Idaho University Patient Records Breach Leads to $400,000 Levy, Corrective Plan

Monday, May 27, 2013

from Privacy & Data Security Law Resource Center™

By Eric Topor

The Department of Health and Human Services May 21 announced a resolution agreement with Idaho State University (ISU) outpatient clinics--over a breach of approximately 17,500 patient records--under which the health care provider will pay $400,000 and implement a corrective action plan (CAP).
ISU notified the HHS Office for Civil Rights (OCR) of the data breach in August 2011.
OCR's November 2011 investigation report revealed Health Insurance Portability and Accountability Act Security Rule violations between 2007 and 2012 involving ISU's failure to conduct a risk analysis of the confidentiality of its electronic patient records; inadequate implementation of security measures to reduce patient record breaches; and inadequate review of information system activity to determine whether patient records were inappropriately disclosed.
The investigation determined that ISU patient records were unsecured for at least 10 months after firewall protections on ISU servers were disabled.
“Risk analysis, ongoing risk management, and routine information system reviews are the cornerstones of an effective HIPAA security compliance program,” OCR Director Leon Rodriguez said in a statement.

School Clinic Comments

“We want to reiterate that as far as we are concerned, and as far as our due diligence demonstrates, as well as the third party that we hired to come in and do an audit, that no patient records were accessed, and data was not compromised,” Greg Ehardt, HIPAA/assistant university compliance officer at Idaho State University, told BNA May 22.
“As we recognized that the firewall had been disabled for maintenance purposes, unfortunately that was not restored properly.” As ISU did its “due diligence and our external audit, we determined that as far as we were concerned, no patient records had been accessed. But we felt it appropriate, given the incident, that we need to report this to the Office for Civil Rights for their determination as well.”
He added that his hiring by the university was one of several steps ISU has taken to “fortify the security measures here.” Ehardt added that the university has implemented “an event logging system that will more closely track these types of events.”
The university also brought in and centralized the IT of the clinics, whereas before it was somewhat decentralized,” he said.
“We feel that with the number of changes that we've made, and the remediation that we've taken upon ourselves, that we're a much stronger, more fortified program and system at this time.”

Corrective Action Plan

The CAP, which began May 13 and will extend for two years, designates ISU as a “hybrid entity” and requires ISU to identify all covered health care components in its clinic system. The plan requires ISU to submit its current risk management plan, a report of its information system activity across all clinics, and a compliance gap analysis report, and to implement any changes to the plans and procedures suggested by HHS after review.
ISU is required to notify HHS if any ISU employee fails to comply with privacy and security procedures under the CAP, following an internal review by ISU. The CAP requires any notification to include the name of the employee involved, which security policies or procedures were implicated, the steps ISU has taken to mitigate any privacy or security breach, and what steps will be taken to prevent future similar occurrences.
The CAP also requires ISU to submit annual reports detailing security and privacy measures implemented, system activity review measures, an update of compliance gap analysis activity, any reportable events, and a signed attestation by an ISU officer that he or she has reviewed the report and believes it to be accurate.
ISU is required to retain all documents and records relating to the CAP for at least six years.
In January, another entity in Idaho, a small nonprofit hospice, agreed to pay $50,000 to HHS to settle allegations of federal data security rule violations over the loss of a laptop containing the personal health information of 441 patients. That settlement was the first involving a breach of protected health information affecting fewer than 500 individuals under the HIPAA Security Rule, HHS said (12 PVLR 41, 1/7/13).

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Wales' first cancer patient survey to be launched

• By Julia McWatt

The Welsh Government and Macmillan Cancer Support launch the first national survey allowing cancer patients to report back on the quality of their care

Cancer patients across Wales will be able to report back on the quality of services they have received after the launch of the first national patient experience survey today.

The survey, developed by the Welsh Government and Macmillan Cancer Support, aims to look at patient experience and drive up standards for cancer services across the country.

It comes just days after campaigners voiced their disappointment that vital cancer targets set by the Welsh Government were missed again.

Figures showed that just 83.6% of people needing urgent treatment for cancer were seen within the two-month target.

The Welsh Government target is for 95% of patients to begin treatment within 62 days of diagnosis, and has not been met since 2008.

Targets for 98% of non-urgent cases to start treatment within 31 days were also missed, with 97.4% of cases being seen in that timeframe.

The publication of the survey, which will be sent to patients in the next month, is part of the Welsh Government’s Commitment to improve care for cancer patients as part of its Cancer Delivery Plan for Wales.

The survey will be issued to patients who had a hospital stay between June 2012 and March 2013.

Health Minister Mark Drakeford said:“The best people to ask about how cancer services are being delivered in Wales are the patients themselves. They have a raft of experience and are experts in their own lives. There is a great deal to learn from what they have to say.

