Weiner Wants City to Test Single-Payer Health Care

Ozier Muhammad/The New York Times

Anthony D. Weiner, a Democratic candidate for mayor, presented a plan on Thursday for insuring city workers, retirees and some immigrants.

By NINA BERNSTEIN

Published: June 20, 2013

Vowing to “make New York City the single-payer laboratory in the country” if he is elected mayor, Anthony D. Weiner on Thursday presented an ambitious plan to create a Medicare-like system for the coverage of municipal workers, retirees and uninsured immigrant residents left out of the Affordable Care Act.

Mr. Weiner, a Democrat who championed a Medicare-for-all style of health care as a congressman, said his plan could curb the rise of $15.5 billion in city spending on health care and save money for raises for teachers and other workers, mainly by using the city’s muscle to reduce the profits or the role of private insurance companies.

In return, he proposed that 300,000 city workers and 300,000 retirees who now pay nothing toward their insurance premiums should pay 10 percent — 25 percent if they smoke. An estimated 500,000 undocumented immigrants would also be expected to buy in to the city’s insurance coverage, he said, describing it as a more cost-effective way to care for those whose treatment in emergency rooms and city hospitals already falls to taxpayers.

“This isn’t about who manages health care; this is about who manages the money in health care,” Mr. Weiner said, flicking through slides showing that city spending on workers’ health benefits was projected to rise by 40 percent from 2014 to 2017 under the current arrangement. Under an entrenched system partly codified in law, he said, a single private insurance company, Emblem, handles 95 percent of the coverage for the city’s workers, and a state board approves annual raises in the rates it charges.

Of insurance companies, he said, “Their job is to take in as much money as they can and pay out as little as they can.” The complexity and delays of private insurance processing are no accident, he added: “They make money on the float.”

Depending on the recommendations of a government task force he would create under a deputy mayor of health care innovation, he said, city coverage might still be placed in the hands of a different insurance company under a more competitive scheme, or the city might outsource just the administration to an insurer, as Medicare does while keeping overhead as low as 1.3 percent. A third option he listed would be for the city “to take the whole thing in-house.”

He said he would reorganize government agencies to seize opportunities presented by the Affordable Care Act, and have his health care innovation task force consider insurance terms that “keep more of the money in the city,” like allowing prescriptions to be filled at local pharmacies rather than only by mail order, or using the city’s development and investment capability to increase primary care at a hospital facing closure.

“This is not just a conversation you can have around cost,” he said, citing the nation’s experience in the 1990s with an H.M.O. model that no one liked, and calling the quality of health care in New York “a crown jewel.”

The coverage devised by the task force, which he called Thrive (standing for Taskforce for Healthcare Reform, Innovation and Vitality for Everyone), could eventually be offered to all New Yorkers by being listed on the state insurance exchange required by the Affordable Care Act. Such an experiment could not be tried in places like Cincinnati or St. Paul, he went on, but “New York is the health care capital of the world,” with more than 560,000 health care workers, including tens of thousands of doctors and nurses in the city’s own employ.

A single-payer model has been a hard sell nationally because of concern that it would reduce individual choice and increase government control over health care. Mr. Weiner would also have to win support from the city’s unions, which may demand raises high enough to offset any contributions they would be required to make to their premiums.

His talk, at a public lecture series sponsored by the Common Good, a nonprofit, nonpartisan organization, at a City University of New York branch on West 67th Street, stirred enthusiasm and interest. In the hour before he spoke, word of Mr. Weiner’s proposal galvanized other Democratic candidates for mayor to issue hurried news releases on health care.

Christine C. Quinn, the City Council speaker, drew attention to the BigAppleRx prescription drug discount card, established by Council legislation, which she said had saved more than 125,000 New Yorkers a total of $15,546,017 on prescription medications, or an overall savings of 47 percent, since May 2011.

Public Advocate Bill de Blasio cited health care positions from his policy book, which includes a pledge to enroll 600,000 uninsured New Yorkers in plans through the Affordable Care Act and to better protect community hospitals.

Mr. Weiner, asked how his health care plan compared with those of his rivals, said he was unfamiliar with theirs, adding with a grin, “And when I say unfamiliar, I may mean I don’t think they have any.”

