People need to remember that the Federal budget cuts after the collapse from massive corporate fraud created $14 trillion in debt was huge.....the program was gutted. States followed suit and made large cuts to their Medicaid contributions... lowering the Federal funding further. Remember, trillions of dollars has been lost to Medicare and Medicaid in health industry fraud and profiteering so pretending we need to cut these programs rather than get that money back----IS NOT WHAT A DEMOCRAT WOULD DO. Please be aware that the ACA with tiered insurance will have most people on or at Medicaid. Medicare has been deeply cut as well so----- Be sure you fight for Expanded and Improved Medicare for All!


News>
Local News>
State GovernmentMedicaid cuts in state 'devastating'Spending: DSHS decision to end coverage for 27,000
By BRAD SHANNON; Staff writer
September 30, 2010 
2010-09-30T12:56:27Z
BRAD SHANNON; Staff writer 

The state government agency that runs the Medicaid health insurance program for low-income people announced $112.8 million in cuts that were described Wednesday as "devastating" to the state safety net. The cuts will end subsidized health insurance coverage for about 27,000 in the state’s Apple Health for Kids program and end out-patient pharmacy benefits for thousands of Medicaid patients – both in March. Other cuts in January will eliminate a host of services including dental, vision, hearing and hospice care for thousands of Medicaid patients.“I would characterize these cuts as devastating and radically altering the face of the medical programs we have created over the last 20 years,” said Doug Porter, state Medicaid director. “What you see and what I hope your readers understand is these don’t represent choices. There was really only one choice to make and that was whether to stay in the Medicaid program.”The cuts are in response to Gov. Chris Gregoire’s order for 6.3 percent across-the-board cuts that spare only pensions, basic education, and state debt payments. The Medicaid cuts are in addition to reductions the Department of Social and Health Services announced totaling $168 million. Announcements by other agencies are due by Friday, the date the governor’s order takes effect. The separate DSHS cost reductions involve cuts in state agency jobs and services, including a 10 percent reduction in hours for home-care workers who assist elderly people with medical problems, according to Adam Glickman of the Service Employees Union 775 NW.“These are the deepest cuts to home care that we’ve ever seen. They are talking about a 10 percent pay cut for home care workers that make $10 an hour and live in poverty,” he said. “There are dozens of home care agencies that could be forced to shut down. … We’ve talked to members who think clients could end up in nursing homes. If they can’t get enough care they may have to move into nursing homes.”Porter said his agency really had one choice, and that was to decide if Washington would remain in Medicaid, the state-federal partnership. Once that decision was made, the state could only cut spending in “optional” category of programs – which includes the pharmacy benefits, adult dental, vision and hearing services, family planning, and the state’s Disability Lifeline, once called General Assistance Unemployed.“Everything is locked in,” he said.Some cuts take effect in January, some in March – and the latter cuts such as children’s health and pharmacy benefits would require legislative approval, according to Medicaid spokesmen. Despite the cuts, Medicaid is keeping help for kidney disease and durable medical equipment, Porter said. State Rep. Brendan Williams, D-Olympia, said in a statement: “A just society does not make the current-biennium cuts announced today by the Department of Social and Health Services. A relevant Legislature would intervene.”“These penny-wise, pound-foolish cuts will devastate children, community-based long-term care, and our most vulnerable citizens in nursing homes. These cuts give the green light to abuse and neglect,” Williams said.But lawmakers have no extra money, and few besides Williams have spoken about raising taxes to reduce the size of cuts next year. Majority Democrats have said it would not be productive to come to Olympia for a special session with little prospect of agreeing on a plan for cutting spending or raising revenue.The children’s health cut is $10.1 million and makes an estimated 27,000 children ineligible for the insurance subsidy. Children’s health was once a sacred cow for majority Democrats in Olympia who kept expanding coverage. After the cuts, some 600,000 children would still be served by the state’s health programs, according to Jim Stevenson of the Medicaid program. The Medicaid cuts and general-fund savings include cutting: • $39.4 million from outpatient pharmacy assistance for all Medicaid clients. • $20.3 million from the recently reformulated Disability Lifeline (formerly General Assistance Unemployed), affecting 21,000 people. • $8.3 million from adult dental services for 105,000 people. • $4.6 million from adult hospice services for 2,600 people. • $800,000 from adult hearing and vision services for 69,400 people. • $3.3 million from interpreter services, affecting 70,000 people. • $3.2 million from a program that paid Medicare Part D premiums for residents eligible for both Medicare and Medicaid, affecting 49,000 people. • $2.9 million from physical, occupational and speech therapy for 20,000 people. • $1.2 million in family planning for 43,000 people. • $8.6 million in emergency medical funding for aliens (state only funded).“They are all regrettable, but the one that causes me the most anxiety is the prescription drug cut,” Porter said. “I cannot imagine the effect that is going to have on state hospitals, on emergency rooms.”If allowed to stand, the medication cuts will leave patients “extremely vulnerable. They are going to have to find some way to pay for it themselves – to get free samples from their doctors’ offices” or seek out free programs sponsored by drug companies, Porter said. In one sliver of good news, the state’s Basic Health Plan is running ahead of budget and should have a surplus of at least $25 million by year’s end, so it won’t have to be cut, according to Porter.


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AS WE WORK FOR EXPANDED AND IMPROVED MEDICARE FOR ALL WE NEED TO REMEMBER THE TRILLIONS OF DOLLARS LOST TO MEDICARE THROUGH FRAUD AND MAKE OVERSIGHT AND ACCOUNTABILITY THE PRIORITY IN HEALTH REFORMS. MARYLAND HAS ABSOLUTELY NO OVERSIGHT AND MASSIVE FRAUD.

All of this information is great and represents lots of hard work. It would be helpful if these articles on Medicare and Medicaid fraud started with what many researchers and in fact most doctors' of conscience say to be $200-400 billion dollars each year. When you talk of such small amounts like $90 billion the big picture is lost. The point is that if recovered health fraud could fully fund Medicare for decades. 

REMEMBER, MEDICARE AND MEDICAID HAVE BEEN LEFT WITH ABSOLUTELY NO OVERSIGHT AND ACCOUNTABILITY AND TRILLIONS HAVE BEEN ALLOWED TO BE STOLEN FROM THE TRUST.  WE MUST RECOVER THESE FRAUDS AND STOP FUTURE ONES.  THE MEDICARE PROGRAM IS THE BEST RUN PUBLIC PROGRAM EVER BUT IT IS BEING ALLOWED TO BE DISMANTLED FROM FRAUD AND CORRUPTION


Even After Doctors Are Sanctioned or Arrested, Medicare Keeps Paying
April 25th, 2014
in econ_news

Special Report from ProPublica

by Charles Ornstein, ProPublica

This story was co-published with NPR

In August 2011, federal agents swept across the Detroit area, arresting doctors, pharmacists and other health professionals accused of running a massive scheme to defraud Medicare.

The following month, several of those arrested -including psychiatrist Mark Greenbain and podiatrist Anmy Tran - were suspended from billing the state's Medicaid program for the poor.



Follow up:

"Health care fraud steals funds from programs designed to benefit patients, and we all pay for it," U.S. Attorney Barbara McQuade said in a press release at the time of the arrests. "We hope that the strength of our efforts will have a deterrent effect."

But the indictment and Medicaid suspensions didn't deter Medicare from continuing to allow the doctors to treat elderly and disabled patients - and billing taxpayers for their services.

In 2012, Medicare paid Greenbain more than $862,000, according to newly released data on Medicare payments to physicians. Tran received $155,000.

Greenbain and Tran were among dozens of doctors identified by ProPublica who Medicare kept paying after they were suspended or terminated from state Medicaid programs, indicted or charged with fraud, or had settled civil allegations of submitting false claims to Medicare.

Outlays to these doctors amounted to more than $6 million in 2012, ProPublica's analysis shows. That's a small fraction of the $77 billion Medicare has publicly reported paying that year for doctors' visits and outpatient services in its Part B program, but it signifies a hole in regulators' ability to protect the program - and patients - against fraud and abuse, said current and former government officials and fraud experts.

The total dollars paid to sanctioned doctors is likely much higher. Only a handful of states post online the names of doctors terminated from Medicaid programs in a way that can be accurately matched to Medicare Part B payments.

"If you've been suspended or terminated in one of the federal programs...I would think that you'd be suspended in the other programs, just as a basis of good practice," said Louis Saccoccio, chief executive of the National Health Care Anti-Fraud Association.

Part B payments to doctors were released last week for the first time. A court injunction that had kept the information secret for 35 years was lifted last year as a result of a lawsuit by Dow Jones & Co., parent company of the Wall Street Journal.

But Medicare has long had access to the information. "They're the ones doing the paying," Saccoccio said.

Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, said he could not discuss the status of individuals, such as Greenbain and Tran, both of whom were finally barred from billing Medicare this month.

By that time, Greenbain had pleaded guilty and been sentenced to four years in prison. Tran had been found guilty and trial and was sentenced to five years. She is appealing her conviction.

Albright said the Medicare payment data may not reflect money already recovered by his agency or held back from providers suspended from billing the program.

Preventing improper payments is a top priority for CMS, Albright said. The agency has employed new enrollment screening techniques to prevent high-risk providers from getting into the system and is using advanced data analytics to spot fraudulent billing before payments are made, he said.

"Already, we have cracked down on tens of thousands health care providers suspected of Medicare fraud," he said in an email.

Medicare's fraud-fighting efforts have been criticized repeatedly in recent years. In an audit released last month, the inspector general of the U.S. Department of Health and Human Services found that about one-third of states hadn't told CMS when they terminated providers from Medicaid and others had provided incomplete information, hobbling regulators' ability to flag sanctioned professionals.

In December, the inspector general faulted Medicare for not systematically reviewing the billings of the program's top-paid doctors and said it should be doing more to spot aberrant claims.

Last year, ProPublica reported that doctors who had been terminated from Medicaid or had been disciplined by state medical boards were able to continue prescribing medications to beneficiaries in Medicare's drug program, prompting Sen. Charles Grassley (R-Iowa) to push for better coordination.

Medicare has more direct responsibility for overseeing activities in Part B than in the drug program, which is administered by private insurers. The drug program doesn't even require that prescribers be enrolled in Medicare and payments go to pharmacies, not doctors. By contrast, in Part B, it's up to Medicare to monitor services and payments, which go to clinicians or their employers.

"There's been a disconnect between Medicaid and Medicare on problem providers," wrote Grassley, ranking Republican on the Senate Judiciary Committee, in an email to ProPublica:

"The release of Medicare billing data should help force better communication between Medicaid and Medicare on these providers. The new transparency makes it harder to ignore when doctors who harm patients or defraud taxpayers in one program face no consequences in the other program."

Sen. Tom Carper, (D-Del.), chair of the Senate Homeland Security and Governmental Affairs Committee, credited Medicare with ramping up efforts to verify the credentials of those treating its beneficiaries. "But there is still much work to be done," he said in a statement.

Among the physicians ProPublica found who continued to collect Medicare payments after being flagged by law enforcement or other oversight agencies:

Dr. Lawrence Eppelbaum, a Roswell, Ga., pain doctor convicted last year of inducing patients to be treated at his Atlanta pain clinic by paying their travel fees through a purported charity he controlled. He was indicted on the charges in March 2011, but Medicare paid him $500,000 to treat 80 patients the following year. This February, Eppelbaum was sentenced to 50 months in prison and fined $3.5 million. He is appealing.

In a sentencing memorandum, Eppelbaum's lawyer maintained that Medicare did not lose any money because of the doctor's conduct. "Virtually every patient would have received treatment somewhere, by some doctor," he wrote:

"Thus, Medicare would have paid the exact same amount of money, albeit possibly to another provider."

Michigan ophthalmologist Matthew Burman was suspended by the state's Medicaid program in 2009 after he was convicted of a misdemeanor count of criminal sexual conduct arising from a patient's accusation against him. He subsequently surrendered his medical licenses in Texas and California and agreed not to activate his registration in New York. He was paid $379,000 by Medicare in 2012. (Medicare has not released payment data for prior years.)

Burman, who continues to practice in Michigan, said he could have re-enrolled in Medicaid but chose not to. "One has nothing to do with the other," he said:

"I didn't violate any Medicare rules. Medicare has nothing to do with why I'm not a Medicaid provider."

Las Vegas pain doctor Steven Kozmary agreed in December 2011 to pay the federal government $1 million to settle health care fraud allegations involving Medicare and other programs. The government could have moved to terminate him from Medicare, according to the settlement. Instead, in 2012, Medicare paid him $563,000. He was disciplined by Nevada's medical board in 2013 related to the 2011 settlement. He did not return a phone call.

Louisville Dr. Steven Stern and his practice paid $350,000 to settle allegations of overbilling Medicare in September 2011. He and his practice were accused of overbilling Medicare for infusing Infliximab, a drug used to treat rheumatoid arthritis. Specifically, they were accused of splitting vials of the drug across multiple patients but billing as if a whole vial was used for each. In 2012, Stern received more than $3 million in payments from Medicare, including $2 million for infusing Infliximab. He did not return a phone call seeking comment.

Eight of 14 New Jersey health providers arrested in December 2011 on charges of receiving kickbacks for referring Medicare and Medicaid patients to a specific MRI center continued to be paid by Medicare in 2012. At the time of the arrests, Tom O'Donnell, special agent in charge for the HHS inspector general said, "The audacity of these physicians should offend honest taxpayers, especially at a time when our taxpayer resources are stretched thin."

Even a guilty plea sometimes wasn't enough for Medicare to cut off payments. Dr. Anthony Jase of New Orleans pleaded guilty to two counts of health care fraud in October 2011. He still collected $97,460 for Medicare billings in 2012. Last fall, he was sentenced to 15 months in prison and ordered to pay $360,293 in restitution.

Mark McClellan, former administrator at CMS who is now at the Brookings Institution, said:

"It certainly looks like there is a need for more attention, One important consequence of the release of this information at the physician level is that it will lead to some further analysis and actions against these truly outlier physicians who are clearly billing improperly."

ProPublica's analysis also found payments to doctors who were subsequently barred from billing the program by the HHS inspector general, mostly because of fraud convictions. Medicare paid 135 of them more than $18 million in 2012, before they were kicked out.

Some doctors have been indicted post-2012, including Michigan oncologist Farid Fata, a Michigan oncologist who was paid $10 million in 2012, ranking him among Medicare's top-paid providers that year. Last year, Fata was accused of misdiagnosing patients with cancer so he could give them unnecessary, expensive treatments. Fata has pleaded not guilty; his lawyer did not respond to a request for comment.

In a conference call last week with reporters, CMS' principal deputy administrator Jonathan Blum said the agency knows it can do more to find fraud. "We know that there's waste in the system. We know that there's fraud in the system. We want the public's help" to review the physician payment data and report suspected wrongdoing.




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THIS ARTICLE DOES A GOOD JOB AT SHOWING HOW MUCH NEO-LIBERALS HATE ALL PUBLIC PROGRAMS AND WORK HARD TO END THEM. THE AFFORDABLE CARE ACT WILL MAKE IT IMPOSSIBLE FOR MOST SENIORS TO ACCESS CARE AND THEY WILL END UP BASICALLY AT A MEDICAID-LEVEL....WHICH IS THE POINT. Remember, all payroll taxes were sent to the US Treasury and the US Treasury is broke with the massive corporate fraud and building of the Homeland Security and NSA-----so neo-liberals say---SORRY, WE SPENT YOUR SOCIAL SECURITY AND MEDICARE TRUSTS AND NOW WE WILL DISMANTLE THESE PROGRAMS. This is why Obama installed myRA for privatizing Social Security as well.

Wall Street will rave about how all these cuts to public services and programs have paid down the national debt caused by massive corporate fraud.

Top 9 Ways Government Attacks American Seniors
April 10th, 2014
in Op Ed

by Elizabeth Lee Vliet, M.D., www.aapsonline.org

Chaos, cost increases, and turmoil reign since Obamacare took effect. Hidden changes drastically transform Medicare, affecting your ability to get neededmedical care-even if you pay out of pocket.





Follow up:

Here is my list of the Top ­9 government attacks on American seniors:

1. CMS proposed a 678-page rule (1-6-2014) requiring enrollment in Medicare for all prescribers of drugs covered under Part D Medicare. Currently, medication prescribers only need to have an active state license permitting prescribing. CMS is restricting Medicare beneficiaries' ability to use their benefits if they see an independent physician outside "the system." Independent physicians can see patients but cannot order anything for them. It's like telling an auto mechanic that he can fix cars but he can't use any tools. Even Doctors enrolled in Medicare risk having their enrollment revoked if, in the eyes of the government bureaucrats, they "fail to meet Medicare requirements." The requirements change almost daily, and Medicare rules are often subjectively interpreted, so this means doctors may avoid prescribing something YOU need rather than risk a Medicare sanction and losing income.
2. Hospitals increasingly are classifying hospitalized Medicare patients as being "under observation," rather than admitting them as "in patients," not telling them this means thousands of dollars in out-of-pocket costs. Only "inpatient" status is covered under Medicare Part A. "Observation" status comes under Part B. After discharge, patients learn about exorbitant hospital bills and increased co-payments for medications, procedures, and tests. Worse, without an inpatient stay, rehabilitation services and skilled nursing care will not be covered by Medicare, hitting unsuspecting patients with huge added medical bills.
3. Obamacare's new Medicare rules deny payment if a hospital patient is readmitted within 30 days of discharge. This is particularly damaging to patients with chronic lung disease, congestive heart failure, diabetic coma, and other such medical problems needing brief readmission to stabilize life-threatening situations. If not re-admitted when medically needed, patients may die. Catch-22 happens if they are readmitted to hospital "under observation," then get hit with unexpected exorbitant hospital bills.
4. In 2012, Obamacare rules forced hospitals contracted with Medicare to do FEWER surgeries for Medicare patients to be paid MORE. If employed by the hospital, doctors may not tell you this reason behind failing to suggest a surgery that could benefit you.
5. Other than government-determined copayments, Medicare patients are not legally allowed to pay cash out of pocket for needed "covered" services if they see a Medicare-contracted physician. Patients must find a physician who has legally opted out of Medicare to be able to pay cash for a service, say one that is not available at the Medicare-allowed price-or to keep their medical records from being sent to the federal government medical database.
6. Medicare patients are likely the ones hit harder by the new Obamacare 2.3% medical device tax that inflates the cost of pacemakers, stents, knee/hip/shoulder replacement devices, prosthetic limbs, etc.
7. Obamacare's new direct Medicare taxes also hit retirees harder: a 3.8% tax on unearned income (dividends, rental income, capital gains), and a 0.9% surtax (for those with incomes above $200,000 individual or $250,000 family), added to existing 1.45% Medicare payroll tax.
8. Reduced payments to cancer, heart/lung, and surgical specialists typically caring for older patients. Medicare fee cuts to these specialists can result in payments below the cost of staying in business, so seniors lose access to more doctors.
9. Draconian $716 billion direct cuts from Medicare attack seniors in serious ways from 2013 - 2022: (Source: CBO)
   • $260 billion from hospital services budget
   • $156 billion from Medicare Advantage
   • $66 billion from home health
   • $39 billion from skilled nursing
   • $17 billion from hospice care
   • $145 billion from DHS (Disproportionate Share Hospital) payments to hospitals that serve a large number of low-income patients
   • $33 billion from all other services

Increases in out-of-pocket costs and higher taxes are a huge burden on seniors on fixed income. Changes in the rules and regulations can be even more significant, even life-threatening, when they lead to covert denial of medical care.

