Monday, June 17, 2013


Released 17/06/2013

The results of the latest NHS GP Survey show that patients are generally happy with the overall service they receive but identify areas for improvement

The majority of patients in England (87%) rate the experience with their practice as ‘good,' with almost half (45%) describing it as ‘very good,' according to the latest national GP Survey.
Those with long-term conditions were the most satisfied with just under 89% giving a ‘good' rating.
The survey covers the period from July 2012 to March 2013 and gained a response rate of 35%, equivalent to 971,232 completed questionnaires out of a total of 2.75m distributed.
The survey also indicated a shift in patient requirements.
Despite 80% of patients booking appointments over the phone, nearly a third (31%) said they would prefer to book online, and 225 said they experienced problems getting through on the phone.
Just over a third of patients (36%) were able to actually see or speak to someone on the day they initially contacted the surgery, but 15% waited a week or more to see or speak to someone.
Most who were able to get an appointment said that this had been convenient (92%), with just under half saying that this had been ‘very convenient.'
Once in the surgery, 26% of patients had to wait over 15 minutes, and while more than half (59%) are happy with their waiting time, one-in-four (25%) believe they wait ‘a bit too long'. Worryingly, 10% felt they have to wait ‘far too long'.
Over half the respondents (58%) said they knew how to contact an out-of-hours GP service. But only one in eight (13%) had tried to access the service in the past six months. Of those who did so, most found it easy to do so (79%), with 38% describing it as ‘very' easy.
However, 31% said it ‘took too long' to get the care they needed. Although (81%) said that they had trust and confidence in the out-of-hours clinician, 12% said they did not.
Overall, 70% said their general experience of out-of-hours GP services was good, with a third (31%) saying it was ‘very' good.
Dr David Geddes, head of primary care commissioning at NHS England said:" "Nine out of ten contacts the public have with the NHS are with their GP practice. The GP patient survey highlights where patients are satisfied with the service they receive, but also helps us identify areas where we could do better and where NHS England along with CCG leaders need to focus.
"The GP survey gives us insight into patient feedback on GP services in and out of hours and this will form an important part of our work to modernise and develop the contribution that general practice can make to the NHS going forward."

Medicare fraud rate is 8 to 10 percent, says Roskam of Illinois

"Worldwide credit card transactions, the credit card fraud rate is 0.04 percent, compared to almost 8 percent, 9 percent, 10 percent of Medicare fraud."

