“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
Non-opioid pain medication prescribing increased after the CDC published guidelines on opioids for chronic pain in 2016, according to a cohort study using insurance claims data.
Among over 15 million individuals, logistic regression models showed that the odds of non-opioid pain prescriptions were higher following the release of the “Guideline for Prescribing Opioids for Chronic Pain” compared with pre-guideline pattern-based estimates:
3% higher in the first year (95% CI 2.6-3.3)
8.7% higher in the second year (95% CI 8.3-9.2)
9.7% higher in the third year (95% CI 9.2-10.3)
“This finding aligns with language in the 2016 CDC guideline advising caution when initiating opioids and avoiding their use as a default first-line therapy,” wrote Jason E. Goldstick, PhD, of the University of Michigan in Ann Arbor, and colleagues in JAMA Network Open.
The magnitude of the post-guideline differences from the pre-guideline pattern varied by several clinical characteristics, including chronic pain, recent opioid exposure, anxiety disorder, and mood disorder, the authors noted.
Of note, there were greater increases in odds of non-opioid prescribing over the post-guideline years among those with opioid exposure versus those without exposure:
Year 1: OR 1.06 (95% CI 1.05-1.06) vs OR 1.02 (95% CI 1.02-1.02), respectively
Year 2: OR 1.11 (95% CI 1.10-1.12) vs OR 1.08 (95% CI 1.08-1.09)
Year 3: OR 1.12 (95% CI 1.11-1.13) vs OR 1.09 (95% CI 1.09-1.10)
Similarly, those with chronic pain, anxiety disorder, and mood disorders showed larger relative increases in prescribing odds of non-opioids compared with those without these factors, Goldstick and team said. For instance, those with chronic pain had a 14.9% higher prescribing rate during the third year compared with the pre-guideline pattern estimates.
In addition, non-opioid medications were more likely to be prescribed for women versus men, and those with Medicare Advantage compared with those with commercial insurance plans.
Across the study period from 2011 to 2018, opioid prescription rates notably decreased throughout the full cohort, from 23.1% in 2012 to 17.6% in 2018. Non-opioid prescriptions were steady through 2015 (20.1%), but increased in each following year, rising to 22.2% by 2018.
“Identifying the best way to tailor treatment options and delivery to the individual is a new area of investigation. Innovations in clinical research, including pragmatic and adaptive clinical trials; stepwise treatments; responder analyses; and machine learning approaches to predictive modeling of the interaction of biopsychosocial factors in response to various treatments are poised to revolutionize the field,” noted Stephanie A. Eucker, MD, PhD, of Duke University School of Medicine in Durham, North Carolina, and colleagues, writing in an invited commentary. “Until we collectively prioritize pain management to include comprehensive multimodal, person-centered treatments, the problem of chronic pain will continue to grow.”
For their study, Goldstick and colleagues constructed seven annual cohorts using claims data from the Optum Clinformatics Data Mart Database for January 2011 through December 2018. The cohorts included adults with commercial insurance or Medicare Advantage plans, no cancer or palliative care claims, and 2 years of continuous insurance enrollment. Patients were allowed to be included in more than one cohort, and each cohort covered a 2-year period.
The first year in each cohort was considered the baseline period, used to measure opioid exposures and other clinical characteristics, while the second year was the follow-up period in which prescribing outcomes were measured. Out of the seven cohorts, four were studied before the 2016 guideline was published, and three were studied after.
Goldstick and team acknowledged some limitations to their study. The requirement of continuous enrollment in an insurance plan meant that participants likely fell within a particular socioeconomic range. The study was also unable to account for pain management for those without insurance, those on Medicaid, those using over-the-counter medications, and those with a secondary insurance plan.
In addition, any comorbidities prior to a participant’s insurance coverage, as well as specialty clinic care, were not included. Some non-opioid pain medicines, such as skeletal muscle relaxants and lidocaine, were also left out of the study, they noted
Chronic pain groups, wow!!! Just wow!! Many claim to be advocates and the upper management boasts about all their accomplishments when actually they do little to nothing to actually make a difference. I joined DPPR – Don’t Punish Pain Rally National & state level after a parent passed away suddenly when their medication was discontinued after their doctors office was raided. In the beginning, I found the members very supportive; however very quickly after watching multiple live meetings that Claudia Merandi did, I became very concerned. These live meeting were filled with vulgar language and disparities about other advocates. She also insisted on supporting many doctors that the evidence against them clearly indicated they were not appropriately prescribing. The group had a lot of back biting amongst members, hatefulness and it became clear to me that this was not a cohesive group. The group actually has a few that were actually trying to make a difference, but some members treated them badly, they had private chat groups that they shared info gossiping about others within the group. I support American Pain & American Pain & Disability Foundation they have many programs including support group, blessing page, advocacy education, etc. They are boots on the ground actually helping pain patients, vets, children to obtain necessary pain treatment. No group will ever get along 100% of the time, they will have struggles and sometimes feelings might get hurt; however my experience with APDF is that they go above and beyond to do the very best they can as a group, it’s not about individual or group recognition. They are not looking for a pat on the back or fame & fortune; they truly care about the pain patients they are trying to help. With all that said, I am disgusted and outraged by the recent remarks and outright lies that Claudia Merandi has been spewing about APDF and Bob Sheerin. If you want to be apart of a pain group and that truly cares, dump DPPR and join APDF.