Who would have thought after a lifetime of service to our country in homes, jobs, and communities, seniors would be attacked by their own government with many threats to their savings and lives in retirement?


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Since government watchdogs and academics place $200-400 billion dollars in fraud each year to Medicare these few decades, we know these people represent the tip of the iceberg.  As everyone knows, having an operation as big as Medicare and Medicaid with almost no oversight and accountability was meant to allow for tons and tons of fraud.  Would you sit there and write checks for any bill a person sent in to you?  No one would.  So, leaving these entitlement programs without oversight for decades was done deliberately to move money to health industry fraud.

There are trillions of dollars in Medicare and Medicaid fraud needing to come back to these Trusts, but neo-liberals are working hard with the Affordable CAre Act to ignore what causes high health costs----fraud and profiteering....and is cutting the losses from fraud from people's ability to access health care.  Did you know the current governor of Florida where health fraud runs rampant was a CEO at HCA-----now a global corporation----found to have committed hundreds of millions of dollars in fraud.  Small fines and no charges has this CEO now governor of the state having the most fraud.  See the problem?  So, rebuilding all of our white collar criminal agencies, rebuilding oversight agencies, and public justice for prosecutions will cut health care spending in the US in half. 

STOP ALLOWING NEO-LIBERALS AND REPUBLICANS TO IGNORE FRAUD AND ALLOWING THEM TO COME AFTER OUR ACCESS TO QUALITY CARE!



Release of Medicare doctor payments shows some huge payouts Some physicians received more than $10 million in 2012, data show, but the government and doctors warn the figures can be misleading.


By Chad Terhune, Noam N. Levey and Doug Smith 12:00 a.m. EDT, April 9, 2014  Baltimore Sun

Ending decades of secrecy, Medicare is showing what the giant healthcare program for seniors pays individual doctors, and the figures reveal that more than a dozen physicians received in excess of $10 million each in 2012.

The Obama administration is releasing a detailed account Wednesday of $77 billion in government payouts to more than 880,000 healthcare providers nationwide that year. The release of payment records involving doctors has been legally blocked since 1979, but recent court rulings removed those obstacles. No personal information on patients is disclosed.

The two highest-paid doctors listed in the Medicare data are already under government review because of suspected improper billing. They include an ophthalmologist in the retiree haven of West Palm Beach, Fla., who topped the list by taking in more than $26 million to treat fewer than 900 patients. That is 61 times the average Medicare payout of $430,000 for an ophthalmologist.

A Florida cardiologist received $23 million in Medicare payments in 2012, nearly 80 times the average amount for that specialty. One California doctor was in the top 10 nationwide: a Newport Beach oncologist who was paid $11 million that year.

The overwhelming majority of doctors billed the government very modest amounts. Overall, 2% of healthcare providers accounted for 23% of the Medicare fees, the federal data show.

Medicare officials said disclosing physician payment data marks an unprecedented opportunity to make the nation's healthcare system more transparent for consumers and accountable to taxpayers. Many consumer advocates and employers applauded the move.

"Providing consumers with this information will help them make more informed choices about the care they receive," Jonathan Blum, Medicare's principal deputy administrator, said last week. Medicare plans to post the data online.

Still, federal officials cautioned against drawing sweeping conclusions about individual doctors from the numbers. High payouts do not necessarily indicate improper billing or fraud, they say. Payments could be driven higher because providers were treating sicker patients who required more treatment or because their practice was focused more on Medicare patients.

The new data reflect only Medicare Part B claims, which include doctor visits, lab tests and other treatment typically provided outside a hospital. They include what Medicare paid plus any money providers received from patients for deductibles and coinsurance. Altogether, the payouts totaled $99 billion paid to healthcare providers in 2012. These government figures don't cover commercial insurance, Medicaid or even Medicare Advantage plans.

Even with those limitations, experts say, the data could serve as an early warning for potential waste and abuse.

Spending on the Medicare program, which covers about 60 million elderly and disabled Americans, is expected to exceed $600 billion this year. There is broad agreement that fraud is rampant in both Medicare and Medicaid, the government health program for the poor, but estimates of the scope vary from $20 billion annually to $100 billion.

The American Medical Assn. and other physician groups have long opposed the release of the Medicare data.

AMA President Dr. Ardis Dee Hoven said the group remained concerned that inaccuracies in the data or misinterpretation might unfairly tar some physicians.

She said some individual physicians might appear to be billing huge amounts to Medicare when in fact it is their entire practice that bills under a single physician's name. In other cases, high-volume physicians may actually be experts in their field who instead will be portrayed in a bad light.

"How does a physician or a practice get their reputation back?" Hoven said.

For 2012, the top recipient of Medicare money in the country was ophthalmologist Salomon Melgen, whose billings have already been the subject of federal investigation.

Melgen has been a heavy donor to Sen. Robert Menendez (D-N.J.). Last year, federal officials said a grand jury was looking into Melgen's billing practices, and a separate investigation was examining whether Menendez had improperly intervened on his behalf.

An attorney for Melgen, Kirk Ogrosky, said the physician had billed in accordance with Medicare rules. Ogrosky said the vast majority of the money attributed to Melgen reflected the cost of drugs used in treatment and that physician reimbursement is set at 6% above what is paid for the medications.

"Dr. Melgen strongly supports transparency in government," Ogrosky said, "but engaging in speculation based on raw data is irresponsible."

Cardiologist Asad Qamar in Ocala, Fla., ranked second nationally with $22.9 million in payments for seeing Medicare patients in 2012.

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Did you know that government watchdogs place Medicare fraud at between $200-400 billion dollars a year.  Trillions in just a few decades needing to be recovered.  Think that would fully fund the Medicare Trust and stop these cuts?  YOU BETCHA. 

IT WOULD ONLY HAPPEN IF YOU SHAKE THE NEO-LIBERAL BUGS FROM THE DEMOCRATIC PARTY BY RUNNING LABOR AND JUSTICE IN ALL PRIMARIES!!


Written by Helen Adamopoulos  | January 15, 2014   Becker's Hospital Review

0
inS The 10-year impact of regulatory actions on hospital payments since 2010 will involve an estimated $113 billion reduction in Medicare and Medicaid reimbursement, according to the American Hospital Association.

The AHA assessment — which excludes payment reductions included in the Patient Protection and Affordable Care Act — shows sequestration will lead to $53.8 billion in cuts, factoring in the two-year extension of sequestration cuts enacted by the Bipartisan Budget Act of 2013.

Additionally, according to the AHA graphic, hospitals will lose $2.1 billion to bad debt as a result of the Middle Class Tax Relief and Job Creation Act of 2012 and $12.2 billion to Medicaid disproportionate share hospital payment cuts included in the Middle Class Tax Relief and Job Creation Act of 2012, the American Taxpayer Relief Act of 2012 and the Bipartisan Budget Act of 2013.

The three-day window provision in the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 will lead to a $4.2 billion payment reduction for hospitals. The three-day Medicare payment window applies to outpatient services that hospitals and hospitals' wholly owned or wholly operated Medicare Part B entities provide to Medicare beneficiaries. It requires providers to bundle the technical component of all outpatient diagnostic and related non-diagnostic services with the claim for an inpatient stay when they are administered in the three days preceding an inpatient admission.

Furthermore, according to the AHA, hospitals will lose $35.3 billion to Medicare severity diagnosis-related group coding cuts in the American Taxpayer Relief Act of 2012 and CMS regulations.

Another $2.4 billion in cuts will come from an offset for the two-midnight rule, under which inpatient admissions are considered reasonable and necessary for Medicare beneficiaries who require more than a one-day hospital stay or who need inpatient-only treatment.

Finally, in accordance with the Bipartisan Budget Act, long-term acute care hospital payments will be reduced by $3 billion.

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Tuesday, 11 March 2014 08:37 I
International Experts Tell Senators That Single-Payer Improves National Health at Less Cost
MARK KARLIN, EDITOR OF BUZZFLASH AT TRUTHOUT

(Photo: niXerKG)Here are two basic facts to remember about the health care system in the United States. First, there is the high cost, as noted in a 2012 report on PBS: 

How much is good health care worth to you? $8,233 per year? That’s how much the U.S. spends per person.

Worth it?

That figure is more than two-and-a-half times more than most developed nations in the world, including relatively rich European countries like France, Sweden and the United Kingdom. On a more global scale, it means U.S. health care costs now eat up 17.6 percent of GDP....

Whether measured relative to its population or its economy, the United States spends by far the most in the world on health care.

The U.S. spent $8,233 on health per person in 2010. Norway, the Netherlands and Switzerland are the next highest spenders, but in the same year, they all spent at least $3,000 less per person. The average spending on health care among the other 33 developed OECD countries was $3,268 per person.

That statistic brings up the much-beloved free market criteria of return on investment (ROI), at which the US performs abysmally according to many studies when it comes to health. 

An NPR article in 2013 is entitled, "US Ranks Below 16 Other Rich Countries In Health Report":

It's no news that the U.S. has lower life expectancy and higher infant mortality than most high-income countries. But a ... new report says Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations.

And the gap is steadily widening.

"What struck us — and it was quite sobering — was the recurring trend in which the U.S. seems to be slipping behind other high-income countries," the lead author of the report, Dr. Steven Woolf, tells Shots.

He says Americans of all ages up to 75 have shorter lives and more illness and injury.

It should be noted that in this report, the United States is being compared to other "developed" nations.  A recent United Nations Population Divison report ranked the US 40th in life expectancy among all nations in 2010.

In short, the US spends the most on medical care with poor life expectancy results, even including many nations that are not considered wealthy.

The Affordable Care Act (ACA) may have made insurance coverage more inclusive, but it keeps the insurance companies in charge of calling the shots (for those without Medicare, Veterans Care or Medicaid) and adding to the cost of health care through administrative costs and profit.

According to the advocacy organization Public Citizen, a number of experts from single-payer nations recently testified at a Senate sub-committee hearing chaired by Sen. Bernie Sanders (I-VT), a leading supporter of Medicare for all. The spokespersons from Canada and Denmark offered compelling reasons why the US should move from a private-insurance system to a government administered program (such as, well, Medicare):

For example, the Canadian witness, Dr. Danielle Martin, vice president of medical affairs and health system solutions at Women’s College Hospital, compared access to care, quality of care and costs in the U.S. and Canadian systems, and found all were superior in Canada. Martin compared the American average for administrative costs of 31 percent to the 1.3 percent administrative costs paid by Canada (not counting costs for private supplemental plans available to Canadians.) Professor Jakob Kjellberg from the Danish Institute for Local and Regional Government Research, who served as the Danish expert witness, said his country’s administrative costs are only 4.3 percent of total health care spending. 

In short, as has been argued before, private health insurance (which we still obviously have under the ACA) increases the cost of medical care, with nearly a third of that cost eaten up by private insurance non-health related revenue.  To repeat the testimony cited above: 31 percent of US health insurance costs goes to insurers, while in Canada only 1.3 percent of medical costs are administrative.

As far as access to care, to the contrary of what Sarah Palin infamously asserted -- that government care would lead to death panels -- it is private insurance companies who employ staff to decide whether medical care -- sometimes a matter of life or death with chronic illnesses and rare diseases -- should be provided.  Medicare does not employ "profit-increasers" to deny care.

Indeed, a spokesperson for Public Citizen pointedly summarized the hearing:

Today’s panel was a good first step that will hopefully inspire a real discussion about the benefits of single-payer health care in the United States, said Susan Harley, deputy director of Public Citizen’s Congress Watch division. A single-payer, or Medicare-for-all, system would eliminate health insurance companies from the equation, ensuring that only patients and their doctors make decisions about care options.

Although the ACA is to be praised for providing many uninsured people an opportunity to sleep with some peace of mind, it is still a rickety system constructed to ensure the political support of medical insurance companies.

US politicians, including President Obama, regularly boast about the US being the leader of the world in progress and a model for other nations.

Having the most expensive healthcare system, with the worst general outcome ranking for developed nations, looks like the US is a wobbly caboose not a powerful engine.

Medicare for all could solve that problem when it comes to cost-effectively fostering a healthy national population.


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Let's be clear, Affordable Care Act seeks to build state health insurance systems with the intent of ending Federal programs Medicare and Medicaid.  Below you see where a private health system has complete control over Medicaid and the state pays that private entity a fee for servicing this public agency.  Keep in mind that we have a Federal system that was doing just fine except that no oversight allowed massive fraud.  Now, we will have private contractors handling Medicaid and the massive fraud will grow with now no public oversight.  IT SHOULD MAKE EVERYONE'S HAIR CURL!!!!!!

THEY WILL DO THE SAME TO MEDICARE!

Health & Human Services State Medicaid Programs Face Millions in New Fees States are trying to figure out how to budget for a new Affordable Care Act fee that varies based on how much they rely on managed-care companies. by Chris Kardish | March 4, 2014
Tennesse Medicaid Director Darin Gordon, right, said it’s hard to draw a distinction between this new fee and others that the state already covers, so they'll be paying all of it. AP/Mark Humphrey
  As states prepare their budgets for the next fiscal year, many are facing millions of dollars in new Medicaid fees under the Affordable Care Act.

Starting this year, the health insurance industry will pay an $8 billion annual fee, which will grow to $14.3 billion in 2018 and keep pace with premium growth thereafter. Private insurers pay their part of the fee based on the size of the market they control. But states that contract with private insurers to manage their Medicaid programs are shouldering those fees as well -- at least according to some of the states that stand to pay the most. They say the actuaries that set premium rates for the private contractors typically consider fees a burden that states have to pay to ensure there's enough money to cover the needs of patients.

There's no official ruling from the federal government on whether states are required to cover the fees, and officials from the Centers for Medicare & Medicaid Services don't plan to issue guidance. States are just beginning to consider how they'll handle the fee and what they'll do to offset any added costs, said Matt Salo, the executive director of the National Association of Medicaid Directors.


"They’ve talked about it, but I don’t think that many have budgeted for it," he said. "The plans are asking, 'Hey, how do we do this?'"

If they completely cover the fee for their Medicaid plans, states will pay at least $15 billion over the next decade, according to a recent report from actuarial firm Milliman, which prepared the study for Medicaid Health Plans of America (MHPA), a trade group. Exactly how much a state pays will depend on how heavily its Medicaid program relies on private managed-care companies, which are paid a lump sum per patient to handle every claim and are incentivized to stay under budget. 




As of 2010, 36 states contracted with managed-care companies, accounting for 50 percent of all Medicaid patients, according to the report. The Kaiser Family Foundation, though, puts the number at 74.2 percent nationwide because it includes managed-care organizations that don't bear full financial risk. Nearly every state uses managed care in at least some capacity.



States where most managed-care organizations are not for profit will face a far lighter burden because of an exemption in the Affordable Care Act. In Minnesota, for example, where 75 percent to 100 percent of managed-care premiums go to nonprofits, the fee will cost only $128 million over the next decade. Florida, by contrast, faces $1.4 billion.  

MHPA maintains that states should cover the full cost of the fee as part of their obligation to serve the Medicaid population.

“If the plans were to be forced to pay some or all of it, they’d probably be in violation of their [agreements with the states],” said Jeff Myers, president and CEO of MHPA. "The Centers for Medicare & Medicaid Services require the state to have a third-party expert validate that the plans they’re contracting with are ‘actuarially sound’ and the amount of money paid to plans is sufficient to pay expected claims.”

Myers said he hasn’t yet heard about a state refusing to cover the fee. Even the states facing the highest burdens --  including Florida, which is still developing a plan to handle the new costs -- agree that it's their bill to pay. State insurance officials point to a 2005 memo from the Academy of Actuaries that says rates have to provide for “reasonable” costs of business, specifically taxes and fees.

Tennessee faces $56 million in added costs this year and $335 million through 2019. Offsetting those costs will take money directly out of the state's general fund, which covers a broad range of state services. Darin Gordon, the state’s Medicaid director, said it’s hard to draw a distinction between this new fee and others that the state already covers, so they'll be paying all of it.

“If I were not to incorporate that into [the budget] as I do other taxes, it would create a question of why this is different and potentially underpaying my plans in total dollars of over $150 million [when including federal fees as well],” Gordon said.

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Maryland always says it has the best health care cost containment and each time there is a Federal or national watchdog report...Maryland is left off because it has privatized Medicare and no data is available.  High costs in Medicare are more often fraud and profiteering and not quality of care!


Average Hospital Cost By State     Average hospital charges vary widely across the country, with many treatments costing far more in some regions than others. In addition, health costs also differ greatly among hospitals within the same region.


The Centers for Medicare and Medicaid Services published data on average hospital charges for the 100 most common diagnosis and treatments for every hospital in the country treating Medicare patients.

Governing compiled average hospital costs for various treatments, ranking states by cost. The following states were found to have the highest average aggregate rankings, indicating the most expensive medical costs:

1. California
2. New Jersey
3. Nevada
4. Florida
5. Pennsylvania
6. Texas
7. Alaska
8. Colorado
9. Arizona
10. South Carolina

Select a procedure type in the menu below to view average provider charges and total hospital discharges by state for fiscal year 2011. Please note that listed medical charges are not the same as what patients actually pay for a service.

Take a look at this map to see where costs are high....remember, high cost has more to do with fraud and profiteering than good care!
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Obama Administration Proposes Removing 'Protected' Status for Some Medicare Drugs

January 10, 2014



In a move that some fear could compromise care for Medicare recipients, the Obama administration is proposing to remove special protections that guarantee seniors access to a wide selection of three types of drugs.

The three classes of drugs — widely used antidepressants, antipsychotics and drugs that suppress the immune system to prevent the rejection of a transplanted organ — have enjoyed special "protected" status since the launch of the Medicare prescription benefit in 2006.

That has meant that the private insurance plans that deliver prescription benefits to seniors and disabled beneficiaries must cover "all or substantially all" medications in the class, allowing the broadest possible access. The plans can charge more for costlier drugs, but they can't just close their lists of approved drugs, or formularies, to protected medications.

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The mantra with the Affordable Care Act people is that these reforms give access to health care to more people and boosts the number insured for health care.  Before all of this the poor had clinics that gave them all the care they needed and they were able to go to the emergency rooms for more serious conditions.  So, the poor were far better off then now.  Now, they are excluded from most hospitals for many kinds of care.....they are eligible for less preventative care, rather than more.   It will be a debacle for the poor as regards access to ordinary medical procedures.

The expanded Medicare takes in what used to be people with strong workplace health policies that were lost or will be shed in this reform as businesses stop health plan coverage for low-income workers.  It is simply an step down to basic Medicaid and will encompass 80% of Americans.  So, the ACA is indeed a type of single-payer.......Medicaid for All.

