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Hospitals Under Scrutiny For Billing Practices That Cost Medicare $11 Billion

If you or a loved one has been to the emergency room lately you might want to request an itemized bill. The highest charge will likely be for what is known in billing parlance as “evaluation and management” services. These services include taking a patient history, performing an initial exam and directing treatment. How much the hospital charges will depend on an all-important choice of billing code—there are a range of codes that coincide with factors like the severity of the problem, underlying health issues of the patient and in some cases, time spent managing this care.

Why take a close look at these charges? According to a new investigative report from the Center for Public Integrity, providers have been increasing their use of billing codes that correspond with care for the most seriously ill or injured patients, adding $11 billion or more to the fees they receive from Medicare over the last decade.

According to the CPI report;

“Use of the top two most expensive codes for emergency room care nationwide nearly doubled, from 25 percent to 45 percent of all claims, during the time period examined. In many cases, these claims were not for treating patients with life-threatening injuries. Instead, the claims the Center analyzed included only patients who were sent home from the emergency room without being admitted to the hospital. Often, they were treated for seemingly minor injuries and complaints.”

A similar analysis by the New York Times that looked at Medicare data from the American Hospital Directory found that “[h]ospitals received $1 billion more in Medicare reimbursements in 2010 than they did five years earlier, at least in part by changing the billing codes they assign to patients in emergency rooms.” These codes refer to what are called “evaluation and management services” and are separate from physician fees and charges for specific tests and treatments. Read more…

A Dangerous Kind of Political Science

When Rep. Todd Akin (R-MO) made his now infamous claim that victims of “legitimate rape” don’t get pregnant because their bodies will “shut that whole thing down,” his was a particularly egregious but certainly not unique instance of junk science being used to justify a political stance.

In this case, Akin was explaining his support for the Republican Party platform (unchanged in more than two decades) that calls for outlawing abortion in all instances except when the life of the mother is endangered. One imagines that Akin also believes that girls who are the victims of incest can also summon their bodies to create an inhospitable environment for pregnancy. Meanwhile, what expertise backs up Akin’s warped version of basic reproductive biology? As we learned, Akin serves on the House Committee on Science, Space and Technology, and his education includes a BS in management engineering from Worcester Polytechnical Institute and a Master of Divinity at Covenant Theological Seminary in St. Louis.

Was there no high school biology in this educational journey? No sex education or even a frank talk with a parent about where babies come from? Alas, Akin, despite his higher education and election to national office is not immune to the ignorant ramblings of a decidedly (and dangerous) anti-science element of our society. It’s no surprise that Erika Christakis, an administrator at Harvard, writes on Time’s Ideas blog that harmful myths about rape and pregnancy  have a long, dark history:

“We heard from periodontist turned lawmaker Henry Aldridge that women who are ‘truly raped’ can’t become pregnant because the ‘juices don’t flow.’ Others, including a federal judge, have called pregnancy from rape as likely as ‘snow in Miami’ and ‘1 in millions in millions,’ while some have embraced specious claims about the effect of emotional trauma on conception from (so-called) ‘assaultive rape’ and other science-bending notions.”

Beyond the rape issue, abortion has been a regular target for anti-science conjectures. There are still prominent people out there who insist abortion causes breast cancer. It leads to infertility. It causes irreversible psychological damage to all women who undergo the procedure. The latest round of anti-choice legislation is founded on the concept that fetuses feel pain. Read more…

Is State Opposition to Medicaid Expansion Mostly Bluster?

When the Supreme Court ruled last month that states cannot be penalized if they refuse to expand their Medicaid programs to meet the new coverage requirements of the Affordable Care Act, the health status of 6 million low-income individuals was thrown into limbo.

