The governor's proposal would also penalize excessive drug price increases and limit surprise emergency billing.
Newsletter editor Brianna Labuskes, who reads everything on health care to compile our daily Morning Briefing, offers the best and most provocative stories for the weekend.
Happy Friday! Today is the day I’m going to challenge you to stretch those creative muscles and enter our Halloween Health Care Haiku Competition. Yes, it is going to be exactly as awesome as it sounds! The entries are already pouring in, check out the rules here. To kick things off, KHN’s very own talented and brilliant haiku master-in-residence Stephanie Stapleton wrote this one: “Goblins wear white coats, and not much is spookier, than the health system.”
Now on to what you might have missed this week.
Democrats packed themselves onto a crowded stage this week for what already feels like the umpteenth debate but was only the fourth or the sixth (depending if you count the two-nighters separately).
Going by the amount of heat she took, it seems safe to say Sen. Elizabeth Warren (D-Mass.) is considered by her rivals to be one of the race’s front-runners. With that spotlight, though, comes a target on her back.
South Bend Mayor Pete Buttigieg and Sen. Amy Klobuchar (D-Minn.) – who are both vying to become the alternative for former Vice President Joe Biden’s moderate voters – were particularly sharp in their demands for Warren to reckon with the costs of “Medicare for All.” The question of how she would pay for such a plan has been one she’s been managing to dodge, but her rivals tried to hold her feet to the fire on Tuesday. “At least Bernie’s being honest,” Klobuchar said at one point in reference to Sen. Bernie Sanders’ (I-Vt.) admission that the proposal will raise taxes.
FWIW: Despite being pressed to answer the direct question: “Will you raise taxes on the middle class to pay for it? Yes or no?” Warren still didn’t let herself be pinned down. Something that, the day after the debate, Biden jumped on as well.
Health care is possibly the broadest (or at least one of the broader) topics that the candidates could talk about, and yet all it seems they’ve been discussing at the debates is health care coverage. Friends, you are not alone if you’re frustrated by not seeing a more diverse range of questions. Even Sen. Kamala Harris (D-Calif.) was fed-up enough to redirect the conversation toward abortion rights and reproductive health. Considering it’s such a viscerally hot-topic at the moment, the omission seems glaring.
But it’s not just reproductive health that the moderators could ask about. Axios came up with at least four great questions that I think a lot of people in the field would like to have answered. Like: Many of the things that make people sick are not the fault of bad health care — they’re social factors like poverty, low-quality housing, etc. Should it be part of the health care system’s job to address them? (Hint, hint moderators.)
Don’t get me wrong, there were a few other health-related moments beyond “Medicare for All” bickering… including one of the more heated exchanges of the night. Beto O’Rourke said Democrats need to be courageous in their policies and not be scared of polls, to which Buttigieg responded: “I don’t need lessons from you on courage.”
Meanwhile, amid all this focus on “Medicare for All,” a new study counsels that there are many paths toward universal coverage—it doesn’t have to be “Medicare for All” or bust.
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A big decision on the constitutionality of the health law is expected to drop sometime in the coming weeks. Although in theory, the Trump administration wants a certain outcome, if the court decides the ACA is unconstitutional, it could be a big ole headache for the White House heading into 2020. A ruling like that could not only foster confusion right around open enrollment, but also allow the Democrats to re-frame the health narrative in a way that could appeal to independent and moderate voters more than the current back and forth about “Medicare for All.”
Rep. Elijah Cummings (D-Md.) passed away this week at 68 from complications of longstanding health problems. House Speaker Nancy Pelosi (D-Calif.) announced that she’ll be renaming her signature drug pricing policy after Cummings as he was a long-time champion of reigning in such costs.
Some might remember that it was Cummings who took Martin Shkreli, of “pharma bro” fame” to task at a hearing.
“It’s not funny, Mr. Shkreli,” Cummings said as Shkreli smirked. “People are dying, and they’re getting sicker and sicker.”
In a high-stakes, eleventh hour gambit Judge Dan A. Polster is summoning the drug CEOs involved in the massive, nationwide opioid trial to try to agree to a massive $50 billion settlement. Although the talks center around the big players involved — like AmerisourceBergen, Cardinal Health and McKesson — plaintiffs’ lawyers say they hope such a deal would have a domino effect on the remaining defendants.
Although the reports seem hopeful, those familiar with the talks say that the cities and counties are hesitant because they’re worried they’re not going to see their fair share of the money.
(This is as of press time! It’s happening today, so there could be developments depending when your read this—ah, the excitement of live news!)