This is a good article showing what basic procedures that save lives will not fall under the venue of ACA......


THAT'S A NEO-LIBERAL FOR YOU.....MAXIMIZING PROFITS BY ENDING PUBLIC SERVICES AND PROGRAMS.

Medicaid Programs Vary in Coverage of Preventive Care, Report Says

Released: 7/3/2013 9:00 AM EDT
Embargo expired: 7/8/2013 4:00 PM EDT
Source Newsroom: George Washington University more news from this source Contact Information Available for logged-in reporters only

Citations Health Affairs Newswise — WASHINGTON, DC—Existing Medicaid beneficiaries have largely been left out of the health reform movement when it comes to preventive services that can ward off cancer, heart disease and other potentially deadly diseases, according to a new study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The study, which appears in the July issue of Health Affairs, notes that under the Affordable Care Act most private insurance plans, Medicare and Medicaid expansion programs are required by law to cover a full range of crucial preventive services such as screening tests for colorectal cancer, high blood cholesterol, HIV infection, and diet counseling that can prevent obesity. But state Medicaid plans are not required to cover such care for adults already enrolled in Medicaid—and this report suggests that those adults will not have access to the full range of preventive services.

“Preventive services save lives by detecting diseases before they can progress,” says lead author Sara Wilensky, PhD, JD, special services faculty for undergraduate education in the Department of Health Policy at SPHHS. “Why should some Medicaid beneficiaries be left out when it comes to coverage for this kind of care?” Screening mammograms, colonoscopies, cholesterol screenings and other preventive services are aimed at staving off health problems early on rather than trying to provide costly health care for established and hard-to-treat disorders, she said.

Wilensky and her co-author Elizabeth Gray, JD, a research associate at SPHHS, reviewed Medicaid policies in all 50 states and the District of Columbia from June 2012 through November 2012. The initial review looked at all publically available information on coverage of preventive services. After that first review, the researchers then contacted state Medicaid officials to fill in any missing information about coverage for this population.

The researchers found that most states do not cover all of the preventive services recommended by the U.S. Preventive Services Task Force, an independent panel that looks at preventive care and offers guidelines for health plans and providers. In addition, it was often difficult to discern exactly which services were covered by Medicaid programs based on the vague language used by many programs. The report highlighted some serious gaps in coverage. For example, while most states provided coverage for screening mammograms, not all Medicaid programs offered such care to existing beneficiaries. In fact, three states don’t cover preventive mammograms for this population at all—a shortfall that could mean low-income women will go without the test, the authors said.

The analysis also says that states appear to rarely cover other types of preventive care for breast cancer for those at high risk. Only 11 state Medicaid programs, for example, make it clear that they will pay for breast cancer susceptibility testing for the BRCA1 gene that increases the risk of breast and ovarian cancer. And just three states explicitly cover chemoprevention for such beneficiaries. This medication can be used to lower the risk of breast cancer, a disease that kills about 40,000 American women every year.

"The Affordable Care Act guarantees millions of low-income Americans access to mammograms, colonoscopies and other lifesaving preventive services, but that assurance does not extend to people who currently have Medicaid coverage," said Chris Hansen, president of the American Cancer Society Cancer Action Network (ACS CAN), the advocacy affiliate of the American Cancer Society and one funder of the study. "States have a responsibility to ensure that all people in Medicaid have access to preventive care for a life-threatening disease such as cancer."

The authors of the study also say there is wide variation in coverage of tests for sexually transmitted diseases (STD) and the test for the HIV virus that causes AIDS. And in some states STD screening is limited to family planning visits, a restriction that means people visiting the doctor for some other reason or those who are not eligible for family planning services may not have coverage. Going without this screen, increases the risk that an infected person will not receive treatment and could unknowingly spread a disease to others, Wilensky said.

Many of the preventive services evaluated by the study, such as screenings for early signs of heart disease, depression or diabetes, were either not covered or it was unclear if they would be paid for by Medicaid. In some cases, state Medicaid officers said that the preventive services would be paid for only if deemed “medically necessary.” But Wilensky says that these terms should not be used together because medically necessary tests are for instances when a provider has a reason to suspect an established health problem, while preventive tests are crucial in detecting an emerging problem in an otherwise healthy, asymptomatic person.

Such confusion could leave providers wondering if preventive services will be covered by Medicaid, says the report. In the end, providers may simply fail to provide care if they are uncertain about Medicaid coverage and/or payment for their services, the authors said.

“By lowering risk factors such as high blood pressure and cholesterol, Americans can reduce their risk of heart disease or stroke by as much as 80 percent,” said Nancy Brown, CEO of the American Heart Association, which also helped fund the study. “Evidence-based screenings play an essential role in identifying and reducing these factors. Without Medicaid coverage of preventative screenings and services, we could fall behind in the battle against the nation’s No. 1 and No. 4 killers.”

The authors conclude that there are many opportunities to increase the coverage of preventive services for this population. For example, managed care plans could choose to cover services that end up saving lives even if not required by state Medicaid programs. In states that do not clearly spell out covered preventive services or require providers to follow a specific standard of care, providers could choose to follow the guidelines of the U.S. Preventive Services Task Force. Alternatively, Congress could step in and give existing Medicaid beneficiaries the same coverage of preventive services as most other Americans enjoy under health reform, the authors point out.

The Health Affairs study, “Existing Medicaid Beneficiaries Left Off the Affordable Care Act’s Prevention Bandwagon,” was funded by the American Cancer Society, the American Cancer Society Cancer Action Network, the American Heart Association and the National Colorectal Cancer Roundtable.

The full report, “Coverage of Medicaid Preventive Services for Adults—A National Review,” includes state-specific data and additional information about this topic. To access the report click here.

About the George Washington University School of Public Health and Health Services:
Established in July 1997, the School of Public Health and Health Services brought together three longstanding university programs in the schools of medicine, business, and education and is now the only school of public health in the nation’s capital. Today, more than 1,100 students from nearly every U.S. state and more than 40 nations pursue undergraduate, graduate, and doctoral-level degrees in public health. http://sphhs.gwu.edu/


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WHY CAN WE NOT HAVE PUBLIC EMPLOYEES RUNNING OVERSIGHT FOR A PUBLIC PROGRAM???

Think what TPP is set to do for global PHARMA and think how a private contractor looking for fraud will be accessing which doctor prescribes what. NSA is a hedge fund that we found doing industrial espionage. The ACA is ending Medicare and Medicaid as public health programs folks.....these private contractors will act just like the Department of Education and its Wall Street debt collectors.

In a Major Shift, Medicare Wants Power to Ban Harmful Prescribers

Tuesday, 07 January 2014 10:07 By Tracy Weber and Charles Ornstein, ProPublica

Medicare plans to arm itself with broad new powers to better control — and potentially ban — doctors engaged in fraudulent or harmful prescribing, following a series of articles by ProPublica detailing lax oversight in its drug program.

The U.S. Centers for Medicare and Medicaid Services (CMS) described the effort late Monday in what’s known as a proposed rule, the standard process by which federal agencies make significant changes.

Two of the changes mark a dramatic departure for the agency, which historically has given much higher priority to making medications easily accessible to seniors and the disabled than to weeding out dangerous providers.

For the first time, the agency would have the authority to kick out physicians and other providers who engage in abusive prescribing. It could also take such action if providers’ licenses have been suspended or revoked by state regulators or if they were restricted from prescribing painkillers and other controlled substances.   

And the agency will tighten a loophole that has allowed doctors to prescribe to patients in the drug program, known as Part D, even when they were not officially enrolled with Medicare. Under the new rules, doctors and other providers must formally enroll if they want to write prescriptions to the 36 million people in Part D. This requires them to verify their credentials and disclose professional discipline and criminal history.

Currently, Medicare and the private insurers that run Part D know little about those writing the prescriptions — even those whose yearly tallies cost millions of dollars or who prescribe high volumes of inappropriate drugs.  ProPublica found that some of the doctors had been criminally charged or convicted, had lost medical licenses or had been terminated from state Medicaid programs serving the poor.

The changes would take effect Jan. 1, 2015. As part of the process, CMS will accept public comments until March 7 and could revise the proposals based on the feedback. Undoubtedly, the new rules would require some patients to change doctors — or force some doctors to apply to be part of Medicare.

Several of the proposed changes address failings detailed by ProPublica’s investigation last year.

The series showed that Medicare’s failure to keep watch over Part D has enabled doctors to prescribe massive quantities of inappropriate medications, has wasted billions on needlessly expensive drugs and has exposed the program to rampant fraud. Part D cost taxpayers $62 billion in 2012.

These problems stem largely from Medicare’s failure to rigorously analyze what drugs, and how many of them, physicians are prescribing to Part D patients.

Using the Freedom of Information Act, ProPublica requested and obtained data on the drugs prescribed by every provider in the Part D program for five years —1.2 billion prescriptions in 2011 alone.

Reporters analyzed the data to spot doctors who prescribed in very different ways than their peers — for example, by choosing drugs that were risky or costly, or in ways that suggested fraud.

In interviews, many of the doctors said they had never been contacted by Medicare even though they agreed that their patterns were worthy of scrutiny.

As part of its reporting, ProPublica sought the advice of experts on how to tighten Medicare’s oversight of the program. Among Medicare’s planned changes are several the experts suggested. But others were not addressed in the proposal.

Medicare, for example, does not detail whether officials now plan to routinely scour their data for providers with suspicious prescribing patterns and, when they find them, what they’ll do.

The proposed rule also does not include other suggestions such as requiring diagnosis codes on prescriptions to assess their appropriateness or requiring private insurers in Part D to report suspected fraud, waste and abuse to Medicare’s fraud contractor. Such sharing is now voluntary.

Among the changes Medicare is proposing:

• Giving its outside fraud contractor the ability to more easily investigate suspicions of fraud. Currently, the contractor cannot directly access patient medical charts to assess whether the patient actually saw the doctor or had a condition that warranted the medication.  The contractor must go back to the insurers, which then request the records from doctors or pharmacies.
  
  Under the rule change, the contractor would be given the power to access the records directly. The inspector general of the U.S. Department of Health and Human Services has repeatedly pressed Medicare to make this change.
  
  
• Whittling down its list of “protected drug classes,” vital drugs for which insurers cannot impose restrictions on use. The agency wants to remove antidepressants and immunosuppressant drugs from this list, giving insurers more latitude to require patients receive prior approval before receiving certain brand-name medicines.
  
  

The agency also said it may remove protection from antipsychotics, which can be inappropriate for seniors with dementia, after 2015.

In a blog post, Jon Blum, the principal deputy administrator for CMS, said his agency is serious about fighting fraud and abuse in Part D. Since 2011, he wrote, the agency has reduced the percentage of Part D patients who are potentially overusing painkillers and acetaminophen, which can cause severe liver damage in high doses.

“CMS strives to ensure that beneficiaries have the medications they need while at the same time is being vigilant to safeguard the program from inappropriate use,” Blum wrote.

But when ProPublica looked at the highest prescribers of narcotics in Part D, it found that many had faced criminal complaints, action by their state medical boards or other accusations of misconduct.

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You know what ACA does to Medicare access? It sends most care for seniors and Medicaid to home health care corporations....guess what? Cuts take even that access away!

Home Health Leaders: Unprecedented Medicare Cut Endangers Millions of Seniors' Access to Home Healthcare
November 25, 2013 2:22 PM PR NewsWire



Final Rule disregards input from lawmakers, seniors' advocates, and home health community –

CMS concedes that "approximately 40 percent of providers will have negative margins in CY 2017"(1)

WASHINGTON, Nov. 25, 2013 /PRNewswire-USNewswire/ -- Home health leaders warned that the Home Health Prospective Payment System (HHPPS) Final Rule, released Friday by the Obama Administration's Centers for Medicare and Medicaid Services (CMS), will directly impact the homebound seniors and disabled Americans who are the Medicare program's most vulnerable beneficiaries and will limit their access to the clinically advanced, cost effective home health care they need.

The HHPPS proposed rule initially included a 3.5 percent annual rebasing cut to Medicare home health funding – the maximum allowable under the Affordable Care Act (ACA) – which was calculated using an incorrect base year.  While the Final Rule now uses the correct base year (2010), it maintains the maximum annual rebasing cut of 3.5 percent, thereby imposing an unprecedented total rebasing cut of 14 percent over 4 years.

"From start to finish, this is a patient care issue," said Chairman Billy Tauzin, Senior Counsel to the Partnership. "The stated purpose of the Obamacare legislation was to expand Americans' access to healthcare, but this Obamacare regulation will do the exact opposite.  Despite pleas by lawmakers, seniors and stakeholders, CMS has decided to impose unprecedented cuts to the home health services on which the nation's most vulnerable Medicare population depends.  These cuts directly impact homebound seniors in rural, minority, and underserved communities who are among the Medicare program's oldest, sickest, and poorest beneficiaries."

"Despite the concerns expressed by more than 200 bipartisan Members of Congress, leading senior advocacy organizations, and dozens of other stakeholders, CMS chose to cut Medicare home health payments to the fullest extent allowed by the ACA," added Eric Berger, CEO of the Partnership.  "On a technical basis, this rule is also deeply flawed in that required analyses were never conducted on its impact over the full 4 years in which its cuts will go into effect or on the thousands of small businesses and their employees who will be impacted by it." 

"Just as troubling, the actual nature of this Final Rule has not been accurately disclosed," continued Mr. Berger.  "Although CMS releases seem to suggest that the Final Rule provides rebasing relief, the reality is that the cut in the Final Rule is the maximum allowable under the law.  The ACA authorized the Secretary to impose an annual rebasing cut of not more than 3.5 percent of the 2010 Medicare home health standardized payment rate.  The proposed rule exceeded the law in that it incorrectly applied the 3.5 percent cut to 2013 payment rates.  By contrast, the Final Rule applies the maximum allowable 3.5 percent annual cut to 2010.  As a result, all that can be said of the Final Rule is that, by properly replacing 2013 with 2010 as the base year, it no longer exceeds the law."


                                               Base Year: 2013                              Base Year: 2010

Proposed Rule                        3.5%                    EQUALS                  4.5%

Final Rule                                  2.7%                    EQUALS                  3.5%

"While there are so many people across the country whose health care will be adversely affected by this Final Rule, we are deeply thankful to the many lawmakers who devoted so much of their time and energy in an effort to protect Medicare home health beneficiaries," Mr. Berger added.  "They and the vulnerable Medicare beneficiaries they valiantly serve deserve better than this regulation."

Since the proposed rule was released, tens of thousands of patients, family members, providers, advocates, and state associations have cautioned the Administration that these cuts go too far and will have severe implications on the delivery of skilled home healthcare.  Extensive action was undertaken, including data and policy analyses, grassroots engagement, and extensive direct dialogue.  In addition, letters were filed by leading advocates including AARP, the American Hospital Association (AHA), the National Association of Home Care and Hospice (NAHC), the Visiting Nurses Association of America (VNAA) and many other stakeholders, all of whom expressed concern that the proposed cuts would negatively impact homebound seniors who depend on home health.

"The extraordinary cuts announced on Friday are alarming, especially in light of the deep cuts that Medicare home health has already suffered in recent years," added Senator John Breaux, Senior Counsel to the Partnership.  "Even before these latest cuts, funding for Medicare home health services had been reduced by more than $72 billion since 2009.  When factoring in these additional cuts, two of the nation's leading health care consulting firms – Avalere Health and Dobson|DaVanzo Associates – project that the home health delivery systems in nearly every State will experience net losses by 2017, which greatly jeopardizes seniors' access to high-quality, low-cost home healthcare.  In fact, even CMS concedes – on page 117 of the HHPPS Final Rule – that 'approximately 40 percent of providers will have negative margins in CY 2017' and that more than 8-in-10 of these providers are already experiencing negative margins as a result of pre-existing cuts!  For these reasons, we strongly urge decision makers to protect homebound seniors from this regulation and any further cuts in the weeks and months ahead."

"The fact that this extreme regulation is a result of Obamacare means it cannot help but have political in addition to access implications," concluded Chairman Tauzin.  "The Medicare cuts in the 2010 Obamacare bill angered seniors so much that voters over age 65 helped give Republicans control of the U.S. House in the President's first midterm elections.  These newest Medicare cuts, coming right out of Obamacare, could now put the Democrats' Senate majority in jeopardy when senior voters cast their ballots next November.  Both Democratic and Republican leaders tried to stop the White House from issuing this unprecedented cut, and both were ignored.  Three and a half million seniors depend on home health, they vote, and they are not likely to take these cuts lying down." 

With an estimated 10,000 American seniors entering the Medicare program every day, the Medicare home health benefit is widely recognized as a clinically advanced, cost-effective and patient preferred means for meeting the post-acute and long-term care needs of this rapidly growing patient population. Medicare home health services are delivered to approximately 3.5 million Medicare beneficiaries, who are documented as being more likely to be poor, old, sick, and minority than the Medicare beneficiary population as whole.  In light of its importance to millions of seniors and their families, the Medicare home health sector has been one of the nation's leading creators of new jobs according to the Bureau of Labor Statistics.


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Cutting a trillion from Medicare and then allowing health corporations decide how those cuts will be made.....by limiting patient access of course. THAT'S A NEO-LIBERAL FOR YOU!

Medicare reimbursement cuts threaten access to care
Published on March 29, 2013 at 1:26 PM ·News Medical

Physicians and patients alike are feeling the impact of Medicare reimbursement cuts that went into effect on January 1, 2013. With an additional 2% sequestration cut to roll out on April 1, it's likely that physicians who treat Medicare patients will be faced with difficult decisions as operating margins continue to shrink.

The the 2% cuts may seem modest, but they come on the heels of much larger cuts to reimbursement for nerve conduction studies (NCSs) of 40-70% for Medicare beneficiaries. These cuts were announced November 1, 2012, and went into effect on January 1, 2013, allowing providers little time to prepare.

While all Medicare providers are feeling the squeeze, private practices are likely to experience the most impact. "These cuts may force private practice physicians to choose between seeing Medicare patients and keeping their practice open," said Catherine French, AANEM senior analyst of medical economic affairs. French is concerned that the sequestration cuts will be adopted by private insurers, too. "It is possible that private insurers will follow suit and reduce reimbursement by 2% because most model their payment rates on Medicare."

Cuts Threaten Access to Care
According to Kristi Snihurowych, MD, a spine interventionalist in Salt Lake City, UT, the cuts pose a serious risk to access to care. Snihurowych has decided to discontinue EMG and NCS testing, which previously made up an eighth of her total practice. "Given the cuts, it's no longer feasible to perform these tests in-house. The problem is, I cannot find anyone to do them for me," said Snihurowych. "It seems everyone has had to give them up, and not just for Medicare patients. Providers anticipate that other payers will soon follow suit, so many have stopped offering EMGs all together."

Snihurowych suspects unnecessary and costly procedures will be among the cuts' ripple effects. "I am seeing patients go to surgery without a definitive diagnosis of, for example, carpal tunnel syndrome because the surgeons cannot get confirmation by an EMG or NCS test."