“When a patient hears a doctor deliver a diagnosis of cancer, it is a life-changing moment. How the doctor delivers that diagnosis and the support the individual receives, not just for their medical care, can impact on the outcome for the individual.

“The cancer experience survey asks questions that cover each stage, from diagnosis to hospital care to home support. I would encourage all those who receive a survey to take the time to complete it. The information you provide can help improve services in the future.”

Susan Morris, general manager for Macmillan Cancer Support in Wales, said:“Macmillan is delighted that the Welsh Government is conducting an all-Wales cancer patient experience survey.

“It is the first time such a comprehensive survey of cancer patients’ experiences of care has been conducted in Wales and Macmillan is really pleased to be a partner in this important initiative.

“It is vitally important to measure survival rates and cancer waiting times targets, but it is equally important to find out what patients really think about the quality of the care they receive.

“Local health boards must take the survey’s results into consideration to inform planning for future cancer services to make sure these services meet people’s clinical and non-clinical needs and that they are truly person-centred.”

Fellow cancer charities welcomed the publication of the survey.

Dr Rachel Iredale, director of Tenovus’ cancer support Team, said: “We welcome any attempt to improve service delivery by asking patients about their experiences.

“We know from our own experience that feedback is vital. We recently surveyed over 1,600 people who use our services and we can clearly see certain issues emerging.

“These include the quality of care patients receive from the NHS, the need for their care to be closer to their home and that patients want to be viewed and cared for as a whole person, not just their cancer, with support for the whole family which continues beyond their treatment.”

Cosmetic eyelid lifts costing Medicare millions

WASHINGTON — Aging Americans worried about their droopy upper eyelids often rely on the plastic surgeon's scalpel to turn back the hands of time. Increasingly, Medicare is footing the bill.

The public health insurance program for people older than 65 typically does not cover cosmetic surgery, but for cases in which patients' sagging eyelids significantly hinder their vision, it does pay to have them lifted. In recent years, though, a rapid rise in the number of so-called functional eyelid lifts, or blepharoplasty, has led some to question whether Medicare is letting procedures that are really cosmetic slip through the cracks — at a cost of millions of dollars.

As the Obama administration and Congress wrestle over how to restrain Medicare's growing price tag, critics say program administrators should be more closely inspecting rapidly proliferating procedures like blepharoplasty to make sure taxpayers are not getting ripped off.

From 2001 to 2011, eyelid lifts charged to Medicare more than tripled to 136,000 annually, according to a review of physician billing data by the Center for Public Integrity. In 2001, physicians billed taxpayers a total of $20 million for the procedure. By 2011, the price tag had quadrupled to $80 million. The number of physicians billing the surgery more than doubled.

"With this kind of management malpractice, it's little wonder that the (Medicare) program is in such dire shape," said Sen. Tom Coburn, R-Okla., who is a physician. "The federal government is essentially asking people to game the system."

Plastic surgeons say there are a number of legitimate reasons for the spike, including a tendency among the elderly to seek fixes for real medical issues they might have quietly suffered through even a decade ago. But surgeons also acknowledge an increased awareness of the surgery fueled by reality television, word-of-mouth referrals and advertising that promises a more youthful appearance. And doctors concede they face increased pressure from patients to perform eyelid lifts, even when they do not meet Medicare's requirement that peripheral vision actually be impaired.

Quick, easy and relatively painless, eyelid surgery is one of the most popular cosmetic procedures, with patients paying out of pocket for more than 200,000 a year, according to the American Society of Plastic Surgeons. The process for purely cosmetic surgeries and Medicare-funded blepharoplasty is the same. Doctors numb the eyelids with a local anesthetic before removing fat and excess skin, often with a laser. The entire process usually takes less than 30 minutes.

Medicare reimbursement ranges from $574 to $640 per eye, depending on the setting, but the rules for Medicare coverage are firm. Purely cosmetic surgeries do not qualify. Before filing a Medicare claim, doctors are required to test a patient's vision and document that drooping skin significantly compromises a patient's eyesight. The exam usually involves lifting a patient's eyelids with tape and comparing their vision results to tests performed without tape.

Unlike private insurance plans, though, Medicare does not require preauthorization of eyelid surgeries. Robert Berenson, a health policy expert at the Urban Institute and a former commissioner of the Medicare Payment Advisory Commission, has pushed for selective preauthorization for some Medicare services. But Berenson questioned whether reviewing physician records in advance would help much in the case of blepharoplasty, if surgeons have learned how to document the need for the procedure in order to work the system.

Some eyelid surgeons were willing to discuss their Medicare billing.