In a sea of heartbreaking stories on the opioid epidemic, this one stands out. The Washington Post took a look at West Virginia’s crisis and how court victories against drug companies aren’t really the panacea they’re sometimes made out to be.
These two court stories feel like they happened ages ago, but really it was just last Friday post-Breeze. If you caught them happening in real time, there’s nothing to update, but I wanted to make sure I included them for anyone who wasn’t glued to their computer on a Friday evening.
This binge-worthy story needs no other introduction than the one ProPublica already wrote for it, so I’m going to quote them: “Welcome to Coffeyville, Kansas, where the judge has no law degree, debt collectors get a cut of the bail, and Americans are watching their lives — and liberty — disappear in the pursuit of medical debt collection.”
And, on a related note, if you’ve missed my colleague Jay Hancock’s coverage of UVA’s lawsuits against their patients, make sure to check out all the developments here.
Meanwhile, in the miscellaneous story file this week:
— Melody Petersen of LAT won the holy cannoli award this week with her investigation into the practice of harvesting body parts—and the coroners that go along with it. My face when reading the entirety of the article was an exact replica of the “shocked and distressed” emoji.
— Deaths, poor quality of care, and other problems have absolutely plagued the Indian Health Service for years, and Native Americans are sick of it. They want to take over running their own health care system, but the task would be daunting.
— You can’t swing a cat these days without hitting some new CBD product. It seems inevitable that that kind of lucrative, thriving marketplace would draw pharma’s attention. Here’s a look at what companies are developing new drugs to tap into those profits. (PSA: but don’t actually swing any cats, please.)
— If you want a fentanyl drug ring story that reads like a thriller, check this article out.
That’s it from me! Have a great weekend and don’t forget to get your flu shot!
Longer Looks: How A DEA Agent Took Down A Fentanyl Ring; Hunger, Addiction And Homelessness On Methadone Mile
Viewpoints: Pros, Cons Emerging In Debates About Medicare For All Vs. Everything Else; Imagine Other Ways To Do This Without Raising Taxes
No Matter How Successful They Are, Drugs With Million-Dollar Price Tags Are Unsustainable, CMS Chief Says
State Highlights: 1,400 New Pharmacists Sidelined In California Over Cheating Scandal Surrounding Exam; Troubled VA Hospital In Atlanta Takes Steps To Improve Services
What’s Behind Rise Of STDS Among Young People?: Epidemic Alarms Health Officials As Prevention Funding Drops
Despite Intense Scrutiny, Doctors Still Receiving Astronomical Sums From Drug and Medical Device Companies
In Latest Round Of Legal Woes, Johnson & Johnson Agrees To $117M Multi-State Settlement Over Pelvic Mesh Products
As Border Patrol Agents Become A Common Feature At Hospitals, Medical Professionals Struggle To Preserve Patients’ Rights
In High-Stakes Move Before Opioid Case Goes To Trial, Judge Summons CEOs To Eleventh-Hour Talks With Plaintiffs
Juul Temporarily Halts Online Sales Of Flavored E-Cigarettes, But Critics Say That’s Far From Enough
Group Health Cooperative in Seattle, one of the nation’s oldest and most respected nonprofit health insurance plans, is accused of bilking Medicare out of millions of dollars in a federal whistleblower case.
Teresa Ross, a former medical billing manager at the insurer, alleges that it sought to reverse financial losses in 2010 by claiming some patients were sicker than they were, or by billing for medical conditions that patients didn’t actually have. As a result, the insurer retroactively collected an estimated $8 million from Medicare for 2010 services, according to the suit.
Ross filed suit in federal court in Buffalo, N.Y., in 2012, but it remained under a court seal until July and is in the initial stages. The suit also names as defendants two medical coding consultants, consulting firm DxID of East Rochester, N.Y., and Independent Health Association, an affiliated health plan in Buffalo, N.Y. All denied wrongdoing in separate court motions filed late Wednesday to dismiss the suit.Email Sign-Up
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The Justice Department has thus far declined to take over the case, but said in a June 21 court filing that “an active investigation is ongoing.”
The whistleblower suit is one of at least 18 such cases documented by KHN that accuse Medicare Advantage managed-care plans of ripping off the government by exaggerating how sick its patients were. The whistleblower cases have emerged as a primary tool for clawing back overpayments. While many of the cases are pending in courts, five have recovered a total of nearly $360 million.
“The fraudulent practices described in this complaint are a product of the belief, common among MA organizations, that the law can be violated without meaningful consequence,” Ross alleges.
Medicare Advantage plans are a privately run alternative to traditional Medicare that often offer extra benefits such as dental and vision coverage, but limit choice of medical providers. They have exploded in popularity in recent years, enrolling more than 22 million people, just over 1 in 3 of those eligible for Medicare.
