December 29, 2011
The Nirvana Fallacy Among Health Care Cost Cutters
One of my fun little Christmas presents was the Gruber/Newquist/Schreiber comic book guide Health Care Reform: What It Is, Why It's Necessary, How It Works. It's wonderfully illustrated and has a lot of good information. It offers a very hopeful vision of what health reform can do. It patiently explains the politics and policy that led to the ACA, portraying it as a compromise that both "left and right" should be able to support.
Unfortunately, the authors have chosen to portray virtually anyone who opposes the ACA, on both left and right, as either angry, exasperated, selfish, or unreasonable. (This animated penguin reminds me of several of the characters in the book.) There are also some questionable implications in various parts of the book. For example, on p. 21, it's suggested that if employers didn't have to pay so much for health care, they'd just pay that in higher wages to employees. But in an economy where corporate profits are capturing "88% of the growth in real national income while aggregate wages and salaries accounted for only slightly more than 1% of the growth in real national income," why should we assume that will happen? Workers' share of national income is declining; they have little bargaining power. We can't extrapolate the economic projections of the "Great Moderation" era to today's Great Recession, where employers are exploiting the desperation caused by high unemployment to hold the line on wages and benefits.
One other objection: check out this graphic (my apologies for the poor camera-work), which suggests the deep problem in the US economy is that we're spending too little on military or homeland security expenditures, and too much on health care:
Again, I'm not saying our health care system is perfect, or that waste can't be eliminated. All I'm asking is: isn't it a bit tone deaf to portray an economy that has poured trillions into foreign engagements, homeland security, and mass incarceration over the past decade as stinting on military and police forces? Gruber is described on the book's back cover as "possibly [the Democratic] Party's most influential health-care expert." If you want to understand why President Obama has done so little to seriously reduce Defense and Homeland Security expenditures, while investing so much effort into "bending the health care cost curve," take a look at this book. This graphic is perhaps as good a symbol as any of what DC's bipartisan technocratic elite thinks has gone wrong with the US over the past half-century.
December 28, 2011
Mental Health Providers Target of Fraud and Other Complaints
By Thomas L. Hafemeister, J.D., Ph.D., Assoc. Prof., University of Virginia School of Law
A recent study published in the New England Journal of Medicine (here) examined the likelihood of being sued for malpractice by medical specialty. The study, which examined nationwide malpractice data from 1991 through 2005 for physicians covered by a large professional liability insurer, found that out of twenty-five specialties, psychiatrists were the least likely of all physicians to get sued.
However, these and other mental health providers may face legal entanglements on other fronts, such as claims for fraudulent billing of Medicare and Medicaid. While the number of these suits has dramatically increased in general in recent years (here), this increase may be particularly pronounced with regard to mental health professionals. In addition, these or other federal complaints may be accompanied by criminal prosecutions of the officials involved or a loss of certification for facilities. The following are recent related accountings focusing on mental health care.
Terri Langford, $90 Million Medicare Fraud Alleged: Clinic Owners Accused of Trying to Bill for Nonexistent Treatments, Hous. Chron., Dec. 15, 2011, at A1, 3 (here):
The owners of a Houston mental health program were arrested [December 14], charged with trying to bilk Medicare out of $90 million for treatments that amounted to little more than patients “watching movies, playing bingo or engaging in other activities,” federal authorities contend.
Mansour Sanjar, 78, and Cyrus Sajadi, 64, both physician owners of Spectrum Care in West Houston were charged in the alleged phony treatment scheme, which involved kickbacks to the owner of an assisted living facility in exchange for finding and funneling patients to the clinic.
Chandra Nunn, 33, the owner of the home, also was arrested Wednesday. All three are charged with conspiracy to commit health care fraud and conspiracy to pay and receive illegal health care kickbacks. Since 2006, Sanjar and Sajadi had been submitting bills to Medicare for supposed treatment at their “partial hospitalization program,” known as a PHP.
