Thursday, June 27, 2013

Kaiser mental health care lacking, state says; HMO hit with $4 million fine

 By Cynthia H. Craft
Published: Wednesday, Jun. 26, 2013 - 12:00 am | Page 1A
Last Modified: Thursday, Jun. 27, 2013 - 8:42 am

Imposing the second-largest fine in its history, the California Department of Managed Health Care on Tuesday slapped Kaiser health plans with a $4 million penalty for failing to provide mental health treatment in a timely manner.
The department also issued a cease and desist order to Kaiser, forbidding the health plan from continuing practices in violation of state law, which ensures equal care for mental and physical health.
An investigation that started in 2012 found that Kaiser's written description of its mental health services was so complicated and misleading that it "could dissuade an enrollee from pursuing medically necessary care."
Kaiser Permanente officials responded Tuesday by saying improvements are under way, and they plan to challenge the fine as too stiff.
Only one other fine in the history of the department exceeded Kaiser's.
That was in 2008 when Anthem Blue Cross was hit with a $10 million penalty for wrongfully rescinding consumers' health insurance coverage.
"The amount of the proposed penalty is unwarranted and excessive, and is unnecessary to ensure our corrective actions," said John Nelson, vice president for Kaiser Permanente. "We will review this with the DMHC."
Three months ago, the department released a detailed report saying Kaiser needed to see mental health patients more quickly and improve its public disclosures or face penalties.
It provided Kaiser with a laundry list of deficiencies to correct, including these examples:
• A FAQ sheet for Kaiser in Northern California says: "We offer brief, problem solution-focused individual counseling. Research shows many people improve in a single visit. … We do not offer long-term individual psychotherapy at Kaiser."
• Kaiser's website for its Northern California Department of Psychiatry says: "In general, we do not begin treatment with individuals whose problems are of such a long-standing nature that short-term treatment would probably not be helpful. We will refer such individuals (elsewhere), although this treatment will not be a Kaiser-covered benefit and will not be paid for by Kaiser."
• Kaiser has failed to ensure that appointments for mental health care are offered in a timely manner, making patients wait too long between visits.
Managed Health Care officials said advising patients that long-term psychotherapy is unavailable violates the state's mental health parity law. The law says that mental illness must be treated on par with physical illnesses.
The investigation follows complaints in 2011 by the union representing Kaiser's mental health clinicians that Kaiser's mental health practices were deficient.
Last March, the department issued a report that contained serious findings but offered Kaiser the opportunity to correct them prior to being fined.
However, DMHC Director Brent Barnhart said Kaiser did not move fast enough to fix its problems.
"The department's actions are a result of both the seriousness of (Kaiser's) deficiencies and the failure of Kaiser to promptly correct them," Barnhart said.
For its part, Kaiser said it has been working diligently to improve its mental health care.
The health care giant pointed out that state regulators did not find fault with members' ability to receive urgent or emergency mental health services.
In addition, Nelson said, Kaiser has hired new providers to reduce the waiting time for appointments, and is recruiting more.
Nelson also pointed to data indicating that the majority of requests for initial therapist appointments are booked within 10 business days.
The state, however, said Kaiser made patients wait at least 14 days after an appointment before they could call to schedule another one, meaning a patient could not receive a treatment plan that was pre-scheduled for several individual appointments over a two- to three-month period.
Dr. Andris Skuja, a Kaiser psychologist, offered strong words in reaction to the news of the $4 million fine and cease-and-desist order.
"This action confirms what every Kaiser clinician knows," Skuja said. "Kaiser doesn't take mental health care for its patients seriously."
Kaiser has 7 million members in California.

For enrollees who have had problems accessing care, department spokesman Rodger Butler suggested they call the department's help line at (888) 466-2219.
Call The Bee's Cynthia H. Craft, (916) 321-1270. Read her Healthy Choices blog, Follow her on Twitter @cynthiahcraft.

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Regional Variation in Medicare Spending and Risk Adjustment

Written By: Jason Shafrin - Jun• 23•13
What is the key driver of regional variation in Medicare spending? According to a paper by Reschovsky Hadley, and Romano (2013), the answer is regional variation in patient health.
Two key casemix adjustment methods—controlling for patient conditions obtained from diagnoses on claims and expenditures of those at the end of life—were evaluated. We failed to find evidence of bias in the former approach attributable to area differences in physician diagnostic patterns, as others have found, and found that the assumption underpinning the latter approach—that persons close to death are equally sick across areas—cannot be supported. Diagnosis-based approaches are more appropriate when current rather than prior year diagnoses are used. Population health likely explains more than 75% to 85% of cost variations across fixed sets of areas.
The leaders of the Dartmouth Atlas series of papers disagrees. They believe that patients in areas that practice more intensive medicine will receive more medical care, which leads to more claims and thus more diagnosis codes to be used in their risk adjustment model. They write
In this case, the authors’ use of the HCC billing codes would falsely “explain” the more aggressive cardiologist’s behavior as the consequence of poor health status, rather than attributing it correctly to intensive physician behavior.
Their response also cites an IOM study that says:
Although a non-trivial amount of geographic variation can be explained by specific demographic and, potentially, health status variables, a substantial amount of variation remains unexplained.



