Utilization of Medicare Ambulance Transports, 2002-2011

09-24-2013

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Summary

WHY WE DID THIS STUDY

Since 2002, Medicare Part B payments for ambulance transports have grown at a faster rate than all Medicare Part B payments. This increase in payments was caused in part by inflation and the transition to the national fee schedule for Medicare ambulance transports. Continued growth in the utilization of transports has also contributed to the increase.

From 2002 to 2011, the number of Medicare ambulance transports increased 69 percent (from 8.7 million to 14.8 million). In 2011, Medicare payments under Part B for ambulance transports totaled $5.7 billion.

HOW WE DID THIS STUDY

We reviewed Medicare Part B claims for ambulance transports from 2002 to 2011 and the Medicare Part A and B claims that were associated with these transports. We also reviewed enrollment data for all Medicare fee-for-service beneficiaries. We determined the extent to which the utilization of ambulance transports changed from 2002 to 2011. For each year, we analyzed the characteristics of beneficiaries, suppliers, and transports and calculated the percentage differences since 2002. We also calculated the changes in utilization within each State.

WHAT WE FOUND

From 2002 to 2011, the number of beneficiaries who received ambulance transports increased 34 percent, although the total number of Medicare fee for service beneficiaries increased just 7 percent. The number of ambulance suppliers increased 26 percent. In particular, the number of ambulance suppliers that primarily provided basic life support nonemergency transports nearly doubled from 2002 to 2011. The number of dialysis related transports increased 269 percent. Furthermore, beneficiaries with end stage renal disease, a condition that often requires dialysis treatment, used a growing and disproportionate amount of transports each year. Transports to and from hospitals increased at a significantly slower rate from 2002 to 2011 than did dialysis related transports, but represented a larger proportion of all transports. Although all States experienced increases in transports from 2002 to 2011, utilization changes varied widely by State.

This report does not contain recommendations.

http://oig.hhs.gov/oei/reports/oei-09-12-00350.asp

Medical Clinic Owners and Patient Recruiters Charged in Miami for Role in $8 Million Health Care Fraud Scheme

Department of Justice

Office of Public Affairs

FOR IMMEDIATE RELEASE

Thursday, September 26, 2013

Medical Clinic Owners and Patient Recruiters Charged in Miami for Role in $8 Million Health Care Fraud Scheme

Several patient recruiters, including two medical clinic owners, have been arrested in connection with a health care fraud scheme involving defunct home health care company Flores Home Health Care Inc. (Flores Home Health).
Acting Assistant Attorney General Mythili Raman of the Justice Department’s Criminal Division; U.S. Attorney Wifredo A. Ferrer of the Southern District of Florida; Special Agent in Charge Michael B. Steinbach of the FBI’s Miami Field Office; and Special Agent in Charge Christopher Dennis of the HHS Office of Inspector General (HHS-OIG) Office of Investigations Miami Office made the announcement.
In an indictment returned on Sept. 24, 2013, and unsealed this afternoon, Isabel Medina, 49, and Lerida Labrada, 59, were charged with conspiracy to commit health care fraud, which carries a maximum penalty of 10 years in prison upon conviction.  Together with Mayra Flores, 49, and German Martinez, 36, Medina and Labrada also face charges for allegedly conspiring to defraud the United States and to receive health care kickbacks as well as receipt of kickbacks in connection with a federal health care program, which carry a maximum penalty of five years in prison upon conviction.
According to the indictment, the defendants worked as patient recruiters for the owners and operators of Flores Home Health, a Miami home health care agency that purported to provide home health and physical therapy services to Medicare beneficiaries.  Medina and Labrada were also the owners and operators of Miami medical clinics which allegedly provided fraudulent prescriptions to the owners and operators of Flores Home Health.
Flores Home Health was allegedly operated for the purpose of billing the Medicare program for, among other services, expensive physical therapy and home health care services that were not medically necessary and/or were not provided.
From approximately October 2009 through approximately June 2012, Flores Home Health was paid approximately $8 million by Medicare for allegedly fraudulent claims for home health services.

Diagnostic Laboratories Settles for $17.5 Million After Healthcare Whistleblowers’ Allegations of Medicare Fraud