A version of this article appeared in print on June 21, 2013, on page A19 of the New York edition with the headline: Weiner Wants City to Test Single-Payer Health Care.

http://www.nytimes.com/2013/06/21/nyregion/weiner-wants-city-to-test-single-payer-health-care.html?_r=0

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor - Kaiser Health News

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor - Kaiser Health News

Panel Tells Congress Medicare Is Unfairly Penalizing Hospitals Serving The Poor

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TOPICS: MEDICARE, AGING, HOSPITALS, HEALTH REFORM, HEALTH DISPARITIES

By Jordan Rau

KHN Staff Writer

JUN 14, 2013

This KHN story was produced in collaboration with 

The financial penalties that Medicare imposes on hospitals with high rates of patient readmissions are too harsh for hospitals serving the poor and should be changed, according to a congressional advisory agency.

Since last fall, Medicare has been reducing its payments to 2,213 hospitals under a provision in the health care law that aims to improve quality at the nation's hospitals. The penalties kick in when patients with heart failure, heart attack or pneumonia are readmitted at higher than expected rates within 30 days.

While the Medicare policy seems to be having an effect - facilities are scurrying to keep better tabs on their high-risk patients after discharge - some hospital officials and other experts say the penalties are unfair because hospitals that treat the poorest patients are getting hit harder than others.

"The idea is right, but the implementation has been greatly flawed by penalizing hospitals that take care of the most vulnerable patients," said Dr. Atul Grover, chief public policy officer at the Association of American Medical Colleges.

Low-income patients, doctors and researchers say, are more likely to have trouble following hospital instructions for taking care of themselves after discharge. They don't always have easy access to doctors to monitor their recuperations and sometimes can't afford needed medications.

The maximum penalties, now set at 1 percent of Medicare payments, are scheduled to double to 2 percent starting in October and 3 percent in the fall of 2014.

In the District of Columbia, Howard University Hospital, which treats the largest share of low-income patients, is being penalized the most of any area hospital; since last October, its Medicare payments have been reduced by 0.95 percent. Sibley Memorial Hospital, which treats the smallest share of poor patients, was the only District hospital to avoid a penalty, data show.

In Virginia, Mary Washington Hospital in Fredericksburg and Culpeper Regional Hospital were penalized 1 percent. Maryland hospitals are exempted from the federal program because the state has a unique reimbursement system.

Medicare has disagreed that the readmissions penalty program needs revisions. But thereport to Congress from the Medicare Payment Advisory Commission, or MedPAC, agreed with critics that there are "shortcomings" that "can work at cross purposes to the policy's intent." The criticisms carry extra weight because MedPAC helped devise the readmission penalties, calling for them back in 2008.

MedPAC found that hospitals where fewer than 3 percent of Medicare patients were low income received an average penalty of 0.21 percent. Hospitals where more than 18 percent of Medicare patients were low income had an average penalty more than twice that, 0.45 percent.

"Income is still an important … variable in explaining variation in readmissions," the commission said. It recommended that in future years, when determining penalties, Medicare compare a hospital's readmission rates to those of hospitals with comparable numbers of poor patients. Penalties can be a drain on safety net hospitals, many of which operate on slim profits or at a loss.

The Centers for Medicare & Medicaid Services did not comment on the MedPAC recommendations. In the past, officials have noted that after years of holding steady, the national hospital readmission rate last year dipped below 18 percent.

But MedPAC warned that if the penalty formula remains unchanged many hospitals will continue to get penalized in future years even if they reduce readmissions because they will be judged on how they compare to the entire industry. MedPAC proposed that Medicare set target readmission rates for hospitals each year and exempt from penalties those that succeed.

"These are all steps in the right direction," said Dr. Ashish Jha, a Harvard School of Public Health researcher who first documented the unevenness of the penalties. “MedPAC is thinking smartly about this and they're looking at the evidence coming and making changes to the metrics."