Word of another whistleblower alleging Medicare Advantage billing fraud comes as the White House is pushing to expand enrollment in the plans. On Oct. 3, President Donald Trump issued an executive order that permits the plans to offer a range of new benefits to attract patients. One, for instance, is partly covering the cost of Apple Watches as an inducement.
Group Health opened for business more than seven decades ago and was among the first managed-care plans to contract with Medicare. Formed by a coalition of unions, farmers and local activists, the HMO grew from just a few hundred families to more than 600,000 patients before its members agreed to join California-based Kaiser Permanente. That happened in early 2017, and the plan is now called Kaiser Foundation Health Plan of Washington. (Kaiser Health News is not affiliated with Kaiser Permanente.)
In an emailed statement, a Kaiser Permanente spokesperson said: “We believe that Group Health complied with the law by submitting its data in good faith, relying on the recommendations of the vendor as well as communications with the federal government, which has not intervened in the case at this time.”
Ross nods to the plan’s history, saying it has “traditionally catered to the public interest, often highlighting its efforts to support low-income patients and provide affordable, quality care.”
The insurer’s Medicare Advantage plans “have also traditionally been well regarded, receiving accolades from industry groups and Medicare itself,” according to the suit.
But Ross, who worked at Group Health for more than 14 years in jobs involving billing and coding, said that from 2008 through 2010 GHC “went from an operating income of almost $57 million to an operating loss of $60 million. Ross said the losses were “due largely to poor business decisions by company management.”
The lawsuit alleges that the insurer manipulated a Medicare billing formula known as a risk score. The formula is supposed to pay health plans higher rates for sicker patients, but Medicare estimates that overpayments triggered by inflated risk scores have cost taxpayers $30 billion over the past three years alone.
According to Ross, a GHC executive attended a meeting of the Alliance of Community Health Plans in 2011 where he heard from a colleague at Independent Health about an “exciting opportunity” to increase risk scores and revenue. The colleague said Independent Health “had made a lot of money” using its consulting company, which specializes in combing patient charts to find overlooked diseases that health plans can bill for retroactively.
In November 2011, Group Health hired the East Rochester firm DxID to review medical charts for 2010. The review resulted in $12 million in new claims, according to the suit. Under the deal, DxID took a percentage of the claims revenue it generated, which came to about $1.5 million that year, the suit says.
Ross said she and a doctor who later reviewed the charts found “systematic” problems with the firm’s coding practices. In one case, the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.” Overall, about three-quarters of its claims for higher charges in 2010 were not justified, according to the suit. Ross estimated that the consultants submitted some $35 million in new claims to Medicare on behalf of GHC for 2010 and 2011.
In its motion to dismiss Ross’ case, GHC called the matter a “difference of opinion between her allegedly ‘conservative’ method for evaluating the underlying documentation for certain medical conditions and her perception of an ‘aggressive’ approach taken by Defendants.”
Independent Health and the DxID consultants took a similar position in their court motion, arguing that Ross “seeks to manufacture a fraud case out of an honest disagreement about the meaning and applicability of unclear, complex, and often conflicting industry-wide coding criteria.”
In a statement, Independent Health spokesman Frank Sava added: “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately.
Whistleblowers sue on behalf of the federal government and can share in any money recovered. Typically, the cases remain under a court seal for years while the Justice Department investigates.
KHN correspondent Shefali Luthra reported this story from Germany as a 2019 Arthur F. Burns Fellow.
HAMBURG, Germany — Researchers around the world hail Germany for its robust health care system: universal coverage, plentiful primary care, low drug prices and minimal out-of-pocket costs for residents.
Unlike in the U.S., the prospect of a large medical bill doesn’t stand in the way of anyone’s treatment. “Money is a problem in [their lives], but not with us,” said Merangis Qadiri, a health counselor at a clinic in one of Hamburg’s poorest neighborhoods.
But it turns out that tending to the health needs of low-income patients still presents universal challenges.
As an American health care reporter traveling through Germany, I wanted to learn not only what works, but also where the system falls short. So when I arrived here — in one of the country’s wealthiest cities, with one of its largest concentrations of doctors — economists and researchers directed me to two of the poorest neighborhoods: Veddel and Billstedt, both home to high populations of recent immigrants.
Entering these areas felt like stepping into another city, where even though people have universal insurance, high rates of chronic illnesses such as diabetes, depression and heart disease persist. Treatment and preventive care are difficult to access.
