What we are seeing in Medicaid is the same game plan as was used with sub-prime mortgages. You target poor neighborhoods to get Federal subsidies for services not needed.....and you do it over and again.......to the under-served family's detriment. Remember, banks targeted the Federal Housing Loan of Freddie and Fannie because the banks didn't like the government competing for banking business so the banks 'imploded' the Federal Housing Loan with fraud leaving it with hundreds of billions in bad debt (these ar the massive fraudulent loans the banks must pay!) Now it wants to implode entitlements and this is how you do it. Give the Medicaid business to chain medical businesses who know there is little oversight by government for health fraud and let them steal the Medicare/Medicaid Trust to its death........and it will be the same 1% that enriched themselves on sub-prime loans who own these medical chains. Your incumbent knows this is what will happen and he/she voted for it.
VOTE YOUR INCUMBENT OUT!
So, a health industry that once was known for great jobs and great service.... when hospitals were all about non-profit care and quality service will now be owned by investment bankers, run by chain owners with little background in health hiring the cheapest labor.....often immigrants....enriching themselves on any number of medical fraud schemes. WHEN I SENT MY LETTER TO THE SECRETARY OF MARYLAND HEALTH AND HUMAN SERVICES....DR. SHARFSTEIN AND THE BALTIMORE COMMISSIONER OF HEALTH DR. BARBOT, THEY KNEW MY CONCERNS WERE REAL......IF THEY DO NOT PROTECT THE PUBLIC'S MONEY FROM FRAUD.......THEY WILL BE COMPLICIT.
This will not end with Medicaid alone......it will be Medicare as well. Your politicians have come up with the Bronze, Silver, Gold, and Platinum level of health coverage according to cost......where will you and your children fall? Meanwhile, with national health care, all patients just appear at the doctor's office or hospital for almost no cost in other countries. The people hurt will not only be those unable to get health care.....below you see what the future holds for those workers tracked into health care vocational schools or brought to the country as foreign workers.
I remember standing in line in mid-2000s, whether for a movie or Chipotle's, and I would hear beside me people speaking about getting a realtor's license.....everybody needed to get into the subprime business to make a mint. This is the same thing.....all involving fraud. THEY ARE SIMPLY SAYING TO YOU AND ME......WE INTEND ON IMPLODING ENTITLEMENTS SO YOU BETTER COME AND GET THE SPOILS!
Who will provide for the providers? Many community health workers and volunteers in Baltimore are themselves in need
By Maiju Lehmijoki-Gardner 2:20 p.m. EDT, August 30, 2012 Baltimore Sun
Over the past year, I have had the privilege to follow the work and lives of many of Baltimore's committed community health advocates. These health promoters, organizers, practical nurses, pastors, interns and volunteers are often the trusted leaders of impoverished neighborhoods. The best ones stay even when grant monies run out and short-term projects are deemed complete; they work and volunteer at odd shifts to reverse the plight of underserved communities. They promote stability that benefits us all. Unfortunately, these local heroes often struggle with the same uncertainties that they selflessly work to ease. Some live in outright poverty. They serve others even when they themselves might be in need of assistance.
Are we as a society doing an adequate job to support those who support and empower our communities?
Many recent initiatives and publications, including the Affordable Care Act, National Prevention Strategy (2011) and Healthy Baltimore 2015, emphasize the preventive aspects of health care and the power of healthy communities. Community health promoters provide exactly the types of comprehensive services called for by the current focus on social determinants of health. Yet, very little discussion is dedicated to the challenging realities that shape the lives of those at the front lines of urban health promotion.
Many health care providers struggle to make ends meet. For instance, a full-time home health aide will have to get through a month with just a little over $1,000. Interns and other recent college graduates provide key services as community health promoters but sustain themselves on salaries that may leave them several thousands of dollars below the federal poverty level of individual annual earnings of $11,170. These young people are building their futures and American communities on food stamps.
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The group that is at the forefront of Baltimore's hands-on community health promotion seems also to be the one that bears the heaviest burden financially and socially: women of color. The people whose work and lives I follow are often African-American women who provide essential health services to underserved, struggling communities through their professional capacity or volunteering.