Utah-based physiatrist Faisel M. Zaman, MD, PC, agreed, "People will pay with their health. Of course there will be financial costs associated with unnecessary surgeries, but the biggest cost will be to the patients with scars and pain from procedures they didn't need."

Zaman is a spine specialist who has had several cases where an EMG has prevented patients from undergoing major surgery. In one case, a healthy and active 70-year-old male patient was referred by a vascular surgeon who thought the patient was experiencing symptoms of peripheral vascular disease. But the surgeon wanted to rule out spinal problems before he did a major bypass operation. Following EMG testing, the man was diagnosed with spinal stenosis.

"EMG was critical in this case," said Zaman. "It turns out that he is a great candidate for nonvascular treatments that will improve his condition. Without the lower-extremity EMG, he would have undergone major surgery. It's scary to think of the consequences to patients if the availability of EMG testing becomes more limited. Ultimately, it would hurt patients the most."

Claire Wolfe, MD, AANEM past president, has similar concerns regarding access to care. Nearing retirement and working part-time, she is the only physician performing EDX studies for an office of 23 physicians, as well as some outside referrals. Before the cuts, two other physiatrists in her office performed EMGs.

"There will be greater uncertainty around diagnoses of upper and lower limb pain/numbness; neck surgeries rather than carpal tunnel releases and vice-versa; delayed diagnoses of motor unit diseases; and delayed recognition of folks with metabolic disorders like diabetes if patients don't have access to an electrodiagnostic study that may catch peripheral neuropathy changes before the diagnosis of the underlying disorder is made," Wolfe said.

Unfortunately, the impact of the cuts may be long-lasting. "These cuts will significantly impact Medicare beneficiary access to appropriate management of their disabling neurologic disorders, limit further the number of neurologists who are currently seeing Medicare patients, and discourage budding physicians from the field of neurology," said Mohammed Zafar, MD, in response to an AANEM survey about the Medicare reimbursement cuts for EDX procedures.

Looking Forward
With the cuts to Medicare reimbursement, AANEM members are asking what can be done to protect their practices and to ensure access to care for patients into the future.



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Do you not see this expanding as these health systems grow to the size of Wall Street?  We will see them dictate to us what we will have more than is happening now and the lying, cheating, stealing that infuses business will now effect public health.

THE AFFORDABLE CARE ACT IS ALL ABOUT CONSOLIDATING THE HEALTH INDUSTRY LIKE CLINTON DID THE BANKING INDUSTRY AND THE RESULT WILL BE MOST PEOPLE UNABLE TO ACCESS QUALITY CARE!!!

Doctors allege for-profit owner of two local hospitals committed Medicare fraud and offered kickbacks
By Karen Garloch
kgarloch@charlotteobserver.com Posted: Friday, Jan. 03, 2014 -


Echoing other complaints across the country, two Charlotte-area emergency room doctors allege the for-profit company that owns hospitals in Mooresville and Statesville offered them illegal kickbacks to order unnecessary tests and admit more patients to increase corporate revenues.

Drs. Thomas Mason and Steven Folstad, of Mid-Atlantic Emergency Medical Associates, filed the lawsuit in 2010 in U.S. District Court in Charlotte against Lake Norman Regional Medical Center in Mooresville, Davis Regional Medical Center in Statesville, and their owner, Health Management Associates, the fourth-largest for-profit hospital chain with 71 hospitals in 15 states.

The so-called whistle-blower lawsuit was sealed while federal investigators looked into the doctors’ complaints. But the suit was unsealed in December after the U.S. Department of Justice decided to join the suit in connection with some of the doctors’ claims against HMA. The Justice Department has also joined seven other lawsuits against HMA in other states.

It is standard practice for hospitals to contract with private physician groups to staff their emergency departments. Mason and Folstad claim their group’s long-standing contracts to provide emergency care at Lake Norman Regional and Davis Regional were terminated in 2010 because they refused to accept “illegal cash inducements” and resisted pressure to meet “corporate benchmarks” to maximize profits.

“These practices interfered with the (ER) physicians’ independent medical judgment regarding the best treatment for the patient,” the lawsuit says.

Citing the federal False Claims Act and similar laws in North Carolina and five other states, the lawsuit seeks to recover “millions of dollars” collected by HMA from Medicare and Medicaid, government health programs for the elderly, low-income and disabled.

“This is a massive, nationwide fraud on the American taxpayers that subjected patients to unnecessary tests and hospital admissions,” said the plaintiffs’ lead counsel, Marc Raspanti of Philadelphia.

In addition to HMA, the doctors sued Emergency Medical Services Corp., a for-profit corporation that provides physician practice management services in emergency departments, including many HMA hospitals. For one year, EmCare replaced the Charlotte emergency group, which had contracts as the exclusive provider of emergency services at Lake Norman from 1996 to 2010 and at Davis Regional from 2000 to 2010.

Allegations denied

In a prepared statement, officials of HMA denied the allegations but said they have cooperated with the Justice Department. “The existence of the government’s investigation… has been disclosed for some time in HMA’s public SEC filings.…HMA intends to contest the allegations.”

In an interview, Kirk Ogrosky, a Washington-based lawyer for HMA, said if the plaintiffs’ claims are true, admissions at the Mooresville and Statesville hospitals should have increased after Pro-Med was implemented in 2008. Citing federal data, he said Lake Norman Regional’s admissions from the ER were “consistent” from 2008 to 2011. The data show a 12.5 percent admission rate in 2011, down from 13.2 percent in 2008 and only moderately higher than the 2009 and 2010 levels of 11.4 percent.

“There will always be doctors who believe that any effort to manage them is designed to interfere with their medical decision-making,” Ogrosky said. “The question is whether a single doctor knows better than everyone else.”

The Naples, Fla.-based hospital chain also dismissed criticism in 2012 from a “60 Minutes” investigation that quoted doctors and other former HMA employees who alleged the company aggressively pressured doctors to admit a certain percentage of patients from the emergency room, regardless of whether it was medically necessary.

2009 email cited in suit

The Charlotte-based lawsuit claims HMA systematically tried to increase its revenues in three ways:

•  By using computer software, called Pro-Med, to automatically order expensive batteries of tests for ER patients, based on their initial complaints and usually before they were seen by physicians. The company monitored each hospital’s performance against “corporate benchmarks” and “harassed” the doctors who failed to measure up, Raspanti said.

•  By requiring emergency departments to admit at least 50 percent of Medicare patients, without regard to medical necessity. As independent contractors, Mason, Folstad and other doctors in their group did not have privileges to admit patients to hospitals. They said HMA mandated that they call the private doctor for every Medicare patient who came to the ER to try to persuade those doctors to admit their patients, the lawsuit said.

“HMA would challenge (ER) physicians … to justify why they did not admit all patients age 65 and older,” the lawsuit said. “… HMA’s mandates for minimum admission rates result in hundreds of millions of dollars in illegal charges each year. This is in addition to illegal charges related to unnecessary tests.”

The lawsuit quoted an August 2009 email from an HMA executive to emergency department nurse managers and directors: “Big declines in (over) 65 admissions – You know what to do!”

•  By providing cash incentives to emergency room doctors who “pushed their fraudulent benchmarks for unnecessary tests and unnecessary admissions,” the lawsuit said. At Lake Norman’s emergency room, the suit said HMA offered each doctor $2,000 per quarter for each of six corporate benchmarks met. Given the number of doctors in the group, “these kickbacks … could total $250,000 per year.”

According to the lawsuit, Mason and Folstad complained about these practices repeatedly to officials at all levels of the corporation.

Mason was medical director of Lake Norman’s emergency department from 1997 to 2010. Folstad was medical director at Davis Regional’s emergency department from 2000 to 2008, when he became CEO of the Mid-Atlantic group, which continues to provide emergency services for three other Charlotte-area hospitals owned by Novant Health.

The group’s contracts with Lake Norman Regional and Davis Regional were valued at a total of $6 million per year. He said the group had 52 doctors in 2010 and now has 41.

Raspanti says he does not yet have an up-to-date estimate of the amount of damages sought. Under the False Claims Act, the government has the right to recover losses, which can be tripled, and to get penalties of up to $11,000 per claim. The doctors want to recover losses resulting from the termination of their contracts, and the law allows for those damages to be multiplied.

‘Good practice’ in place

HMA’s lawyer Ogrosky, who previously investigated health care fraud for the Justice Department, defended the practice of using computer programs to standardize hospital practice.

“The software protocols at issue were designed by doctors, reviewed by doctors, and implemented by doctors. It reduces risk and attempts to protect patients by assuring that physicians don’t miss standard and appropriate medical tests and treatment. … Alerting physicians to standard tests and admissions criteria is not pressure, it is good management.”

He added: “It’s good practice for ER doctors to call a patient’s primary care doctor if the ER doctor is considering admitting the patient to the hospital. To allege that it is fraud to encourage ER doctors to call primary care doctors is absurd.”

HMA is in the process of being acquired by Community Health Systems, a Franklin, Tenn.-based for-profit hospital chain. If the merger is approved, Community Health Systems will become the largest for-profit hospital company in terms of number of hospitals, with a total 206 hospitals across 29 states.

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Do you know what this article does not say?  Medicaid was gutted of funding by Congress and then again by the states.  It hardly exists as a public program and the limitations are greatly different.  Access to care is being confined for the most part to huge low-income complexes that are largely staffed by health care worker not very qualified or offering quality work.   Many of the staff are immigrants unable to speak English and Medicaid patients do not want to go to these health clinics.  This is a large part of people still going to the Emergency room in addition to lack of knowledge.  You will see Medicare being placed in these same complexes offering the same lower quality care if we do not demand a strong expanded Medicare for All!

Study: Expanding Medicaid doesn’t reduce ER trips. It increases them.

• By Sarah Kliff


• January 2 at 2:00 pm Washington Post
  

As the health-care law expands Medicaid to cover millions more Americans, a new Harvard University study finds that enrollment in public program significantly increases enrollees' use of emergency departments.

The research, published Thursday in the journal Science, showed a 40 percent increase in emergency department visits among those low-income adults in Oregon who gained Medicaid coverage in 2008 through a state lottery. This runs counter to some health-care law supporters' hope that Medicaid coverage would decrease this type of costly medical care, by making it easier for low income adults to see primary care providers.

"I would view it as part of a broader set of evidence that covering people with health insurance doesn't save money," says Jonathan Gruber, a health economist at the Massachusetts Institute of Technology, who has also studied Oregon's Medicaid expansion but is not affiliated with this study. "That was sometimes a misleading motivator for the Affordable Care Act. The law isn't designed to save money. It's designed to improve health, and that's going to cost money."

The Science study is part of a much larger research project that looks at Oregon's 2008 Medicaid expansion, where the state had limited funding to expand the public program to a set number of low-income residents. Oregon used a lottery to determine who would gain access to coverage, and that created a unique opportunity for researchers: The chance to study what happens when some people are randomly assigned to receive health insurance, and others are not.

Previous research on the Oregon Medicaid expansion has found that enrolling in the public program increased hospital visits, primary care trips and prescription drug use. That left an unanswered question: Were new Medicaid enrollees going their primary care doctor instead of the emergency department, or, were they using more of all types of health-care services?

This study suggests the latter answer: With financial barriers removed, Medicaid patients see their primary care doctor more -- and also go to the emergency department at an increased frequency. Medicaid enrollees made, on average, 1.43 trips to the emergency department during the 18-month study period, compared to an average of 1.02 visits among those who entered the Medicaid lottery but did not gain coverage.

Medicaid coverage also increased the probability of having any visit to the emergency department by 7 percent. The researchers also looked at the types of visits and found no decline in use of the emergency department for primary care treatable conditions among those who had enrolled in Medicaid coverage.

"Part of what makes emergency department use interesting is there are different theories about what to expect," lead study author Sarah Taubman, also at the Harvard School of Public Health. "There's one theory that it increases, because insurance pays for emergency room care that would lead people to use more than if they faced the full cost. The other theory is that, by paying for primary care visits, insurance may lead to a decrease in emergency department use. We looked at this and, taken altogether, we see a net increase.

Twenty-five states and the District of Columbia expanded their Medicaid programs under the Affordable Care Act, extending coverage to all adults who earn less than 133 percent of the federal poverty line, about $15,000 for an individual and $31,400 for a family of four. Two more states, Indiana and Pennsylvania, are seeking to move forward with the health-care law program at a later date.

Although the Affordable Care Act initially mandated that all states expand their Medicaid programs, the Supreme Court ruling in June 2012 found that provision to be too restrictive, allowing each state to decide whether to participate.

Some governors have cited a reduction in emergency department visits as a reason to expand the public program.

"Today, uninsured citizens often turn to emergency rooms for non-urgent care because they don't have access to primary care doctors -- leading to crowded emergency rooms, longer wait times and higher costs," one fact sheet from Michigan Gov. Rick Snyder (R) states. "By expanding Medicaid, those without insurance will have access to primary care, lowering costs and improving overall health."

And, when Congress was debating the Affordable Care Act in 2009, Health and Human Services Secretary Kathleen Sebelius cited the high number of uninsured Americans being seen at the emergency department as a reason to pass the law

“Our health care system has forced too many uninsured Americans to depend on the emergency room for the care they need,” she said in a July 2009 statement. “We cannot wait for reform that gives all Americans the high-quality, affordable care they need and helps prevent illnesses from turning into emergencies.”

Gruber, the MIT economist, doesn't see the Harvard study as a compelling case against expanding Medicaid. There are still other benefits to insurance coverage, he says, that aren't about saving public funding. Separate research on the Oregon expansion, published last spring in the New England Journal of Medicine,  found Medicaid enrollees to have significantly lower rates of depression and were more able to pay their medical bills.

"The overall notion is we're getting people more health care," Gruber says. "There are huge improvements in mental health. For those who want to argue that expanding Medicaid is a free lunch, this is bad. But that was never the right argument." 



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If you have not figured out yet that ACA is only about maximizing health business profits look at the soaring fraud in entitlements with hardly any increased oversight.  Hedge funds and global corporations are now being handed Medicare and Medicaid patient businesses and public health privatized so the public will not have access to health data......

THIS IS SERIOUS FOLKS!  SHOUT OUT FOR EXPANDED AND IMPROVED MEDICARE FOR ALL!


For profit hospice care: Celtic Health Care

By Danny Weil on January 2, 2014 7:20 pm  DAily Censored

    The Washington  Post, formerly owned by Donald Graham, just published a story on how for profit hospices are ripping off Medicare , but the story neglects to mention  that former  owners of  the Washington Post  (especially, grimy Donald Graham) own a hospice company (Celtic Health Care).  Yep, Mr. ‘point and click’, the owner of Kaplan University a sub prime college, is now on the for-profit hospice care circuit. This man and his corporation are shameless.  They continually seek to prey on the young and then when they have sucked the juice out of youth abandoning them in debt, they go after the old and disabled.  A society where the young are handcuffed and the old are trampled, indeed.  Of course you will hear how much your interests lie in their Wall Street privatization plans but of course this is not only nonsense it is offensive. For those of you who are interested in how the for-profit, subprime hospice care scam works and what is being and has been set in motion for your ‘Golden Years’, you might wish to take a look at the following sites. Again, no mention of Donald Graham, the wealthy heir of the Washington Post Empire who broke the back of the Post forcing it into a fire sale through his illicit oversight of the practices of the notorious, serial cancer-debt school, Kaplan University. If you are familiar with Kaplan University and their practices you should then be able to make room within your mind for how terrible the hospice care racket is and will be. Anything these one percenters can get, they will.  From selling organs to selling phony diplomas to selling rancid on-line ‘health care’.  Celtic Health Care is just the latest of these for-profit misery centers.  Donald Graham never misses a beat!  But be sure he is not alone.  There are millions if not billions to be made in health care and ‘on-line’ hospice and dying are now monetized as are people needing care.

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NEO-LIBERAL SENATORS SAY------NOW THAT THIS FRAUD IS OUT IN THE OPEN WE NEED TO DO SOMETHING ABOUT IT!

Meanwhile, trillions in entitlement fraud the last decade has yet to have justice and it is all easily discovered and well documented with government watchdogs.  Did you know that neo-liberals have yet made the definition of fraud well-defined so as to prosecute?  Sounds like Aiding and Abetting to me!


Senators Press for Answers on Drug Program Charles Ornstein and Tracy Weber ProPublica / News Report Published: Thursday 26 December 2013

A Senate committee chairman said he is concerned about the “serious vulnerabilities” detailed in a ProPublica report about scams that target Medicare’s popular prescription drug program. Post a Comment Resize Text + | - | R Plain Text Print SHARE Email A Senate committee chairman said he is concerned about the “serious vulnerabilities” detailed in a ProPublica report about scams that target Medicare’s popular prescription drug program.

Sen. Tom Carper, D-Del., who chairs the Homeland Security and Governmental Affairs Committee, said in a statement that he plans to ask Medicare officials and the inspector general of the U.S. Department of Health and Human Services “to look into the specifics of these cases, as well as determine the extent of any program-wide vulnerabilities that may have allowed them to occur.” The committee monitors fraud in government programs.

ProPublica reporters, using Medicare’s own data, identified scores of doctors whose prescription patterns within the program bore the hallmarks of fraud. The cost of their prescribing spiked dramatically from one year to the next — in some cases by millions of dollars — as they chose brand name drugs that scammers can easily resell.

The cost of medications prescribed by one Miami doctor jumped from $282,000 to $4 million in one year, but her lawyer said Medicare never questioned it. A Los Angeles psychiatrist said Medicare didn’t shut off his provider identification number, used to fill prescriptions, even though he claimed someone had forged his name on more than $7 million worth of them.


All told, just the schemes identified by ProPublica totaled tens of millions of dollars. While credit card companies routinely flag or block suspicious charges as they happen, the detection system used by Medicare’s massive drug program sometimes allows years to pass before taking action that might stop the fraud.

Known as Part D, the program provides coverage to 36 million seniors and disabled people. It cost taxpayers $62 billion last year.

ProPublica has spent the past year examining Medicare’s oversight of Part D. It found that Medicare doesn’t analyze its prescribing data to root out doctors whose inappropriate drug choices endanger patients. Nor has it flagged those whose unchecked devotion to name-brand drugs, instead of generics, adds billions in needless expense.

ProPublica also noted how doctors who had been terminated from state Medicaid programs for questionable prescribing patterns have continued to give patients large quantities of those same drugs through Part D.

Spurred by that report, Sen. Charles Grassley, R-Iowa, the ranking Republican on the Senate Judiciary Committee, sent a letter Friday to Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services, asking what the agency is doing about such doctors.

Several months ago, Grassley asked each state Medicaid program to explain its process for terminating doctors and notifying Medicare once it does so. In his letter to Tavenner, Grassley said he is particularly concerned that doctors can be terminated “without cause” from Medicaid and remain in good standing with Medicare.

He cited three doctors identified by ProPublica who had been suspended or terminated from Medicaid but remained large prescribers in Part D.