The challenges faced at both outposts ― Poliklinik Veddel and Gesundheit für Billstedt/Horn (literally, “Health for Billstedt and Horn”) ― underscored a point: Universal health care, in and of itself, may be a first step, but it isn’t a magical solution.Email Sign-Up
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Life expectancy in these areas is estimated to trail that in Hamburg’s wealthier neighborhoods by 13 years ― about equivalent to the gap between Piedmont, a particularly wealthy California suburb, and neighboring West Oakland. In Hamburg, the difference persists even though residents never skip out on doctors’ visits or medication because of cost.
Medical care is only part of the equation. An array of other factors ― known collectively as the “social determinants of health” ― factor strongly into these populations’ well-being. They include big-picture items like affordable healthy food and safe areas to exercise as well as small ones, like having the time and money to get to the doctor.
In Germany, as in the U.S., these are exceptionally difficult to treat.
In its three years of operation, Gesundheit für Billstedt/Horn has been visited by about 3,500 patients — 3% of the population in the two neighborhoods it serves. And maybe half of the people who come for a first visit return for a follow-up, said Qadiri, who works at Billstedt/Horn.
For one thing, many don’t know the health outpost exists. For another, people might not feel they can spare the time from chaotic lives.
To address that problem, the Billstedt site, with its patient rooms up front and a large meeting space in the back, is situated in a bustling mall among shops that include an Afghan bakery, Turkish restaurant and McDonald’s. The outpost doesn’t have doctors onsite, but it employs health counselors, who offer advice on healthy living and guidance on how patients can manage chronic conditions, and communicate with patients’ physicians as needed.
The Poliklinik, located in a separate neighborhood known as Veddel, uses social and community events to get patients in the door. The clinic organizes coffees, shows up at local church events and holds local movie nights. The strategy appears to work, at least somewhat: By 11 a.m. on a Tuesday morning, the brightly decorated waiting room was filled with patients, waiting to see a doctor or other health professional.
Still, Poliklinik sees only about 850 unique patients every three months, far short of the area’s 5,000 residents, said Dr. Phillip Dickel, a general practitioner at the clinic.
Another limit on the clinic’s ability to meet need: a shortage of doctors willing to work in this part of town. That includes general practitioners, to say nothing of gynecologists, mental health specialists and pediatricians ― few of whom practice in the area, he added. In theory, one could take public transit to another part of the city to find such a doctor, but that involves time and money for the commute.
Meanwhile, the environmental problems that plague these areas are in some ways more intractable, said Dickel.
Poliklinik’s neighborhood, for instance, is just off the autobahn and filled with old industrial warehouses and factories.
That creates lower air quality and higher risks of asthma and lung diseases, said Dickel. Patients in all these neighborhoods confront housing shortages, so families become overcrowded in small flats. Aside from the psychological toll, illnesses and infections ― influenza, a cold or something more serious ― spread quickly.
While the clinics advocate for improved housing, sometimes the best the staffers at the clinics can do is give advice on how to minimize these risks.
Qadiri, the Gesundheit health counselor, tries to help patients with diabetes and heart disease find and incorporate fruits and vegetables in their diets and teaches them strategies to replace sugary beverages. And she encourages them to attend onsite exercise classes.
But healthy food is harder to find in the areas these clinics serve than in one of Hamburg’s wealthier neighborhoods. And fresh produce costs more than fast food.
“People can get care in Germany if they need it,” said Dickel. “Much more important [than access], I would say, are the social conditions. That’s the cause of the life-expectancy gap.”
In response to a Kaiser Health News investigation into University of Virginia Health System’s aggressive collection practices, Senate Finance Committee Chairman Chuck Grassley (R-Iowa) sent a letter Thursday demanding answers to questions about UVA’s billing practices, financial assistance policies and even its prices.Special Reports Investigation
Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.
The Finance Committee oversees federal tax laws, and Grassley wrote that it is “my job to make sure that entities exempt from tax are fulfilling their tax-exempt purposes.”
The KHN investigation found that UVA Health System, a taxpayer-supported and state-funded entity, filed 36,000 lawsuits for more than $106 million in six years.
“Unfortunately, I have seen a variety of news reports lately discussing what appear to be relentless debt-collection efforts by tax-exempt hospitals, including UVA Health System,” Grassley wrote. “I am also concerned about how patients’ hospital bills get so high in the first place.”
Even though the letter only questions UVA Health System, whose practices were pegged in the investigation as particularly aggressive, it sends a signal that the Senate will be paying attention to an issue that impacts all state run and nonprofit health systems. Many medical providers pursue patients for unpaid bills, sometimes forcing them into bankruptcy. Several news stories have highlighted similar collections practices at other nonprofit hospitals.