In many instances, the socio-economic volunteer profile in the city of Baltimore falls outside the stereotypical philanthropy where a volunteer or a donor shares the fruits of their plenty. The common impression of a volunteer or a donor is of a well-off person sharing the fruits of their plenty, but the socio-economic profile of many Baltimore volunteers and advocates does not fit this stereotype. Many of these women are vulnerable, yet many embrace their roles as health promoters because they are survivors of difficult circumstances. Many turn their experiences of struggle into communal currency, often with little or no financial benefit.
A broad range of studies demonstrates that women — and their children — bear a disproportionate share of poverty. The Great Recession of recent years left t African-American women especially vulnerable. A study by The National Women's Law Center revealed that the black women's unemployment crisis has included a particularly slow employment recovery, even after the recession officially ended in June 2009. We must ask: What can we do to empower those who serve their communities even as they often struggle with unemployment?
Though women shoulder much of Baltimore's health-related volunteering and supply significant labor to the health care industry — one of the largest employment sectors in the city — their own struggle with poverty correlates with a broad range of health challenges. When the Social Science Research Council surveyed female life-expectancy in "Measure of America" (2012), Baltimore landed in the second to last place of 25 metro areas studied. Again, what mechanisms should nonprofit, governmental and educational agencies have in place to ensure that the various positive ways in which women promote health reward them and support their own wellness?
Community health advocates deserve society's solidarity and recognition. Particular attention should be paid to empowering those who often are the most vulnerable, young people and women, so that their involvement in health advocacy serves their professional career advancement. It is hardly possible to imagine a healthy Baltimore if the grass-roots conditions of health promotion work force the workers and volunteers to provide to others that which they, themselves do not have.
Maiju Lehmijoki-Gardner, R.N., Ph.D., teaches theology at Loyola University. She blogs at http://www.healthfaithbaltimore.org.
THIS IS WHAT YOUR INCUMBENT IS DOING FOR YOU.....ALL MARYLAND'S POLITICIANS ARE FOLLOWING THIS POLICY!
VOTE YOUR INCUMBENT OUT OF OFFICE!!!
Giant Hospital Chain Creates a Windfall for Private Equity
By JULIE CRESWELL and REED ABELSON Published: August 14, 2012
During the Great Recession, when many hospitals across the country were nearly brought to their knees by growing numbers of uninsured patients, one hospital system not only survived — it thrived.
Readers’ Comments "When a company is allowed to ask - Is it financially viable for us to treat this illness? - there is a huge conflict of interest. "Outraged in D-town, Denver
In fact, profits at the health care industry giant HCA, which controls 163 hospitals from New Hampshire to California, have soared, far outpacing those of most of its competitors.
The big winners have been three private equity firms — including Bain Capital, co-founded by Mitt Romney, the Republican presidential candidate — that bought HCA in late 2006.
HCA’s robust profit growth has raised the value of the firms’ holdings to nearly three and a half times their initial investment in the $33 billion deal. The financial performance has been so impressive that HCA has become a model for the industry. Its success inspired 35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms eager to repeat that windfall.
HCA’s emergence as a powerful leader in the hospital industry is all the more remarkable because only a decade ago the company was badly shaken by a wide-ranging Medicare fraud investigation that it eventually settled for more than $1.7 billion.
Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with ways to reduce the cost of medical staff, a move that sometimes led to conflicts with doctors and nurses over concerns about patient care.
In late 2008, for instance, HCA changed the billing codes it assigned to sick and injured patients who came into the emergency rooms. Almost overnight, the numbers of patients who HCA said needed more care, which would be paid for at significantly higher levels by Medicare, surged.
HCA, which had lagged the industry for those high-paying categories, jumped ahead of its competitors and was reimbursed accordingly. The change, which HCA’s executives said better reflected the service being provided, increased operating earnings by nearly $100 million in the first quarter of 2009.
To some, HCA successfully pushed the envelope in its interpretation of existing Medicare rules. “If HCA can do it, why can’t we?” asked a hospital consulting firm, the Advisory Board Company, in a presentation to its clients.
In one instance, HCA executives said a private insurer, which it declined to name, questioned the new billing system, forcing it to return some of the money it had collected.
The hospital giant also adopted a policy meant to address an issue that bedevils hospitals nationwide — reducing costs and overcrowding in its emergency rooms. For years, the hospital emergency room has been used by the uninsured as a de facto doctor’s office — a place for even the most minor of ailments. But emergency care is expensive and has become increasingly burdensome to hospitals in the last decade because of the rising number of uninsured patients.