This practice by states, he wrote, “may speed their ability to protect Medicaid patients, but it can expose Medicare recipients to potentially unsafe medical treatment and keeps tax dollars flowing to unworthy providers,” he wrote.

Grassley found that states varied widely in how they terminated providers in Medicaid. He asked Tavenner to explain how her agency keeps track of such providers.

Jonathan Blum, principal deputy administrator of CMS, said in a statement that his agency takes fraud in Part D seriously and is committed to making improvements. "We look forward to working with Congress and the HHS Inspector General to continue to protect beneficiaries and taxpayers from Medicare fraud, waste and abuse," he wrote.



Get Email Alerts from NationofChange TOP STORIESSenators Press Medicare for Answers on Drug ProgramBy Charles Ornstein and Tracy WeberA Senate committee chairman said he is concerned about the “serious vulnerabilities” detailed in a ProPublica report about scams that target Medicare’s popular prescription drug program.

Judge Deals a Blow to BP’s Efforts to Dodge Deepwater Horizon PaymentsBy Rebecca LeberIn an earlier decision, Barbier also blasted the company for “attempting to rewrite or disregard the unambiguous terms of the settlement agreement.” BP had once called the class action settlement “more than fair.”

Obama’s Good YearBy Bill ScherDespite the headwinds from the fractious Republican House and the major distraction of the Snowden leaks, Obama secured significant policy achievements and battled naysayers to keep historic initiatives on track.

Merry Christmas, Right-Wingers, The Red Pope, and JesusBy Jim HightowerThe infidels are not accused of lobbing actual bombs in this "war," but Words of Mass Destruction. Specifically, wail the purists, unholy left-wingers go around saying "Happy Holidays," rather than "Merry Christmas," as Jesus taught us to say.

Bill O’Reilly’s War on JesusBy Robert ScheerSo, what would Jesus do about the profound inequality of opportunity that both the pope and our president have identified as the most pressing moral crisis of our time?

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How many states will send their public Medicaid private? Just look at what they are doing with public pensions and 401Ks.....Baltimore does it!

Obama has made so many exceptions so as to end Medicaid and soon to be Medicare as a Federal health plan.

Feds Approve Iowa's Medicaid Expansion Plan That Mirrors Arkansas'
by Kaiser Health News | December 11, 2013        By Julie Appleby Governing



The Obama administration Tuesday granted Iowa much of what it requested to move forward with a Medicaid expansion through the use of private insurance plans but refused to allow the state to charge premiums for those who earn less than the federal poverty level.


If the state accepts the terms of the agreement, it would become the second to be allowed to use federal dollars to finance the purchase of private health insurance for the newly Medicaid eligible.  Arkansas was earlier granted that permission by the Centers for Medicare & Medicaid Services (CMS).



Iowa was among the states that refused to expand Medicaid eligibility under the health law after the Supreme Court ruling made the move optional, but Republican Gov. Terry Branstad and state Democrats reached an agreement last spring that would send many of those new members to private health plans. The state then submitted a Medicaid waiver request to the federal government.



Under the agreement announced Tuesday, those above the poverty line would pay a small portion of the premium, but the administration said the state could not charge those below the poverty line, which is currently about $11,490 for an individual or $19,530 for a family of three.



Consumer groups and some policy experts said charging a premium for those below the poverty line  would set a bad precedent. No other state charges those enrollees. About 40 states allow for limited premium payments for some residents above the poverty level, according to CMS.



“Premiums for people under poverty is a line that CMS cannot cross,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University Health Policy Institute.



“Iowa has pioneered innovative, state-based solutions for Medicaid expansion, and we are pleased to grant this waiver,” said CMS Administrator Marilyn Tavenner in a press release.  The expansion is expected to affect about 100,000 Iowans.



Even before winning approval, Iowa began allowing residents to sign up for the program.


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Why did MarketPlace Money sound like a winner when it said that these private state exchanges handled mostly Medicaid-eligible people? Because Medicaid has been defunded and thrown to the states and is no longer a Federal program-----strike one for eliminating entitlements. The states now have almost all control of Medicaid and how it is managed and as we knew----the republican states are making it next to nothing as they work to wipe it out. Think how Right to Work went from republican to now taking neo-liberal states. The same will happen as Medicaid is dismantled. Next, Medicare. Once these state systems are up and running and have Medicaid and public sector health plans Medicare will be thrown in as well.

THIS IS A REPUBLICAN PLAN FOR ENDING ENTITLEMENTS BROUGHT TO YOU BY NEO-LIBERALS.
Take a look at this map to see how many people fall into this category of Medicaid and then think how Medicaid was gutted of funding by Federal and State pols.  It is a shadow of itself.  It now only gives public health checkups for the most part.

Medicaid Expansion: State Eligibility Totals

The map below details each state's uninsured population that could be eligible for Medicaid and each state's expected spending for the ACA's Medicaid expansion. Darker states have higher percentages of uninsured residents who are potentially Medicaid eligible. Click a state for additional information.



Maryland
Uninsured Potentially Medicaid Eligible: 38.6%
Additional State Medicaid Spending: $533 million
ACA Stance: Do not oppose PPACA

Estimated Medicaid Eligible Uninsured
Below 100% Federal Poverty Level: 205,000
100-138% Federal Poverty Level: 46,000
Total Less Than 138% Federal Poverty Level: 251,000
Total Uninsured: 651,000

Zoom out to view Alaska and Hawaii data.
SOURCE: Medicaid eligibility estimates obtained from Urban Institute analysis of American Community Survey and Integrated Public Use Microdata Series data. State spending figures obtained from Medicaid Coverage and Spending in Health Reform: National and State‐by‐State Results for Adults at or Below 133% FPL, published May 2010 by the Kaiser Family Foundation.

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Those of you thinking there is still a Medicaid program need to be aware that neo-liberals made the same deep cuts to the program as republicans.  Maryland and California both joined NY in drastic cuts in funding and services knowing that large numbers of Americans were falling into poverty and they do not want these War on Poverty programs in place.  They will do the same with Medicare....that is what state health systems are for-----moving Federal programs to the states where they are gutted.

Medicaid is now simply a public health service with checkups that monitor for communicable disease and do minor surgeries in clinics.  You will see Medicaid patients barred from most hospitals as this clinic system is developed. WE ALL KNOW THAT MASSIVE NUMBERS OF PEOPLE THAT WERE FORMALLY MIDDLE-CLASS AND MORE TO COME ARE NOW FALLING INTO THIS CATEGORY.  SO, THEY ARE TAKING AWAY HEALTH COVERAGE FOR MOST.

IT MAKES NO DIFFERENCE IF A STATE EXPANDS MEDICAID OR NOT------THE LEVEL OF CARE WILL NOT BE THERE!

Devastating Cuts in NYS Medicaid Program Proposed

25 Feb, 2011   NY Health Access

Yesterday, February 24, 2011, the governor’s Medicaid Redesign Team approved a package of 79 cost-cutting Medicaid recommendations -- nearly half of which were hurriedly presented that day for the first time.  The team , which had solicited ideas for cost-cutting and reform in public hearings around the state over the last month, was slated to spend three days reviewing a package of 39 reforms that had been selected by the State Department of Health.   The Team's selections were then to be sent on to Gov. Cuomo.

But the State health department expanded the number of reforms to 79 late Wednesday February 23rd.  The next day, which was the first of three days scheduled for review and discussion, state staff urged the team to take a vote before the day was even over.

 Advocates for Medicaid  consumers, including Lara Kassel, co-ordinator of Medicaid Matters NY, a statewide coalition, and the lone advocate appointed to the Redesign Team, denounced the hurried process.  Despite the fact that the package was to be reviewed over the 3 days, allowing time" to delve into the details, become familiar with the impact, probe the authors for details, and have discussions within the advocacy community about how to respond, a vote was taken to approve the package." (Statement of Medicaid Matters NY)

The next step is for Gov. Cuomo to amend his budget proposal to incorporate these proposed cuts.  This will likely happen in the next few days.    Then the usual budget wars begin, except this time, the powerful trade groups that represent health care providers  -- and labor unions --have been disarmed by agreeing to these cuts as members of the Redesign Team.

The official list of proposals is posted here.  The references to proposal numbers and page numbers are to this document.

Read the governor’s press release about the recommendations.

Click here for Selfhelp Community Services' summary of the proposals. 

Click here for an initial reaction to the proposals by the Center for Indepencence of the Disabled - NY (CIDNY). 

See more reaction on the Housing Works Blog and in the Albany Times-Union (Feb. 25, 2011)


Here is a short list of the proposals (again, not approved).     

1.  ELIGIBILITY CUTBACKS --

 §         ELIMINATE SPOUSAL/PARENTAL  REFUSAL

 §         Apply the 60 month look back period for transfer of assets to non-institutional long-term care applicants with spousal impoverishment protections.  DOH claims, “Any income placed in a pooled trust that is used appropriately for allowable services will not be affected. The proposal does not violate the ACA Maintenance of Effort requirement  because it does not affect the eligibility determination. If someone has made a transfer, it would affect the services they can receive not their eligibility for Medicaid.”  We dispute this and believe this change cannot be effective until 2014 because of the maintenance of effort requirement in the health reform law.  

§          GOOD THINGS re ELIGIBILITY, PROCEDURES  --

 o        Disregard IRA’s and 401(k) for Medicaid-Buy-in for Working People with Disabilities (but they are already exempt if in payout status.)

 o        Aged, disabled would no longer have to recertify every year, if they have fixed incomes -- for Medicaid and Medicare Savings Programs.. DOH can automatically calculate eligibility by COLA increases.  

  o      Increase efforts to simplify, automate enrollment and increase retention of insurance - eg. ask for waiver for 2-year enollment, maximize online verification of eligibility,

 2.         HOME CARE --

 §         "Improve management and utilization for split-shift & other hi-intensity” personal care (home attendant) cases - pilot program will be developed as part of transition to Managed Long Term Care -- clearly they are intending to limit use of 24-hour split-shift care.  

 §         Level I - Limit Housekeeping to 8 hours/week (reduced from current 12 hours)  

 §         Replace all assessment instruments in all home care programs with a Uniform Assessment Tool, which must be piloted   

 §         Incorporate personal care (home attendant) into the Medicaid managed care benefit package (joining a Medicaid managed care plan would be mandatory for almost all people but dual-eligibles and people with a spend-down) 

§         Transition most personal care, CHHA and other home care recipients to Managed Long Term Care programs, making enrollment mandatory (now it is voluntary).  See articles about concerns about these growing programs reprinted from the Elder Law Attorney, along with links to lists of these programs statewide at http://wnylc.com/health/entry/114/      

 §         Create incentives to join Managed Long term care: 

MLTC programs will be permitted to include (not mandated) Consumer-Directed ( CDPAP) services -- would do this through state regulation, not a state plan amendment…  (# 1427)  

 Housing income disregard for MLTC enrollees - State would seek 1115 federal waiver to allow nursing home eligible individuals to receive a disregard of a portion of housing expenses if they join a Managed Long Term Care Plan (this would waive requirement that same allowance be given to all “medically needy” Medicaid recipients. (#1032)

• Lots of other cuts in CHHA reimbursement that will impact our CHHA.  

3.              Expand Medicaid Managed Care enrollment for Non-dual eligibles -- While Medicaid managed care is mandatory in most parts of the state, there are many categories of people currently  EXEMPT or EXCLUDED.  (For current rules see this article).  Most of these exemptions will be eliminated over a three-year rollout.   Virtually the only people still excluded are people with a Medicaid spend-down and dual eligibles.

• Examples of categories that are currently EXCLUDED, but will no longer be are below.   The notation (YEAR x) indicates what year exclusion is lifted in the 3-year roll-out.   (EXEMPT categories not listed here) .  Managed care will become mandatory for people who:

            * are in institutional foster care (Year 3)      * live in a nursing home, or are in a long-term home health care program,  or residential treatment facility for children (Year 2) (LTHHCP have option of joining MLTC plan)

    * are a blind or disabled child and live away from their parents, and residents of state-operated psychiatric facilities (Year 3);
    * are in Medicaid’s Restricted Recipient program (Exclusion lifted Year 1);
   
    * are an infant who weighs less than or equal to 1200 grams at birth and other infants meeting the SSI-related categories. (Year 2);        

FOR COMPLETE LISTS of exemptions and exclusions that will be removed see  Proposal 1458 in  this document. p. 210.

• Managed care will also be expanded to include services currently carved out -- prescription drugs, personal care, nursing home.              
  
  
• Dual Eligibles -- Though still exempt, the proposal calls for development of more managed care for dual eligibles -- in addition to the push to put all home care services into Managed Long Term Care.                                          
  
  

4.    OTHER SERVICE CUTBACKS

§         ENTERAL FORMULA - limit coverage for nutritional supplements to those who can only ingest food by tube feeding, those with rare metabolic disorders, those with low Body Mass Index, and children with developmental conditions.. Will eliminate those who just oral nutrition formulas "for convenience" 

§         BEHAVIORAL HEALTH CLINICS - utilization controls - would set thresholds for number of visits per year for OASAS, OMH, and OPWDD .  If number of visits exceeds 1st number (lower threshold), claims paid at 25% discount.  Visits exceeding higher threshold paid at 50% discount

§         ORTHOPEDIC SHOES & ORTHOTICS - Coverage limited to growth and development problems in children, diabetics (Medicare coverage) and when a shoe is attached to a lower limb orthotic brace.  Would cut usage in half. 

§         ELIMINATE BED-HOLD WHILE ADULT  ( >21)  NURSING HOME RESIDENTS ON MEDICAID are temporarily hospitalized or away from the nursing home for other reasons.   Nursing homes could regain the ability to receive reserved bed payments if they enroll 50% of their eligible residents in a Medicare Managed Care Program.  (DOH says federal law makes it optional for states to pay for bed-hold, and that in 2010 state law reduced the bed hold rate to 95% from 100% of the regular per diem rate and limited the number of bed hold days.)

§         Physical Therapy, Occupational Therapy, and Speech Therapy/Pathology, -- Establish Utilization Limits of 20 per YEAR for except for Developmentally Disabled and children 

§         COMPRESSION STOCKINGS - limit to Medicare criteria (treatment of open wounds only) and during pregnancy. No longer cover  poor circulation, varicose veins and discomfort except In pregnancy.  Would reduce by 75%.

§         MEDICAID LIMITS PAYMENT OF  MEDICARE PART B COINSURANCE  -- Medicaid will no longer pay the Medicare Part B coinsurance for services not otherwise covered by Medicaid. (it does now?) Medicaid will limit reimbursement to clinics so that their total Medicare/ Medicaid payment does not exceed the amount that Medicaid would have paid the clinic for a Medicaid-only patient. (They did not adopt wholesale elimination of all Medicaid payment for Part B coinsurance. NOTE: This may not be legal for QMBs).

§         INCREASE copays for Medicaid, Family Health Plus --  and charge copays for additional services -- physician, nurse practitioner, eye glasses, dental, audiology, and rehabilitative services.  Increase Copay annual cap from $200 to $300. 

§         Reduce dental   rates reduced  to match managed care rates on high volume procedures   - may diminish number of dentists willing to accept Medicaid

§         Eliminate Part D Wraparound and other Prescription Drug Cuts  Medicaid will no longer cover the few drugs it now covers if not on the Part D plan's formulary  -- Atypical antipsychotics, Antidepressants, Antiretrovirals used in the treatment of HIV/AIDS, Anti-rejection drugs used in the treatment of tissue and organ transplants, and Medicaid won't cover most of these without "prior approval".     For drugs not on an expanded Preferred Drug List, the physician must request approval, and the law will no longer have a "provider prevails" policy, which currently requires approval of the drug if the physician goes to the trouble of requesting the approval.    



5.    ESTATE RECOVERY, MEDICAL MALPRACTICE LIMITS, LONG TERM CARE    INSURANCE

• Expand the Medicaid definition of "estate" to include assets that normally bypass probate (e.g., assets that pass directly to a survivor, heir or assignee through joint tenancy rights of survivorship, life estates, or living trust).  The proposal would (1) as required by federal law, prohibit a Medicaid estate recovery at a time when the recipient has a surviving spouse, minor child, or blind or disabled child of any age; and (2) allow the Medicaid program to waive an estate recovery in undue hardship situations.
  
  

•  Give statewide responsibility for making Medicaid recoveries from recipients, in personal injury actions and in legally responsible relative refusal cases - already in state law since 2008.  
  
  
•  Cap non-economic damages for medical malpractice awards and  establish a Neurologically Impaired Infant Medical Indemnity Fund. 
  
  
• Encourage new options for private Long Term Care insurance
  
  

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AS WE SEE HERE...QUALITY OF CARE IS FALLING AND REGULATORS AND OVERSIGHT ARE BEING DISBANDED......THIS IS NOT WHAT A FIRST WORLD HEALTH SYSTEM LOOKS LIKE!

Critics Question Medicare's Competitive Bidding Program, Set to Begin Saturday
Written by Rachel Fields | December 28, 2010

  As Medicare's Competitive Bidding Program gears up for its Saturday launch, critics renew their warnings that the program will put patients in jeopardy, according to a Press-Enterprise report.

CMS will implement the program in nine metropolitan statistical areas during its first round. CMS hopes that these areas will start to see savings of up to 30 percent on certain durable medical equipment, prosthetics, orthotics and supplies beginning Jan. 1.

The government says the process is a necessary change to a program marked by wasteful spending and fraud, according to the report. But critics say the program will close businesses or force suppliers to cut staff, and that Medicare and Medicaid have cut rates so low that winning bidders can't afford to provide the services they promised. Critics fear patients will ultimately suffer when contracts are awarded to financially unstable business who cannot meet patient needs.


Dissolution of California Board of Registered Nursing Raises Patient Safety Concerns
Written by Jaimie Oh | February 01, 2012

Critics are speaking out after an October veto by Calif. Gov. Jerry Brown led to the formal dissolution of the state's Board of Registered Nursing, which went into effect this year, according to a California Watch report.

The nursing board, which has been in existence for more than 100 years, investigated complaints against nurses and also processed applications for new nurses. Gov. Brown vetoed a bill that would have extended the nursing board's existence until 2016, citing the proposal "would dramatically expand pension benefits for […] board investigators" and makes "no sense fiscally and flies in the face of much needed pension reform," according to a statement.


As a result of the veto, the state's Department of Consumer Affairs was granted authority to oversee the dissolved board's everyday operations. The move has sparked criticism from former members of the nursing board, including the former president Jeannine Graves. Ms. Graves argues the board's disbanding is a disservice to the public as well as nurses, who are entitled to due process if they are accused of any misconduct.

Another former public member of the board, Richard Rice, who served as a former senior adviser to then-Gov. Arnold Schwarzenegger, also criticized the board's dissolution. He argued the move put a stop to the board's ongoing policy work, including more robust legislation that would require nursing schools to teach clinical and classroom skills, according to the report.

However, state government officials said although the board has been dissolved, its work is still being done.

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HEALTH CARE REFORM IS ALL ABOUT MAKING HEALTH INSTITUTIONS MOST PROFITABLE....SENDING ALL THE COSTLY PATIENTS TO THESE SMALL BUSINESS OWNERS NEEDING SHORTCUTS TO STAY PROFITABLE?  REALLY?