The health law directed states to provide Medicaid coverage for residents earning up to 133 percent of the federal poverty level (FPL) or about $14,800 for individuals and $25,400 for a family of three. This provision was expected to provide coverage for some 17 million of the uninsured. Currently, 33 states limit Medicaid eligibility for working parents to less than 100% of FPL, with half of those limiting eligibility to less than 50% of the poverty level. Only 9 states offer any coverage at all for impoverished adults who are not parents.

Since the ruling, 29 governors—all from Republican states—have announced that they are considering rejecting the federal government’s offer to cover 100% of the cost of Medicaid expansion for three years (scaling back to 90% by 2020) in order to maintain the status quo or even reduce benefits for their poorest residents further. According to a survey by USA Today, seven states, including Texas, Louisiana and Florida, have already pledged to sidestep the law. The USA Today survey provides an excellent interactive map  that lists the percentage of uninsured in each state, as well as details about where states stand on forming health insurance exchanges and the Medicaid expansion. Not surprisingly, many of the states (like Texas) with the highest percentage of uninsured residents (at 25%, the highest in the nation) are voicing the most opposition to forming exchanges and expanding Medicaid.

Much ink has been used to explain why states oppose the Medicaid expansion but the official line from holdouts boils down to two objections; money and distrust of the federal role in state health programs. (Of course political partisanship is the unstated but always looming background for any discussion of “Obamacare”.) Read more…

Health Law Repeal: A Trail of “Broken Promises”

As House Republicans gear up for today’s vote on legislation to repeal “Obamacare”—the 31st such attempt in just 18 months—they return once again to the theme of broken promises.

To start, the bill charges; “President Obama promised the American people that if they liked their current health coverage, they could keep it. But even the Obama Administration admits that tens of millions of Americans are at risk of losing their health care coverage, including as many as 8 in 10 plans offered by small businesses.” A recent post on the House Ways and Means Committee’s website warns that “4 million to 20 million to 65 million” employees will lose insurance because of “Obamacare”—a range that seems curiously inexact.

The reality is quite different. Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University says that the “tens of millions of stuff” refers to bare-bones policies that do not meet the health law’s standard requiring insurers to spend 80% of what they collect in premiums on actual medical care. These are plans offered by McDonald’s and other employers that hire low-wage workers. Many of these employers were granted waivers, allowing them to offer this sub-par coverage to workers until 2014, when “subsidies and insurance reforms will make more comprehensive policies more affordable for most,” says Nichols. He continues, “They are technically correct that tens of millions [of workers] are in these policies now. They are NOT correct that people like them. They cover very small amounts of care, but they are all some employers currently offer.”

Another “broken promise” detailed by the latest repeal bill is that “the average American family already paid a premium increase of approximately $1,200 in the year following passage of the law. The Congressional Budget Office (CBO) predicts that health insurance premiums for individuals buying private health coverage on their own will increase by $2,100 in 2016 compared to what the premiums would have been in 2016 if the law had not passed.” Read more…

A Supreme Decision on Health Reform

The decision is finally out; the Supreme Court ruled that the Patient Protection and Affordable Care Act, including the individual mandate requiring all Americans to obtain health insurance, is constitutional. In making their decision, the justices in the majority concluded that the penalty for not carrying insurance is actually a tax and therefore falls within Congress’ power of taxation.

As many commentators have noted, the original decision to frame the cost of opting out of coverage as a “penalty” under the Commerce Act vs. a “tax” justified by Congress’s power to raise revenue almost backfired on the Obama administration. Of course, when the bill was being formulated two years ago, the climate of anti-tax fervor was at its height with the vast majority of Republican elected officials signing Grover Norquist’s anti-tax oath. (“Read My Lips: There Will Be No New Taxes” is an enduring mantra.) The administration took a gamble and went with the concept of  a “penalty” to enforce the insurance mandate.