Peter Roskam on Wednesday, June 12th, 2013 in an interview with Fox News

Medicare fraud rate is 8 to 10 percent, says Roskam of Illinois

Fraud by its very nature tries to hide from view. So when Rep. Peter Roskam, R-Ill., talked about how big the problem is for the Medicare program, he gave himself some wiggle room.
Roskam was talking to Fox News about a bill he has that would borrow tools used in the credit card industry to pare down the tens of billions of dollars that criminal gangs and unscrupulous operators pocket from the federal government’s health care program for the elderly.
"Worldwide credit card transactions, the credit card fraud rate is 0.04 percent," Roskam told Fox News. "Compared to almost 8 percent, 9 percent, 10 percent of Medicare fraud."
When PolitiFact checked the size of Medicare fraud five years ago, we quickly discovered that hard and fast numbers are hard to come by. In this fact-check, we’ll examine Roskam’s estimate of 8 to 10 percent and see what sources he relies on.
Before we dive into Medicare fraud, a review of credit card studies shows that Roskam is pretty much on the mark when he speaks of a 0.04 percent rate. A 2010 report from the Federal Reserve Bank of Kansas City gives a fraud rate of 0.05 percent for U.S. issued cards, both debit and credit. Roskam’s office pointed us to a trade publication, the Nilson Report, that cites an international rate of 0.04 percent rate.
On Medicare, Roskam’s office cited a Government Accountability Office report, a watchdog website created by an executive order from President Barack Obama, and an article from theU.S. Administration on Aging. All three give us rates that range from 7.9 percent to 8.5 percent for the largest Medicare program, and up to 11 percent for a smaller program, Medicare Advantage.
While the fraud rates fall into Roskam’s range, none of them is talking about fraud alone. Rather, they address the much broader category of improper payments. If a doctor orders too many tests, or provides a service but submits the wrong payment code, those come under the umbrella of improper payments.
Out and out fraud is not as large as improper payments, but it can be egregious. The FBI recently charged 25 people in Miami for allegedly bribing Medicare beneficiaries and then using their account numbers to bill for services that were unnecessary or never provided. The government says the scheme netted the conspirators about $44 million.
Malcolm Sparrow, professor of public management and a specialist in corruption control at Harvard’s Kennedy School, told us that fraud and improper payments are far from identical.
"There is a serious problem with conflating these different types of overpayment," Sparrow said. "They are quite different in origin and require very different types of control mechanisms."
When we raised this with Roskam’s office, his staff sent us several examples where Roskam has spoken collectively of fraud, waste and abuse. On Fox News, however, he spoke only of fraud.
PolitiFact also found a study that restores a measure of credibility to Roskam’s estimate. Donald Berwick, a former head of the Centers of Medicare and Medicaid Services or CMS, the agency that runs Medicare, collaborated with an analyst at RAND to produce a landmark paper in 2012 in JAMA, the Journal of the American Medical Association.
That paper offers three estimates of fraud in the Medicare and Medicaid programs: a low of 3 percent, a medium of 6 percent and a high of 10 percent. CMS told us they have no official estimate of fraud but pointed us to this study, and they cited FBI figures that mirror the numbers in this paper.
If it turns out that the high end of the range in the JAMA article is correct, then Roskam is in the right ballpark.
Of course, nobody knows for sure because fraud is a crime, and criminals don’t advertise their work.
Two caveats for policy makers
The JAMA article doesn’t stop at Medicare and Medicaid. It also looks at fraud in the health care sector as a whole, both public and private. The fraud rates don’t change much when the private sector is included.
For Sparrow at Harvard, this is no surprise.
"The systems and structures they use for control are the same, across public, private, and not-for-profit programs," Sparrow said. "They all tend to share the same strengths and weaknesses, and are roughly equally vulnerable."
Put another way, the nature of the American health care system lends itself to a certain level of fraud, and the Medicare program is no more and no less susceptible to this type of crime.
Sparrow says this also suggests the comparison to the credit card industry might be less useful than might appear. In the first place, the transactions are much simpler. When a thief tries a scam with a credit card, the card holder tends to notice by the next bill. In general, this kind of fraud is more easily detected and tracked. But Sparrow says there’s a bigger difference.
"The losses are borne by banks," he said. That creates a powerful incentive, in real time, to control the problem. In health care, the incentives are "more diffuse and ambiguous."
Our ruling
Roskam said the Medicare fraud rate is 8 to 10 percent. His office pointed us to various documents that analyzed the problem of improper payments, an issue that mixes fraud together with nominally legal activities such as referring patients for more tests than are necessary. This suggested Roskam was using an inflated estimate of fraud. However, a recent study tends, in the worst-case analysis, to support Roskam’s figures.
Roskam’s comparison to credit cards overlooks many key differences between the structures of the health care and credit card industries, and it tends to obscure the systematic nature of fraud in health care, whether public or private. But Roskam is right that credit card fraud is a tiny percentage of all transactions.

Home health care helps make Dallas' Medicare spending among highest in nation

By JIM LANDERS, Washington Bureau
Published: 16 June 2013 10:03 PM
Updated: 17 June 2013 12:14 AM