Here is a recent post that I made on my bloghttps://www.pharmaciststeve.com/i-heard-it-through-the-grapevine/ that came to me from what I consider to be a fairly reliable source and the people/entities that are referenced, they know who they are and most people should be able to recognize who is being referenced.
Collecting and monetizing personal information based on specific pt health issues, would be a violation of HIPAA, but none of the individuals collecting and monetizing pt health information, are healthcare professionals/practitioners… the HIPAA law does not apply and is not violated.
Sharing is NOT ALWAYS CARING !!
FULL DISCLOSURE: I am “officially” the unpaid/volunteer Pharmacist consultant for the APDF, and I routinely have chronic pain pts reach out to me for a consult. I have never charged a pt for my advice and have always declined to accept payments from chronic pain pts that has sought out my advice. Anyone who claims that I do – or have – charged pts for my advice – IS A LIAR.
Retail pharmacy giant says it will suffer “substantial, immediate, and irreparable harm
Walgreens has filed a lawsuit against Hagerstown, Maryland-based Meritus Health after the community hospital and health system opened an independent pharmacy in the lobby of its flagship medical center.
The retail pharmacy giant alleged that by opening an 1,800-square-foot pharmacy inside Meritus Medical Center (MMC), the health system is in violation of its lease agreement, which promised no other pharmacy would be established on the Robinwood medical campus, where MMC is both located.
But Meritus claimed the 2013 lease agreement is no longer valid, since the unit currently leased by Walgreens was sold to another company and is no longer part of the Meritus portfolio.
Maulik Joshi, DrPH, president and CEO of Meritus Health, told MedPage Today that the company opened its own pharmacy for better continuity of care, to ensure that patients who are discharged can get any medications before they leave the building.
“Our mission is to improve the health of our community,” Joshi said. “We’re doing this for our community.”
In its complaint, filed May 13, Walgreens argued that selling the unit “was a bad faith attempt by Meritus to avoid having to comply with the exclusivity obligation imposed by the [lease contract].” It alleged that Meritus sold the unit to Water Street Investments LLC, whose “managing member … is a physician affiliated with Meritus.”
Joshi said the physician “to which we believe the complaint refers … is a community physician (not employed) with Meritus medical staff membership. Almost all the community physicians have medical staff membership and/or privileges at the hospital.”
In a press release shared with MedPage Today, Joshi called the lawsuit a “tough pill to swallow.” The release noted that “Walgreens is one of the largest for-profit corporations in the country, and, according to their Q2 2022 SEC filing, had Net Earnings of over $4.3 billion for the six months ending February 28, 2022.”
Joshi said Meritus is a 100-year-old independent, non-profit community organization, with the 327-bed MMC as its flagship facility on the Robinwood campus. The system is the sole provider for Washington County, Maryland, which has more than 150,000 residents.
Walgreens argued in its complaint that it will suffer “substantial, immediate, and irreparable harm” due to the new pharmacy. “The operation of the Meritus Pharmacy poses a significant and substantial threat to Walgreens’ business because it directly competes with and is substantially similar to the Walgreens Pharmacy,” the complaint stated.
A spokesperson for Walgreens declined to comment for this story, given the pending litigation.
Meritus has since filed a motion to dismiss the lawsuit, alleging that Walgreens’ claims fail essentially because Meritus has been released of any obligations as landlord when the unit was sold.
“Meritus had the absolute unfettered right to sell [the unit] to a new owner without the consent of Walgreens and did so, and, upon that sale and transfer of the ownership of [the unit] to a new owner, Meritus was relieved of all obligations thereafter arising expressed in the Lease or implied by law,” the filing stated.
Doctor is “convicted” ON ALLEGATIONS of over prescribing & NOT FOLLOWING GOOD MEDICAL PRACTICES. From what I have heard about a person being taken to FEDERAL COURT that 90%-95% will be FOUND GUILTY… Apparently in our federal court system, the DOJ/DEA can take a doc to federal court and can get them convicted over JUST ALLEGATIONS. Using the words in this article the EVIDENCE was ALLEGATIONS that the doc did not follow “good medical practices” – what the hell is the DOJ/DEA’s definition of “not good medical practices” ?
From what I have concluded, the DOJ/DEA’s opinion of “good medical practices” is based on 2016 CDC opiate dosing guidelines, which has claimed was developed by a number of “so called medical experts” and it has been stated that the studies that they used… were mostly rated on a credibility scale of 3 to 4. Where “1” was EXCELLENT and 3 to 4 were poor/crappy.
They created a “one size fits all” formula for treating pain, based on the MME systemhttps://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154which this article strongly suggests that system is not supported by VALID SCIENCE nor any double blind clinical studies and totally ignored any variation of a pt’s particular disease issue and/or pt’s pharmacogenomics DNA testing- which would isolate those pts who are fast/ultra fast metabolizers and required higher singular doses and/or higher mgs/day in hopes of providing proper pain management for a individual chronic pain pt.