Moody's: ASCs to Benefit From Declining Hospital Inpatient Surgeries

Written by Bob Herman  September 24, 2013

  As hospitals continue to record stagnant or falling inpatient surgery procedures, ambulatory surgery centers will see their volumes increase, according to a report from Moody's Investors Service.

Patient utilization in hospitals, especially for elective surgeries, has decreased significantly over the past five years for several reasons. Millions of Americans lost health insurance due to rising unemployment, and those with insurance have been forced to pay more of their healthcare costs through high-deductible health plans.

In addition, private payers, Medicare and Medicaid have been looking for ways to reduce their own costs, and consequently, they have turned to lower-cost ASCs for surgeries. On average, ASCs are reimbursed 57 percent of hospital rates for similar procedures.

Moody's found that from 2007 through 2012, hospital same-facility inpatient surgery cases dropped 0.22 percent per year, on average. At ASCs, same-facility inpatient surgery cases grew between 0.5 percent and 1 percent.

Moody's analysts said the 5,000-plus ASCs in the United States will continue to record growth in surgery cases this year and more years going forward. In particular, the large for-profit ASC companies like AmSurg, Symbion, Surgical Care Affiliates, Surgery Partners and United Surgical Partners International — which together own 14 percent of the ASC market — will fare the best because they can leverage economies of scale and attract more physician joint ventures, which could provide a "steady supply of patient referrals," according to the report.


Small Businesses in Your CommunityASCs,
sometimes called surgicenters, are usually small businesses owned by members of their com-munity. In fact, 70 percent of ASCs have 20 or fewer full-time employees. These small, community-based businesses benefit their communities not only by providing access to reasonably priced surgical care, but also by contributing to the local property and income tax bases and providing services and con-tributions to community charities. ASCs also make significant contributions to their communities as family-friendly employers that usually offer good health and retirement benefits and often offer flex-ible work schedules to their employees. Several anesthesiologists opened the first ASC in Phoenix in 1970 to provide high-quality, cost-effective surgical care to their patients. Continuing that tradi-tion, most ASCs today are owned and operated by community physicians. Some ASCs are jointly owned by local hospitals and physicians. By involving physi-cians in their management, ASCs ensure that those who are committed to providing topnotch patient care and actually deliver that care are also choosing the equipment and designing the policies they need to provide that care. This makes ASCs great places for physicians to practice and great places for patients to receive care. For nearly four decades, ASCs have worked to im-prove patient care and advance outpatient surgery. As a result, ASCs have introduced a number of health care innovations that benefit all patients, not just those who receive care in ASCs _______________________________
Medicaid programs vary in coverage of preventive care, report says

Existing Medicaid beneficiaries have largely been left out of the health reform movement when it comes to preventive services that can ward off cancer, heart disease and other potentially deadly diseases, according to a new study by researchers at the George Washington University School of Public Health and Health Services (SPHHS).

The study, which appears in the July issue of Health Affairs, notes that under the Affordable Care Act most private insurance plans, Medicare and Medicaid expansion programs are required by law to cover a full range of crucial preventive services such as screening tests for colorectal cancer, high blood cholesterol, HIV infection, and diet counseling that can prevent obesity. But state Medicaid plans are not required to cover such care for adults already enrolled in Medicaid—and this report suggests that those adults will not have access to the full range of preventive services.

"Preventive services save lives by detecting diseases before they can progress," says lead author Sara Wilensky, PhD, JD, special services faculty for undergraduate education in the Department of Health Policy at SPHHS. "Why should some Medicaid beneficiaries be left out when it comes to coverage for this kind of care?" Screening mammograms, colonoscopies, cholesterol screenings and other preventive services are aimed at staving off health problems early on rather than trying to provide costly health care for established and hard-to-treat disorders, she said.

Wilensky and her co-author Elizabeth Gray, JD, a research associate at SPHHS, reviewed Medicaid policies in all 50 states and the District of Columbia from June 2012 through November 2012. The initial review looked at all publically available information on coverage of preventive services. After that first review, the researchers then contacted state Medicaid officials to fill in any missing information about coverage for this population.

The researchers found that most states do not cover all of the preventive services recommended by the U.S. Preventive Services Task Force, an independent panel that looks at preventive care and offers guidelines for health plans and providers. In addition, it was often difficult to discern exactly which services were covered by Medicaid programs based on the vague language used by many programs. The report highlighted some serious gaps in coverage. For example, while most states provided coverage for screening mammograms, not all Medicaid programs offered such care to existing beneficiaries. In fact, three states don't cover preventive mammograms for this population at all—a shortfall that could mean low-income women will go without the test, the authors said.

The analysis also says that states appear to rarely cover other types of preventive care for breast cancer for those at high risk. Only 11 state Medicaid programs, for example, make it clear that they will pay for breast cancer susceptibility testing for the BRCA1 gene that increases the risk of breast and ovarian cancer. And just three states explicitly cover chemoprevention for such beneficiaries. This medication can be used to lower the risk of breast cancer, a disease that kills about 40,000 American women every year.

"The Affordable Care Act guarantees millions of low-income Americans access to mammograms, colonoscopies and other lifesaving preventive services, but that assurance does not extend to people who currently have Medicaid coverage," said Chris Hansen, president of the American Cancer Society Cancer Action Network (ACS CAN), the advocacy affiliate of the American Cancer Society and one funder of the study. "States have a responsibility to ensure that all people in Medicaid have access to preventive care for a life-threatening disease such as cancer."

The authors of the study also say there is wide variation in coverage of tests for sexually transmitted diseases (STD) and the test for the HIV virus that causes AIDS. And in some states STD screening is limited to family planning visits, a restriction that means people visiting the doctor for some other reason or those who are not eligible for family planning services may not have coverage. Going without this screen, increases the risk that an infected person will not receive treatment and could unknowingly spread a disease to others, Wilensky said.

Many of the preventive services evaluated by the study, such as screenings for early signs of heart disease, depression or diabetes, were either not covered or it was unclear if they would be paid for by Medicaid. In some cases, state Medicaid officers said that the preventive services would be paid for only if deemed "medically necessary." But Wilensky says that these terms should not be used together because medically necessary tests are for instances when a provider has a reason to suspect an established health problem, while preventive tests are crucial in detecting an emerging problem in an otherwise healthy, asymptomatic person.

Such confusion could leave providers wondering if preventive services will be covered by Medicaid, says the report. In the end, providers may simply fail to provide care if they are uncertain about Medicaid coverage and/or payment for their services, the authors said.

"By lowering risk factors such as high blood pressure and cholesterol, Americans can reduce their risk of heart disease or stroke by as much as 80 percent," said Nancy Brown, CEO of the American Heart Association, which also helped fund the study. "Evidence-based screenings play an essential role in identifying and reducing these factors. Without Medicaid coverage of preventative screenings and services, we could fall behind in the battle against the nation's No. 1 and No. 4 killers."

The authors conclude that there are many opportunities to increase the coverage of preventive services for this population. For example, managed care plans could choose to cover services that end up saving lives even if not required by state Medicaid programs. In states that do not clearly spell out covered preventive services or require providers to follow a specific standard of care, providers could choose to follow the guidelines of the U.S. Preventive Services Task Force. Alternatively, Congress could step in and give existing Medicaid beneficiaries the same coverage of preventive services as most other Americans enjoy under health reform, the authors point out.

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Ala. transfers nursing services to contractors
 8/04 2:05 pm MONTGOMERY, Ala. (AP)

— State officials are trying to help nursing home workers find jobs with private companies as services that had been handled by the state will be transferred to contractors in 2014.

Alabama Department of Public Health administrative officer Grover Wedgeworth told the Florence Times Daily (http://bit.ly/1b4TUmB ) the department will no longer be the provider for the state's Elderly and Disabled Medicaid Waiver program.

He says the department didn't get the funding it requested from the Legislature that would have allowed it to continue as the service provider in 2014.

Wedgeworth says the services that were provided by the Alabama Department of Senior Services will still be available, but will be handled instead by private contractors next year.

The newspaper reports about 600 nursing home attendants and clerical staff will be impacted.

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Medicaid cuts could come from Democrats

The administration's Medicaid proposal has Jay Rockefeller nervous. | Jay Westcott/POLITICO Close By J. LESTER FEDER | 6/28/11 11:26 PM EDT

Defenders of Medicaid have been fighting hard against Republican proposals to cut the program, but they’re just waking up to the threat of one proposed by the Obama administration.

It’s an idea to change the way federal matching funds work and save money in the process — and it would probably do it by shifting costs to the states. If that happens, Medicaid advocates fear, the states will just pass on the cuts to providers and, ultimately, the patients.



In the budget blueprint unveiled in April, President Barack Obama proposed adjusting the way federal matching funds paid to the states are calculated for Medicaid and its companion, the Children’s Health Insurance Program. Sources close to the administration tell POLITICO that White House officials have been trying to develop the idea into a version that could become part of a deal in the ongoing deficit reduction talks.

Today, state dollars in these programs are matched at different rates for different populations. For the Medicaid population, under the matching formula known as the Federal Medical Assistance Percentages, the federal government pays an average of about 57 percent of the national costs. For CHIP, the rate is about 70 percent.

And when the Patient Protection and Affordable Care Act expands Medicaid coverage starting in 2014, the federal government will initially pick up all of the costs of the new population entering the program, then scale back to 90 percent in later years.

The administration wants to create what’s known as a “blended rate” for these programs, recalculating the levels so states receive federal dollars at the same rate for all populations in joint state-federal health programs. And in the process, they want to contribute to Medicaid savings totaling $100 billion.

This has Sen. Jay Rockefeller (D-W.Va.) nervous.

“What we know is that in order to generate ‘at least $100 billion’ in savings, any blended-rate proposal would have to severely reduce federal Medicaid and CHIP payments to every state over time, with some losing a lot more than others,” Rockefeller said. “And the underlying needs and costs don’t disappear — they just move from the federal side of the ledger to the state side.”

“Such a substantial cost shift to already financially strapped states would force states to reduce or eliminate Medicaid coverage, cut provider payments even more and completely undermine the Children’s Health Insurance Program. This is not a viable option and would spawn a formula fight among the states,” he said.

One reason little attention has been paid to the blended-rate proposal is that the administration has been noticeably silent on it. The only public information it has released on the plan came in the fact sheet accompanying the president’s April speech, which contained a single sentence on the issue that also references introducing a new mechanism for enhanced federal support during hard economic times.

“The president’s framework would replace the current complicated federal matching formulas with a single matching rate for all program spending that rewards states for efficiency and automatically increases if a recession forces enrollment and state costs to rise,” it reads.

But despite the public silence since then, White House officials have been actively developing a detailed proposal that could be part of a budget deal, sources close to the administration say.

This information void has led advocates to hold their fire, especially in the face of threats that were getting a lot of public attention: block-granting the program, capping federal expenditures or repealing Affordable Care Act prohibitions on cutting the program in the run-up to 2014.




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Below is a great article that speaks to just how much these cuts to Medicare will change the level of care you receive.  Now, I'm no fan of doctors and health institutions that have sucked entitlements dry with fraud, but we know that simply telling these health businesses to cut will simply leave patients and labor taking the hit and not the businesses needing to pay.  Read the 'report' marked below.

The big concern will be for staffing as hospitals already have inadequate staffing and with baby boomers coming, they are forcing cuts in staffing just as numbers of people rise.  We will see lower wages and with that a fall in quality.


Remember our old friend at the center of this NSA surveillance scandal BOOZ and Co.  They are an International private management company tasked with making businesses profitable.  The Affordable Care Act is only about consolidating the health industry into global corporations and is only profit-driven.  So, these 'forced' staffing changes and quality of care is simply the BOOZ first step to a lean and mean profit machine that is the US health care industry.  None of the policies work to reign in on massive health industry fraud in the $200-400 billions each year.  In fact these global health systems will be as unaccountable as Wall Street so they will prey on the public.  So whether Third Way corporate democrats or republicans...the goal is global and profit with lost patient access and quality!  JUST GET RID OF YOUR INCUMBENT AND RUN AND VOTE FOR LABOR AND JUSTICE.


Consumerization
Booz & Company strongly believes that consumerism is a revolutionary force that will fundamentally alter the status quo in the health industry. We work with our clients—payors, hospitals and health systems, and life sciences companies—as they seek to understand all the implications of this new world and become leaders in the consumerization of healthcare.



AMA: Cuts to physicians who treat Medicare patients hurt jobs, patient access and Medicare modernization Jeremy Lazarus, MD | Policy | September 13, 2012

A guest column by the American Medical Association, exclusive to KevinMD.com.

Physicians contribute significantly to both the health of our patients and the economic health of our nation, and a new report shows that the 2 percent Medicare spending sequestration cut will put the jobs supported by the health care industry in jeopardy.

The AMA recently teamed up with the American Hospital Association (AHA) and the American Nurses Association (ANA) to release a new study showing that hundreds of thousands of jobs will be lost due to the Medicare sequestration cut dictated by the Budget Control Act.



Right now, we have an aging population of baby boomers who need the health care Medicare makes available, and we also have Americans who are grateful to have – or are looking to find – the good jobs the health care system provides. Common sense tells you that this is not a good time to take a hatchet to health care, which saves American lives and puts Americans to work.

The new report gives us a first look at the direct and indirect employment impact of the sequestration cuts to Medicare. It estimates that during the first year of this sequester, more than 496,000 jobs will be lost, and this number will grow to a job loss of 766,000 by 2021. Coupled with the looming 27 percent cut in payments to physicians who treat Medicare patients caused by the flawed Sustainable Growth Rate enacted by Congress, this sequestration cut will hurt patient access to care and will insert more uncertainty into Medicare. We need stability in the Medicare program as we work to promote high quality, high value, better coordinated patient care.

Payments to physicians who treat Medicare patients have been nearly frozen for a decade while the cost of caring for patients has increased by more than 20 percent, creating a huge gap between Medicare payments and the cost of providing care to seniors. Those who rely on Medicare for their health care already face roadblocks to physician access: according to a 2010 MedPAC survey, about one in four Medicare patients looking for a new primary care physician has had trouble finding one.

As we look to shape the health care system of the future that focuses more on keeping patients healthy and coordinating their care, physician practices must make investments in technology, hiring new staff and training for their current staff.  The impending sequester, paired with more than a decade of essentially flat Medicare payments, denies practices the resources they need to make these investments in the future of health care.

As part of the AMA’s new strategic plan, we currently have the opportunity to improve and restructure care delivery and payment policy. Physicians have already begun transitioning into alternative payment and delivery models, both in Medicare and the private payer market, and many ground-breaking innovations are already underway. It is critical that we continue our work to modernize physician practices and support the coordinated care that can improve patient health and prevent costly complications.

Congress must take action to remove the threat of an impending cut to physicians who care for Medicare patients. The AMA, along with state and specialty medical societies, sent a letter to Congress today urging the passage of legislation to nullify the sequestration cut. To prevent widespread patient access problems, significant job losses and slowed progress toward Medicare innovation, we must have stability in payments for those who treat Medicare patients.

- See more at: http://www.kevinmd.com/blog/2012/09/ama-cuts-physicians-treat-medicare-patients-hurt-jobs-patient-access-medicare-modernization.html#sthash.iwiJDzR9.dpuf


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THIS ARTICLE SHOWS WHAT ARE CLOSER TO REAL NUMBERS....WE KNOW THAT 1/2 OF ENTITLEMENT SPENDING IS FRAUD SO THESE NUMBERS LOOK CLOSE TO THAT REALITY.  You will see government figures that say that fraud is only tens of billions of dollars and THAT IS A LIE!!
Cost of Medical Fraud Could Pay for Health Care Reform —By James Ridgeway  Mother Jones

| Wed Aug. 19, 2009 4:45 AM PDT

1

According to reporting yesterday on NPR, the cost of medical fraud in the United States runs anywhere from $60 billion to $600 billion a year--in other words, it might actually exceed the price tag for health care reform. Instead of whining about the expense of reform measures, Republicans and Blue Dog Dems might think about saving us money by cracking down on fraudulent practices, which target both the government and private insurers. 

Obama has recently announced a new DOJ/HHS task force to combat fraud, and some versions of the health care reform bill have a measly $100 million set aside for anti-fraud measures. It seems like far too little and too late--but apparently, it's more than has been done by past administrations, or by the oversight committees, the appropriations and legislative committees whose job it is to ride herd on taxpayer funds. 

Here is a bit from the NPR report:

Medical fraud takes several forms. Most commonly, criminals get a list of patients’ names, then create fictitious doctors. They send bills to Medicare or Medicaid or health insurers for services supposedly rendered to these patients. By the time the payers figure out that the doctors they’re paying are fictitious and no service was ever rendered, the criminals have closed up shop and moved on.

Another popular form of health care fraud is the “rent-a-patient” scheme. Recruiters find people with health insurance willing to get care they don’t need, in exchange for cash or cosmetic surgery. Several years ago, insurers and the FBI said they had cracked a big case. People from 47 states were paid to come to California to receive unneeded care, including colonoscopies and surgery for sweaty palms. The doctors who performed the work reportedly charged insurers a total of $1 billion.

I suppose the libertarian Republicans would say it’s just a small price to pay for our free market system. And of course, if the government started taking a closer look at the crooks who illegally rip off the system, they might also have to deal with the crooks who rip off the system quite legally--the price-gouging insurance and pharmaceutical companies and their ilk.

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This is actually a good thing as we need to look at these doctor's bills in order to stop what we know is massive entitlement fraud...

Federal judge lifts ban on public access to Medicare data

• By Maurice Tamman
  

Fri May 31, 2013 8:01pm EDT

n">(Reuters) - A federal judge lifted a 33-year-old injunction barring public access to a confidential database of Medicare insurance claims, a decision that could lead to greater scrutiny of how physicians treat patients and charge for their services.

Judge Marcia Morales Howard ruled Friday in favor of a motion by Dow Jones, publisher of the Wall Street Journal, that the U.S. District Court for the Middle District of Florida lift an injunction imposed in 1979.

The American Medical Association had fought lifting the ban, arguing that disclosure of the information would violate physicians' right to privacy. Doctors had successfully made the same argument in 1979, when a judge ruled the release of such information would violate the 1974 Privacy Act.

The AMA suggested Friday that it might appeal the decision. In a statement, AMA President-elect Ardis Dee Hoven said the doctors lobby was "considering its options on how best to continue to defend the personal privacy interests of all physicians."

Officials at the Centers for Medicare and Medicaid Services couldn't be reached for comment. A Dow Jones spokeswoman declined to comment.

Dow Jones went to court in January 2011, attempting to overturn the injunction after a series of stories in the Journal found tens of millions of dollars in fraud and other abuse by doctors and other Medicare providers. Medicare is funded by U.S. taxpayers.

The Journal's work, however, was restricted by limitations placed on the data released by the U.S. Department of Health and Human Services, which rendered anonymous all information pertaining to individual Medicare providers. That meant reporters weren't allowed to name individual doctors who the Journal identified solely through using the data.