Home health care, an industry plagued by allegations of fraud and abuse, is the biggest reason why Medicare spending in Dallas County is among the highest in the nation.
A recent report by the U.S. Health and Human Services Department’s inspector general found suspicious billing activities at 1,000 of the 2,212 home health agencies in Texas in 2010. The report recommended a moratorium on accepting claims from new home health care agencies in Texas until the billing practices were sorted out.
A separate report in March by the Medicare Payments Advisory Commission found Texas accounted for 13 of the 25 U.S. counties with the highest spending on home health care. (Dallas County was not on the list.) For every 100 Medicare beneficiaries in Duval County, Medicare was billed for 152 visits by home health care nurses, therapists and health aides.
(In Dallas, Medicare was billed in 2011 for 62.5 visits per 100 beneficiaries. The national average that year was 19.6 visits.)
“Our work with law enforcement has shown us that there is tremendous fraud going on, particularly with home health,” said Jon Blum, director of Medicare Services, during a congressional hearing Friday.
Federal prosecutors last year charged two Dallas physicians and several home health care agencies with fraudulent Medicare billings worth more than $450 million.
Dallas County Medicare spending per beneficiary fell in 2011, the most recent year available for spending data. But spending under the federal insurance program for the elderly and disabled was still 25 percent higher in Dallas than the national average. Among the nation’s most populous metropolitan counties, only Miami-Dade County in Florida and Harris County, Texas, spent more.
Fraud concerns
Most of the difference between the Dallas County and national spending averages was because of the higher use of home health care.
Medicare spends an average of $1,624 for home health care for each Medicare beneficiary in Dallas County, while the national average is $546.
Rachel Hammon, executive director of the Texas Association for Home Care & Hospice, said seniors get treatments and rehabilitation for serious medical conditions by skilled health workers at home that would cost far more in institutions such as inpatient nursing facilities.
But she said the association shares the concern about fraud and has endorsed the moratorium recommended by the federal inspector general’s August report. There are now 2,949 home health care agencies in Texas eligible for Medicare payments.
“Certainly nobody, none of our providers appreciates fraudulent agencies,” she said. “We have fraud and abuse education at every meeting.”
The association is hosting a meeting next week with federal officials for home health care agencies along the Rio Grande Valley, where several of the highest-use counties are located.
Post-acute care costs
Recent Medicare data shows spending in Texas, Louisiana and Florida exceeded the national average by 10 percent or more between 2007 and 2011.
The biggest factor in high Texas spending was costs for post-acute care — charges incurred after patients are released from hospitals and enter treatment at home or at inpatient residential facilities, skilled nursing facilities or long-term acute care hospitals. Spending in Dallas County on post-acute care was $1,608 per beneficiary higher than the national average in 2011. Hospital charges, meanwhile, were just $81 above the national average.
The high Medicare spending in Dallas County held true for Tarrant and other North Texas counties as well, according to the recent data. Medicare spending in Collin, Denton and Tarrant counties was 12 percent to 24 percent above the national average in 2011. In each county, spending on home health care was at least double the national average.
Follow Jim Landers on Twitter at @landersjim

Medicare fraud and for-profit hospitals:

Medicare fraud and for-profit hospitals:

Medicare fraud and for-profit hospitals:

A story that never ends

Sunday, CBS’ Sixty Minutes took a close look at Health Management Associates (HMA), a for-profit hospital chain that, according to its employees, has “relentlessly pressured its doctors to admit more and more patients – regardless of medical need-in order to raise revenues.” contributor
“We talked to more than 100 current and former employees and we heard a similar story over and over,” CBS correspondent Steve Kroft reported. Emergency room physicians were told “that if they didn’t start admitting more patients to the hospital, they would lose their jobs.” The orders came from the top:
With 71 hospitals in 15 states, HMA is the fourth-largest for-profit chain in the country. Last year, it raked in revenues of nearly $5.8 billion; half of that came from Medicare and Medicaid. In other words, taxpayers were footing the bill for a large share of those unnecessary hospitalizations.
Patients also paid. As one doctor observed: “If you are put into the hospital for reasons other than a good, justifiable medical reason, it puts you at significant risk for hospital-acquired infections and what we would refer to as ‘medical misadventure’” (i.e. preventable medical errors).

“Putting heads on beds” – an old story

The piece was shocking. But it is not a new story. It is an old story. To be more precise, it is a never-ending story. In Money-Driven Medicine: The Real Reason HealthCare Costs So Much, I profiled several for-profit hospital companies that did just what Health Management Associates has done: “put heads on beds” even though the patient didn’t need to be hospitalized.
At Tenet, in Redding, California, patients weren’t just hospitalized, they underwent heart surgery. An investigation would reveal that in many cases, they “had no serious cardiac problems whatsoever.”
An FBI affidavit estimated that in one-quarter of all cases, Tenet’s two “rainmaker” heart surgeons were slicing open patients who should never have been on an operating table. Other doctors tried to alert the hospital’s administration. They were ignored.
Some of those patients did not survive. Others were crippled. All suffered psychological trauma.