I have notice lately that the DOJ/DEA have went after “clawing back” Medicare/Medicaid monies, I guess a lot easier than using the civil asset forfeiture act… the former involves all CASH and the latter involves various assets, and the need to acquire the asset and liquidate of non-liquid assets – like various personal property/assets that many in multiple states and liquidation value may be less than the net proceeds of liquidating the asset.
I like Dr Bauer’s comment:he refused to abandon chronic pain patients and that he did what was necessary to help patients in severe pain and he remains concerned over the fate of thousands of chronic pain patients: people who suffer from substance abuse disorder and people who need mental health treatment. They are not getting the help them need and can’t defend themselves.
Pathetic that it has been state by the CDC that last year 70K-75K people died from illegal fentanyl – from China & Mexico – POISONING/RESPIRATORY ARREST and the DOJ/DEA continues with the hypothesis they started with in 1973 when the DEA was placed in charge to fighting the war on drugs/pts. Opiate Rxs causes addiction and OD’s. One has to ask, how many of these pts of Dr Bauer, will end up committing suicide because they cannot find another practitioner to treat their chronic pain, how many will end up trying to treat their chronic pain using “street drugs” and may end up ODing or how many will just end up trying to exist/live in a TORTUROUS LEVEL OF PAIN and end up with a premature death… because of their untreated pain ?
So much for what our founding Fathers promised us… the unalienable rights which the Declaration says have been given to all humans by their Creator, and which governments are created to protect…. Life, Liberty and the pursuit of Happiness
SANDUSKY — Dr. William Bauer, a local doctor convicted in federal court of over prescribing pain medications, will report to federal prison on Thursday, when he’ll begin serving a five-year prison term.
Bauer, 85, was convicted of multiple charges in a federal trial in Toledo over allegations that he over prescribed pain medications and committed fraud on federal health care programs by not following good medical practices.
A jury convicted Bauer of 76 counts of distribution of controlled substances and 25 counts of health care fraud.
Many law enforcement and regulatory authorities contend that over prescribing pain pills has contributed to the opioid epidemic. Critics of the policy argue that deaths have soared because of the “war on drugs” approach.
Bauer contends that he refused to abandon chronic pain patients and that he did what was necessary to help patients in severe pain. Many of his patients continue to defend him.
“I’ve been following the sentence I’ve been given, but I firmly believe I can defend my position,” Bauer said Tuesday.
Bauer said he remains concerned over the fate of thousands of chronic pain patients: people who suffer from substance abuse disorder and people who need mental health treatment. They are not getting the help them need and can’t defend themselves, he said.
On March 10, U.S. District Judge Jack Zouhary sentenced Bauer to five years in prison. Bauer also was told to pay $464,099 in restitution, which includes $253,300 paid to Medicare and $210,798 to Medicaid.
In addition, Bauer was ordered to pay $100,000 in community restitution. It was recommended he give that payment to the Mental Health and Recovery Services Board of Seneca, Ottawa, Sandusky and Wyandot Counties.
On Thursday, Bauer will report to the Federal Correctional Institution in Morgantown, West Virginia.
It’s a minimum-security federal prison that has sometimes been nicknamed “Club Fed” because of its amenities. It is commonly used to house white-collar, nonviolent inmates.
Bauer is appealing his conviction to the U.S. Sixth Circuit Court of Appeals in Cincinnati. The grounds for the appeal will become public in a few weeks when his appeals brief is filed. Bauer said only that he believes his attorney will be able to file a strong appeal.
Bauer practiced in Sandusky and lived in the Port Clinton area.
About two weeks ago, his daughter, Catherine “Cate” Whiddon, helped Bauer and his wife move to the Dallas-Fort Worth area in Texas. Bauer was able to attend his grandson’s wedding before preparing to report to prison.
The grounds for the appeal will become public in a few weeks when his appeals brief is filed. Bauer said only that he believes his attorney will be able to file a strong appeal.
Firms mined patient records for outdated, irrelevant conditions to increase profits, Justice Department contends
Kathy Ormsby’s work auditing medical case files uncovered an alleged scheme to defraud the federal government: The California health system that employed her was scouring health histories of thousands of elderly Medicare patients, then pressuring doctors to add false diagnoses it found to their current medical records.
The point of larding the medical records with outdated and irrelevant diagnoses such as cancer and stroke — often without the knowledge of the patients themselves — was not providing better care, according to a lawsuit from the Justice Department, which investigated a whistleblower complaint Ormsby filed. It was to make patients appear sicker than they were.
The maneuver translated into millions of dollars in inflated bills to the federal Medicare Advantage insurance program, the government alleged in its false-claims lawsuit filed in U.S. District Court in California.
The case was part of a broader government crackdown on abusive billing practices in Medicare Advantage, the privatized insurance option that by next year is expected to cover more than half of all Medicare beneficiaries. The Justice Department is pursuing civil lawsuits against multiple companies that participate in the privatized system, from huge insurers to prestigious nonprofit hospital systems, alleging they have cheated the system for unfair profit.