Nonprofit hospitals get big tax breaks in exchange for providing “charity care and community benefit,” though there is no clear standard about what that should mean. Experts have questioned whether those breaks are deserved, given hospitals’ pricing, billing and collections practices.
In the seven-page letter, Grassley asks 19 detailed questions on various topics, including the system’s charity care (free or discounted care provided to low-income patients), debt collection policies, and its rationale for the litigation threshold of $1,000, enacted in 2017. Grassley asks specific questions about UVA’s standard price list, commonly known as the “chargemaster,” which lists prices for procedures and equipment posted on its website.Email Sign-Up
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The letter was addressed to CEO Pamela Sutton-Wallace, who will depart UVA Health System for NewYork–Presbyterian Hospital next month. UVA Health System has until Nov. 19 to respond.
“UVA is committed to assisting indigent and uninsured patients and making sure they receive all necessary care,” UVA Health System spokesman Eric Swensen said in an email to KHN. “We will review the letter, and look forward to working with Sen. Grassley to respond to his questions and share with him the policy changes we have announced and started implementing over the past month to better serve our patients.”
In response to KHN’s investigation, UVA Health System swiftly vowed to change its policies to increase financial assistance, give bigger discounts to the uninsured and reduce its use of the legal system. However, KHN reported that some critics do not think the news policies go far enough.
"To have this animal walk by and, you know, offer you its unconditional love. That tail wag has the ability to make that day, and I see that all the time in the hospital."
Can’t see the audio player? Click here to listen on SoundCloud.Julie Rovner
Kaiser Health NewsRead Julie's Stories Joanne Kenen
PoliticoRead Joanne's Stories Tami Luhby
CNNRead Tami's Stories Margot Sanger-Katz
The New York TimesRead Margot's Stories
Despite the turmoil from the ongoing impeachment inquiry, Democrats in the U.S. House of Representatives are proceeding with work on a major prescription drug price bill crafted by House Speaker Nancy Pelosi.
Meanwhile, broader health issues continue to be a point of contention among the Democratic presidential candidates.
And courts around the country are dealing setbacks to many of the Trump administration’s health agenda items, including one that would make it harder for immigrants to get green cards if they use public programs.
This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN, and Margot Sanger-Katz of The New York Times.
Among the takeaways from this week’s podcast:
- Getting an ambitious drug pricing package through Congress by the end of the year seems unlikely, not only because of impeachment, but because the Senate is not on board with Speaker Pelosi’s plan.
- Still, a Congressional Budget Office analysis released this week found the Pelosi bill would save Medicare $345 billion over 10 years, giving Democrats a major talking point. On the other hand, the CBO also suggested the measure could reduce the number of new drugs that come to market by 8 to 15 in the coming decade, providing a talking point for opponents.
- Also of interest, the House Energy and Commerce Committee is planning to consider adding some benefits — including dental, vision and hearing — to traditional Medicare. It’s not clear if this is a response to the campaign season, or the idea that before pursuing “Medicare for All” there are changes to the traditional Medicare program that could be done.
- Health care again was a hot topic in this week’s Democratic presidential primary debate and Massachusetts Sen. Elizabeth Warren, now viewed as the front-runner, was in the hot seat. Warren again evaded the question of how and who would pay for her preferred Medicare for All plan, and was criticized by candidates like Sen. Amy Klobuchar of Minnesota and Mayor Pete Buttigieg of South Bend, Ind., both of whom support more incremental changes to the health system.
- Meanwhile, the courts continue to play a key role in health policy. Federal judges in several states blocked the administration’s “public charge” rule that would make it harder for legal immigrants to obtain green cards if they or their family members use any of a long list of public programs. Federal judges also heard arguments on Medicaid work requirements. Meanwhile, a federal judge in Ohio blocked an Ohio state abortion ban, while a federal court judge in Texas blocked an Obama era rule intended to enforce anti-discrimination provisions of the Affordable Care Act.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: KHN’s “We Vape, We Vote’: How Vaping Crackdowns Are Politicizing Vapers, by Rachel Bluth and Lauren Weber
Joanne Kenen: The Los Angeles Times’s “In the rush to harvest body parts, death investigations have been upended,” by Melody Petersen
Tami Luhby: ProPublica’s “It’s Very Unethical”: Audio Shows Hospital Kept Vegetative Patient on Life Support to Boost Survival Rates,” by Caroline Chen
Margot Sanger-Katz: “Tradeoffs,” a podcast hosted by Dan Gorenstein, Sayeh Nikpay, and Anupam Jena
To hear all our podcasts, click here.