Changing the program, however, might not be easy. Medicare officials have said that many details were spelled out in the 2010 law, making them difficult to change in light of deep partisan divisions in Congress.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

http://www.kaiserhealthnews.org/Stories/2013/June/14/medpac-hospital-readmissions-poor-congress.aspx

Home Health Leaders Call for Targeted Program Integrity Reforms to Prevent Medicare Fraud

Published: May 16, 2013 

Read more here: http://www.heraldonline.com/2013/05/16/4868464/home-health-leaders-call-for-targeted.html#storylink=cpy

By Partnership for Quality Home Healthcare

WASHINGTON, MAY 16, 2013 — /PRNewswire-USNewswire/ -- On behalf of the Partnership for Quality Home Healthcare - a coalition of community - and hospital-based home healthcare agencies dedicated to developing innovative reforms to improve the program integrity, quality, and efficiency of home healthcare for our nation's seniors - Chairman Billy Tauzin (R-LA) and Senator John Breaux (D-LA) made the following statement:

"Yesterday's announcement that the Medicare Fraud Strike Force has charged nearly 100 individuals for allegedly defrauding the federal government for $223 million should prompt immediate action by lawmakers and stakeholders to advance policies that stop Medicare fraud and abuse before it takes place. 

"The government's own data show that abusive billing practices in home health occur in isolated parts of the country where excessive Medicare utilization is taking place. Nearly 90 percent of all improper payments for home health services are occurring in a small number of counties in just five states. Therefore, policymakers should undertake action to address fraud and abuse in a targeted manner.

"Recognizing the critical need to prevent taxpayer dollars from entering criminal hands, the Partnership has been working for more than a year to develop targeted reforms to combat waste, fraud and abuse.

"Reforms called for in the 'Skilled Home Health and Integrity Program Savings' proposal include beneficiary protections that prevent criminals from entering the system and payment safeguards that confirm the accuracy of filed claims to ensure validity prior to payment. Targeted measures have proven to save money, and could have potentially prevented the $51 million in fraudulent payments made to the Miami-based scheme uncovered yesterday.

"As lawmakers look for federal savings, we urge them to take a hard look at how much money is being lost to fraud and abuse and address this national dilemma before asking seniors and honest providers to pay the price.

"We commend the Medicare Fraud Strike Force for rooting out these criminals and look forward to working with lawmakers in Congress to advance reforms that address weaknesses in the Medicare program that allow fraud and abuse to threaten America's seniors, the Medicare program and the nation's taxpayers."

The Partnership for Quality Home Healthcare was established in 2010 to assist government officials in ensuring access to skilled home healthcare services for seniors and disabled Americans. Representing more than 1,500 community- and hospital-based home healthcare agencies across the United States, the Partnership is dedicated to developing innovative reforms to improve the quality, efficiency and integrity of home healthcare. To learn more, visitwww.homehealth4america.org. To join the home healthcare policy conversation, connect with us on Facebook, Twitter and our blog. 

SOURCE Partnership for Quality Home Healthcare

Read more here: http://www.heraldonline.com/2013/05/16/4868464/home-health-leaders-call-for-targeted.html#storylink=cpy

How waste is directly harmful to patients

JIM SABIN, MD | PHYSICIAN | MAY 14, 2013

Experts, most recently former CMS administrator Don Berwick, tell us that no less than 20% – 30% of medical care is waste. At the very least, waste is harmful to all those who pay for Medicare. But often it’s directly harmful to the patient as well.

I recently saw a friend at a party. Since we’d last seen each other my friend’s spouse had died. (I’m deliberately avoiding gendered pronouns and omitting other identifying details.) My friend contrasted the excellent hospice care the spouse received with problem-ridden hospital care. Here are two examples of waste that were thwarted only by my friend’s vigilance.

My friend’s spouse (“the patient”) was declining rapidly, and was admitted to the hospital. While my friend was attending to some bureaucratic aspects of the admission, the hospitalist ordered a CT and insertion of a PICC (peripherally inserted central catheter) line.

On returning to the patient’s bedside my friend pointed out that an identical CT scan had been done four days earlier.

The hospitalist responded, “I don’t have it.”

My friend replied, “Rather than putting such a sick person through another CT and spending another few thousand dollars, let’s get it.”

With regard to insertion of the catheter, my friend asked, “what aspect of the plan does it serve?”

The answer was it was an automatic part of a protocol, not tailored to the wishes of the patient and family. When their goals were clarified, the PICC line idea was dropped.