Ormsby’s former employer, the Palo Alto Medical Foundation, which has 1,600 doctors, and its parent affiliate, Sutter Health, which runs 24 hospitals in Northern California, settled the case with the government in August 2021 for $90 million. It admitted no wrongdoing or liability.
The government said its investigation confirmed that Palo Alto Medical and Sutter systematically added false diagnoses to patient records. In a sample of hundreds of cases Ormsby audited, the government’s lawsuit said, she discovered 90 percent of diagnoses for cancer were invalid, as were 96 percent for stroke and 66 percent for fractures.
“As we continued to audit, I started to see more things,” Ormsby said in an interview with The Washington Post, the only time she has spoken publicly since reporting the alleged misconduct in 2015. “I couldn’t believe how bad it was.”
In response to questions from The Post, Sutter indicated it was ready to move on. “The agreement brought closure to a long-running dispute and enabled Sutter to avoid the uncertainty and expense of protracted litigation,” it said in an email statement.
Medicare Advantage, which is run by outside companies under contract with the government, was added to traditional Medicare in 2003 with the support of Republicans in an effort to improve care and lower costs through privatization. But it is costing taxpayers increasingly more money to run than traditional fee-for-service Medicare, according to MedPAC, a government watchdog panel. The higher cost, what MedPAC labels “excess payments,” reached $12 billion in 2020 out of total program costs of $350 billion and are projected to top $16 billion next year, MedPAC said in March.
A coronavirus vaccine is administered at a Sutter Health clinic in San Francisco in 2021. (Lea Suzuki/San Francisco Chronicle/Hearst Newspapers via Getty Images)
The aggressive billing tactics stem from incentives built into Medicare Advantage. Under the program, companies are paid a flat fee per month to provide whatever care is required for a patient based on age, gender, geography and health risk factors. To compensate plans and providers for potential costs of care for individual patients with conditions such as diabetes, heart disease or cancer, Medicare boosts the monthly payment to Medicare Advantage plans under a “risk adjustment” for each additional condition. The system differs from the traditional “fee for service” payment, in which Medicare pays hospitals and doctors directly each time they provide a service.
If companies add more risk adjustment codes to a Medicare Advantage beneficiary’s medical record to receive higher payment — but don’t spend money on the additional care — they make more money.
Industry officials broadly rebut the charge that companies game diagnostic risk codes for financial gain. They say Medicare Advantage firms adhere to Medicare’s rules and follow the system’s guidance on regulations that are not always clear. Moreover, the industry says that listing all health issues on medical records is a crucial part of Medicare Advantage’s promise to anticipate health problems, proactively manage disease and reduce hospitalizations.
But the government considers it improper — potentially even fraudulent — for providers to add codes for medical conditions that have been resolved or have no bearing on a patient’s current health.
For-profit insurance companies have typically been the primary target of these probes. More recently, unsealed whistleblower cases such as Ormsby’s against Sutter Health, and a pending case against Kaiser Permanente, reveal how such investigations have spread to prestigious, nonprofit physician and hospital groups.
Doctors, or sometimes even non-physician medical coders, updated patients’ current records without providing treatment and often unbeknown to the patients themselves, the government’s investigations have found.
Heart attack, stroke, cancer, vascular disease, depression, obesity and malnutrition were among diagnoses most often cited by the government in its false-claims lawsuits. In an example cited in the Sutter case, thyroid cancer was added as a current condition in a patient record even after the thyroid gland had been removed five years earlier and the patient had been free of cancer for years. None of the allegations has been fully tested in court, because they were settled by the companies without an admission of liability or, in the case against Kaiser Permanente, remain pending.
Kaiser Permanente is accused in a lawsuit of allegedly bringing in about $1 billion in improper billings from 2009 to 2018. The case is pending. (AaronP/Bauer-Griffin/GC Images)
Some critics contend that a byproduct of these practices is that patients’ medical records, padded with false diagnoses, are inaccurate. That could unnecessarily stigmatize patients who were improperly deemed obese, or malnourished, or mentally ill. It introduces potential phantom influences on treatment decisions, critics say.
In addition to her shock over thousands of alleged false billings, Ormsby “was not comfortable with what she perceived as the complete divorce from the reality of what was in patient records” at Sutter Health, said Sarah “Poppy” Alexander, a whistleblower lawyer at Constantine Cannon, which represented Ormsby.
“The accuracy of patient records is critical for anyone’s health-care treatment,” she said. “Think about all the decisions that are made based on what’s in your health-care record. If that health-care record is not accurate, it’s extremely dangerous.”
Several doctors interviewed by The Washington Post said it was common practice for insurance companies and medical systems to search or data-mine the histories of patients covered by Medicare Advantage. Health systems were known to advise doctors on the most lucrative billing strategies, cajole them to document the maximum number of illnesses, and grade and rank them among their peers based on how they coded patients, they said.
David Terry, a recently retired psychiatrist, said there is pressure to “code for more money.” (Christopher Smith for The Washington Post)
“The emphasis is on how to code for more. It’s not ethical coding, it’s how to code for more money. That pressure is there,” said David Terry, a recently retired psychiatrist who worked within large health organizations in Kansas that are not part of any of the lawsuits.