"I'm disappointed that I am not No. 1. I wish I was on top," joked John LiVecchi, a Florida plastic surgeon who was among the top 10 billers listed in 2008 Medicare data. LiVecchi, an eyelid specialist, said his practice at St. Luke's Cataract and Laser Institute is one of the largest in the country, which accounts for his numbers. St. Luke's operates five offices in the Tampa Bay area.

LiVecchi, who has had an eyelid lift himself, disputes that patients are flocking to the procedure primarily with vanity in mind. Patients with droopy eyelids often don't realize how much the droopy skin is narrowing their field of vision, he said. LiVecchi said he jokes with his patients that he doesn't want them driving in his neighborhood until after the surgery. "It's safer for society," he said.

As for the cosmetic boost, LiVecchi compared eyelid surgery to removing a cancerous lump from a patient's face. In both cases the doctor's primary objective is keep a patient healthy, he said. A more youthful appearance is only a pleasant side effect, which he sees no problem with. "Doesn't everybody want to look good?" he asked.

The benefits of functional eyelid surgery for some patients are documented. A 2011 study published in the journal Ophthalmology, for example, found that the surgery provided "significant improvement in vision, peripheral vision and quality of life activities."

Plastic surgeons interviewed said vision problems are not always the draw. Dr. Michael Migliori, the president of the American Society of Ophthalmic Plastic and Reconstructive Surgery, said he sees three or four people a day who need the surgery at his practice at Rhode Island Hospital. But he conceded he faces a lot of pressure from patients who do not qualify. "They come in begging for you to do this surgery," Migliori said. "You get a lot of pressure to bend the rules."

Migliori said fudging the paperwork wouldn't be hard. "You could tell the patient to squint," he said, regarding the requirement that the condition be documented by a photograph, and then fake the vision test. But he thinks the majority of his colleagues are honest.

http://www.tampabay.com/news/aging/medicare/cosmetic-eyelid-lifts-costing-medicare-millions/2123530

Miami actor, wife face detention hearing in $15 million Medicare fraud case

Posted on Wednesday, 05.29.13

BY JAY WEAVER

JWEAVER@MIAMIHERALD.COM

Roberto F. Marrero made his name as an actor who played bit parts in shows such as Miami Vice and as a TV entrepreneur who launched a cable station featuring Cuban cultural programs.

But according to federal prosecutors, Marrero led a con man’s life as the owner of a Medicare-licensed home healthcare agency that fleeced $15 million from the government program. Marrero, prosecutors say, spent the ill-gotten gains on luxury cars, his cable business, Cubana de Television, and many trips to Cuba and Mexico.

On Wednesday, prosecutors plan to ask a federal magistrate judge to detain Marrero, 59, and his wife, Sandra Fernandez Viera, 49, before the couple faces trial on Medicare fraud charges.

Earlier this month, the couple, former owners of Trust Care Health Services in Miami, were charged with conspiring to submit bogus bills to the taxpayer-funded Medicare program for purported skilled nursing and physical therapy services for supposedly homebound diabetic patients.

Justice Department prosecutor Brendan Stewart asserted in a detention motion that Marrero and his wife were born in Cuba, have family ties there and have traveled frequently to the island nation. Stewart noted that Marrero has traveled more than 40 times to Cuba or Mexico since 2007, the start of his alleged theft from the Medicare program.

The couple’s “access to substantial financial resources, including millions in missing proceeds from the fraud at Trust Care, makes them an especially high flight risk,” Stewart wrote.

In the motion, Stewart said Trust Care’s bank records show a series of checks and other transfers to Marrero totaling $5.5 million and $400,000 to his wife.

In addition, Marrero moved large sums from Trust Care to other companies, including $3 million to Cubana de Television, $800,000 to Miami Vision International and $400,000 to Noche Cubana Supper Club, according to the motion.

Also, Marrero spent another $1 million on a fleet of fancy cars, including Lamborghinis, a Ferrari and a Bentley, and an additional $2 million on real estate, including a six-bedroom, six-bath home with a pool in the Roads section of Miami.

Stewart noted that federal agents have only been able to locate a “fraction” of Medicare’s payments to Marreo and his wife. In a separate civil action, prosecutors are seeking to freeze the couple’s assets and bank accounts.

Marrero’s attorney, Jose Quiñon, said he plans to challenge the government’s no-bond position, arguing Marrero has strong ties to the community. His wife’s attorney, Leonard Sands, said she, too, plans to fight any detention.

“An indictment is only an accusation,” Sands said. “We ask that she be afforded the presumption of innocence in the court of public opinion, the same presumption that she be afforded in a court of law.”

According to his résumé, Marrero comes from a family of actors in Cuba. It says he has had roles in soap operas and lists bit parts in television shows, including America’s Most Wanted and Unsolved Mysteries.