When the Supreme Court arguments were underway at the end of March, the National Review (and other conservative outlets) derided Donald Verrilli, the solicitor general, for flip-flopping on whether the mandate was a tax or a penalty. Avik Roy wrote: “The highlight of the session was when President Obama’s solicitor general, Donald Verrilli, got up to articulate the administration’s position, which was that the mandate wasn’t a tax, for the purposes of the Anti-Injunction Act, and yet also that ‘the minimum-coverage provision of the Affordable Care Act is an exercise of Congress’ taxing power.’”

Roy quotes Justice Alito: “General Verrilli, today you are arguing that the penalty is not a tax,” Alito said. “Tomorrow you are going to be back, and you will be arguing that the penalty is a tax. Has the Court ever held that something that is a tax for purposes of the taxing power under the Constitution is not a tax under the Anti-Injunction Act?”

“No, Justice Alito,” replied Verrilli.

Despite the confusion (and derision from conservatives who concluded that Verrilli had badly bungled the Obama administration’s defense) Justice Roberts, for one, saw clear to the reality that the individual mandate really was a tax—and that Congress has a right to collect taxes. Perhaps this “bungle” was actually a stroke of genius?

So the question remains: What happens next? Most importantly, health reform implementation can now proceed without the specter of imminent demise. This enormous experiment whose ultimate goal is to re-design our dysfunctional health care system and offer affordable, comprehensive coverage to the majority of Americans, can begin to play out—warts and all. It’s like making the decision to get married after a couple has lived together a couple of years—there’s no guarantee of success but at least the threat of an uncomplicated break-up is gone.

There are huge questions about implementation, the most compelling of which involve how reform will play out in the states. Will states maintain their Medicaid programs in the run up to the ACA-mandated expansion now that the Supreme Court has ruled that they no longer have to? Or will some states opt out of the Medicaid expansion altogether; refusing an expected infusion of billions of federal dollars and leaving hundreds of thousands (if not millions) of their poorer residents without benefits? How will states that have so far refused to set up health insurance exchanges carry out their required duties?

Now that the mandate has been upheld, ironically questions arise about how well it will function to prevent healthy people from “gaming the system;” staying out of the health insurance pool and making coverage more expensive for the rest of us.

As Ezra Klein wrote in Washington Monthly at the start of the Supreme Court arguments; “Perhaps the best deal in the bill is to pay the mandate penalty [which maxes out in 2016 at $695 per adult and $2,085 or 2% of income for families] year after year and only purchase insurance once you get sick. To knowingly free ride, in other words. In that world, the mandate acts as an option to purchase insurance at a low price when you need it. For that reason, when health-policy experts worry about the mandate, they don’t worry that it is too coercive. They worry it isn’t coercive enough.”

More on that in another post, as well as a discussion of how this ruling will affect just how affordable—and comprehensive—private insurance, including employer-sponsored plans, will really be.

In the end, there is much to cheer in today’s decision; not least of which is a show of support for the signature legislation of Obama’s administration. Of course there will be ongoing debate as to whether this decision will provide a needed “bump” in the President’s approval ratings and second-term aspirations or whether it will energize his opponents who remain set on a strategy of “repeal and defund.”  There’s a good argument to be made that a Republican presidency and/or political shifts in Congress could be more devastating to the implementation of health reform than the Supreme Court decision would have ever been.

As the SCOTUS decision is carefully read, dissected, analyzed and spun over the next few weeks, there will no doubt be fodder for many more blog posts. But today, I am going to sit back for just a few hours, breathe a sigh of relief and offer my thanks to Chief Justice Roberts and this unlikely turn of events.




A Hospital Stay—In Your Own Home

By Howard Gleckman

Gleckman is a Resident Fellow at The Urban Institute and author of the book “Caring for Our Parents” This post ran originally on the “Caring for Our Parents” blog.

What if you could be admitted to the hospital—in your own bedroom?

That’s the idea of a health care model called Hospital at Home, which is aimed at elderly patients with diseases such as congestive heart failure, emphysema, urinary tract infections, or pneumonia.