The Justice Department said in February that Medicare Advantage investigations are an “important priority.” In federal whistleblower cases, the government investigates allegations brought by people with knowledge of alleged fraud against the government and then decides whether it will join the lawsuit, based on its findings. Whistleblowers are rewarded for stepping forward with a portion of any settlement or court awards. Justice Department whistleblower allegations and similar lawsuits also are playing out in federal courts against UnitedHealth Group, Cigna and Anthem. The government’s Office of Inspector General has audited Humana and found it overbilled the government. United Healthcare, which is under the umbrella of UnitedHealth Group, and Kaiser Permanente denied any improper conduct. Cigna, Anthem and Humana did not respond to requests for comment.
The health insurance industry’s trade group, AHIP, did not comment on allegations of false billings. MedPAC’s estimates of excess payments, when compared with traditional Medicare, are exaggerated, AHIP executives said, because its calculations do not factor in all differences between the two payment systems.
“The Medicare Advantage system is designed to promote accurate coding and support integrated care,” said Mark Hamelburg, AHIP senior vice president for federal programs. “Plans
10-year growth in Medicare Advantage Enrollment
2011
2021
Beneficiaries (millions)
11.9
26.9
Share of all Medicare
26%
46%
Source: MedPAC
Medicare Advantage plans cut costs using the tools of the private insurance industry. They control the use of MRIs and other costly tests, for instance, cutting down on waste. They restrict care to certain hospital and physician networks. Then they use a share of those savings to keep monthly premiums lower than traditional Medicare, while offering extra benefits traditional Medicare does not offer, such as dental and hearing and gym memberships.
“It is a vast, complicated system. It involves all these various components,” Hamelburg said. “Our view is that you shouldn’t just look at individual components, you need to look at the totality.”
An industry-backed study found that Medicare Advantage members pay $1,965 less in out-of-pocket costs, including premiums, than traditional Medicare beneficiaries. Beneficiary satisfaction is high. Membership in the plans grew by 10 percent last year; they are expected to cover more than 50 percent of all patients next year.
‘Something unseemly’
Ormsby, one of the Medicare Advantage whistleblowers whose case was investigated by the government, quit her job at Palo Alto Medical Foundation in 2015 after two years in her job as a risk adjustment project manager. An outside consultant had found 8,000 false codes for the years 2012 and 2013, the government alleged in the whistleblower lawsuit she initiated.
The governme investigation of her complaint revealed how physicians received computerized “daily alerts” for their patients flagging “suspected” diagnoses unearthed via data-mining. When their risk-adjustment diagnosis numbers fell short, doctors were urged by higher-ranking colleagues to improve, the government lawsuit alleged. In some cases, the government said, coders would add diagnoses to patient records without participation of doctors.
Some doctors pushed back on the pressure to add diagnostic codes.
“With my patient on hospice, there is something that seems unseemly about pursuing a new diagnosis of PVD [pulmonary vascular disease] when she has weeks to live,” one physician, Joann Falkenburg, wrote to colleagues helping lead the pressure tactics. The email was obtained by Justice Department investigators. “I try to be pretty legitimate about how I diagnose, document and chart and want to avoid any possibility that it looks like I am working someone up just for the financial upside.”
The government’s lawsuit does not indicate how Palo Alto Medical responded to her email, and Falkenburg did not respond to a phone message requesting comment.
A Palo Alto Medical auditor reported in internal correspondence that another physician, Thomas Deetz, complained that “pre-populating diagnoses into his visit encounter is possibly fraud. … Does CMS know about what you all are doing?” Deetz also did not respond to a request for comment.
Ormsby maintains that her multiple warnings about the practices were ignored or rebuffed. She said she received a poor performance review in early 2015, but by then she had already sought out private lawyers, a step that led to her whistleblower suit.
“I was finding too many errors, and they didn’t want to send the money back,” Ormsby said in the interview. Under rules for federal whistleblower lawsuits, Ormsby, 56, will receive 15 to 30 percent of the $90 million Sutter Health settlement.
‘Coding parties’
The practices at Sutter were not isolated, according to the government. Kaiser Permanente, a nonprofit health-care organization that treats patients in California, Colorado and elsewhere, including Virginia and Maryland, is accused in a separate Justice Department lawsuit of similar tactics that allegedly brought in about $1 billion in improper billings from 2009 to 2018. The case, which is pending, was consolidated from six whistleblower complaints against the company.
“As each year drew to a close, some employees referred to Kaiser’s rush to capture as many diagnoses as possible as the ‘dash for cash,’ ” the government said in its lawsuit. It alleges that at Kaiser Permanente, doctors were invited to “coding parties,” where physicians would be gathered in a room after hours and be expected to add diagnosis codes found in data-mining operations to current patient records.
Kaiser Permanente said in response to the government’s allegations that it was following the rules.
“We are confident that Kaiser Permanente is compliant with Medicare Advantage program requirements and we intend to strongly defend against the lawsuits alleging otherwise,” the company said in a statement sent to The Washington Post. “Our medical record documentation and risk adjustment diagnosis data submitted to the Centers for Medicare and Medicaid Services comply with applicable laws and Medicare Advantage program requirements. Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance from CMS.”