The Department of Justice announced yesterday that Diagnostic Laboratories and Radiology, the West Coast’s largest supplier of laboratory and X-ray services to nursing homes, will pay $17.5 million to settle whistleblower allegations that the California-based company violated the False Claims Act by giving kickbacks for referral of mobile lab and radiology services, which were subsequently billed to Medicare and Medi-Cal (California’s Medicaid program).  Diagnostic Labs allegedly took advantage of Medicare’s and Medi-Cal’s reimbursement systems by billing them at standard rates while secretly giving discounted fees to the participating nursing homes. According to the lawsuit, those fees were as much as 80 percent below the lab’s normal rates.
For inpatients, Medicare pays a fixed rate based on the patient’s diagnosis, regardless of specific services provided.  For outpatients, Medicare pays for each service separately.  Diagnostic Labs’ scheme supposedly enabled the nursing homes to maximize their profits for providing inpatient services by decreasing the cost of them.  It also allegedly allowed Diagnostic Labs to obtain a steady stream of lucrative, outpatient referrals that it could directly bill to Medicare and Medi-Cal.  This provision of inducements, including giving discounted rates to generate referrals, is prohibited by both federal and state law. By law, the discounts should have been passed along to the government programs.
The Medicare whistleblowers in this case were two former Diagnostic Lab employees, Jon Pasqua and Jeff Hauser, who said they were fired after reporting the secret discounts and kickbacks to the authorities. Hauser and Pasqua worked in the company’s sales office and said they tried to report the questionable discount practices to supervisors first, but were ignored. They then provided information to state and federal officials, and were subsequently fired from their jobs shortly before filing the healthcare fraud case in February 2010, according to their lawyers.
This settlement will resolve Hauser and Pasqua’s lawsuit, which was filed under the qui tam, or whistleblower, provisions of the federal and state False Claims Act. This act allows private citizens with knowledge of fraud to bring qui tam lawsuits on behalf of the US government. The individual filing the lawsuit is known as the relator, or whistleblower.  Healthcare whistleblowers, such as Hauser and Pasqua, serve an important role in exposing and eliminating healthcare fraud.
While it is true that whistleblowers take on a personal risk in these cases, it is still worthwhile for them to come forward with their information. Because qui tam whistleblowers help to eliminate government fraud, they receive a significant proportion of the lawsuit’s settlement for their efforts.
Together, Pasqua and Hauser will receive a total $3,755,500 as their share of the federal government’s recovery.

http://www.natlawreview.com/article/diagnostic-laboratories-settles-175-million-after-healthcare-whistleblowers-allegati

'Real Answers' Panel Stresses Importance of Family Physicians in Health Care Transformation

September 27, 2013 03:52 pm Matt Brown San Diego – Family physicians are helping transform an uncooperative health care system into a patient-centered care delivery model that really works. But helping is not enough. It's time to start leading. That was the message delivered Sept 26 during the "Panel Session: Real Answers" at the AAFP Scientific Assembly here.

Panelists John Bender, M.D.; Marci Nielsen, Ph.D., M.P.H.; and Sam Nussbaum, M.D., offer "real answers" to some of the major issues facing family medicine during a panel discussion at the AAFP Scientific Assembly.

Panelists John Bender, M.D., senior partner and CEO at Miramont Family Medicine in Fort Collins, Colo.; Marci Nielsen, Ph.D., M.P.H, CEO of the Patient Centered Primary Care Collaborative (PCPCC) in Washington; and Samuel Nussbaum, M.D., EVP and clinical health policy and chief medical officer for insurer WellPoint Inc., told a standing-room-only crowd of family physicians that they are a central cog in the transformation process. The panel took questions electronically from AAFP members during the discussion.

"We haven't yet made the patient the real center of the medical home because, all too often, we stop at patient," said Nielsen. "We need to elevate the role of consumer in this process, because (consumers) are not yet demanding this model of care. If you want the (insurers) and Congress to pay for this model and reimburse primary care, you've got to start with patients and explain to them why it is so important."

AAFP LEADERS CONTINUE PANEL DISCUSSION

During the "Panel Session: Real Answers" at the AAFP Scientific Assembly in San Diego, panelists took questions from the audience that were submitted electronically. The volume of questions meant that some questions did not get answered.

However, the AAFP captured the questions the panelists didn't have time to answer, and the Academy's officers have agreed to respond to these questions via the AAFP Leader Voices blog. You also can sign up to receive e-mail notification when the Leader Voices blog is updated.

That is critical, Nielsen said, because, although groups like the AAFP and PCPCC are working hard in Washington and elsewhere to push for reform, insurers are only going to make real changes when employees begin demanding that employers pay for the patient centered medical home (PCMH) model.

"All of this can happen based on your leadership, but that means you can't just talk about this in your offices, you have to go out into your communities and talk about it, as well," said Nielsen. Primary care physicians "have got to keep leading and stepping outside of their comfort zone on this issue, because if not, we won't continue to be the 'it girl' of public policy that we are now."

Good evidence is another part of the payment equation, said Nussbaum. "We are developing different payment models for different (regional) settings, all based on performance and quality-of-care criteria," he said. "Family practice physicians can expect to see a 40 to 50 percent increase in total revenue based on value provided instead of patient volume."

Bender said he has found this to be true in his own practice, which is recognized as a PCMH by the National Committee on Quality Assurance (NCQA). "After we attained NCQA (recognition) for our PCMH transformation, we saw serious changes in quality," he said. "Hospitalization rates for our patients declined by 83 percent compared to our peers, while emergency room utilization by our patients was -218 percent compared to other practices in our area."

Bender said it is all a good story, but he cautioned that recognition or certification is not an end in itself.