In her ruling, Judge Howard said that because judicial rulings in the years since the injunction have restricted the Privacy Act's reach, the ban was based "upon a legal principle that can no longer be sustained."

When the suit was filed, the Journal's editor-in-chief at the time, Robert Thomson, said: "The Medicare system is funded by taxpayers, and yet taxpayers are blocked from seeing how their money is spent. It is in the interest of law-abiding practitioners that those who are gaming the system are exposed."

Dow Jones is a unit of News Corp.



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WHAT THIRD WAY CORPORATE DEMOCRATS ARE DOING BY HAVING A DEMOCRATIC PRESIDENT AND CAPITOL HILL ADOPTING REPUBLICAN POLICY THAT KILLS THEIR VERY CONSTITUENTS IS TO CAPTURE THE DEMOCRATIC PARTY SO THAT IT BASICALLY ELIMINATES THE PEOPLE'S ABILITY TO AFFECT POLICY. IT ELIMINATES THE DEMOCRATIC PARTY WHEN THIRD WAY MOVE FURTHER AND FURTHER RIGHT.

If you listen to the media like NPR they pretend that it is the republican party being eliminated as democrats lead the policy issues. As Third Way move right by adopting republican policy .......Third Way becomes the only policy-making group. ALL THIS POLICY IS FREE MARKET, FREE TRADE, EMPIRE-BUILDING, AND CORPORATE RULE.....ONE PARTY = NO POLITICS......THAT IS THE GOAL OF THIRD WAY.

It is important for democrats to kick Third Way out of the party by not allowing the DNC choose your candidates.....run and vote for labor and justice next elections!!!!


Don't Look Now, but Our Medicare Spending Projections Are Plummeting

Predictions are hard, especially about health care inflation Derek Thompson May 14 2013, 4:07 PM ET More Here's the story budget wonks will tell from today's Congressional Budget Office report: The deficit is poised to shrink to its lowest level since 2008. Good news? Yes, if you're a deficit hawk. Bad news? Yes, if you think (as I do) the deficit is falling too quickly, especially at a time of high unemployment and declining household debt.


Here's the story I wish more people would talk about: Our incredible shrinking Medicare projections. Since August, CBO has now revised down its projections of mandatory health care spending by nearly $500 billion, as Michael Linden pointed out. Since the 2010 CBO report, projected Medicare spending between 2013 and 2020 has fallen by just over $1 trillion ... or 16%.

Here's the graph comparing 2010's Medicare projection to 2013's ...




...  and here's the graph comparing cumulative Medicare spending over that time. In three years, we've taken projected Medicare spending in the twenty-teens down from about $6.5 trillion to about $5.5 trillion.


So many numbers. Why should you care?


Two reasons. First, the "runaway" growth of health care costs has been a motivating reason for responsible Washingtonians to ignore the unemployment crisis and focus on our deficit. But lo-and-behold, we've cut more than ONE TRILLION DOLLARS from projected Medicare spending -- and much more if you project out for the full decade. Many of the cuts have come from laws, like the Affordable Care act. Others came from lower growth in overall health care spending.

Second -- and this is the really important point I wish I could make more often -- this is an invaluable lesson in the folly of long-term budget projections (yeah, I appreciate the irony that I'm graphing budget projections to make this point). In a world where all predictions about the future of U.S. government spending turn out to be true, it makes a lot of sense to pay rapt attention to 10- and 20-year forecasts of spending and revenue. But in a world where the most exquisitely delicate change in hospital cost inflation suddenly saves hundreds of billions of dollars, it makes projections impressionistic, at best. In the future, there are budget crises that some people think might happen. In the present, there is a long-term unemployment crisis that we know is happening.


Why should impressionistic statistics about the future win that fight for Washington's attention?
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The Affordable Care Act has as its goal to consolidate all health institutions into global health systems that will be just as big, greedy, and unaccountable as Wall Street so they will be preying on the poor, elderly, and chronically ill not caring for them.  So the goal is to make health care ever more profitable.  This means entitlements will be gutted and people will fall into what these politicians are creating as public health clinics.  Medicaid is going first as MD defunded Medicaid even more then Capitol Hill (this is how O'Malley balanced his budget after all).  Medicare is close behind as this policy from the Feds is a back door defunding of Medicare and will indeed cause patients to lose care and quality.

Remember, 1/2 of entitlement spending has been lost to fraud for these few decades..that is trillions of dollars needing to be recovered and brought back to the Trusts.  Do you know that Reagan started sending payroll taxes to the Treasury rather than the Trusts way back then?  That means $3-4 trillion in payroll taxes are missing from the Trusts so why all the cuts rather than the effort at recovery?  They are telling us they don't intend to recover the fraud so they are replacing the lost funds with lost patient care.

We need to tell these politicians goodbye by RUNNING AND VOTING FOR LABOR AND JUSTICE THESE NEXT ELECTIONS!  Stop letting them steal your money!



Maryland hospitals warn of jobs losses if federal cuts hit


By Andrea K. Walker, The Baltimore Sun 6:22 p.m. EDT, April 26, 2013

The Maryland Hospital Association said Friday that jobs may be in jeopardy if a state commission approves a plan that would make hospitals absorb all of the 2 percent Medicare cuts required under federal sequestration.

The board of the Health Services Cost Review Commission, which sets the state's hospital rates, is scheduled to vote Wednesday on how to implement the cuts. The commission's staff has recommended a plan that keeps hospital rates flat for the last three months of fiscal year 2013, which ends June 30.

Hospitals are pushing for a rate increase to help offset the cost of the cuts. Medicare accounts for 41 percent of hospital revenue on average, according to the American Hospital Association.

The state hospital association released a report Friday that said 1,450 Maryland jobs would be lost for every 1 percent drop in total hospital revenue. The job losses would come from hospitals and from firms related to the hospital industry. Hospitals in Maryland employ nearly 100,000 people, according to the report.

The commission staff declined to comment on the report. It had considered other options to deal with sequestration, including spreading the cost between insurers and hospitals and increasing hospital rates slightly.

In its recommendations, the commission staff worried how a rate increase would affect the state Medicare waiver, an agreement with the federal government unique to Maryland that allows the state to set hospital rates. Maryland keeps the waiver only if the average cost per admission rises no faster than in other states. The state is negotiating a new waiver test with the federal government, and commission members worried that a rate hike would harm those talks.

Sequestration cuts will be considered further in coming weeks as the commission hammers out hospital rates for fiscal year 2014, the commission staff wrote in its recommendations.

The hospital association has said the Medicare cuts come as hospitals already face financial pressure. The commission increased rates by 0.3 percent in fiscal year 2013, when inflation was expected to increase by 2.11 percent.

The commission staff said that hospitals are more profitable as a group this year than they were last year despite a reduced operating margin.

andrea.walker@baltsun.com



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Raise your hands if you think that aiming cuts to Medicare(M) towards hospitals not at M benefits is a back door cut to benefits!  That's right.  The cuts to M spending will be felt by the quality of services rendered and by staff who will see increased workload and/or cuts to pay and benefit.  Why do health insurers like that?

The bulk of health care costs come from health fraud/waste.  Entitlement spending is almost 1/2 fraud.  Fraud/waste often comes from preventative medicine..multiple uses of testing such as blood labs and Xrays for example.  Fraud/waste happens in more complicated hospital procedures but it is more rare.  Using heart stents or orthopedic surgery are two areas of fraud we know.  What we see with health reform is a push to these very preventative health areas with the most fraud/waste.  Doctors keep fraud. Insurers keep profit.


Policies placing the burden of cuts to the hospital cut access to the costly hospital procedures and give the patient's staff the burden of poor working conditions, a lose lose for the patient.  Why would insurance companies like this?  They don't pay for hospital labor so won't feel that and the cost of multiple lab tests are cheaper than serious hospital procedures requiring hospital stays.  M patients will see is less access to quality of life procedures and more blood checks for high levels of salt, sugar, and fat. Longevity falls.


Rate-setting commission recommends no increase in hospital charges Hospitals hoped increased rates would offset sequestration cuts


By Andrea K. Walker, The Baltimore Sun 9:49 p.m. EDT, April 25, 2013

The state's hospitals would absorb all of the 2 percent Medicare cuts required by federal sequestration under a proposal released Thursday by the state panel that sets hospital rates.

The recommendation by the staff of the Health Services Cost Review Commission would mean that state hospitals would not get rate increases for the last three months of fiscal year 2013, a decision that prompted intense criticism from medical institutions that say they already operate on slim margins.

Hospitals sought a rate increase to help offset the cost of the federal budget cuts and said they will have to cut services and jobs without one.

"Our view is now is not the time to impose yet another cut on Maryland hospitals," said Carmela Coyle, president and CEO of the Maryland Hospital Association. "We are too financially fragile."

Insurers, however, supported the plan recommended by the commission staff.

The commission is scheduled to vote on the proposal Wednesday. Collectively, hospitals would lose about $7 million to $8 million a month under the proposal for April, May and June, the commission said.

The Medicare cuts are part of $85 billion in across-the-board federal spending reductions known as sequestration. The U.S. Department of Health and Human Services plans to cut $15.5 billion under the plan, with much of it coming from Medicare.

Medicare patients will not face reductions in benefits under sequestration. Instead, the federal government specifies cuts should be made to payments to hospitals and doctors and to monthly payments made to private plans that administer parts of Medicare.

The cost review commission staff, which developed the recommendation not to increase rates, declined to comment, saying its views were clear in the recommendations posted on its website.

Maintaining hospital rates was one of three options considered by the commission staff. The option supported by hospitals would have treated revenue lost from sequestration as a one-time "unusual expense," and rates would have risen to compensate. Hospital rates would have increased 0.16 percent for the last quarter of the fiscal year, which runs through June.

Another plan would have split the sequestration impact between insurers and hospitals. Half of the sequestered revenue would have been treated as a one-time expense and hospitals would have gotten a 0.08 percent increase in rates until the end of the fiscal year.

The state's largest insurer had no comment on the staff's final recommendation Thursday, but had supported not increasing rates for hospitals.

Increasing hospital rates would have "diluted" the intent of sequestration, which was to reduce federal expenditures nationally by 2 percent, wrote a CareFirst BlueCross BlueShield executive in a March letter to the rate-setting commission.

CareFirst and the rate-setting commission staff said they also worried how raising rates would affect the state's Medicare waiver, an agreement with the federal government unique to Maryland that allows the state to set hospital rates.

The state must pass a test to maintain the waiver. Maryland keeps the waiver if the average cost per admission rises no faster than in other states. The state is in the process of negotiating a new waiver test with the federal government.

Rate increases would "erode the state's position on the current waiver test and disadvantage Maryland under any new waiver test," CareFirst said in its letter.

The hospital association, which represents 46 acute-care hospitals in the state, has tried to sway the commission to make up for the cuts with higher rates. The group issued a report Thursday detailing financial troubles it says the state's hospitals are facing.

As a group, the hospitals' operating margin was 0.8 percent for the first eight months of fiscal year 2013, the second-lowest performance in 14 years, the report said. Twenty-five of Maryland's 60 hospitals — 42 percent —have negative operating margins, according to the report. In other words, they were losing money caring for patients.

The rate-setting commission increased rates by 0.3 percent last year, when inflation was expected to increase by 2.11 percent, the report said.

In its recommendation, the commission staff said hospitals are more profitable as a group this year than they were last year despite the reduced operating margin.

The rate-setting commission will begin discussing fiscal 2014 rates in coming weeks and said it will look at the impact of sequestration then.

Hospitals will have to make cuts immediately once a decision is made. Coyle said the cuts will likely have to come from services and jobs.

"There is no ability for hospitals to say 'OK, we're just not going to purchase this new piece of equipment next year,'" Coyle said.

The commission staff's recommendation isn't final and will be further debated at Wednesday's meeting. Coyle hopes some commissioners will have a change of heart. She said the federal law enabling the waiver requires the rate-setting commission to ensure hospitals are financially sound.

"I feel strongly there is still a chance, and I hope the commissioners will take a good hard look at the financial condition of hospitals and really think about rejecting the staff's recommendations," she said.






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HOME HEALTH CARE IS THE LARGEST GROWTH CENTER IN ENTITLEMENTS AS THE BABY BOOMERS AGE AND NO WITHOUT REASON IT IS THE LARGEST SITE FOR HEALTH CARE FRAUD.  WE ARE SHOUTING OUT AT STATE LEVEL TO MAKE HEALTH CARE FRAUD A PRIORITY!!!

DO YOU HEAR YOUR INCUMBENT SHOUTING LOUDLY AND STRONGLY TO BRING TRILLIONS IN FRAUD BACK TO THE TRUST FUNDS????

VOTE YOUR INCUMBENT OUT OF OFFICE!!!

Blistering inspector general report says feds are failing to fight Medicaid home care fraud Jasmine Norwood/The Center for Public Integrity

IG has repeatedly warned Centers for Medicare and Medicaid Services about personal services program for home care By Joe Eatonemail 12:01 am, November 15, 2012 Updated: 10:48 am, November 15, 2012 Advertisement Cracking the Codes Medicare has emerged as a potent campaign issue, with both Barack Obama and Mitt Romney vowing to tame its spending growth while protecting seniors. But there’s been little talk about some of the arcane factors that drive up costs, such as billing and coding practices, and what to do about them.  Our 21-month investigation documents for the first time how some medical professionals have billed at sharply higher rates than their peers and collected billions of dollars of questionable fees as a result. 

Stories in this series How doctors and hospitals have collected billions in questionable Medicare fees By Fred Schulte and David Donald September 15, 2012 Blistering inspector general report says feds are failing to fight Medicaid home care fraud By Joe Eaton November 15, 2012 Feds tighten scrutiny of health records By Fred Schulte December 14, 2012 Medicare paid $3.6 billion for electronic health records but didn't verify quality goals were met By Fred Schulte November 29, 2012 More stories Like a growing number of disabled Americans on Medicaid, Keith Foreman, a 57-year-old in Metropolis, Ill., qualified for a personal caregiver to help him with daily activities like dressing, shaving, and preparing meals.

Foreman, who prosecutors say suffers from a spinal injury, hired his girlfriend, Sheila McDonald, for the job. In 2011, McDonald received almost $5,000 from Medicaid for six months of care she provided to Foreman.

These personal care services, which are available in all 50 states, are designed to help the sick, elderly, and disabled remain in their homes — and out of expensive nursing facilities. But Foreman was not living at home. During the days marked on McDonald’s timesheets, Foreman was housed in the Massac County jail in Illinois, serving time for forging a stolen debit card signature at a local liquor store.

Like Foreman and McDonald, who both pleaded guilty to charges of making false statements, unscrupulous beneficiaries and home health workers are increasingly targeting personal care services programs for illegal money-making schemes, according to a new federal report. Investigators say lax requirements for both caregivers and patients, along with poor state and federal oversight, has made the rapidly growing programs a lucrative target for fraud.  And this isn’t the first time they’ve issued such a warning.

Report faults federal oversight of state programs A Health and Human Services Office of the Inspector General (OIG) report scheduled to be released today faults the Centers for Medicaid and Medicare Services (CMS) for inadequate oversight of personal care services programs, whose costs are shared by states and the federal government, as is the norm for Medicaid.  The report, which brings together six years of OIG investigations and 23 reports on the topic, describes a program hindered by poor claims documentation, insufficient monitoring of claims data for fraud and waste, and a crazy-quilt of varied requirements for personal care workers in different states.

“Historically, CMS has left a lot of the responsibility for overseeing waste, fraud and abuse to the states,” said Christi Grimm, special assistant to the principal deputy inspector general. “As a result, we have 301 different sets of requirements for caregivers across the states.” 

Although some states mandate criminal background checks and licensing for home health workers, Grimm said others lack even the most basic requirements, including age minimums, which has led to cases in which juveniles escape prosecution for fraud and abuse. Worker requirements are set by counties in a number of states, she added, which has led to a hodge-podge of rules that are difficult to enforce, and nearly impossible to monitor.

“We are asking CMS to step up to the plate,” Grimm said, and use its authority to regulate and monitor the state programs.

The report includes six previous OIG recommendations to CMS and state agencies which have gone unimplemented. In a 2008 report that found five states may have paid up to $11 million in error for personal care services during one quarter of 2005, OIG recommended that the CMS work with states to stop payments for personal care when patients were receiving care in institutions, not at home. The agency agreed with the recommendation, but according to the OIG, the work has not been completed.

In addition to asking the agency to address previous recommendations, the report offers four new goals for CMS to improve oversight and monitoring of state plans, including standardizing rules for personal care workers to set minimum age and education levels, and require criminal background checks.

The report, however, seems unlikely to spur the agency to follow the OIG’s specific suggestions..  In a written response, CMS — part of the Department of Health and Human Services — explicitly concurred with only one of  the OIG recommendations: that it should provide states with claims data to help root out cases in which beneficiaries are simultaneously receiving both institutional care and home health services.  In response to the recommendation on establishing federal guidelines for personal care workers, CMS pointed out there is a shortage of care attendants.

 “Personal care services are an important part of keeping people in their homes and out of nursing homes, which lowers costs and improves the quality of life of the patient,” said CMS spokesman Brian Cook. “We are working to protect personal care from fraud and abuse by promoting stronger training programs for workers who provide personal care, working with states on background check programs for these workers, and developing new data methods to analyze claims for potential fraud and abuse."

Grimm called the CMS response to the report unacceptable. “It’s not uncommon for CMS … to identify things on the horizon, or things they hope to do, but not necessarily commit to doing something,” Grimm said, adding that CMS’s efforts so far simply have not worked. “[CMS] has the authority to do what we are asking. It has not done it yet. And it hasn’t committed to doing it after reading our report.”

A wealth of opportunitiesAccording to investigators, most fraud schemes in personal care services involve billing for care that was not provided or was not allowed. Self-directed programs, which allow beneficiaries to hire and manage their helpers, may be particularly vulnerable, but some prosecutions have also involved home health care agencies.

In January, for example, the owner of a Minnesota home health care company outside Minneapolis was sentenced to two years in prison for cheating Medicaid out of more than $650,000 in charges for personal care services. In March, the owner of Families First Home Health Care in Sparta, N.C., pleaded guilty to fraud and money laundering stemming from a scheme in which she billed Medicaid for personal care services she did not perform and split the proceeds with plan members.

“Fraud goes where the money is,” said Barbara Zelner, executive director of the National Association of Medicaid Fraud Units, which represents state law enforcement agencies that investigate Medicaid fraud.  After nursing homes, Zelner said, home health represents one of the larger slices of state Medicaid budgets.

Personal care services programs have grown quickly since a 1999 Supreme Court decision held that unjustified segregation of the disabled is a civil rights violation. The ruling led to increased spending for home health services; in 2011, Medicaid paid more than $12 billion for personal care services, up 35 percent since 2005, according to the OIG. Investigators say program fraud has kept pace. In 2010, state Medicaid fraud units investigated more than 1,000 cases involving personal care services, more than any other type of Medicaid service.