Useful Data Files for Simulation Modelling

Written By: Jason Shafrin - Jun• 26•13
In recent years, researchers have created a number of complex simulation models to estimate future trends and the impacts of policy changes.  Some of the more prominant models include:
  • RAND Comprehensive Assessment of Reform Efforts (COMPARE)
  • CBO’s Health Insurance Simulation Model (HISim)
  • Urban Institute’s Health Insurance Reform Simulation Model (HIRSM),
  • Future Elderly Model (FEM)
These models use a variety of data sources.  For instance:
…the RAND COMPARE microsimulation model uses the Survey of Income and Program Participation (SIPP) as the principal base dataset. Data from the Medical Expenditure Panel Survey (MEPS) regarding health care utilization and medical expenditures are statistically matched to SIPP respondents based on age, insurance status, health status region, and income, and individuals are assigned to synthetic firms with particular characteristics and health benefit offerings using data from the Kaiser/HRET survey and based on region, firm size, and industry…Additional data regarding expected birth and death rates and rates of immigration may be used to project the population forward over time.
What data sources are available to model changes in the supply of providers? An article by Gresenz, Auerbach, and Duarte (2013) provide an overview answering just this question.

Type I Data: Supply of Providers

Unit-level data on the current supply of providers, including characteristics of the providers.  The characteristics can describe the providers themselves (e.g., primary care vs. specialists, for-profit vs. non-profit hospitals) and also describe the patient populations they treat (e.g., share of Medicaid patients)
Key data files for estimating current provider supply include:
  • American Medical Association’s (AMA) Masterfile. All allopathic and most osteopathic medical students in the United States are entered into the Masterfile’s records and are contacted every several years throughout their lifetimes.  Core elements include information about the physician’s age, location, contact information, detailed specialty, some practice and employer characteristics, and major function (e.g., patient care, research, education, administration).  However, variables such as hours worked, income, detailed practice setting, characteristics of patients seen, or time spent in various activities are not collected.  Summary information from the AMA Masterfile are available HRSA’s in the Area Resource File (ARF).
  • State Licensing data from state regulatory agencies. These data vary substantially across states in breadth and quality and there is little or no coordination across to standardize data elements or to aggregate data across states (although the Health Resources Services Administration—HRSA—is undertaking efforts toward such standardization)
  • Current Population Survey (CPS). The CPS contains more labor supply-relevant data than the AMA Masterfile, such as hours worked, family characteristics, and industry. Physicians are identified in survey if they report their primary occupation as a physician (or, if out of the labor force, they would remain in the sample if they identified physician as their predominant occupation over the past 5 years). However, the sample size is relatively small (on the order of 1,000 physicians per year are obtained) and information by physician specialty is not available.
  • American Community Survey (ACS). This survey is a large nationally representative survey, that replaces the long-form Census.  The survey has been collecting information on roughly 10,000 physicians per year since that time. Geographic location is available at the MSA level.
  • Community Tracking Study administered by the Center for Studying Health System Change, includes a physician survey which has been administered every 4 years since 1996 (although it may not be continued in the future).  The CTS physician sample was clustered within 60 metropolitan areas in the United States, but the 2008 sampling frame was changed to obtain a representative sample of physicians across the United States. Physicians are asked detailed questions about their practice size, type and organization, the financial incentives they face, the payer mix of the patients they see, and the percentage of their (or their organization’s) revenues derived from different payers. The physician component of the CTS is also known as the Health Tracking Physician Survey (HTPS).
  • National Ambulatory Medical Care Survey (NAMCS).  These data contain practice and organizational details for office-based physicians, but excludes anesthesiologists, radiologists, and pathologists. The sample goes back to 1973.  Although the NAMCS has county-level information, these data are restricted use.
  • Other sources.  IMS Health, SK&A, and the Medical Group Management Association (MGMA) assemble provider data primarily for marketing purposes.

Type 2 Data: Estimating future demand

Typically, these models assume that provider supply will respond to demand for medical services.  One can project demand for medical services using demographic projects.  These data may include age-adjusted death rates, birth rates, and immigration rates on the demand side.  One can use these statistics to to create a synthetic population for some future date in time.