According to a new study published in the journal Health Affairs, people receiving this care through the New Mexico-based Presbyterian Healthcare Services had equal or better outcomes than those getting  traditional hospital treatment, and were more satisfied with their care. In addition, care at home cost nearly 20 percent less than a hospital stay.

Hospital at Home (HaH) was created by Dr. Bruce Leff and colleagues at the Johns Hopkins School of Medicine and Public Health. The idea is pretty simple, though a little hard to grasp at first.

Like anyone else, an HaH patient is admitted to the hospital, usually through the emergency department. But some carefully selected patients—if they choose–can be cared for at home instead of receiving treatment in a room at the hospital. All the necessary equipment, such as a bed, oxygen, or medications, as well as monitoring devices, is provided at home. Physicians and nurses visit regularly and the patient’s vital signs are constantly monitored remotely. As with any hospital stay, the patient is discharged at an appropriate time, after which she may receive separate post-acute care if she needs it.  Read more…

Big Health Insurers Go For Big PR Boost With Coverage Promises

United Health Group, Aetna and Humana announced yesterday that even if the Supreme Court overturns the Affordable Care Act or rejects key provisions like the individual mandate, the large insurers promise to continue some popular early initiatives. UnitedHealth, which provides coverage for about 26 million people and is the nation’s largest insurer, was the first to announce that they would:

1) Allow parents to keep children on their plans until they are over 26

2) End lifetime limits on dollars spent on medical care

3) Continue to provide preventive services without co-payments

4) Allow third-party appeals when services are denied

Humana and Aetna pledged later in the day that they would continue similar coverage provisions. Other insurers are sure to follow.

The companies haven’t said how much it will cost them to maintain what one Humana executive calls “common sense” provisions, but my guess is that they’ve done a thorough analysis and realized that keeping healthy young adults in family plans is a no-brainer in financial terms and also gives the insurers a big boost in public relations. Polls have consistently shown that this, along with eliminating co-pays for preventive services like mammograms and immunizations are very popular with consumers.

And they aren’t very expensive. The government estimates that keeping young adults on their parents’ plans and prohibiting lifetime limits on benefits each add less than 1 percent to insurance premiums . As Washington and Lee University law professor Timothy Jost told Kaiser Health News, the UnitedHealth statement seems to indicate that “the provisions are not bankrupting the industry.” Read more…

When Opportunity Is the Best Birth Control

I was talking with a friend this morning who is a social worker at a large Brooklyn high school. She told me that of the 12 girls she’s seen regularly this year for counseling and group sessions, four of them are currently pregnant. Some of the other ones already have babies or toddlers; others have had abortions in the past. Pretty much everyone at this high school knows someone who has been pregnant or already has a child.

This was especially surprising to me because I read this week that the nation’s teen birthrate actually dropped by 17% between 2007 and 2010 to 34.3 births per 1,000, the lowest rate ever recorded. How could there be such great dissonance between the fact that in New York State, teen birthrates have dropped 13% over that period and my friend’s first-hand experience with her students?

Of course I’ve been around health statistics long enough to know that anecdotal evidence often has little to do with larger-scale trends or findings. Take the case of mammography and its contribution to saving women’s lives: when I wrote about the wealth of evidence pointing out that yearly mammograms for women under 50 actually has little impact on reducing breast cancer mortality but does increase the rate of false positives and over-treatment, I received phone calls and emails from plenty of women whose own experience told them otherwise. “My life was saved by a mammogram that caught my cancer before it could spread,” a close family friend argued. “I don’t believe these studies and I think what you’re writing is dangerous.” Read more…

What Women Have to Gain (or Lose) In the Battle Over Health Reform

By Maggie Mahar

(This post is excerpted from a series that originally appeared on

When Vice President Joe Biden told President Barack Obama that health reform is a BFD, he wasn’t kidding—especially for women. Currently, state law decides what insurers have to cover. Under the Affordable Care Act, federal law will call for equal benefits in all states.

