Corporate Giants and the government revolving door create costly and fragmented care

By: Marion Mass, M.D. and Craig M. Wax, D.O.

Insurers, Pharmacy Benefit Managers(PBM), advocacy groups  such as AARP, and others are using their amassed wealth and influence to game the over-complicated and burdensome healthcare system for their own profit on the backs of the American taxpaying patient while fragmenting their care.  Let’s follow one pathway of corporate profiteering that results in a poorer quality of patient care:

United Healthcare’s subsidiary Optum (the company formerly known as Inginex) is one of the three big PBM…  companies that control what drugs your insurance company pays for and how much, while having the government given right to receive kickbacks from pharma manufacturers (conflict of interest much?). These kickbacks are costing Americans $200 BILLION PER YEAR and a prime reason why Optum got so rich. Their 2018 profits put them at the 100 billion mark.

How did a company with a history of fraud get so rich? Round up the usual suspects of the government/corporate cronyism.

After the fraud charges,  Ingenix rebranded itself as Optum, it’s CEO Andy Slavitt left and in 2015 became the Head of Center for Medicare and Medicaid Services(CMS)  while the former head of CMS, nurse Marilyn Tavenner, left to become the president of the insurance industry’s  lobby group AHIP. Slavitt was able to cash out stock options TAX FREE, getting a $4 million windfall.

Curiously, in 2015, while Slavitt is running CMS, Optum seems to take over the publication and administration of the CPT and ICD coding, their logo appearing on the coding material.

As if kickbacks, and coding are not enough, Optum finds another revenue stream via home visits. They send clinicians to medicare advantage patient’s homes often incentivizing the patients with gift cards.  ( apparently they discovered that kickbacks work)  These “wellness visits” prevent patients from being able to see their primary care physician for an annual physical, thus fragmenting care, while failing to forward critical information to the patients’ physicians.

These visits seem designed for Optum to be able to increase risk scores, and thus collect more from Medicare. A possible scenario: order protein levels, often low in elderly patients, increase the patients risk score, and viola!  Optum collects more from Medicare, and thus from the pockets of TAXPAYERS. Apparently, someone in the Justice Department is paying attention, as United looks to be in the hot waters of fraud yet again.

All this money-making benefits the AARP, a formidable lobby force in DC. The AARP gets nearly 50% of its income from royalties the big insurance companies pay them to peddle Medicare advantage plans, the bulk from United/Optum. A mere  17% of AARP’s collections come from membership fees from its 37 million members.
https://capitalresearch.org/article/aarp-advocacy-group-or-crony-capitalists/

There you have it: big insurance and their PBM henchmen, hired by our government, teaming up with the AARP all getting rich gaming the system while Medicare patients get fragmented care and taxpayers pay more. Medicare advantage plans? They ought to call them “taking advantage of taxpayers plans. ”

Marion Mass, MD is co-chair of Practicing Physicians of America (PPA) and Craig M. Wax, DO is PPA’s VP of Health Care Policy.  Learn more: https://practicingphysician.org

Advertisements

Be There! New Jersey Doctor-Patient Alliance Inaugural Summit

You will not want to miss this summit on February 8-9, 2019!

IP4PI’s own Craig M. Wax, D.O. will join an all star lineup as a featured speaker. Dr. Wax will share reform priorities that will help put doctors and patients back in the driver’s seat. It is time to put and end to the shenanigans politicians pull to hand advantages to their crony buddies in the hospital industrial complex. Patients and their physicians must team up to reclaim their rights, increase the availability, and slash the cost of high quality care.

Coming soon to an EHR near you: Downtime and Missing Patient Data

Electronic Health Records are often full of bloat and incorrect data, except when they are not accessible at all and/or relevant patient data isn’t even entered into the system. Here’s a frightening note from management sent to “providers” in one health system earlier this week:

Subject: Downtime Message to Providers
To the Health Network Medical Staffs :

On December 12 from approximately 7:30-10 AM the entire network experienced a EHR unplanned outage. It was due to a server issue in Kansas City and affected several customers. The Issue was identified quickly and remedied. We were back up in under 2 hours.

We identified the fact that data from the EHR had not transferred since Nov 16th. We failed to actively monitor that transaction so did not know that data transfer had failed. The data transfer issue has been fixed by our EHR vendor and we are putting a process in place to assure that the monitoring of the transmission of data happens without fail.

Your IS team understands that this impacted your workflow and we apologize. We continue to work toward no disruption in information flow at all times.

Chief Medical Information Officer

Shenanigans, Larceny, And Fraud Define The Corporate Practice of Medicine

Bob Campbell, MD, co-founder of Physicians Against Drug Shortages writes in:

I have been gathering a lot of information for a “Corporate Practice of Medicine” project. Not sure what will come of it if anything but some of the shenanigans are very harmful at times. At other times just simple larceny.

The federal court in Philadelphia has issued a new decision in Aetna v. Mednax/Pediatrix Medical Group, 2018 WL 5264310 (E.D. Pa. 2018) involving fraud allegations asserted by Aetna against Mednax, a pediatric private equity firm.