In 2008, he opened his cable TV studio in Allapattah and later moved the operation to Miami Beach. It has stopped providing programming since Marrero and his wife’s arrests in mid-May.

They were charged with conspiring to submit $20 million in bogus bills to Medicare for purported home healthcare services for diabetic patients. Medicare, known for its lax oversight of operators and their bills, approved most of the couple’s claims.

The couple was among 89 accused Medicare fraud offenders charged in a federal operation that stretched from Miami to Detroit to Los Angeles. Collectively, the defendants, including doctors, nurses and clinic operators, were accused of plotting to bilk $223 million from Medicare.

The crackdown was part of a continuing Medicare Fraud Strike Force effort in Miami and eight other regions riddled with healthcare corruption.

Marrero and his wife were co-owners of Trust Care from 2007 to 2010. According to the indictment, the couple submitted false bills to Medicare to treat 700 homebound diabetic patients who purportedly could not inject their own insulin and needed the assistance of costly, skilled nurses. The couple also billed Medicare for physical therapy that was not necessary, according to the indictment.

The indictment further states the couple paid thousands of dollars a month to a recruiter, Enrique Rodriguez, who supplied them with patients with valuable Medicare cards. Rodriguez, accused of bribing patients, was also charged in the indictment.

Read more here: http://www.miamiherald.com/2013/05/29/3421218/miami-actor-wife-face-detention.html#storylink=cpy

June 6 Webinar Offers Winning Medicare Advantage Go-to-Market Strategies for 2014

Experts from Gorman Health Group and Bloom Marketing Group will discuss how to build and follow a successful go-to-market strategy for Medicare Advantage plan sponsors in a co-hosted webinar from Atlantic Information Services and Gorman Health Group

Washington, DC (PRWEB) May 28, 2013

Many Medicare Advantage (MA) plans focus on marketing only during the fall open-enrollment period. But with more competitors having five-star quality ratings that are winning the right to market 12 months a year — and more baby boomers aging into Medicare — marketing must become a year-round focus. But how can MA marketing pitches win attention this fall amid all the advertising for new health insurance exchanges? Which marketing channels will yield the best outcomes? And how can MA plans increase sales-close ratios? The upcoming June 6 co-hosted webinar from Atlantic Information Services, Inc. (AIS) and Gorman Health Group, LLC (GHG), “Winning Medicare Advantage Go-to-Market Strategies for 2014,”will offer insights and answers to key Medicare Advantage marketing questions.

GHG’s Vice President Mary Kaye Thibert, and Whitney St. Jean, Chief Strategy Officer at Bloom Marketing Group, will outline the components of a successful go-to-market strategy for MA plan sponsors and their partners geared to the new environment, sharing results from a survey of thousands of beneficiaries on which marketing messages, technologies and channels are most effective. Among the questions to be answered at the June 6 webinar: 

• What lessons can Medicare Advantage plans learn from the 2012 sales cycle?
• What are and will be the most effective media outlets for MA plans, based on sales, response rate, cost per lead and cost per sale?
• What types of technologies will be most instrumental in helping MA plans to execute on their sales and marketing strategies?
• What is the ideal timeline for ad placements and direct-mail drops?
• How can plans cut through the clutter of advertising for health insurance exchanges this fall?
• How can management teams keep MA marketing strong even as resources are diverted into Medicaid expansion and exchanges?
• What special steps should be taken to market to baby boomers aging into Medicare?
• How can plans make sure call centers will support sales strategies effectively in this dynamically changing climate?

Visit http://aishealth.com/marketplace/c3ag25_060613 for more details and registration information.

ICD-10 implementation: Myths and facts from CMS

Author Name Jennifer Bresnick   |   Date May 28, 2013   

Scary stories from Canada, dire warnings from the AMA, and a stream of experts alternately comforting providers and warning them to hunker down and prepare for the worst are leaving providers confused and conflicted a mere seventeen months beforeICD-10 implementation on October 1, 2014.  In response to the jumbled avalanche of information hitting providers at a time when the industry is in the midst of several massive changes, the Centers for Medicare and Medicaid Services (CMS) has developed afact sheet identifying several myths about ICD-10 and clarifying the truth behind these common misconceptions.

Myth: Not everyone has to switch to ICD-10

Fact: All HIPAA-covered entities, including physicians and hospitals, are mandated to switch to ICD-10 in 2014.  But that doesn’t include every single type of organization that currently uses ICD-9.  Worker’s Compensation and auto insurance companies, for example, use ICD-9 codes but are not required to make the leap to ICD-10. But it’s in their best interests to do so, says CMS, since physicians and hospitals will be using the newer codes.  The increased detail and specificity will be just as useful for worker’s comp as it is for the emergency department, and CMS will work with non-covered entities to help them make the transition.  State Medicaid Programs will also receive CMS help to ensure that they will meet the deadline.