HCA decided not to treat patients who came in with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance. In a recent statement, HCA said that of the six million patients treated in its emergency rooms last year, 80,000, or about 1.3 percent, “ chose to seek alternative care options.”
“Many E.R.’s in America, particularly in densely populated urban areas where most HCA-affiliated facilities are located, have adopted a variety of systems to determine whether a patient in fact needs emergency care,” the statement said. “About half our hospitals have done so. Typically, our affiliated hospitals have two caregivers — usually a triage nurse and a physician — make that determination. It should be noted that other non-HCA affiliated hospitals are using similar processes to address E.R. issues.”
As HCA’s profits and influence grew, strains arose with doctors and nurses over whether the chain’s pursuit of profit may have, at times, come at the expense of patient care.
HCA had put in place a flexible staffing system that allowed it to estimate the number of patients it would have each day in its hospitals and alter the number of nurses it needed accordingly.
Several nurses interviewed said they were concerned that the system sometimes had led to inadequate staffing in important areas like critical care. In one measure of adequate staffing — the prevalence of bedsores in patients bedridden for long periods of time — HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.
Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the dialysis programs at two HCA-owned hospitals prompted state investigations.
I ATTENDED THE MEETING OF THIS BOARD THIS WEEK AND WHAT WAS MOST APPARENT IN THE DEVELOPMENT STAGE WAS THE CONTINUED USE OF VERY VAGUE LANGUAGE WHEN DEFINING WHO, WHAT , AND HOW OF THESE INSURANCE EXCHANGES. THE AREAS DEFINING QUALITY AND OVERSIGHT WERE LEFT UNDEVELOPED AS 'THOSE AREAS WILL BE THE HARDEST TO MAP OUT'.
Gov. Martin O’Malley has appointed the nine members to serve on the board overseeing Maryland’s health benefit exchange.
The exchange, required under federal health reform to be in place by January 2014, will provide individuals and small-business owners with a one-stop shop for comparing insurance products, buying coverage and obtaining federal subsidies. O’Malley signed legislation providing the framework for the exchange in April.
- Georges Benjamin, a doctor and executive director of the American Public Health Association
- Lisa Dubay, Urban Institute senior fellow
- Darrell Gaskin, an associate professor and health economist at the Johns Hopkins Bloomberg School of Public Health
- Jennifer Goldberg, a lawyer and assistant director of advocacy for Health Care at the Maryland Legal Aid Bureau
- Enrique Martinez-Vidal, vice president at AcademyHealth and director of the Robert Wood Johnson Foundation’s State Coverage Initiatives program
- Thomas Saquella, former president of the Maryland Retailers Association
Maryland Department of Health and Mental Hygiene Secretary Josh Sharfstein was appointed to serve as the initial chair of the board. In the coming months, Maryland’s exchange board will establish advisory committees, adopt procurement guidelines, conduct a search and select an executive director, and undertake a series of studies required by its enabling legislation signed in to law by the governor last month.
Lt. Gov. Anthony G. Brown, joined by Sharfstein, Howard County Executive Ken Ulman, and other state and federal officials at Howard County General Hospital, described the six appointees to Maryland’s Health Benefit Exchange Board as “dedicated and highly-qualified individuals from the non-profit and business communities.”
Brown served as co-chair of Maryland’s Health Care Reform Coordinating Council, a group appointed by O’Malley last year to explore how the Patient Protection and Affordable Care Act, approved in March 2010, would affect Marylanders.
NEW YORK HAD THE TOUGHEST HEALTH FRAUD OVERSIGHT IN THE COUNTRY. THIRD WAY DEMOCRAT CUOMO COMES ON BOARD AS GOVERNOR AND THE FIRST THING HE DOES IS REMOVE THE GUY FINDING TOO MUCH FRAUD.....AFTER ALL, THAT FRAUD MAXIMIZES PROFITS HE SAYS!!!! MARYLAND RECOVERED A FEW HUNDRED MILLION OF BILLIONS IN HEALTH FRAUD IN THE STATE.
Under Pressure, New York Moves to Soften Tough Medicaid Audits
Nathaniel Brooks for The New York Times James C. Cox, New York’s new Medicaid inspector general, has said he intends to pursue a less “adversarial” auditing strategy.