"NCQA (recognition) is like a high school diploma -- you've accessed something, but it is not your career," he said. "Now you're licensed to go out and do it."

http://www.aafp.org/news-now/2013-cod-assembly/20130927answerspanel.html

2014 Family Physician of Year Is Small-town Doc With Statewide Impact

 September 27, 2013 03:28 pm Jessica Pupillo – A little more than a month ago, Keith Davis, M.D., returned to Albany, Ore., for his 40th high school reunion. While he was in the area, he visited his mother, who reminded him of one of the many reasons he has championed patient access to care in the Idaho community that he now calls home.

His mother had found an image in a Shriners Hospital fundraising booklet of Davis as a small child. The black-and-white image shows 2-year-old Davis sitting in a hospital crib with casts on his legs and two physicians in attendance.

"I was born with bilateral club feet," Davis recalled. "We went to Shriners Hospital in Portland, Ore., and I had surgery when I was 2 and when I was 5.

"I was really a beneficiary of a program set up to allow access to care way back in the '50s," he said. Without the life-changing surgery, Davis added, his life may have been much different. "There are people out there who can benefit so much from really basic medical services that are available, but not available to them."

Improving access to primary care services has been Davis' vocation throughout his 28-year career in family medicine in Shoshone, Idaho. Because of his work, he has been named the AAFP's 2014 Family Physician of the Year. The award honors one outstanding American family physician who provides patients with compassionate and comprehensive care and who serves as a role model -- both professionally and personally -- in his or her community, to other health professionals, and to residents and medical students.

STORY HIGHLIGHTS

• AAFP 2014 Family Physician of the Year Keith Davis, M.D., has focused on improving patients' access to care throughout his 28-year family medicine career in rural Idaho.
• Davis juggles his time seeing patients at the Shoshone Family Medicine Center with serving as a hospice medical director, an ER physician at a local hospital and a mentor to medical students, among other responsibilities.
• He also serves on the steering committee of the Idaho Statewide Healthcare Innovation Plan, a CMS-funded initiative that aims to design and develop an integrated and efficient health care system in the state.

Putting Patients First

As the sole physician in Lincoln County, Idaho -- an area about the size of Rhode Island with a population of more than 5,000 -- it's hard to find a health care program in the community that Davis has not had an impact on. In addition to running Shoshone Family Medical Center, Davis is the medical director of a local hospice, the county coroner, an ER physician at St. Luke's Jerome Medical Center, and the emergency medical services director for Lincoln and nearby Jerome counties.

On top of all that, Davis routinely makes house calls, nursing home calls and assisted-living calls. He recently delivered a baby who marks the fifth generation of patients Davis has cared for from the same family. It all comes with the territory when you practice rural medicine, he said.

"When you know the parents, grandparents, even great-great-grandparents, it helps you know the setting the patient is in," said Davis. And his patients hail his attentiveness and their ready access to him or to one of his physician assistants or nurses.

"At our appointments, he has never hurried us and always has taken the time to visit with us after the medical treatment or examination was through," said Dorrell Hansen in his letter supporting Davis' nomination as AAFP Family Physician of the Year. Hansen has been a patient of Davis' since 1985. "His friendliness seems to rub off on his staff. He is and has been a definite asset to the community, and we thank him for his service," Hansen added.

To help meet the needs of the community, Davis has brought additional patient-centered medical services into Lincoln County. For example, he hired two licensed clinical social workers to provide mental health services to county residents. "This has been a huge help because there was little to no counseling available in the county previously," Davis said. He has also expanded his practice to offer patients an American Diabetes Association-recognized diabetes education program.

2014 AAFP Family Physician of the Year Keith Davis, M.D.

Staying True to His Roots

Davis is devoted to encouraging the next generation of family physicians to consider practicing in rural underserved communities. As a clinical instructor for the University of Washington School of Medicine in Seattle, Davis mentors medical students during a four-week immersion program in rural family medicine called the Rural/Underserved Opportunities Program.

"I know that students usually study medicine in urban areas. Unless they grew up in a rural area like I did, they may believe they will have to live and practice in urban areas, too," said Davis.

But that's not necessarily the case, he added. "One of the great qualities of family medicine is the need for our services in all parts of the country. Idaho ranks low in physicians per capita but also high in average age of practicing physicians. It is important to Idaho and many other parts of the country to show students that rural practice can be personally rewarding and financially sustainable."

Another way Davis is working to foster a healthier Idaho is by serving on the steering committee of the Idaho Statewide Healthcare Innovation Plan, a CMS-funded initiative that aims to design and develop an integrated and efficient health care system in the state. Davis hopes this initiative ultimately will improve health care delivery by strengthening primary care and enhancing access to affordable, quality care.

And, next year, Davis will take on a new challenge. He was named president-elect of the Idaho Medical Association during the association's annual meeting in July, and will ascend to the presidency in July 2014. The position provides one more opportunity for Davis to advocate the issues he is passionate about, including ensuring access to care and providing the state's residents with patient-centered medical homes.

http://www.aafp.org/news-now/2013-cod-assembly/20130927fpoy.html