Myth: Everything is going to get prohibitively more complicated

Fact: ICD-10 has a lot of codes.  140,000 of them, to be exact.  But just as increasing the number of words in a dictionary doesn’t make it harder to use, the greater number of ICD-10 codes won’t significantly affect the complexity of coding, CMS explains.  Electronic decision support tools and organized code books will make finding the right code easy, and the new logical structure of ICD-10 will help coders find exactly what they’re looking for.

Non-specific codes are still available for use if supported by clinical documentation, and much of the detail necessary for ICD-10 coding is already present.  Providers do not need to perform unnecessary diagnostic tests just to get to the most specific code that exists in the code book.  Superbills based on ICD-10-CM won’t necessarily be any longer or more complicated than ICD-9 superbills, and codes can be crosswalked to help the conversion process.

Myth: I can just use GEMs for coding medical records

Fact: The General Equivalence Mappings (GEMs) are a handy tool for converting large amounts of data from ICD-9 to ICD-10, and are intended to help update payment systems, risk adjustment logic, quality measures, and research databases by mapping one code set to the other.  They aren’t a one-to-one solution for coding an individual clinical chart.  Mapping isn’t the same as coding, CMS warns, because the GEMs don’t allow for the selection of the most accurate and applicable ICD-10 code.

The GEMs are free of charge and available to any provider who wishes to use them, but code books, which are available in physical hard copies and electronic editions, should be used to deal with individual patient charts.

Myth: CMS is going to push the conversion date back again

Fact: No, they won’t!  CMS and HHS currently have no plans to move the date or extend the conversion process.  Any provider who is not ready to use ICD-10 codes starting on October 1, 2014 will not be reimbursed for services performed on or after that date if they are coded in ICD-9.  The one year delay from 2013 to 2014 has already caused significant disruptions in the planning process, but CMS has repeatedly said that the date will not budge again.

Providers should take advantage of CMS resources, such as detailed timelines andupdated implementation guides, in order to plan their transition.

HHS OCR director leon rodriguez's dialogue on HIPAA/HITECH compliance

• Baker & Hostetler LLP
• Kimberly M. Wong
• USA
• May 23 2013
• 

Author page »

“HIPAA is a valve, not a blockage,” stated HHS OCR Director Leon Rodriguez, at the OCR/NIST 6th Annual Conference on Safeguarding Health Information:  Building Assurance through HIPAA Security.  Discussing the tension inherent in HIPAA, between patient access to patient information and an organization’s safeguarding of protected health information (PHI), Director Rodriguez characterized OCR’s HIPAA guidance as providing the “super highways” to ensuring patient access to PHI and to safeguarding PHI.   An organization, on its own, must figure out the “surface streets,” emphasizing once again the flexibility and scalability of HIPAA.  Regardless of the type or size of an organization governed by HIPAA, the basic rules remain the same.  To adequately safeguard PHI, HIPAA defines a process.  HIPAA provides an organization with a series of decisions, policies and procedures, analyses, and plans.  Above all, patient expectations govern. 

Where does an organization draw the line between patient access and protecting PHI, especially in light of increased OCR enforcement of HIPAA/HITECH?  To ease a covered entity’s and business associate’s anxiety, Director Rodriguez reassured organizations that OCR is not playing a game of “gotcha.”   OCR is neither trolling for enforcement actions and civil monetary penalties (CMPs), nor seeking to punish a proactive organization for a single incident.   In support of his statement, Director Rodriguez highlighted the fact that of the 74,554 complaints filed since 2003, and the 26,513 total cases investigated by OCR, 17,767 cases resulted in corrective action, and only 13 cases since 2008 resulted in a Resolution Agreement and CMPs.   

Director Rodriguez acknowledged that breaches of PHI are going to happen, as risks exist even where organizations are doing everything right.   OCR is interested in what an organization is not doing, and whether the proper analysis is being conducted.  An organization must identify, remedy and change (if needed).  

So what type of action/inaction ends up in an OCR monetary enforcement scenario?  Director Rodriguez categorized two culprits:  (1) an ongoing failure to comply with the HIPAA Privacy and Security Rules, and (2) an unforgivable disclosure.  Regarding the first category, an ongoing failure usually exists over several months and/or years.  Often times, a risk analysis is missing, including a lack of routine information system reviews.  Director Rodriguez stressed the importance of conducting risk analyses to identify vulnerabilities.  Once risk is identified, it must be properly evaluated and addressed.  Another reoccurring ongoing failure is the lack of updating of policies and procedures after a change in business operations or a change in technology.  Director Rodriguez summarized the routine case OCR falling under monetary enforcement scenario as an incident affecting a large number of records, a vulnerability that exists for a number of months, and a failure to assess risk (e.g. OCR’s May 21, 2013 Resolution Agreement with Idaho State University).  The second category is an unforgivable disclosure of PHI that is borderline criminal (e.g. UCLA breach of celebrities’ privacy resulting in OCR’s July 6, 2011 Resolution Agreement). 