By NINA BERNSTEIN Published: March 18, 2012 New York times
New York State was paying for the medical care of dead people when Gov. George E. Pataki and the State Legislature created the Office of the Medicaid Inspector General to curb billions of dollars in fraud and misspending by health care providers.
The turnaround was startling. Within four years the state had recouped $1.5 billion in Medicaid overpayments, the highest recovery rate in the nation. Other states rushed to create inspectors general like New York’s.
But a backlash from the politically powerful health care industry has erased broad support for the crackdown. Last year, amid a crescendo of provider complaints of overzealous, nitpicking audits and unfair tactics, Gov. Andrew M. Cuomo quietly dismissed the state’s first Medicaid inspector general, James G. Sheehan, and directed Mr. Sheehan’s successor, James C. Cox, to collaborate with providers on changes to the agency’s policies and auditing methods.
In an interview, James Introne, Mr. Cuomo’s deputy secretary for health, expressed the state’s new view.
“An audit need not be an adversarial enterprise,” Mr. Introne said. “To the extent that an audit turns into an adversarial affair, it may not be conducted properly. An audit is successful when people agree.”
The Cuomo administration said that enforcement was as vigorous as ever, and that Mr. Cox was on target to avoid $1.1 billion in improper Medicaid spending this year, even more than his predecessor. But veterans of Medicaid policing pointed to important audits that were started by Mr. Sheehan but have not been released, and said the inspector general’s office was at a difficult crossroads, caught between the Legislature’s allegiances to campaign contributors from the health care field and the governor’s plans to cut Medicaid costs, which depend on the goodwill of nursing homes, hospitals and home health agencies.
“An industry that’s regulated doesn’t love the regulator unless the regulator isn’t doing much,” said Arthur A. Levin, the longtime director of the Center for Medical Consumers, a nonprofit advocacy organization, who admired Mr. Sheehan. “Asking the regulator and the regulated party to sit down and come to some sort of consensus on how the regulation should be — to me, it makes no sense.”
Michael A. Zegarelli, a past president of the national association of Medicaid oversight officials and a senior regulator in New York until 2003, said that by definition, an audit that found overbilling, fraud or waste was “going to be adversarial.”
“Sheehan’s successor will have a short leash,” Mr. Zegarelli said. “Will that be for the benefit of the program, or to keep Cuomo’s constituency happy?”
New York’s Medicaid program, jointly financed by federal, state and local taxpayers, is the nation’s largest, at $53 billion. In 2005, an investigation by The New York Times found that Health Department regulators had uncovered only 37 cases of suspected fraud in 400 million annual claims, overlooking red flags like a storefront dentist whose billings spiked to 991 procedures daily and a nursing-home operator who took in $1.5 million in salary and profit the same year he was fined for neglecting the home’s residents.
The 2006 overhaul spurred by that investigation was financed by a $1.5 billion payment from the federal government with tough terms: the state had to recoup the money by September 2011 or pay back the shortfall. To take charge, Gov. Eliot Spitzer in 2007 appointed Mr. Sheehan, who had prosecuted health care fraud for 20 years as an assistant United States attorney in Philadelphia.
Mr. Sheehan exceeded recovery targets. Over all, the state reclaimed 1.2 percent of its total Medicaid spending, the nation’s highest rate.
But complaints from providers mounted, and were taken up by legislators. The providers charged that under pressure to meet the federal target, Mr. Sheehan treated paperwork errors like fraud. At one legislative hearing, he was accused of “gangster tactics” for demanding that providers settle with the state or risk having to pay more based on findings extrapolated from statistical samples.
“Jim Sheehan was able to make up his own rules,” said Richard J. Herrick, president of the New York State Health Facilities Association, a nursing-home trade group. “It wasn’t for purity, it was where can we find money to recoup.”
In June, Mr. Sheehan was dismissed with a month’s notice in a phone call from Mr. Cuomo’s director of operations.
“He said, ‘We’ve decided to go in a different direction,’ ” recalled Mr. Sheehan, who has since been hired as the chief integrity officer and executive deputy commissioner for the Human Resources Administration, which oversees Medicaid in New York City.