I know from my own practice experience that getting test results and records can be difficult. But repeating an identical test four days after it had been done elsewhere is a very expensive workaround that would have imposed avoidable distress on the patient. And although threading a catheter to place near the heart is a fairly routine hospital procedure, it carries risks (such as infection) and burdens (being hooked up to tubing). The hospital protocol should have required clarity about treatment goals before a non-emergency intervention was set into motion.

What struck me about these examples of overtreatment is how mundane they were. The hospitalist meant well. It was important for him to have the information the CT scan would provide, but repeating it wasn’t the right way to get it. And having routines can promote patient safety, but only when the routine is tailored to the true situation. In a non-emergency, getting clarity about the treatment goals of patient and family should be part of what we physicians routinely expect of ourselves.

My friend improved the spouse’s care and, at the same time, reduced costs. The public won’t be ready to consider reduced Medicare benefits or rationing until this kind of lose-lose waste is eliminated from the health system.

Jim Sabin is a psychiatrist and director, ethics program, Harvard Pilgrim Health Care.  He blogs at Health Care Organizational Ethics.

U.S. charges 89 people with healthcare fraud

U.S. Attorney General Eric Holder refers to his notes during testimony before the Senate Judiciary Committee on Capitol Hill in Washington, March 6, 2013.

Credit: Reuters/Jonathan Ernst

WASHINGTON | Tue May 14, 2013 4:26pm EDT

(Reuters) - U.S. Attorney General Eric Holder said on Tuesday the Department of Justice had charged 89 defendants in eight cities with healthcare fraud, and warned that budget cuts could limit future efforts to crack down on fraudulent claims.

The government's sixth national crackdown on healthcare fraud since 2010 involved $223 million in fraudulent claims in jurisdictions including Miami, Detroit, Los Angeles and Brooklyn, New York, the Justice Department said.

But Holder said efforts to expand the battle against fraud is being affected by automatic across-the-board federal budget cuts, known as sequestration, which have stripped $1.6 billion in funding from the Justice Department for the fiscal year ending September 30.

"Unless Congress adopts a balanced deficit reduction plan and stops the reductions currently slated for 2014, I fear our capacity to protect the American people from healthcare fraud ... will be further reduced," Holder said.

Since 2007, officials say the government's Medicare Fraud Strike Force has charged more than 1,500 defendants who have falsely billed the Medicare program for the elderly and disabled for $5 billion.

(Reporting By Susan Heavey and David Morgan; Editing by Sandra Maler and John Wallace)

From god to guide: can patient-centred care become a reality in the NHS?

Most parts of the NHS are only paying lip service to patient engagement, recently hailed as the 'next blockbuster drug'

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Educating patients so that they can make informed choices is vital. Photograph: Suzanne Plunkett/Reuters

As healthcare systems the world over continue to groan under the weight of rising expectations, ageing populations and squeezed finances, the search for viable long-term solutions shows no sign of slowing.

For many, the focus remains on system reform – finding new ways to make the money go further by redesigning services to be more efficient. But, increasingly, attention is turning to the people who use healthcare services as the potential saviour of them.

As Maureen Bisognano, president of the influential US-based Institute for Health Improvement, told the International Forum on Quality and Safety in Health in London in April: "Patient engagement is the next blockbuster drug."

Patient engagement is certainly not a new concept but, in truth, most parts of the NHS are still only paying lip service to it. The default position for many health professionals is still to think in terms of, "What's the matter with you?" rather than, "What matters to you?"

It's easy to see why. Most systems, our own included, are heavily geared towards the five hours a year that, on average, we each consume healthcare. However, ccording to a new report by KPMG, called Something to Teach, Something to Learn: Global perspectives on healthcare, the real gains are being made by health systems that understand the importance of the 8,760 hours a year when we are not officially classed as patients.

Technological advances, such as smartphone apps which can speed a patient's hospital discharge by allowing them to measure ECGs at home, or telemedicine systems, which deliver multidisciplinary virtual clinics, offer a partial solution to empowering patients.

But the reason these breakthroughs have not revolutionised care in the way we thought they might 10 years ago is that a more fundamental issue is being missed – that of understanding a patient's needs beyond treating the condition with which they have been diagnosed. Too often, our systems encourage the health professional to treat the illness, not the person. We chase narrow biomedical indicators, which, while important, don't capture all that matters to the patient.