  • American Association of Medical Colleges collects information school applicants, enrollments, and graduates
  • National Residency Matching Program publishes counts of physician residents by year and residency type (also in the September issue of JAMA).

Type 3 Data: Behavioral Parameters

Type 3 data includes not only primary data sources that can be used to estimate behavioral parameters but also secondary data sources that include published estimates of relevant parameters. The specific behavioral parameters selected depend on the impacts the model is trying to estimate.


Global Survey Finds One in Five Feel Discriminated Against Because of Their Diabetes


Jun 26, 2013
This press release is an announcement submitted by , and was not written by Diabetes Health.
Novo Nordisk funded the study
CHICAGO, June 24, 2013 /PRNewswire/ -- Key results from the global Diabetes Attitudes, Wishes and Needs 2 study (DAWN2TM) show that one in five people with diabetes feel discriminated against because of their condition, and support from the broader community is scarce. Results from the DAWN2 study were presented at the 73rd Scientific Sessions of the American Diabetes Association (ADA). DAWN2 represents opinions from more than 15,000 people living, or caring for people, with diabetes in 17 countries across four continents.
Family members and health care professionals surveyed as part of DAWN2 report similar beliefs. According to the study, one in five family members also believes that their loved ones with diabetes face discrimination. Among the diabetes health care professionals participating in the survey, one out of three were concerned about discrimination and said there was a "major need" for improvement in the acceptance of people with diabetes as equal members in society. Furthermore, the DAWN2 study revealed that the experience of being discriminated against due to diabetes is associated with emotional distress.
"Evidence suggests that even with the best modern therapies and care, the experience of discrimination can influence self-management, quality of life as well as clinical outcomes for people with chronic illnesses. The DAWN2 study results highlight surprisingly high rates of perceived experienced discrimination and allow for an in-depth understanding now of the nature of this discrimination and the consequences it has for health and quality of life," said Professor Mark Peyrot, Principal Investigator and Chair of the International Publication Planning Committee (IPPC) overseeing DAWN2.
The DAWN2 study also found major variations between countries in perceived discrimination, ranging from 11-28 percent for people with diabetes1 and 10-40 percent for family members, suggesting that there are viable pathways for improvement and that countries can look to others for models to follow.
"Through DAWN2, people with diabetes and their families have been given a voice. In this day and age, no one should face discrimination because of diabetes and people with diabetes have the right to live full, active lives and have an equal role in society. We will use the results of DAWN2 to educate decision-makers to make changes that are desperately needed to improve the quality of life for people with diabetes," said Sir Michael Hirst, president of the International Diabetes Federation (IDF).
Additional DAWN2 study results released during ADA highlighted significant inadequacies across countries in relation to empowerment and education of people with diabetes, psychosocial support and quality diabetes care.2
Key results presented were (data were adjusted according to age and gender to reflect the general diabetes population in each country):
• People with diabetes had significant emotional distress related to their diabetes (mean 44.6 percent, ranging from 22 percent in the United States and 21 percent in the Netherlands to 65 percent in Algeria)
• 13.8 percent of people with diabetes had severely impaired emotional well-being and were at risk of depression (ranging from 8 percent in Mexico to 16.6 percent in the United States and 20 percent in Algeria)
• Over one-third (35.3 percent) of family members reported a significant burden on the family related to diabetes (ranging from 12-60 percent)
• 48.8 percent people with diabetes had attended diabetes education (ranging from 23 percent in India to 74 percent in the United States and 83 percent in Canada)
• 23.1 percent of family members had attended diabetes education (ranging from 12percent in The Russian Federation to 31 percent in the United States and 40 percent in Denmark)3
Three scientific articles were released on June 23, 2013, focusing on country variations in psychosocial indicators of diabetes care as assessed by people with diabetes, family members and health care professionals.
DAWN2 is a global Novo Nordisk initiative conducted in collaboration with the IDF, the International Alliance of Patient Organizations (IAPO), the Steno Diabetes Center, and a range of other national, regional and global partners. The DAWN2TM results will be used internationally and nationally to facilitate dialogue among patient organizations, health care professionals and other key stakeholders to develop action plans for improvement of the lives of people with diabetes. Further information available at

Medicare and Medicaid Programs: Requirements for Long Term Care Facilities; Hospice Services


Final rule.