The male body has long been considered the “standard” for health care coverage. Having a woman’s body is seen as an expensive anomaly, and women pay dearly for being different. When they buy their own health insurance in the individual market, women must lay out an extra $1 billion a year, simply because they are women.

Take maternity care: In the 41 states where such benefits are not mandated, a 30-year-old woman will find that only 6 percent of plans in the individual market now offer coverage. Guess how expensive those plans are? Under the ACA, maternity care will be considered an “essential benefit” that all insurers selling policies to individuals and small businesses must cover, without charging extra, beginning in 2014.

Some argue that charging women more for insurance is only fair: after all, a woman could become pregnant, and labor and delivery are costly.

But the truth is that, even when maternity benefits are excluded, one-third of all health plans charge women at least 30 percent more, according to a report released last month by the National Women’s Law Center. In 36 states, “92 percent of best-selling plans charge 40-year-old women more than 40-year-old men,” the Center reports, and “only 3 percent of these plans cover maternity services … One plan in South Dakota charges a woman $1252.80 more a year than a 40-year-old man for the same coverage.”

Today, less than half of American women can obtain affordable insurance through a job, which explains why millions buy their own insurance in the individual market. In that market, just 14 states ban gender rating:  California, Colorado, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, New Jersey, New York, North Dakota, Oregon, Vermont, and Washington. Read more…

On Prostate Cancer Screening, Warren Buffett and Ignoring Science

Prostate cancer is all over the news these days.

First Warren Buffett, 81, announced to his Berkshire Hathaway shareholders that after a routine PSA test, followed by a surgical biopsy, he had been diagnosed with early-stage prostate cancer and planned to undergo a two-month course of radiation therapy.

This announcement immediately set off controversy as prostate cancer experts weighed in on Buffet’s case and bemoaned the precedent it sets. In 2008, the United States Preventive Services Task Force (USPSTF) and other medical organizations began discouraging men over age 75, and their doctors, from using the PSA test. Although it can detect silent prostate cancer, the false positive rate is high and the vast majority of these older men would die of something else in the 10 to 20 years that it would generally take for the cancer to even cause clinical symptoms.

Meanwhile, as Marc B. Garnick, professor of medicine at Harvard Medical School and a prostate cancer expert writes on the Harvard Health Blog, “Buffett’s PSA test set off a disastrous chain of events that will probably do the legendary money manager more harm than good.” Immediate side effects of radiation treatment, writes Garnick, include fatigue and bowel problems; “Over the long term, about 50% to 70% of men lose the ability to get or sustain an erection or experience rectal bleeding.” The better choice is clearly “watchful waiting”—close surveillance and treatment only when and if the cancer progresses.

Now it turns out that Buffet is far from an outlier among men over 75 who, despite recommendations to the contrary, are still getting routine PSA tests. In a research letter published today in the Journal of the American Medical Association, we discover that “Despite the USPSTF recommendation against prostate cancer screening in men aged 75 years or older in 2008, PSA screening rates did not change [in 2010].” In fact, among men 75 and older, some 43% were getting screened in 2008 vs. 44% two years later. This is higher even than the 33% of men aged 50-59 who are getting routinely screened.

In case patients and doctors haven’t kept up with the evidence, here are the undisputed facts about PSA screening and men over 75: The USPSTF gives the test a D-rating and the American Cancer Society holds  that “men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening.” Or as Richard Albin , one of the discoverers of PSA wrote in a 2010 op-ed piece for The New York Times, “men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.” Finally, all evidence to date has failed to demonstrate that prostate screening actually decreases mortality.

This is not news. Ablin’s op-ed two years ago noted that 30 million American men were getting the test every year at a cost of  $3 billion, much of it paid by Medicare and the Veteran’s Administration. “The test’s popularity,” he wrote, “has led to a hugely expensive public health disaster.” Read more…