There's now a great deal of evidence which shows that when patients are asked what they really want, they often choose a different (and in many cases less expensive) course of action to the one their doctor or nurse might have recommended. For example, most patients do not want to spend their last hours in hospital, yet the majority do.

Educating patients so that they can make informed choices, not just about their care but about their overall lifestyles, is vital. But it is also only half the battle. The key is listening to, and acting on, those choices – only then do patients become truly empowered.

And that's where system change comes in. The emerging evidence from around the world, as highlighted in Something to Teach, Something to Learn, is that to thrive in the challenging years ahead, healthcare systems will need to reorient themselves around the needs of patients.

Hospitals will have to look beyond their four walls, bridging the gap with primary care and transforming to become part of health systems, taking responsibility for entire pathways of care.

Primary care will need to become more accessible and more time will need to be given to understanding the needs and expectations of the 3% of patients that drive 50% of NHS costs every year.

These patients, often with multiple conditions, need continuity and access to integrated services which combine primary care, supported by specialists and the effective use of telephone and web-based tools and support. For this to work, health system funding also needs to be reshaped. There are already signs, from around the world, that payers – be they private insurers or governments – are becoming more active.

They are gaining a better understanding of what constitutes quality in the eyes of patients and designing new types of contracts that reward "value" rather than "volume".

ParkinsonNet, a ground-breaking patient-led education programme in the Netherlands, is a great example. It has shifted perceptions about what constitutes value for Parkinson's patients and, as a result, has radically changed practitioner behaviour. The programme has already halved the number of hip fractures suffered by this patient group and delivered savings of £13m.

In a system designed around the patient, clinicians need to move from god to guide, focusing their skills on the provision of information and support to help patients make effective choices and manage their own health and wellbeing.

True patient empowerment is not a bolt-on; it should be the centrepiece of the healthcare jigsaw.

This partnership is pivotal and central to an NHS which delivers both high quality healthcare and value too. Is it possible? With our greatest asset – the hundreds of thousands of front-line NHS staff who work with patients every day – yes, absolutely.

Mark Britnell is chairman of KPMG's global healthcare practice.

This article is published by Guardian Professional.

Responsible Solutions That Protect and Preserve Medicare

Posted on 05/13/2013 by Ian Cunningham  

This is a guest post by Sean Voskuhl – State Director, AARP Oklahoma

Growing up in rural Oklahoma, I saw first-hand the importance of Medicare.  Finding accessible and affordable health care was always very difficult.  Many folks had no choice but to purchase a catastrophic/high deductible plan, or they relied on a spouse to get coverage by taking a job in town, or they went without health insurance at all. Simply put, most people gambled and prayed, trying to hold on till they could get on Medicare.

Today, Medicare is the primary health insurance program for the 49 million Americans who are 65 and older.  Roughly, one in four of those beneficiaries are rural residents, and that number will only rise in coming years.  With changing demographics and rising health care costs, Medicare is facing a number of challenges.  Unfortunately, some in Washington believe the only way to address those challenges is to cut Medicare benefits or force seniors to pay more.  No doubt any such changes to Medicare will greatly impact rural America.

Is there a better way?  What about cracking down on waste, fraud and abuse?  The U.S. health system wastes as much as a third of all spending because of inefficient payment systems, uncoordinated care, duplication, over-testing and unnecessary paperwork.  It’s estimated that Medicare could save hundreds of billions of dollars just by reducing waste.  More could be saved by stepping up fraud detection.  In 2011 alone, anti-fraud efforts recovered $4.1 billion.  In October 2012, Medicare Strike Force operations in seven cities led to charges against 91 individuals-including doctors, nurses and other licensed medical professionals-for their alleged participation in Medicare fraud schemes involving some $432 million in false billing.  And yet we know much more can and should be done.

Here are some other examples of Medicare fraud that may hit closer to home: a healthcare provider bills Medicare for services you never received; a supplier bills Medicare for equipment you never got; someone uses your Medicare card to get medical care, supplies, or equipment; a company offers a Medicare drug plan that has not been approved by Medicare; or, a company uses false information to mislead you into joining a Medicare plan.