Regarding CMPs, Director Rodriguez highlighted the guidance provided in the Final Rule regarding factors to consider in determining the amount of CMPs to assess.  The Resolution Agreement in the Alaska DHSS, where there was an alleged lack of remediation over a long period of time, is an example used by Director Rodriguez to demonstrate how the failure to remediate over a prolonged period of time can increase a CMP.  In Alaska DHHS, the Resolution Agreement required payment of $1.7M.  Accordingly, in addition to identifying, assessing and responding to a breach incident, an organization must also timely remedy any vulnerability in order to keep the amount of any potential CMP low.       

Director Rodriguez also commented on the vulnerabilities associated with mobile devices, which remains a topic of interest for OCR.  Of the breach reports received by OCR, 25% are related to paper records and vulnerability of mobile devices.  Director Rodriguez encourages all organizations to focus on securing mobile devices (a “great vulnerability”) and to use HHS resources regarding mobile device security.   

OCR’s HIPAA audits were also discussed – specifically OCR’s findings regarding encryption.  Not surprisingly, OCR found that encryption, an addressable implementation specification under the Security Rule, was not always implemented by organizations.  Director Rodriguez stressed the importance of conducting an analysis – shopping for technology, evaluating the risks and costs with implementation, and how encryption might affect patient care in the clinical setting.  An organization must weigh the pros and cons of encryption in making the final decision to encrypt or not to encrypt.  This lack of analysis regarding the adoption of encryption is a red flag.   

Director Rodriguez, concluding his dialogue on HIPAA/HITECH compliance, recommended that every organization “be smart and implement best practices” and remember that the patient is most important.  Organizations must determine how to best ensure patient access to PHI while also adequately safeguarding PHI.  “[A] risk analysis, ongoing risk management, and routine information system reviews are the cornerstones of an effective HIPAA security compliance program.”

NHS surgery: death risk rises through the week

WEDNESDAY 29 MAY 2013

Having an elective operation? Make sure it is on a Monday, says a new study published in the BMJ, which found that patients are more likely to die in operations conducted at the end of a week.

Death rates for elective surgery patients are lowest on Mondays and increase for each subsequent day of the week, said researchers.

The odds of death after a planned operation in the UK are still very low. But they are 44 per cent higher for patients who had their procedure on a Friday than on a Monday, the study by Imperial College London researchers found.

The landmark study of more than four million elective procedures conducted in NHS hospitals in England between 2008 and 2011, found that the risk of dying got steadily worse as the week went on.

Differences in mortality rates [could be] due to poorer quality of care at the weekend, perhaps because of less availability of staff, resources- Dr Paul Aylin, lead study author

It became higher still if the operation was carried out at the weekend, however only a small number of operations are scheduled to take place on Saturday and Sunday, and this represent a different type of patient.

Elective procedures are surgical operations to correct a condition that is not life-threatening, such as hip or knee replacements, and are scheduled in advance.

The report's authors looked at data concerning patients who had to stay in hospital overnight following their operation. They found that 27,500 patients died within 30 days of their surgery.

Post-op care

The findings could reflect differences in quality of care at the weekend, the authors said.

"The first 48 hours after an operation are often the most critical period of care for surgery patients," said lead author Dr Paul Aylin, from the school of public health at Imperial University.

"So if the quality of care is lower at the weekend as some previous studies have suggested, we would expect to see higher mortality rates not just for patients operated on at the weekend, but also those who have operations towards the end of the week, whose post-operative care overlaps with the weekend. That is what we found.

"Unlike previous studies, we included both deaths in hospital and deaths after discharge, so this eliminates a potential bias of counting only in-hospital deaths. We tried to account for the possibility that different types of patients might have operations at the end of the week, but our adjustment made little difference.

"This leaves us with the possibility that the differences in mortality rates are due to poorer quality of care at the weekend, perhaps because of less availability of staff, resources and diagnostic services."

In an accompanying editorial, Canadian experts question whether officials should rethink the scheduling of elective surgery at the weekend.

They wrote: "Although emergency procedures, such as the repair of ruptured aortic aneurysms, cannot be controlled, the scheduling of elective procedures, such as knee replacements, is wholly within our control.