The arrests come just two months after a Houston Chronicle investigation uncovered hundreds of millions in Medicare dollars spent to shepherd mentally fragile Texans by ambulance to mental health clinics and PHPs where patients claimed they watched TV and ate junk food.
According to the indictment, the Spectrum Care owners submitted $90.4 million in claims starting in 2006 even though the PHP services "were not medically necessary, and in some cases, never provided."
Nunn's role was that of a patient broker, or what clinics call, a “marketer.” Sanjar is accused of paying Nunn with a $10,000 check in September 2010 to refer patients their way.
The indictment accused all three defendants of paying Medicare beneficiaries cash and cigarettes if they came to Spectrum.
Tom Brown, Miami Health Executive Gets Stiff Sentence for Fraud, Reuters, Dec. 9, 2011 (here):
A former Miami health care executive was sentenced to 35 years in prison for her role in a $205 million healthcare fraud scheme, authorities said on [December 9].
Judith Negron, the owner of American Therapeutic Corp, a chain of mental health care centers shut down after a raid on its Miami headquarters in October 2010, was convicted in August on charges that she helped mastermind what prosecutors described in court documents as “one of the largest and most brazen healthcare fraud conspiracies” in U.S. history.
Her sentencing in federal court on Thursday by U.S. District Judge James Lawrence King followed the sentencing in September of her co-defendants and co-owners. Lawrence Duran received a 50-year sentence and Marianella Valera received a 35-year sentence.
The prison sentences have been described by prosecutors as the harshest ever for defrauding Medicare, the federal insurance plan for the elderly and disabled.
Prosecutors said American Therapeutic, operating out of the southeastern city widely viewed by law enforcement officials as a central point for healthcare fraud in the United States, billed Medicare for more than $205 million in claims over eight years for mental health services that were either unnecessary or never provided to patients.
In addition to their time behind bars, Negron, Valera and Duran were ordered “jointly” or with other co-defendants to repay more than $87 million in restitution, covering the amount of fraudulent bills that Medicare actually paid out to American Therapeutic over eight years.
Todd Ackerman, Psychiatric Hospital Loses Medicaid/Medicare Contract, Hous. Chron., Dec. 15, 2011 (here):
[A] major inpatient psychiatric hospital[ in Houston, Texas,] has lost its Medicaid/Medicare certification in the wake of inspections that found “an immediate and serious threat to patient health and safety.”
The Centers for Medicare and Medicaid Services [CMS] has notified IntraCare Medical Center, a 148-bed acute-crisis care facility, that it is terminating its contract Dec. 23 because of the threat. The potential closing of the hospital represents a huge blow to the area’s overburdened mental health-care system.
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The IntraCare deficiencies, not corrected over a series of CMS inspections from July to November, mostly involved the improper use of restraints and seclusion, used to secure the safety of patients or staff. They also included a suicide attempt that was not investigated.
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CMS summaries of three inspections at IntraCare Medical Center make frequent references to patients being secluded or restrained, physically and chemically, without doctor's orders. The two practices have become an increasing focus of debate in the psychiatric community.
Jeffrey Anderson, D.C. Clinic Accused of Fraud in Reimbursement Bid: Corners Were Cut, Fired Staffer Says, Wash. Times, Dec. 13, 2011 (here):
A mental health clinic in Southeast Washington stands accused of defrauding Medicaid and the D.C. Department of Health Care Finance (DHCF) by counseling patients without first doing proper diagnostic examinations, cutting corners when it conducts the exams and manipulating requests for reimbursement . . . .
Family Preservation Services (FPS) . . . has pressured employees to engage in such practices to recoup $500,000 in mental health service reimbursements that otherwise would have been denied, according to a former billing specialist, Patrice Lancaster, who recently was fired.
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. . . [T]he written complaint filed by Ms. Lancaster, . . . contains seven additional complaints, including failure to conduct 90-day follow-up visits with mental health patients and continuation of services billed to Medicaid where patients no longer needed services, but [a spokeswoman for the D.C. Department of Mental Health] said they could not be substantiated.