If we want to preserve and protect Medicare for future generations, it’s essential to crack down on fraud and abuse.  The resulting savings will cut costs for families, businesses and the federal government, and increase the quality of services for those who need care. But stopping fraud requires the cooperation of everyone-the federal government, state governments, health care providers, insurers, law enforcement, and even people like you and me.

To learn more about the challenges facing Medicare, and hear what you can do to help stop Medicare fraud, tune in to AARP Live on RFD-TV this Thursday, May 16^th at 9p.m. CT on RFD-TV. I’ll be joined by AARP state director Greg Marchildon (VT), AARP senior advisor Pete Jeffries, and AARP Iowa volunteer Maryalice Larson, all of whom have a first-hand view of the challenges facing Medicare. Let’s find responsible solutions that will keep Medicare strong without shifting the burden of higher health care costs onto seniors and future retirees.

Tune in to AARP Live on RFD on Thursday, May 16^th at 9 pm CST to learn more.

Please join me this Thursday night for AARP Live! on RFD-TV, or watch it streaming live at www.aarp.org/rfdand on Facebook

(click here  for “by zipcode” channel locator) Viewers are encouraged to phone in during the show, 888- 687-2277 toll-free, to share your questions/concerns.

Mission Critical: Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012

$34.1 Billion: Overpayments to MA Plans in 2012

By: Kameron Gifford, CPC 5/11/2013
www.ermconsultinginc.com

Medicare Advantage plans received $34.1 billion in overpayments in 2012, according to a study published today in the International Journal of Health Services by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled "Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.”

This number is even more alarming if we consider that there were only 3,518 private health plans providing benefits to 13 million Medicare beneficiaries in 2012. That is, on average, $100,000,000 in overpayments per plan.

Who is regulating this spending and where is it going?

It is a typical Monday morning at my office, I won’t transfer the phones for another 15 minutes, but I already know that we are in for a long day. My computer screen informs me that we have received 73 refill requests over the weekend and I have 2 “emergencies” that “really need to see the doctor”. After politely reminding, that we do not accept walk-ins, I agree to work them in and they are happy to wait.

Mrs. Jones saw her cardiologist on Friday and he changed her BP medication, but she couldn’t remember what else she was asked to stop. Our patients are taught early on to bring all of their medicine bottles with them to their appointments. After 15 years, this has become habit and before I even ask I have two plastic bags filled with various prescription bottles, creams, inhalers and vitamins piled in front of me. It takes about 3 minutes for us to retrieve the notes from her cardiologists and another 3 minutes to mark a large red “X” across three bottles. Mrs. Jones thanks me over and over again for my help and I can see the relief in her face as she proudly shows me the notes she has taken in her journal. Under her Medicare Advantage HMO, Mrs. Jones doesn’t have to pay a copay when she sees her PCP and there is no charge for our services today.

Mr. Garcia is next. He states that he doesn’t remember why he is here, but then his eyes light up, as he pulls out a crumpled up piece of paper from his back pocket. In blue pen, his daughter has written down his temperature, BP and pulse readings from 5 various times and even made notes of some symptoms her father had been complaining of over the weekend as well as a list of a current medications. I made a mental note to call Maria after lunch and thank her (HIPPA release on file gives us permission to coordinate care with his daughters and wife). No one was able to get off work to bring her dad this morning, so he had to ride the bus. By the time he got there he was so tired and anxious from the journey (not to mention early dementia) that he couldn’t remember anything except that little note in his pocket.

After seeing the doctor, orders are given for a urine to be collected. A quick look under the microscope and in less than 10 minutes the origin of the fever was discovered to be an acute UTI. A prescription for antibiotics was emailed to his pharmacy and Mr. Garcia was feeling much better in 48 hours. The cost of his care was $3.14 for the urinalysis done in the office and he took his first dose of Cipro at 9:15 AM. His total out of pocket cost came to $5.

Tragedy averted by a simple act of kindness? Perhaps, but I prefer to use the modest words of my father, “It’s Just Good Medicine!”

His primary care practice is still located within 15 miles of where he completed his residency 35 years ago. Over 50% of our patients have been with the practice for more than 20 years, and our typical patient is an 83 year old male with 3 or more chronic conditions.

In 2012, with a patient mix of 65% Medicare Advantage, 25% Medicare and 10% Commercial patients we posted real profits of over $400,000.