This final rule will revise the requirements that an institution will have to meet in order to qualify to participate as a skilled nursing facility (SNF) in the Medicare program, or as a nursing facility (NF) in the Medicaid program. These requirements will ensure that long-term care (LTC) facilities (that is, SNFs and NFs) that choose to arrange for the provision of hospice care through an agreement with one or more Medicare-certified hospice providers will have in place a written agreement with the hospice that specifies the roles and responsibilities of each entity. This final rule reflects the Centers for Medicare and Medicaid Services' (CMS') commitment to the principles of the President's Executive Order 13563, released on January 18, 2011, titled “Improving Regulation and Regulatory Review.” It will improve quality and consistency of care between hospices and LTC facilities in the provision of hospice care to LTC residents.


These regulations are effective on August 26, 2013.

For Further Information Contact

Lisa Parker, (410) 786-4665.!documentDetail;D=CMS_FRDOC_0001-1236

Austin Doctor Charged in Alleged $2M Billing Fraud

HOUSTON (AP) A Texas neurologist and his clinic administrator have been charged with conspiring to defraud Medicare of more than $2 million.
Prosecutors in Houston say the case involves 40-year-old Dr. Dennis Barson Jr. of Austin and 53-year-old Dario Juarez of Beeville. Both are accused of fraudulent bill and filing false claims for procedures not done.
The indictment returned June 19 includes 19 health care fraud counts and one conspiracy charge. Details were announced Tuesday when the indictment was unsealed and Barson was arrested. Investigators say Juarez was already in custody serving time for practicing medicine without a license.
Prosecutors say Barson was the only practicing doctor at a clinic in Houston but Juarez allegedly was the medical person seeing patients.
Barson didn't immediately respond to a message for comment Wednesday.

Medicare Fraud – If You Really Don’t Need it, We Really Don’t Want to Pay For It


2013-06-27 09:20:04 (GMT) ( - False Claims, Featured, Justice News Flash, Press Release)
06/25/2013 // Justice News Flash: Featured Column // Kathleen Scanlan // (press release)  Healthcare has come a long way in the last one hundred years. We look back at treatments for soldiers wounded in World War I a century ago and it seems downright crude. Anyone watching Downton Abbey cringed all through Season 2. We’ve obviously come a long way. However, in at least one way healthcare remains largely unchanged since then – the deference given to doctors in making the ultimate decision about the care and treatment of their patients. Generally speaking, this is a good thing. As healthcare consumers, we all want the doctors who care for us to be the ones to make the ultimate decision about what is in our best interests. However, some have used the deference to the doctor-client relationship as a blind behind which they engage in Medicare fraud. One way that doctors and other health care practitioners exploit the patient relationship and game the Medicare system is by performing procedures on patients that are not medically necessary. Exploiting the patients’ trust and risking their health, these fraudsters fleece Medicare and other government programs by billing them for illegitimate costs.
The good news is that the U.S. Department of Justice, the Department of Health and Human Services, and the FBI—often with the crucial assistance of whistleblowers —are cracking down on the unnecessary procedure racket.
A prime example is the case of Dr. Steven J. Wasserman, a dermatologist in Venice, Florida. Wasserman agreed to pay $26.1 million to settle allegations that, among other misdeeds, he performed medically unnecessary skin biopsies and conducted unnecessary skin surgeries—on thousands of patients. Over and over, when it was not required, Wasserman performed a complex and time-consuming procedure on patients called adjacent tissue transfer. The dermatologist targeted Medicare beneficiaries so that he could be reimbursed by the government. Wasserman’s settlement is the largest ever against an individual practitioner under the federal False Claims Act. The lawsuit was initiated by a pathologist who worked at a lab that was paying Wasserman kickbacks for improper referrals. As contemplated by the False Claims Act, the pathologist received a percentage of the settlement, more than $4 million, for having stepped forward with the information.
In another case, in April of this year, a renowned cardiologist and CEO of a pair of medical services companies in New Jersey agreed to pay $19 million to settle allegations that he performed unnecessary procedures stemming from false diagnoses. The doctor, Jose Katz, advertised heavily to the Spanish-speaking community and drew in a lot of Medicare and Medicaid beneficiaries that he could exploit. Katz falsely diagnosed numerous patients with coronary artery disease and subjected many of them to a procedure called external counter pulsation. This procedure put many patients at risk of injury or death.
While all fraud cases are complex and difficult to prove, these unnecessary procedure cases are particularly challenging because they require the government to, in effect, override whatever the doctor (or other professional) gave as the medical reason for the procedure that occurred and for which Medicare paid. The government obviously doesn’t want to be in the business of second-guessing health professionals’ medical decisions. But, at the same time, it can’t allow a known pattern of fraud to continue unchecked behind the curtain of “doctor decision-making.” This is yet another instance where a whistleblower is invaluable. Someone with material information about an unnecessary procedure scheme can provide evidence to the government to show this is not about medical decision-making at all; it’s about systematic efforts to use patients as a means for billing Medicare.