A spokesman for the Cuomo administration would not specify the reasons for the decision, and Mr. Sheehan said that as a political appointee, he had no problem with it. But he disputed providers’ accusations, saying that the real issue was his challenge to a powerful industry that is a large employment engine.
“Medicaid is to New York what corn is to Iowa,” he said. “It’s a heavy lift.”
He said that audits of nursing homes, for example, found that some had inflated their profits by needlessly sending every patient to physical therapy during the month when annual reimbursement rates were calculated.
The nursing-home trade group sought an injunction to stop the audits. A court dismissed the association’s argument that Mr. Sheehan had exceeded his jurisdiction.
Mr. Herrick said that the decision was on appeal, and that his association was revising audit protocols with Mr. Cox, the new inspector general. “I have no personal knowledge that facilities followed the practice alleged,” he said, “and as a practical matter find it highly unlikely.”
In home health care agencies, Mr. Sheehan said auditors found widespread patterns that violated Medicaid requirements linked to quality of care.
“Nurses are supposed to review the work and design the plan of the home health aides, but there were cookie-cutter plans,” he said, citing one plan that failed to mention that the patient was an amputee or to explain how the aide was to care for the stump.
“Home health aides would not show up, or would be in two places at once,” he added. “One entity billed us 500 times for home health care while patients were in the hospital.”
Mr. Sheehan would not name audited agencies, but two of his former managers said the largest audit was of Visiting Nurse Service of New York, a $1 billion nonprofit group. That audit gained attention a year ago, when an internal report citing tens of millions of dollars in overpayments was leaked to The Wall Street Journal. At the time, the agency’s chief executive was on a task force advising the new governor on how to redesign Medicaid to trim costs.
Richard Rothstein, a spokesman for Visiting Nurse Service, said that under an agreement with the inspector general’s office, he could not talk about the audit, which started in 2008 and has not been released. But he added, “There is absolutely no discussion about fraud,” only “errors in paperwork.”
One example cited in the preliminary report was a bill for an eight-hour-long sponge bath. Mr. Rothstein said that there had been no intent to cheat Medicaid and that the aide who started the sponge bath had forgotten to report that a nursing crisis had intervened before she finished it hours later.
Many providers welcomed Mr. Sheehan’s exit, but Richard J. Mollot, executive director of the Long Term Care Community Coalition, which advocates for nursing-home residents, did not.
“It was politics at its worst to see him leave,” Mr. Mollot said. “They put enormous pressure on that office to sustain their budget, so to then turn around and say they were too aggressive is the height of hypocrisy.”
After Mr. Sheehan’s dismissal, lawmakers unanimously passed a bill curbing the office’s authority. It cut the government’s time to reclaim overpayments to three years from six and let providers submit corrected bills rather than repay.
Mr. Cuomo, an aggressive prosecutor of Medicaid fraud as attorney general, vetoed the bill. “The provider community, as a whole, plays a critical role,” his veto message said, “and many of their concerns reflected in this bill are legitimate.” But, he added, the bill “would potentially allow fraudulent and abusive activity to go undetected or unprosecuted.”
Instead, he ordered Mr. Cox to review policies with “a working group comprised of representatives of provider associations and others.”
Mr. Cox’s confirmation last week, after a nine-month wait, underscored the change in climate. At genial committee hearings, state senators said they were receiving positive feedback from providers, but one warned that the vetoed bill would be resubmitted “if we hear otherwise.”
Mr. Introne, the deputy health secretary, said that Medicaid providers followed rules better now than they did five years ago. Mr. Sheehan agreed, and said his successor was well-qualified. But he noted that dozens of city audits he had asked to start or to release in his new job were still awaiting Mr. Cox’s approval.
Audit figures released by the state show that Mr. Cox’s findings of overpayments have fallen steeply since Sept. 30, when the state met the deadline for the $1.5 billion federal target.
Mr. Cox, a 23-year veteran of audits for the Health and Human Services inspector general, said he involved government lawyers and providers at the outset of an audit and examined every audit himself to make sure its findings could withstand a court challenge. That has held up some audits, he acknowledged, including that of Visiting Nurse Service, which is “still being reviewed and discussed with the entity and its lawyers to see what areas we agree on or disagree on.”
“We’re all about fighting fraud,” he said, and “also about improving program integrity, quality of care, and saving taxpayer dollars. That’s our mission, and we’re sticking with it.”