My father was a business man first, physician second, and true to his roots, he has spent his career working to provide quality, comprehensive, preventive care at a tremendous cost savings to both his patients and their health insurers.

The structure of his practice closely resembles the early days, one physician and 3 staff members. In some respects, we still practice “old school” medicine.

When you call our office, we still answer the phone, not a confusing recording. The majority of our patients wait less than 5 minutes to be seen and can be worked in same day if necessary. A patient’s history is not completed in the waiting room by placing checkmarks next to applicable conditions. It is taken in question and answer form face to face with the physician. We schedule appointments every 15 minutes, but new patient visits average 30 minutes. When a patient is referred for a test or to a specialist we make the appointments. This ensures that WE get the report. Every patient gets an annual comprehensive exam, if they are willing (and most are.) All diabetic patients are seen every 3 months fasting, even when they complain. Changes in medications (such as BP) are followed up on in 2-3 weeks to ensure target levels. Everyone in the office works together to ensure that all patients have a current LDL and all efforts are made to keep it under 100. Prescription medications are not refilled for 12 months at a time. We allow enough refills only until the next appointment to provide a safety net for “lost patients”. This system, although labor intensive, provides the best outcomes for our patients.

All referrals and authorizations are processed by set protocols that deliver continual oversight and monitoring of our patients between home providers, specialists, inpatient facilities, outpatient facilities and rehabs. Most importantly, we strive to educate our patients at every point along the way.

The brilliance is in the simplicity of that solution my father sought back in 1979 to guarantee his patients received the “Gold Standard” of care. It is that system that he has refined and modified over and over again, year after year, to continually do what is right for the patient.

In Managed Care terms, our practice was able to provide high quality care at an average savings of $400 per member when compared with our counterparts.

The majority of Medicare Advantage plans are operating light years behind where they need to be. Employer sponsored health plans have long been reaping the benefits of their innovative Wellness Programs designed to engage employees as partners instead of numbers.

Correct me if I wrong, but wasn’t it this expertise that the government so desperately sought to save our Medicare program. Twelve years have passed since the inception of “Part C” and what value have we added to America’s health system for seniors?

Last week, I received a call from one of my patients, who had been with our practice for about a year. During that time, her MA plan, like many others experienced many “system errors” a common side effect these days of healthcare companies trying to frantically upgrade hardware and software to comply with new regulations. Her call that morning was to tell me that she was switching doctors. It wasn’t because she had been treated badly or because she didn’t like the doctor. Her reason was simple. Her insurance company had denied our third appeal to cover a routine check-up for rheumatoid arthritis and again refused to pay the $49 cost of her visit. I couldn’t believe what I was hearing. She went on to say that when she called the number on the back of her card to ask why she was again told, it was “because her PCP didn’t obtain an authorization for services.”

The patient had a valid authorization, but it had “accidentally” gone into the wrong system. We all make mistakes, but it is what we do to correct the situation that defines our integrity.

Even after submitting all supporting documentation and following “standard procedures” the decision was final: DENIED.

Now, allow me to pose the question again, where did that add value?

Medicine is the only trade in the world in which we provide a service and then have to fight to get paid. Where is the accountability to the patient who signed up with the plan or to the tax payers who fund the system?

$31.4 Billion in Overpayments to Medicare Advantage plans and my patient can’t sleep at night because she is worried her rheumatologist (the only one in town) won’t see her next month…

As Americans, we must demand fiscal responsibility and stop allowing seniors to pay the price.

The future of our healthcare system depends on putting the patient first, and change must be initiated at the initial point of contact. Care must be integrated, and flexible enough to fit the needs of each patient. Disruptive innovation doesn’t necessarily mean a new idea or concept, but additionally represents the ability to improve the experience for our patients.

Our public health care system is in serious trouble, we must act before it is too late.

Medicare Advantage, as it is today, must be changed. We need to eliminate the opportunity for big business to profit from this system, and give the power back to the physicians and patients. I can’t help but ask, have we forgotten who pays the premiums?

We must create educational opportunities for patients, office staff and providers to empower a partnership for greater health. Solutions founded in the most basic ideas of prevention and primary care combined with patient centered technology will provide long term stability and positive outcomes. The greatest thought leaders of our time have yet to be defined, who will be the next disruptor? 