"If weekend care proves to deliver poorer outcomes than its weekday counterpart, it might be argued that elective procedures should not be scheduled at weekends at all."

Treo Solutions to Host Mini-Summit on Innovative Care Delivery Models for Safety Net Populations at 8(th) Annual Medicaid Congress

• PRESS RELEASE
• May 28, 2013, 9:00 a.m. ET

Barbara DeBuono MD, MPH of Treo Solutions to Lead Panel on Medicaid Innovation

TROY, N.Y.--(BUSINESS WIRE)--May 28, 2013-- 

Treo Solutions, a leading healthcare transformation company leveraging enhanced data to deliver value to payers, providers and government, announced today that Barbara A. DeBuono MD, MPH, Senior Vice President of Treo Solutions, will host a mini-summit as part of this year's Medicaid Congress on May 30 at 1 p.m. The Eighth National Medicaid Congress brings together the best and the brightest from federal and state government, academia, health plans, advocacy groups, and providers to explore key policy and operational issues. The mini-summit is titled "Innovative Care Delivery Models for Safety Net Populations."

"The Medicaid program, implemented at the state level, is proving to be a driver of healthcare innovation by adopting a population health management approach, creating new delivery models, leveraging analytics and intelligence, and building stakeholder alliances," said Dr. DeBuono. "At Treo, we know that healthcare transformation is a result of alignment, collaboration, and transparency, themes that are woven throughout the session of the Medicaid Congress."

During the mini-summit, Dr. DeBuono will share how Treo is working with states and Medicaid programs to help drive transformation by implementing multi-payer initiatives, transforming payment and delivery systems, integrating the dual-eligible population, establishing transparency, and operationalizing risk adjustment. In addition, she will highlight specific client examples, including the Colorado Accountable Care Collaborative, the Adirondack Medical Home Demonstration, and Community Care of North Carolina.

Dr. DeBuono has led and managed large healthcare organizations and budgets in government and the private sector during her career as a public health physician. Previously, she has served as Commissioner of Health for the State of New York and Director of Health in Rhode Island. In both roles she led efforts to develop Medicaid Managed Care and State Children's Health Insurance Programs (SCHIP), and crafted public health prevention programs in HIV, immunization, and breast and cervical cancer. Following her role as Commissioner, Dr. DeBuono joined the New York Presbyterian Health System in New York City serving as Executive Vice President of its network.

About Treo

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House panel rejects pay cap, most proposed TRICARE hikes

Published: May 28, 2013

Even as defense budgets drop like a rock and the Joint Chiefs urge Congress to spread some of the fiscal pain across personnel accounts, the House armed services subcommittee on military personnel has said "No."

On Wednesday, the panel unanimously rejected the Obama administration's call to cap the 2014 military pay raise at one percent versus the 1.8 percent needed to keep pace with recent private sector wage growth.

It also blocked almost all of the administration's plans to increase TRICARE fees substantially for military retirees and their families over the next five years, including an idea to vary fees based on retired pay levels.

The lone exception is that the House panel will not block a $4 increase in co-payments for retirees under age 65 and their family members for outpatient care under TRICARE Prime. Co-pays for doctor visits would increase to $16 except for mental health care, which would stay at $12.

"We cannot block this $4 increase because it would incur significant mandatory spending that we cannot offset without taking resources from other medical research and health programs our service members depend upon," explained a press aide to Rep. Joe Wilson (R-S.C.), chairman of the personnel subcommittee.

"The Department of Defense does not have authority to raise any other fees within TRICARE and we are not granting them statutory authority to do so," she added. "Chairman Wilson is committed to ensuring that our service members and retirees have the highest quality medical care as well as ensuring that DOD honors the commitments that have been made" to current beneficiaries.

The Joint Chiefs of Staff and secretary of defense had argued for the higher TRICARE fees so that readiness accounts -- training, maintenance, supplies and weapons procurement -- could remain in balance amid the steepest drop in defense spending seen since just after-World War II.

But in a phone interview, Wilson said there is bipartisan resistance inside the House Armed Services Committee to capping pay raises or boosting TRICARE fees. He cited several reasons for this.

First, U.S. troops still are fighting terrorism across the world. Second, over the last several years, Defense officials have overstated health care costs, enough so that they were able to reprogram on average $400 million a year from projected pops in health spending into other defense accounts.

Finally, Wilson said, "there were commitments made to service members and retirees" to sustain the value of their health benefits, even presumably as health costs continue to climb nationally. "And I believe the commitment should be maintained."

Wilson and staff said President Obama has authority to cap the military pay raise without congressional approval. He only need to claim "serious economic conditions" or national emergency to do so, and then to present Congress with an "alternative pay adjustment" plan by Sept. 1.