HCA: Florida Governor Rick Scott’s back story

In 1997, Health Corporation of America (HCA) made headlines when FBI agents swarmed HCA offices in five states, and found evidence that at HCA, executive salaries hinged on meeting financial targets such as “growth in admissions and surgery cases.”
The FBI also discovered that HCA had been keeping two sets of books – one to show to Medicare, a second that contained the real numbers. Ultimately, the investigation would reveal that the hospital chain had been bilking Medicare while simultaneously paying kickbacks to physicians who steered patients to its hospitals.
Just as at HMA, whistleblowers said that the directives came from the top. Rick Scott, who would later become governor of Florida, was the CEO of HCA.
In 2000, HCA finally settled with the government, pleading guilty to no fewer than 14 felonies – the biggest case of Medicare fraud ever. The company paid $1.7 billion in fines.
No one went to jail – probably because the Frist family (as in Senate Majority Leader Bill Frist) had founded the hospital and hired Scott to run it. (Some would say he was hired to do their dirty work.)
HCA settled with the government shortly before the Senator’s brother, Dr. Tommy Frist, (who served as HCA’s chairman) was scheduled to be deposed by the government’s attorneys.
Rick Scott was never indicted, and waltzed away with $10 million in severance. In 2009, when he led a committee to kill health reform, I told his story on HealthBeat, and wrote about him again when he became Florida’s governor.

For-profit hospital chains: the pattern

Tenet, HCA and HMA are just three examples of corrupt for-profit hospitals. After defrauding Medicare and hurting patients for years, these chains are caught, and pay a huge fine. No one goes to prison. Frequently they change the name of the chain, paint the front door, hire executives who are cronies of the former management team, and start all over again.
Update: Sure enough, HMA CEO Gary Newsome has announced that he will be retiring July 1. Newsome, 55, said in a news release that he is stepping down after being “called by the First Presidency of the Church of Jesus Christ of Latter-day Saints to serve as the president of its Uruguay-Montevideo mission.” (It appears that he’s getting out of Dodge.)
Newsome, who has been at the helm of the company since September 2008, took home $8.3 million in total compensation last year.
Meanwhile, the word on Wall Street is that HMA is now a takeover target. Bloomberg reports that, according to financial analysts, Community Health Systems (CHS), a sister for profit hospital chain is the most likely suitor.
HMA and CHS have quite a lot in common: CHS has disclosed that it, too, has received requests for information from numerous law-enforcement agencies regarding its admissions policies, some of which are based at least in part on whistle-blower allegations. Unfazed by charges of wrong-doing, shareholders have sent HMA’s share price soaring, up 25% in a week. ( Typically, takeover rumors spur buying.)

Why do they do it?

The hospital industry is a tough business, and it’s not easy to make the fat profits Wall Street expects. This is why the whole idea of trying to make hospitals “for-profit” is a truly terrible idea. Too often, shareholders’ interests trump patients’ interests.
More importantly, the hospital business is a labor-intensive, capital-intensive business. It just about impossible to reap the returns investors demand – unless you become creative.

Non-profits follow the for-profits

This is not to say that for-profits have a monopoly on fraud. A few years ago, a whistle-blowing doctor at a non-profit Catholic hospital contacted me. The administration at his hospital was pressuring doctors to admit ER patients. The hospital ultimately closed down his practice, transferring his patients to other doctors at the hospital. But he didn’t back down.
Unfortunately, no one at the hospital would talk to me. And none of the doctors’ colleagues would talk on the record – though they had all heard the CEO tell staff they were going to have to hike admissions from the ER.
His partner did talk to me and corroborated the story, but wouldn’t talk on the record. It is so sad; people are so afraid.
I was seriously disappointed. This had all the elements of a great story: The Catholic Church! Nuns! Blood! Money! A guy who is willing to stand up!
I will always remember this physician. He was in his early 60s, and devastated when they closed his practice and he lost so many long-time, patients. Many of them were older, and he told me he kept a notepad by his bed, in case, during the night, he thought of something that he should check on regarding one of his patients.
After he lost his practice, his girlfriend left him.