Internally, some doctors questioned the company’s practices, the lawsuit contends. Among the diagnoses Kaiser Permanente physicians were frequently asked to add to patient medical records was aortic atherosclerosis, according to the government’s lawsuit.
The condition, a hardening of the aorta wall, could often be observed incidentally in a chest X-ray or scan for some other ailment. Radiologists were instructed to record the presence of the condition if they detected any calcium in the aorta, “regardless of significance,” according to the government’s complaint.
Physicians would then be pressured via computerized queries to amend the patient records retroactively to include aortic atherosclerosis, which Kaiser had identified as having a “high rate of reimbursement” in the Medicare Advantage risk adjustment formula, the government alleged.
Some Kaiser Permanente doctors objected, saying the disorder was typically not serious in their elderly patients.
According to the government’s lawsuit, one physician, Matthew James Sena, observed in internal correspondence that “Aortic atherosclerosis is nearly ubiquitous in patients this age. It is not a clinically relevant diagnosis and doesn’t require treatment. Isolated [chest X-ray] interpretations are not grounds for clinical diagnosis in this case. … [It’s] clinically inconsequential in almost all cases.”
A coding administrator for Kaiser Permanente is quoted in the complaint as saying “[n]o one believes it is a real diagnosis,” and since “it is non-compliant to tell people to code for money, we need to really sort out a way to package this.”
Medicare Advantage programs are touted by industry as a way of ensuring that chronic conditions are carefully monitored through disease-management programs. But Kaiser Permanente’s increased diagnoses of aortic atherosclerosis threatened to create so many new patients with the condition that its disease management program for cardiovascular disease threatened to buckle.
Kaiser Permanente managers in 2011 came upon a solution, the government said: stop automatically enrolling aortic atherosclerosis patients in the cardiovascular disease management program.
Kaiser Permanente has been accused by the government in a civil whistleblower case of submitting false risk codes for Medicare Advantage patients to boost government payments. (iStock)
After the change, the lawsuit alleges, medical leaders continued to pressure doctors aggressively to code for the disorder, identifying it as worth an additional $40 million in annual billing opportunity at one physician practice.
“How do we rally the herd?” a physician executive director wrote to colleagues at Kaiser’s Northern California Medical Group, in an email quoted in the lawsuit. “Everybody join in the discussion. $40m is no chump change.”
‘Where’s follow-up care?’
Minnesota-based United Healthcare, the largest health-insurance company in the country, quotes a founding father on the homepage of HouseCalls, its program that dispatches clinicians to Medicare Advantage beneficiaries’ homes: “Benjamin Franklin said it best, ‘An ounce of prevention is worth a pound of cure.’ We agree.”
Under such initiatives, companies routinely send clinicians, often nurse practitioners, into patients’ homes to conduct “health risk assessments.” Companies say the assessments are intended to identify any risks to beneficiary health that their physicians may have overlooked or that have developed since their last doctor visit.
But government reports have questioned whether the practice is intended to improve or capture more lucrative diagnosis codes. The visits often result in new codes added to patient bills without any evidence of doctors’ having considered or treated the newfound diagnoses, the Office of Inspector General of the Department of Health and Human Services found in a report last year.
A Connecticut primary-care physician, Kenneth Dardick (whose spouse is the executive director of the Center for Medicare Advocacy, a nonprofit that advocates for patients), said he routinely receives copies of United Healthcare’s in-home risk assessments and never learns anything about his patients that he did not already know.
He does notice that new patient codes are added to the reports, documenting conditions he already knew about or were irrelevant, he said.
He shared a copy of one assessment, with identifying information of the patient removed, that was sent to him by HouseCalls in April. He was already treating the patient, a man in his 70s, for diabetes. But the health risk assessment, in a section called “new diagnosis,” had added a different code, diabetes with complications. The new diagnosis section also listed a personal history of a type of skin cancer. Dardick said a precancerous growth was removed from the patient’s skin nine years ago and is no longer being treated.
“My sense is they are doing that just to game the system,” Dardick said, citing the “new” diagnosis codes as “irrelevant.”
United Healthcare stood out among Medicare Advantage companies for its aggressive use of risk assessments without evidence new risk codes were related to ongoing medical care, according to the Office of Inspector General report last year. (OIG did not identify the company in its report, but it did confirm its identity after a records request from the Minneapolis Star-Tribune.)
United Healthcare has the largest share of Medicare Advantage patients in the country, with 7.2 million beneficiaries, or 27 percent of the total.
United Healthcare did not respond directly to the OIG report’s findings. In response to questions from The Post, spokesman Matt Wiggin emailed a brief statement. “Simply stated, compared to fee-for-service Medicare, Medicare Advantage costs less (for beneficiaries), is more equitable, has better quality, access, and outcomes with greater coverage and benefits and nearly 100% consumer satisfaction,” he said.
Jacqualine Reid, a government research analyst who led the review, said the findings about United Healthcare raised red flags. Of the $9.2 billion in risk adjustment payments in 2016 based on health risk assessments with no other records to support the diagnosis, United received $1.38 billion, Reid and her team found in their review.