Wilson said he hopes the president won't choose that path given bipartisanship support for a full 1.8 percent military raise next January.

To the argument that pay and allowances need to share in the historic budget slowdown occurring to keep the force "in balance," Wilson said he doesn't share that view nor do his colleagues, a sign of "how much we, and the American people, appreciate their service."

Wilson acknowledged planned defense cuts that would total more than a trillion dollars over the next decade, including almost $600 billion in cuts mandated by the budget sequestration formula Congress and the President Obama devised to try to force a deal on reducing the nation's debt.

But Wilson said he opposed it all - the sequestration feature of the 2011 Budget Control Act, that law's initial swipe at the debt with $487 billion in defense cuts over a decade, and $100 billion in "defense efficiencies" directed by then-Defense Secretary Robert Gates in 2011. Why?

"We have a worldwide threat that raises its head everyday. And we need to be ever vigilant. And we are truly, I believe, in a global war on terrorism," he said. "The American people are being threatened and the way to respond is through strength, not by reducing our capabilities."

Wilson's subcommittee approved the military personnel section of the fiscal 2014 defense authorization bill Wednesday and referred it to the full committee for mark up June 5. It featured initiatives to deal with rising incidents of sexual assault within the ranks, through new whistle-blower protections and dedicated legal assistance for victims.

Rep. Susan Davis (Calif.), ranking Democrat on the subcommittee, agreed with Wilson's comments on bipartisanship. She did not give her own reasons for rejecting the smaller pay raise or Obama's call for sharply higher co-pays on prescriptions filled off base or raising TRICARE enrollment fees on working-age retirees.

The Senate Armed Services Committee will work its own version of the defense authorization bill next month and is expected to embrace more of the personnel cost controls proposed by the president. Even Sen. Lindsey Graham (S.C.), ranking Republican on the personnel subcommittee, has said he will support higher TRICARE fees if they made the benefit more sustainable, which military leaders argued in defending their 2014 budget.

The staff of the House committee noted that TRICARE cost growth will be slowed this fall by Defense plans to end TRICARE Prime for 177,000 current enrollees living more than 40 miles from military treatment facilities. These Prime provider networks will end, forcing retirees under 65 and their families to use TRICARE Standard, the less generous fee-for-service option.

Also Oct. 1, beneficiaries 65 and older must have their maintenance medications for chronic conditions filled on base or through mail order rather than at local drug stores or supermarkets. This will begin as a pilot program but it could become permanent, saving TRICARE millions of dollars a year on pharmacy costs.

Also, House staff noted, Congress did approve some pharmacy co-pay increases and modest TRICARE Prime enrollment fee hikes last year, and agreed to increase them annually based on the inflation index used to adjust government retired pay.

"That's the deal we made with the Defense Department, with retirees and service organizations," said a House staffer. "We don't particularly see any need to revisit that deal." He added that retirees and families "deserve some predictability" versus benefits at risk of new hikes year after year.

- Syndicated columnist Tom Philpott has covered the military for more than 35 years. To comment, write Military Update, P.O. Box 231111, Centreville, VA, or email milupdate@aol.com or twitter: Tom Philpott @Military_Update

Highmark-UPMC dispute may hurt seniors

May 28, 2013, 12:28pm EDT UPDATED: May 28, 2013, 2:48pm EDT

Kris B. Mamula

Reporter-Pittsburgh Business Times

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Senior citizens with Medicare Advantage coverage may feel the sting of the Highmark-UPMC contract dispute more than others. Here’s why.

Medicare Advantage plans have an unusually high penetration rate in Allegheny County – exceeding 50 percent. And Highmark has a controlling 55.5 percent of the Medicare Advantage market in the 29 counties of southwestern Pennsylvania, according to an Insurance Department filing.

UPMC is a distant second with 24.8 percent of the market and everybody else trails in the single digits: HealthAmerica, 8.7 percent; UnitedHealthcare, 3.3 percent; and Aetna, 3 percent, to round out western Pennsylvania’s top five Medicare Advantage insurers.

UPMC has said there will be no contract extension with Highmark. That means seniors with Medicare Advantage coverage, like Highmark’s commercial members, may find UPMC doctors and hospitals out-of-network come Jan. 1, 2015.

Whether Highmark's Medicare Advantage members will be drawn into the contract dispute isn't clear.

Hospital executives have said the sticker prices for services have little or no meaning. But the reality is out-of-network means Highmark members could be responsible for up to 70 percent of UPMC’s charges.

A routine emergency room visit to UPMC Presbyterian Shadyside Hospital for abdominal pain, for example, would mean an out-of-pocket expense of $8,400, well outside what most seniors could afford.