Not everyone agrees with the OIG’s views on personal care services.  In 2011, an OIG review of Medicaid claims for personal care services in New Jersey found that 40 percent should have been denied. Sherl Brand, president of the Home Care Association of New Jersey, which advocates for home health care providers, questions the OIG’s work, saying the agency often draw broad conclusions from examinations of a limited number of claims. “It is almost a bit ridiculous because of the extrapolation they do,” Brand said.

New Jersey home health workers face criminal background checks and certification and licensure requirements, Brand said. Personal care services programs save money, she said, in addition to helping disabled people live better lives. When New Jersey was faced with budget cuts, Brand said the association determined the average weekly cost for personal care services was $242 dollars a week, only slightly higher than the cost of a single day in a nursing home.

But as funding for the programs increase, fraud follows. Kirk Ogrosky, a former top federal health care fraud prosecutor who is now a partner at the Washington law firm Arnold & Porter, said home health has long been a hotbed of fraud, both in Medicaid and in Medicare. The fraud, he said, is not hard to uncover. Ogrosky recalled that after an extensive analysis of Medicare claims, he sent agents out to interview questionable beneficiaries. When the agents knocked on the doors, they often learned the person they were looking for was at work, Ogrosky recalled.  “That’s utterly preposterous,” he said, “since home health requires that you are homebound.”

In other cases, Ogrosky said, agents found that home health care agencies were filing claims for beneficiaries who did not live at the homes indicated on the claims. “One of my favorite stories is about a homeless guy we found,” Ogrosky said. “He didn’t even have a home to be homebound to.”



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BECAUSE HEALTH CARE COSTS DO NOT FACTOR INTO COST OF LIVING INCREASES WE WILL GET TO A POINT WHERE SENIORS WILL SEE ALL OF THEIR COLA TAKEN AS EXPENSE.  THIS IS NOT ACCIDENT.....IT IS DELIBERATE AND YOUR THIRD WAY DEMOCRATIC INCUMBENT MADE SURE IT STAYED THAT WAY WHEN THEY HAD THE SUPERMAJORITY.

National Briefing | Washington Medicare Premiums to Rise by $5 a Month By THE ASSOCIATED PRESS Published: November 16, 2012

Medicare premiums will rise by $5 a month next year, the government said Friday. That is less than expected, but enough to consume about a fourth of a typical retiree’s cost-of-living raise in Social Security payments next year. Marilyn Tavenner, the acting administrator of Medicare, said the new “Part B” premium for outpatient care would be $104.90 a month. In most cases, it is deducted from a beneficiary’s monthly Social Security payment. The government had projected a premium increase of as much as $9 a month for 2013, but health care inflation has remained modest.
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LET'S BE CLEAR.....YOUR MARYLAND INCUMBENT VOTED FOR THESE PROVISIONS IN THE AFFORDABLE CARE ACT.  THIS IS WHY MEDICARE PATIENTS ARE PAYING MORE AND MORE AND WHY IT IS GETTING HARDER TO FIND A DOCTOR WHO TAKES MEDICARE.  REMEMBER, THESE POLS ARE CUTTING $1 TRILLION IN SPENDING EVEN AS $200-400 BILLION EACH YEAR IS BEING STOLEN.  THESE ARE THE SAME THIRD WAY CORPORATE DEMOCRATS WHO THREW MEDICAID FUNDING OUT THE DOOR.

WE CAN ALWAYS REVERSE THESE CUTS......ALL WE NEED TO DO IS

VOTE OUR INCUMBENT OUT OF OFFICE!!!!


Editorial Health Care Entitlements Published: November 28, 2012 New York Times
Congressional Republicans are insisting that big cuts to Medicare and Medicaid be on the table in the negotiations over the so-called fiscal cliff and deficit reduction. That stance is largely a political move against two programs, which have been critical to the public welfare for the past half-century.

Postelection polls show that large majorities of voters for both President Obama and Mitt Romney opposed making large Medicare cuts as a way to reduce the budget deficit. And, the fact is, the Obama administration has already pledged to extract more than $1 trillion in savings over the next decade from these programs. There is not much more that can be cut without hurting the most vulnerable Americans.

The Affordable Care Act contains provisions that will reduce projected Medicare spending by $716 billion over 10 years, primarily by reducing the annual increases in Medicare reimbursements for hospitals, nursing homes and other health care providers and by reducing unjustified subsidies paid to private Medicare Advantage plans. During the campaign, the Romney-Ryan ticket criticized the president for making such a big cut and even fatuously promised to restore all of it.

On top of those savings, President Obama, in his budget for fiscal year 2013, proposed cutting another $340 billion from Medicare spending over 10 years through tactics like requiring drugmakers to pay rebates to Medicare in some circumstances; reducing payments to some health care providers for treating patients just released from the hospital; reducing coverage of bad debts that hospitals and skilled nursing homes have failed to collect from patients; and charging higher premiums to high-income beneficiaries.

Those cuts seem acceptable as part of a larger budget deal to avert the fiscal cliff. There may be room to squeeze additional savings from health care providers as long as their fiscal health is not jeopardized. OH, PEOPLE'S LIVES ARE BEING SHORTEN AND THEY ARE DYING BECAUSE OF THESE CUTS.....BUT DON'T HURT THE FISCAL HEALTH OF THE HEALTH CARE PROVIDERS!!! But, beyond that, there are very limited options for further reducing Medicare or Medicaid spending.

Upper-income beneficiaries already pay higher Medicare premiums, and there may be some room to charge them more. But middle-income beneficiaries need to be protected from higher costs. And the half of all Medicare beneficiaries who have incomes below $20,000 already pay sizable portions of their income for health care and certainly cannot afford to pay more.

Some ideas should be off the table entirely. The election made it clear that there is strong opposition to turning Medicare into a voucher system. And, as for raising the Medicare eligibility age, respected analysts have concluded that this change would actually increase total health care costs and shift the burden to employers and individuals, without saving the government much money.

Finally, it’s important to keep in mind that short-term cuts in Medicare are not urgently needed. Medicare spending per enrollee is projected to increase more slowly than per capita gross domestic product or private insurance spending per enrollee over the next decade, and it is only in the following years that strong cost controls may have to come into play as the population ages and medical costs continue to rise.

Medicaid, a joint state-federal program of health insurance for the poor, has even less ability to absorb cuts. Although Mr. Obama proposed last year to cut federal spending on Medicaid by about $100 billion over 10 years, he soon trimmed that amount to $55 billion in his 2013 budget. Since then, the picture has changed drastically.

Although the Affordable Care Act required the states to expand their Medicaid programs to cover millions of the uninsured, the Supreme Court said the states could decide voluntarily whether to expand. Those that refuse to expand will save the federal government a lot of money in matching funds. The administration should not make any further cuts lest it discourage states from expanding coverage, unless the savings are achieved through better health care management.

The best way to rein in the Medicare and Medicaid costs is to speed up and extend provisions in the Affordable Care Act to encourage better and more efficient ways to deliver health care. That would help reduce federal deficits in the future and save substantial money for the private sector as well.




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TAKE TIME TO EMAIL COMMENTS ON THESE RULE-MAKING SESSIONS.....WE WANT TO SHOUT LOUDLY AND STRONGLY ON WHAT WILL BE LIFE AND DEATH TO YOU AND ME!!!!!

Medicare, Medicaid, and SCHIP Payments The Centers for Medicare & Medicaid Services (CMS)

of the Department of Health and Human Services administers the Medicare program, and works in partnership with state governments to administer Medicaid and the State Children's Health Insurance Program (SCHIP). CMS establishes Medicare payment schedules to reimburse physicians and other health care providers serving the elderly, provides funding to states to partially cover the costs of the Medicaid program for lower income persons, and provides SCHIP funding to assist states in covering uninsured children in families with modest incomes.

Entitlement Reform Rule/Lawmaking -

See Federal Register to Read:

• Medicare Program; Semi-Annual Meeting of the Advisory Panel on Hospital Outpatient Payment (HOP Panel)-August 27, 28, and 29, 2012 A Notice by the Centers for Medicare & Medicaid Services on 05/25/2012PDF - 2 pages This notice announces the second semi-annual meeting of the Advisory Panel on Hospital Outpatient Payment (HOP, the Panel), (the Ambulatory Payment Classification (APC) Panel) for 2012. The purpose of the Panel is to advise the Secretary of the Department of Health and Human Services (DHHS) (the Secretary) and the Administrator of the Centers...
  
  
• Medicare and Medicaid Program; Regulatory Provisions to Promote Program Efficiency, Transparency, and Burden Reduction A Rule by the Centers for Medicare & Medicaid Services on 05/16/2012PDF - 30 pages This final rule identifies reforms in Medicare and Medicaid regulations that CMS has identified as unnecessary, obsolete, or excessively burdensome on health care providers and beneficiaries. This rule increases the ability of health care professionals to devote resources to improving patient care, by eliminating or reducing requirements that...
  
  
• Medicare and Medicaid Programs; Reform of Hospital and Critical Access Hospital Conditions of Participation A Rule by the Centers for Medicare & Medicaid Services on 05/16/2012PDF - 43 pages This final rule revises the requirements that hospitals and critical access hospitals (CAHs) must meet to participate in the Medicare and Medicaid programs. These changes are an integral part of our efforts to reduce procedural burdens on providers. This rule reflects the Centers for Medicare and Medicaid Services' (CMS) commitment to the...
  
  
• Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2013 Rates; Hospitals' Resident Caps for Graduate Medical Education Payment Purposes; Quality Reporting Requirements for Specific Providers and for Ambulatory Surgical Centers A Proposed Rule by the Centers for Medicare & Medicaid Services on 05/11/2012PDF - 323 pages We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs of acute care hospitals to implement changes arising from our continuing experience with these systems and to implement certain statutory provisions contained in the Patient Protection and Affordable Care Act and...
  
  
• Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for Vaccine Administration Under the Vaccines for Children Program A Proposed Rule by the Centers for Medicare & Medicaid Services on 05/11/2012PDF - 21 pages This proposed rule would implement new requirements in sections 1902(a)(13), 1902(jj), 1932(f), and 1905(dd) of the Social Security Act, as amended by the Patient Protection and Affordable Care Act of 2010 (the Affordable Care Act). It implements Medicaid payment for primary care services furnished by certain physicians in calendar years (CYs)...
  
  
• Agency Information Collection Activities: Proposed Collection; Comment Request A Notice by the Centers for Medicare & Medicaid Services on 05/11/2012PDF - 2 pages
  
  
• Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements A Rule by the Centers for Medicare & Medicaid Services on 04/27/2012PDF - 35 pages This final rule finalizes several provisions of the Affordable Care Act implemented in the May 5, 2010 interim final rule with comment period. It requires all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and...
  
  
• Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self-Referral; and Patient Notification Requirements in Provider Agreements; Corrections A Rule by the Centers for Medicare & Medicaid Services on 04/24/2012PDF - 7 pages This document corrects technical errors that appeared in the final rule with comment period published in the Federal Register on November 30, 2011, entitled ``Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self-Referral; and Patient...
  
  
• Medicare Program; Extension of Certain Wage Index Reclassifications and Special Exceptions for the Hospital Inpatient Prospective Payment Systems (PPS) for Acute Care Hospitals and the Hospital Outpatient PPS A Notice by the Centers for Medicare & Medicaid Services on 04/20/2012PDF - 8 pages This notice announces changes to wage indices and hospital reclassifications in accordance with section 302 of the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) as amended by section 3001 of the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA). The TPTCCA and MCTRJCA extend the expiration date for certain geographic...
  
  
• Statement of Organization, Functions, and Delegations of Authority; Administration for Community Living A Notice by the Health and Human Services Department on 04/18/2012PDF - 11 pages The Department of Health and Human Services establishes the Administration for Community Living in order to achieve several important objectives: reduce the fragmentation that currently exists in Federal programs addressing the community living service and support needs of both the aging and disability populations; enhance access to quality...
  
  
• Agency Information Collection Activities: Proposed Collection; Comment Request A Notice by the Centers for Medicare & Medicaid Services on 04/18/2012PDF - 2 pages
  
  
• Medicare Program; Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs for Contract Year 2013 and Other Changes A Rule by the Centers for Medicare & Medicaid Services on 04/12/2012PDF - 104 pages This final rule with comment period revises the Medicare Advantage (MA) program (Part C) regulations and prescription drug benefit program (Part D) regulations to implement new statutory requirements; strengthen beneficiary protections; exclude plan participants that perform poorly; improve program efficiencies; and clarify program requirements....
  
  
• Agency Information Collection Activities: Proposed Collection; Comment Request A Notice by the Centers for Medicare & Medicaid Services on 04/04/2012PDF - 1 page
  
  
• Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans; Exchange Standards for Employers A Rule by the Health and Human Services Department on 03/27/2012PDF - 166 pages This final rule will implement the new Affordable Insurance Exchanges (``Exchanges''), consistent with title I of the Patient Protection and Affordable Care Act of 2010 as amended by the Health Care and Education Reconciliation Act of 2010, referred to collectively as the Affordable Care Act. The Exchanges will provide competitive marketplaces...
  
  
• Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 2 A Proposed Rule by the Centers for Medicare & Medicaid Services on 03/07/2012PDF - 132 pages
  
  
• Medicare Program: Notice of Six Membership Appointments to the Advisory Panel on Hospital Outpatient Payment A Notice by the Centers for Medicare & Medicaid Services on 02/16/2012PDF - 2 pages This notice announces six new membership appointments to the Advisory Panel on Hospital Outpatient Payment (HOP, the Panel). The six appointments to the 19 member Panel will each serve a 4-year period. Five of the new members will have terms that begin on February 1, 2012 and continuing through January 31, 2016. The sixth member's term will...
  
  
• Regulatory Agenda A Proposed Rule by the Health and Human Services Department on 02/13/2012PDF - 13 pages The Regulatory Flexibility Act of 1980 and Executive Order (EO) 12866 require the semiannual issuance of an inventory of rulemaking actions under development throughout the Department with a view to offering summarized information about forthcoming regulatory actions for public review.
  
  
• Medicare Program; Emergency Medical Treatment and Labor Act (EMTALA): Applicability to Hospital Inpatients and Hospitals With Specialized Capabilities A Proposed Rule by the Centers for Medicare & Medicaid Services on 02/02/2012PDF - 5 pages This request for comments addresses the applicability of the Emergency Medical Treatment and Labor Act (EMTALA) to hospital inpatients.
  
  
• Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates; Corrections A Rule by the Centers for Medicare & Medicaid Services on 02/01/2012PDF - 2 pages This document corrects technical errors that occurred in the Addendum of the final rule entitled ``Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Fiscal Year 2012 Rates'' which appeared in the August 18, 2011 Federal Register.
  
  
• Administrative Simplification: Adoption of Standards for Health Care Electronic Funds Transfers (EFTs) and Remittance Advice A Rule by the Health and Human Services Department on 01/10/2012PDF - 35 pages This interim final rule with comment period implements parts of section 1104 of the Affordable Care Act which requires the adoption of a standard for electronic funds transfers (EFT). It defines EFT and explains how the adopted standards support and facilitate health care EFT transmissions. 
  

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REMEMBER, THE SHORTFALL IN THE STATE BUDGETS FOR ENTITLEMENTS BEGINS WITH MASSIVE HEALTH FRAUD.  THE MEDICAID DENTAL COVERAGE WAS ONE OF THE HARDEST HIT BY FRAUD.  SO, THE ANSWER IS FIRST, STOP THE FRAUD, SECOND IS TO RECOVER THE MONEY LOST TO FRAUD, AND THEN THIRD TRIM COVERAGE IF NECESSARY.  NO, THESE GUYS GO RIGHT FOR THE CUTS WITH NO MENTION OF FRAUD. 


Sharp Cuts in Dental Coverage for Adults on Medicaid Gretchen Ertl for The New York Times Richard Lewis of Revere, Mass., at the Lynn Community Health Center before having a tooth extracted.

By ABBY GOODNOUGH Published: August 28, 2012


BOSTON — Banned from tightening Medicaid eligibility in recent years, many states have instead slashed optional benefits for millions of poor adults in the program. Teeth have suffered disproportionately.

  Republican- and Democratic-controlled states alike have reduced or largely eliminated dental coverage for adults on Medicaid, the shared state and federal health insurance program for poor people. The situation is not likely to improve under President Obama’s health care overhaul: it requires dental coverage for children only.

Illinois became the latest state to drastically cut dental benefits last month, when Gov. Pat Quinn, a Democrat, cut $1.6 billion out of its $15 billion Medicaid budget, reducing adult dental coverage to emergency tooth extractions. The state, whose Medicaid program was considered among the most generous, also cut vision benefits, eliminated chiropractic and podiatry coverage and started requiring co-payments for drugs.

In about half the states, Medicaid now covers dental care only for pain relief and emergencies, according to a recent report by the Kaiser Commission on Medicaid and the Uninsured, a national health research group. Other states cover preventive exams and cleanings but not restorative services, like fillings and root canals.

The federal health care law generally prohibits states from tightening eligibility for Medicaid before 2014, when a vast expansion of the program to cover people with incomes up to 133 percent of the federal poverty line is supposed to take effect. But states are still allowed to cut optional benefits, like vision, dental and drug coverage. Whether to seek broader cuts is part of a contentious debate between Mr. Obama and Mitt Romney over the future of Medicaid and Medicare, the government health care program for older Americans.

The dental benefits issue came to the forefront recently here in Massachusetts, a state known for generous Medicaid benefits. Under budgetary pressures, the state stopped paying private Medicaid providers for fillings, root canals, crowns and dentures in July 2010. But it recently decided to restore part of that coverage. Starting in January, Massachusetts Medicaid will pay for fillings — but only for those in the front of the mouth. The reasoning was that healthy front teeth were more important for getting and keeping jobs.

“A lot of folks are out of work,” said Courtney Chelo, coordinator of an oral health task force at Health Care For All, an advocacy group in Boston. “If you have a gap in the front of your mouth because you had a tooth extracted, it’s much more difficult to get a job.”

Dr. Michael Wasserman, the president-elect of the Massachusetts Dental Society, said that he was disappointed Massachusetts did not restore full coverage but that even a partial restoration was extraordinary in these fiscal times. Medicaid patients make up about 20 percent of his practice in Pittsfield, he said. “Of course we would have also liked to see the back teeth covered,” he said. “It’s nice to smile; it’s nice to chew. But we have to take what we can get at this point.”

Many adults on Medicaid have turned to community health centers. In Massachusetts, such clinics received 22,000 new dental patients statewide — 760 per site, on average — in the first six months after coverage was dropped.

At the Lynn Community Health Center outside Boston, demand has not stopped growing. The center added six dental chairs this year, bringing the total to 12, and hired more hygienists and dentists. Still, “the waiting room is packed,” said Lori Abrams Berry, the executive director.

 Even in states where Medicaid enrollees can still get regular dental care, finding dentists who accept Medicaid can be next to impossible. That is partly because reimbursements, which were low to begin with, have also been cut. Dentists, many of whom do not take even private insurance, can get much higher payments from non-Medicaid customers.