SC hospital found guilty of $39M in false claims

| May 9, 2013

COLUMBIA, S.C. (AP) — A South Carolina hospital has been found guilty of collecting millions of dollars in false Medicare claims.

After a four-week trial in Columbia, a federal jury on Wednesday found that Tuomey Healthcare System signed doctors to lucrative, part-time contracts to ensure that they would get referral fees associated with those physicians' procedures, according to a report by The Item of Sumter (http://bit.ly/10urxfq).

Paying physicians with part of the referral fees a hospital receives creates an illegal kickback under Medicare law. The contracts did not spell out the referral agreement, but prosecutors said the hospital agreed to pay those doctors well above market value.

Tuomey's lawyers argued the contracts were legal and were part of the hospital's effort to provide services to a medically underserved community.

Prosecutors said Tuomey collected $39 million in fraudulent Medicare claims between 2005 and 2009 based on those doctors' procedures, according to the government. On top of that amount, a federal judge has ordered both sides to submit petitions on any additional penalties, fees and fines.

Tuomey has several weeks to decide if it will appeal. In his closing arguments, defense lawyer Matthew Hubbellsaid a verdict against Tuomey would "annihilate" the hospital.

Tennessee Oncology Chooses Navigating Cancer's Patient Engagement Portal Leading provider of oncology patient portals to support Tennessee's largest oncology practice in delivering patient-centered care < SEATTLE, May 7, 2013 /PRNewswire/ -- Navigating Cancer, the leading provider of oncology specific patient portals, announces that Tennessee Oncology has selected Navigating Cancer's Patient Engagement Portal for its practices and patients.  Navigating Cancer's portal will enable Tennessee Oncology to provide a more coordinated and patient-centered approach to the care it delivers to patients and help the practice meet all the new patient-centered care requirements.  With nearly 800 providers signed up for Navigating Cancer's Portal, Tennessee Oncology joins an established and expanding network of influential oncology practices that are working to improve healthcare by engaging patients in their care.   Navigating Cancer's cloud-based Patient Engagement Portal integrates with any electronic medical record (EMR) system, enabling providers to easily and securely connect patients to their personal health information and educational resources.  More than 45,000 patients currently use Navigating Cancer to learn more about their condition, receive copies of their health information and stay connected with their healthcare team. Navigating Cancer helps practices meet many of the new patient-centered care requirements that are part of HITECH Meaningful Use, new medical home and accountable care organization models and updated care standards from professional organizations such as the American College of Surgeon's Commission on Cancer. "Our focus is to provide innovative, exceptional cancer care that puts patients and their families first," said Jeff Patton , M.D., CEO of Tennessee Oncology. "This partnership gives our patients easy access to their personalized treatment information and resources to help them better understand their diagnosis, allowing them to be at the center of their care and well-equipped to make important healthcare decisions." "Tennessee Oncology has a long-standing reputation for innovation and thought leadership in oncology, which translates to state-of-the-art cancer care for their patients," said Gena Cook , CEO of Navigating Cancer. "We're excited to work with Tennessee Oncology providers and patients and are looking forward to a strong partnership in the coming years as we work together to improve the quality and efficiency of care through the use of our service." About Tennessee Oncology Tennessee Oncology, PLLC is one of the nation's leading teams of cancer care specialists, nationally recognized for improving patient outcomes and innovative treatments. Its comprehensive range of cancer care services include specialized oncology nursing care, laboratory services, outpatient chemotherapy, PET/CT services and patient education and support services. Founded in 1976, Tennessee Oncology is one of the largest physician-owned practices in the country, employing more than 75 physicians in 30 locations throughout Middle Tennessee, Chattanooga, and Northwest Georgia. Visitwww.tnoncology.com for more information. About Navigating Cancer Navigating Cancer's mission is to transform healthcare through patient centered care by using technology to connect cancer patients to their healthcare team, their own health records, and the right information at the right time. Navigating Cancer's Patient Engagement Portal provides oncology clinics with a branded, online extension of their care model, empowering them to save time and money while providing better quality care. The company was founded in 2008 by technology and healthcare veterans and is based inSeattle, Washington. SOURCE Navigating Cancer RELATED LINKS http://www.navigatingcancer.com/