The three top diagnoses generating those payments were peripheral vascular disease, major recurrent depressive disorder and Type 2 diabetes with peripheral angiopathy.
“These are serious medical conditions. If they are getting payments for in-home visits, but we do not see any other evidence of services being provided to them, it raises concern,” Reid said. “If they are appropriate, where’s the follow-up care that in most cases you would expect to see?”
Pharmacy benefit managers are hired to negotiate rebates and fees with drug manufacturers, create drug formularies and surrounding policies and reimburse pharmacies for patients’ prescriptions.
The FTC says that certain pharmacy benefit managers have “enormous influence” over which drugs are prescribed to patients, what pharmacies patients can use and how much patients ultimately pay at the pharmacy counter.
The agency will request records and other information from the six largest pharmacy benefit managers about their business practices. They include CVS Caremark, Cigna subsidiary Express Scripts Inc., UnitedHealth Group subsidiary OptumRx Inc., Humana Inc., Prime Therapeutics LLC and MedImpact Healthcare Systems Inc.
The investigation will shed light on several practices that have been scrutinized in recent years, including:
Fees and clawbacks charged to unaffiliated pharmacies
Methods to steer patients towards pharmacy benefit manager-owned pharmacies
Potentially unfair audits of independent pharmacies
Complicated and opaque methods to determine pharmacy reimbursement
The prevalence of prior authorizations and other administrative restrictions
The use of specialty drug lists and surrounding specialty drug policies
The impact of rebates and fees from drug manufacturers on formulary design and the costs of prescription drugs to payers and patients.
The FTC will issue compulsory orders under Section 6(b) of the FTC Act, which authorizes the agency to conduct studies without a specific law enforcement purpose. The companies will have 90 days from the date they receive the order to respond.
The Pharmaceutical Care Management Association (PCMA), a trade group representing pharmacy benefit managers, tells FOX Business that “drug manufacturer price-setting is the root cause of high drug costs.”
“The most effective study of issues around drug costs for consumers would examine the entire supply chain,” PCMA president and CEO JC Scott said. “PBMs are holding drug companies accountable by negotiating the lowest possible cost on behalf of consumers, and by driving and delivering local competition that consumers are demanding.”
Representatives for CVS Caremark, Humana and Prime Therapeutics told FOX Business that they will cooperate with the FTC’s investigation. OptumRx deferred comment to the PCMA. The other companies did not return FOX Business’ request for comment.
It would seem in hindsight, that the war on drugs was mostly built on racism, bigotry and lies. It has been claimed that the Controlled Substance Act bill was signed into law by a President (“tricky dick nixon) that was known to be a racist/bigot and he wanted to throw blacks and “hippies” into jail. This law was design to deal with the “black drug market” that was created in 1914 by the Harrison Narcotic Act https://en.wikipedia.org/wiki/Harrison_Narcotics_Tax_Act This law created the Bureau of Narcotic and Dangerous Drugs https://en.wikipedia.org/wiki/Bureau_of_Narcotics_and_Dangerous_Drugs by combining Bureau of Narcotics (Dept of Treasury) & Bureau of Substance Abuse Control (under HHS). Moving dollars committed to deal with narcotic use/abuse/diversion combined with abt 3 million budget and created the BNDD with a 43 million budget and 1500 agents. In 1973, the BNDD transitioned into being the DEA.
Today the DEA has abt 10,000 employees – down to 2003 levels and 3.1 billion budget – up abt 50%-60% from 2003. That just tells part of the story, because many cities, counties, states. Plus prisons (private & gov), our court system ( prosecuting attorneys, defense attorneys, judges & supporting staff ). Over the last 50+ yrs, the war on drugs has become a 100+ billion/yr INDUSTRIAL COMPLEX.
For those of you who believe that trying to talk to your member of Congress and/or getting the local media to cover the denial of care… here is the website for DEA Press Releases https://www.dea.gov/what-we-do/news/press-releases. JUST TODAY (06/08/2022) the various DEA regional district and/or HQ put out SEVEN PRESS RELEASES to various media sources – on how the DEA is winning the war on drugs.. A number of years ago – maybe during the Reagan Admin, some entity within the Federal Gov was charged with making determination of how successful various federal agencies were in meeting their operational charge. As I remember, the DEA got a GRADE OF ZERO !!!
I started this blog abt 10+yrs ago, just as the prescribing of opiates were peaking. I have seen many advocates come and go… I have seen some non-profits come and go.. I have seen some people who imply that they are part of a non-profit, when they are not.. While most all of these entities profess that they have the same goal, better pain management… but just like a ROAD MAP, there is numerous ways to get from point A to point B. If everyone has a “different path” and won’t compromise/discuss different paths to come up with a compromise… then the odds of good results, probably decreases dramatically.
The first thing that the pt needs to get a answer to… is what intensity of pain does the practitioner expects the pt to live/exist in. IMO, a pt’s intensity of pain can basically put into two levels .. =<5 is probably a tolerable level of pain and >5 is an intolerable level of pain and is most likely requiring the pt to live/exist in a torturous level of pain.
