi-Cal patients when they are effectively donating their services plus subsidizing their losses resulting from overhead expenses that are greater than reimbursement rates. As more physicians turn them away, the crowd out of privately insured patients will threaten the solvency of the few remaining dedicated physicians.
This underpayment has real consequences. Access to primary care is impaired, and specialized services are especially difficult to obtain since most specialists are particularly resistant to allowing these patients in their practices, no matter how great the need. Outcomes for Medicaid patients are not as favorable as for those who have Medicare or private insurance. In some studies, the outcomes are as bad as the outcomes for the uninsured.
What good is a Medi-Cal card if it won’t provide access to health care?
If we had a single improved Medicare that covered everyone, this problem wouldn’t exist. Everyone would have the level of care that we should expect from a high-performance health care system. Are there too many politicians who still believe that we should offer only inferior health care to the poor because that is all they deserve? The rhetoric of the recent elections doesn’t bode well for a more egalitarian approach.