MURDER, POLITICS, AND THE END OF THE JAZZ AGE
by Michael Wolraich
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Hits of the Day
Hospital Chain Said to Scheme to Inflate Bills
By artappraiser on Fri, 01/24/2014 - 6:05am |By Julie Creswell and Reed Abelson, New York Times, Jan. 23, 2014
[....] Physicians hitting the target to admit at least half of the patients over 65 years old who entered the emergency department were color-coded green. The names of doctors who were close were yellow. Failing physicians were red.
The scorecards, according to one whistle-blower lawsuit, were just one of the many ways that Health Management Associates, a for-profit hospital chain based in Naples, Fla., kept tabs on an internal strategy that regulators and others say was intended to increase admissions, regardless of whether a patient needed hospital care, and pressure the doctors who worked at the hospital.
This month, the Justice Department said it had joined eight separate whistle-blower lawsuits against H.M.A. in six states. The lawsuits describe a wide-ranging strategy that is said to have relied on a mix of sophisticated software systems, financial incentives and threats in an attempt to inflate the company’s payments from Medicare and Medicaid by admitting patients like an infant whose temperature was a normal 98.7 degrees for a “fever.” [....]
URL:
http://www.nytimes.com/2014/01/24/business/hospital-chain-said-to-scheme-to-inflate-bills.html?_r=0
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Comments
The article makes the point that this is not an isolated case but may be a side effect of the way our (for profit) health care system is moving:
And I'd like to point out that, alongside Medicare and Medicaid, insurers are on the other side of the fence here. I.E., whether the insurance is non-profit or for-profit isn't the source of problem, but how the providers will always seek out ways to profit from their payment systems, whatever they may be. That's the Money-Driven Medicine problem that I've always argued, before ACA was law, is the main problem we in the U.S. have (& not the "greedy health insurance companies," greedy tho they may be.) The profit motive just does not jive with the practice of medicine, period. It's actually far easier to defend a profit motive in the business of insurance, though that has nasty side effects in the health realm, too.
by artappraiser on Fri, 01/24/2014 - 7:17am
Insurers and providers should be adversaries, at least somewhat. Ambition or greed checking greed. Especially now that the insurers can't refuse the sick.
by Peter Schwartz on Fri, 01/24/2014 - 1:37pm
Yes, it's hard to disagree.
I could pick a nit that charging a high fee isn't the same as profit.
But does it really make sense to have the CEO of a chemical manufacturer making 5 million a year, while a highly skilled professional with years of difficult and expensive training behind him and who saves lives and keeps people from getting sick or sicker shouldn't make as much or more?
At some level, what "we" pay people reflects how much we value them, and I certainly value the doctor over the CEO, all things being equal. Of course, other things enter into what someone gets paid, but keeping their remuneration down while allowing others to make quadzillion seems a bit perverse.
by Peter Schwartz on Sat, 03/08/2014 - 7:31pm
It's worth noting, too, that virtually everyone is always trying to make more.
by Peter Schwartz on Sat, 03/08/2014 - 7:32pm
Ugh.
by Peter Schwartz on Fri, 01/24/2014 - 1:36pm
Basically a primer on how some docs have already learned how to inflate income for wellness checkups under ACA. Suffice it to say: don't be surprised if your wellness checkup never ends up being free of charge. Realize that every step of the way, you have to ask the doc: "is this going to be extra?"
BTW from reading the above kinds of sites lately, I get the impression that the big news in provider world is that the new illness coding system is still being mandated for fall and that the Obama administration does not appear to want to give any mulligans on that, even though they have given many mulligans to ACA rollout and many are begging for delays. I don't know much about it all, but from what I see, it will open a whole new world of manipulation, the old manipulations no longer good, new ones needing to be learned by hard experience and invented. That as George Bush might say, it's hard work trying to figure out how to be paid more for something in medical care these days, people changing all the rules means figuring out new ways to get around them...
by artappraiser on Sat, 03/08/2014 - 6:03pm
When medical office administrators reference "the art of coding elegantly", they are not talkin' about writing beautiful computer programs (like the rest of us C++ geeks...)
by jollyroger on Sat, 03/08/2014 - 6:04pm
Being a relatively savvy consumer of medical care since pre-internet days, who also seeks out docs that are simpatico with that, I have been privy to some docs and staff actually splainin' to me how using this code or that code could help me or mine out in our situation, whatever that may have been at the time.
But this is really a brave new world where everyone is starting from scratch. Excellent evidence for that: the biography of the writer of the Healthworks post: Bill Crounse, MD, is Senior Director, Worldwide Health for the Microsoft Corporation.He is responsible for providing worldwide thought leadership, vision, and strategy for Microsoft technologies and solutions in the healthcare provider industry. Even he got fooled until he starting investigating the bills. Shouldn't have fallen for that "now let's talk about how your insomnia problem is going" line...if the doc says "now, let's move on to" or "have you ever thought of getting a...?", suspicion is your friend.
The proper answer to the Shingles vaccine thing in his post, mho: Is it included? No? Well then, doc, since I and my insurance are going to be charged extra for it anyway, I am going to go home and research whether I think it is right for me. Unless it is a trusted doc that you have been going to for many years and knows your body well, doing otherwise is exactly what feeds the part of our medical industrial complex that not only raises costs but causes iatrogenic illness. Mho, you always have to be on guard for iatrogenic illness with a new doc that does not know your history well.
by artappraiser on Sat, 03/08/2014 - 6:27pm
Interesting example, cuz I went for the scare ad and got the shingles vax but I had to self-procure thru Med D at the Pharmacy and walk it in to get shot up, cuz Med. B won't reimburse for it.
That said, I'm glad I got it cuz I did have chicken pox, back in the day...it did seem to me that the ad (one in three gets shingles) referenced a hell of a lot of shingles.
by jollyroger on Sat, 03/08/2014 - 6:39pm
I agree with this guy totally.
However, whenever I read these things, I always think I must be the luckiest guy in the world. This stuff doesn't happen to me. And when I ask how much X costs, they always tell me right then and there.
As far as I can tell from this article, the doc himself isn't paying hardly anything for this--which is significant for the consumer.
Ultimately, insurance companies and providers will duke it out as the government keeps premiums down or at a certain percentage. I just got a full blood work up and a shingles shot and paid a total of $20 for my co-pay. Somewhere in the back of my mind, I thought my copay was $40, so I was surprised to learn it was half that.
That small amount I was paying for my generic drugs a few months back? It's been zeroed out...
by Peter Schwartz on Sat, 03/08/2014 - 7:24pm
We've just gone through the whole Medicare/supplemental changeover because my husband's company has decided to get out of the provider business. Our premiums starting April 1 will be about half what they are today, and that'll include optical, which we didn't have before.
We could have opted for a plan where we would pay out-of-pocket exactly $0 per month but we wanted better coverage with lower deductibles and co-pays so we decided on a plan that will cost us something over and above what the company is going to pay.
It seems too good to be true, so we're not breaking out the apple juice just yet, but there's no doubt that health care is changing and moving toward fairer, more equitable solutions.
by Ramona on Sat, 03/08/2014 - 8:27pm