Posted June 13, 2013
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The Supreme Court’s Bad Science on Gene Patents

Today’s Solomonic decision is intuitive on the surface. On the one hand, as my 6-year-old daughter explained to me, “if you discover something, that means it was already there. And if it was already there, you couldn’t have invented it.” Patents are reserved for inventions, not naturally occurring phenomena. On the other hand, the synthetic gene -- in this case, a sequence of what is called “complementary DNA” that includes only those elements of the gene sequence that actually encode proteins --has some claim to having been invented, because it is not (exactly) naturally occurring.
Noah Feldman

About Noah Feldman»

Noah Feldman is a professor of constitutional and international law at Harvard and the author of five books, most ... MORE
Yet beneath the court’s formalist decision lies an attempt to reconcile the ethical principle that natural phenomena can’t be patented with the economic reality of the contemporary U.S. We increasingly rely on the products of intellectual property to produce goods that the rest of the world might want to buy. If there were no patent available for gene identification, it would significantly reduce the incentive of big pharmaceutical companies to go after the basic science needed to identify genes and, potentially, create treatments for the diseases that those genes might cause. The Supreme Court cut the genetic baby in half in the hopes of preserving that incentive.

Shaky Reasoning

The devil, as usual, lies in the details. Those details strongly suggest that the court’s distinction rests on very shaky scientific grounds -- and can be explained more by political economy than by logic.
To simplify a modestly complex scientific process -- as Justice Clarence Thomas skillfully did for a unanimous Supreme Court -- the complementary DNA (or cDNA for short) is created by taking a naturally occurring messenger RNA molecule and, using ordinary nucleotide binding, turning it into cDNA. The now patentable cDNA is different from the original DNA in that it omits those elements of the original sequence that do not code for protein formation (if you’re keeping score at home, these are called introns).
Notably, however, it is not the scientists who removed the introns from the officially unpatentable original DNA sequence to make the new, patentable cDNA sequence. It is nature itself, through the magic by which pre-RNA, which includes the introns, becomes messenger RNA, which does not. The Supreme Court described this process by saying, “the pre-RNA is then naturally ‘spliced’ by the physical removal of the introns” -- that is, the introns are removed as part of the ordinary process by which messenger RNA is created. The role scientists then subsequently play is to take the messenger RNA and use it to synthesize the intron-free cDNA.
To put it much more simply, there is nothing that a 6-year-old would consider “invented” about the patentable cDNA. It is nothing more than the messenger RNA flipped into a DNA sequence that omits unnecessary elements that nature already excluded. The sequence that codes the proteins is just as naturally occurring as the original DNA itself, which the court held couldn’t be patented because it was naturally occurring. The distinction is, to put it bluntly, a lawyer’s distinction, not a scientist’s. We are accustomed to disparaging law-office history. The Myriad Genetics case is giving us law-office biology.

Preserving Research

But if the court’s formalism is a bit unconvincing, its desire to preserve something capable of being patented in genetic research makes a certain amount of sense. Much basic science is and remains government funded, but a large and ever-increasing share of scientific advances connected to particular genes and diseases is dependent on private financing -- driven, of course, by the desire to produce drugs and get them to market.
Patent is a form of intellectual property, and intellectual property is increasingly one of the basic drivers of the U.S. economy. From big pharma to computer technology to Hollywood films, exports that depend upon the protection of intellectual property lie at the heart of American competitiveness in global markets. For the Supreme Court to be too relaxed about defining intellectual property might send a global message that our government may not be vigilant about protecting intellectual property abroad.
It therefore makes sense for the Supreme Court to have found some mechanism for patent protection in genetic research, however tenuous or formalist the reasoning.
On the other side of the equation lie the concerns of ethics. It really would be too Orwellian if the court had allowed naturally occurring phenomena such as genes to be patented and thus owned, if only temporarily. As philosophers Margaret Radin and Michael Sandel have argued, some things really shouldn’t be made into commodities, no matter what advantages might accrue from it -- and our naturally occurring genes are surely such things. We should applaud the court for underscoring this basic principle. At the same time, we should realize that the same court that produced an ethically appealing judgment also left room for private enterprise to play its role. The baby has been split -- or maybe spliced -- in half. Let’s hope she survives, and that we do.
To contact the writer of this article: Noah Feldman at