If the practitioner can only answer that whatever level of pain the pt has to exist/live in …depends on the MMG/day that the CDC’s guidelines states is the max allowable dose for all disease issues. If this is the limit to the practitioner’s treatment plan and the pt is willing to live/exist in the intensity of pain level that xx MME/day will provide, all advocacy efforts are finished. If this is the answer to the pt’s treatment, or the pt can share this article with the practitioner https://www.acsh.org/news/2022/03/01/true-story-morphine-milligram-equivalents-mme-16154and ask the practitioner why he/she is limiting pain management therapy based on the MME system which has no science nor double blind clinical study behind it.
Here is a chart that demonstrates the possible complication of pt’s comorbidity from under/untreated pain …
If the practitioner, suggests/insists that you get non-opiate, non-covered health services (PT, massages, aqua therapy, etc ) not covered by your insurance. here is free software that has included in its package a spread sheet. Just create a spread sheets for your monthly income and your monthly expenses… don’t have to detail, just each month’s total expenses. Ask the practitioner who he/she would suggest that you work the cost of such health services into your budget. https://www.openoffice.org/download/index.html If you don’t drive, how are you suppose to get to the medical appt ?
If your BP increases dramatically (>180/100), when your pain meds are reduced/stopped, and even after given up to four different BP meds.. suggest that the following graphic be shared with the practitioner, to get confirmation that the practitioner understands the risk – you as their pt – are being put into… high blood pressure – per American Heart Association has always referred to as the “silent killer”
So the practitioner just tells you to take a NSAID (Aspirin, Motrin, etc) to manage your pain. Just find a number of studies on warning the potential consequences to a pt using NSAIDS long term- kidney damage the most common.
So the practitioner just tells you to take Acetaminophen (Tylenol) to manage your pain. Just find a number of studies on warnings the potential consequences to a pt using Acetaminophen long term – liver damage the most common
If your practitioner basically “blow your concerns off”, I would created a cover letter and I would take copies of all the information that you provided the practitioner and send them back to the office or dept that manages pt medical records and ask that they all be put into your medical records. It might not do you, individually, much good, but your family will be able to sue the practitioner if/when you suffer a stroke, heart attack, eye/kidney/liver damage, premature death or commit suicide… You have put your practitioner on notice that you made them aware that you were aware of the physical health consequences you may suffer, because of their plan of treatment of you.
The American Association of Retired Persons (AARP) agreed to an exclusive promotional deal in September with Oak Street Health, which operates 100 primary care clinics in a dozen states, according to Kaiser Health News.
The deal allows Oak Street Health to use AARP in its marketing for an undisclosed fee, according to the report.
This arrangement falls in line with a lucrative practice by the AARP, where the organization collects “royalties” in exchange for exclusive marketing deals with healthcare businesses eager to promote themselves to AARP’s membership.
In total, the AARP collects $1 billion in these kinds of royalties, according to its 2020 financial statement, KHN reported. About two thirds, or $752 million, of those royalties come from “health products and services,” according to the article. For comparison, AARP collected roughly $300 million in member dues in 2020.
There are questions about whether these partnerships are chosen because they benefit AARP’s members or because they are so profitable for the organization, according to the report. Marilyn Moon, who is a health policy analyst with ties to AARP since the 1980s, told KHN that it “certainly is a problem,” when the organization is profiting from these medicare-focused marketing partnerships while also lobbying on Medicare issues in Washington, D.C.
The partnership with Oak Street Health highlighted those concerns when the company came under investigation by the U.S. Department of Justice for its marketing tactics, KHN reported.
“It’s hard to know whether they’re advocating for their business interests or for the seniors that they are supposed to represent,” Joshua Gordon, director of health policy for the Committee for a Responsible Federal Budget, a nonpartisan group, told KHN.
The time frame for Social Security and Medicare to go-broke has been pushed back, helped by a stronger-than-expected economic recovery from the coronavirus pandemic.The annual Social Security and Medicare trustees report says the Social Security trust fund will be unable to pay full benefits beginning in 2035, instead of last year’s estimate of 2034.
The projected depletion date for Medicare’s trust fund for inpatient hospital care moved back two years to 2028 from last year’s forecast of 2026.
The annual Social Security and Medicare trustees report says Social Security’s trust fund will be unable to pay full benefits in 2035.
According to the report, “Economic recovery from the 2020 recession has been stronger and faster than assumed in last year’s reports, with positive effects on the projected actuarial status of the trust funds in these reports.”
Forecasters said in the report that the ongoing COVID-19 pandemic will have no net effect on their long-range projections.
The assumptions for the latest report were made in February, which was before cases began climbing again and inflation rose even higher.
President Biden said in a statement that the report “shows that the strong economic recovery driven by my economic and vaccination plans has strengthened programs that millions of Americans rely on and has put our nation in a better fiscal position.”
Social Security pays benefits to more than 65 million Americans, mainly retirees as well as disabled people and survivors of deceased workers. Medicare covers roughly 64 million older and disabled people.
A main source of financing for the programs is payroll taxes on earnings paid by employees and employers. About 183 million people paid those taxes in 2021.
Social Security retirees got a 5.9% boost in benefits this year, the biggest cost-of-living adjustment, also known as COLA, in 39 years.