The federal court held that Aetna’s allegations regarding Mednax’ alleged fraud upcoding scheme could proceed in litigation. Aetna alleged that Mednax routinely listed CPT codes that exaggerated the care needed and performed by designating infants as being sicker than they truly were so that it appeared as if the infants required more intensive treatment than was truly the case. This process allowed Mednax to submit inflated bills to Aetna so that Aetna would reimburse Mednax for more money than was justified.

Aetna also alleged the upcoding scheme permeated Mednax’ operations. Mednax trained and required physicians to engage in upcoding and encouraged physicians to perform unnecessary services to support higher billing rates. Mednax also sometimes inflated the codes itself above the level indicated by the physicians before submitting the claim forms. Aetna obtained evidence from former employees of Mednax that were aware of the upcoding scheme.

The court ultimately held that the specific types of upcoding that allegedly occurred, such as listing an infant as requiring critical care rather than general hospital care, sufficiently established the legal basis for fraud.

The federal court also allowed the litigation against the private equity firm controlling pediatric/neonatal intensive care physicians to proceed far beyond the 2-year statute of limitations based upon the “continuing fraud violation doctrine.”

I just wanted to keep you apprised of additional developments in the fraud realm in the context of private equity firms and some of the concerns raised about driving profits improperly. This is literally in your backyard, but also involves an alleged nationwide scheme.

You are either FOR Killer GPO PBM Kickbacks or Against Them

Bob Campbell, MD, co-founder of Physicians Against Drug Shortages writes:

Want to introduce an element of competition into healthcare? Ending the GPO/PBM kickbacks is the best place to start. Low hanging fruit and no room for compromise. You are either FOR sole source pay to play inflationary kickbacks or against.

So far since Trumps rumored new introduction of barriers to the kickbacks have been “rumored” to be “possibly written for possible introduction “ as new HHS rules Sen Warren and Hatch and Congressman Walden have emerged to keep the kickbacks in place and unfettered by HHS. They have not seen the rumored rules but if the rules might interfere with the essential kickbacks then the rules must never be enforced. Not good for America. Senators Toomey and Casey of Pennsylvania are both long time defenders of pay to play kickbacks. Pennsylvania Senate campaigns are very expensive and the PBM GPO cartels are very generous to supporters. Remember Trump can only erect barriers to access to the safe harbor. Congress made kickbacks and racketeering legal for GPOs and PBMs with the safe harbor law. Only Congress can make pay to play payola illegal again. That is an enduring solution. Trump cannot do that. Congress can.

A bill that is written, reviewed polished, and ready to go for any courageous Member of Congress. One version for the House and one for the Senate. President Trump says not one person in Congress is capable enough to take action on this matter. Is anyone willing to take him up on his challenge? All we need is a Healthcare Hero.  How about 100 new generic medication manufacturing plants with 200 jobs at each plant all in the state that leads the way. High paying clean manufacturing jobs that will stay busy throughout economic boom and bust cycles. Hundreds more just like it across the country, but the state of the Member of Congress who will introduce the bill gets first dibs.

A capital investment frenzy occurs if this bill passes. We need chemotherapy, saline, potassium chloride, potassium phosphate calcium carbonate, calcium chloride, sodium bicarbonate, epinephrine,ephedrine, norepinephrine, dopamine dobutamine, glucose, nitroglycerin, cardiac surgical drugs, antibiotics, obstetric medications, pediatric seizure medications and hundreds more.

I need drugs to paralyze people and unparalyze them. I need drugs to increase blood pressure and increase heart rates when they are too low. I need drugs to decrease blood pressure that is too high and slow down heart rates that are too high. Right now using smoke and mirrors. We should postpone all cardiac surgery until the Unsafe Safe Harbor is repealed. Right now we have Fake Anesthesia.

Trust me that is way more dangerous than Fake News. No more Fake Solutions from politicians for explosive healthcare costs and drug shortages. Exclusive Pay to Play Market Allocation Contracts is all that is keeping American companies from lowering costs for drugs and ending drug shortages. All contracts are written by an unnecessary extra layer of Middlemen inserted into the healthcare supply chain with a uniquely powerful ability to demand kickbacks from manufacturers to permit them to make lifesaving medications and medical devices for Americans who need healthcare. Drug Shortages never had to happen and can be ended. Healthcare Kickbacks never had to happen and can be ended.

Permission Denied

Friend of IP4PI Gene Uzawa Dorio, M.D. writes in:

I received a phone call from a hospital case manager that my patient did not meet criteria for further admission and should be discharged. Unfortunately, the patient was just removed from a breathing machine, and was still in the ICU for sepsis.

There are several criteria used by hospitals guiding whether a patient should be admitted or discharged. Who establishes these criteria? Hospitals of course, with evidence-based bias to divert money into their pockets.

This conspiracy by business people has been detrimental to the quality of healthcare the American people receive when hospitalization is required.

With almost 40 years of practice and experience, I remain up to date on how to provide scientific evidence-based care to patients. Unfortunately, I now have to ask permission for a patient to be admitted, have certain testing and procedures, and remain in the hospital setting.

Asking for permission from those in authority who ultimately benefit from denial is not only intuitively wrong, but crosses the boundary of moral and ethical sense.

It also violates the Hippocratic Oath I have taken, and reminds me they have only taken an oath to benefit themselves.

Comments: http://scvphysicianreport.com/2018/07/01/doctors-diary-july-1-2018-permission-denied/ Hit “Home” for past snippets.