Health junction

How Profit-taking Distorts Health Care Delivery in America Recently, a Public Broadcasting Station (Channel 9) featured a story on a for-profit hospital group which was using obscure diagnostic codes to achieve higher Medicare payments. The level of unethical and fraudulent activity was so egregious that more than one of their billing coders quit their jobs and testified against their former employer. The Wall Street Journal has also reported on fraudulent Medicare billing, including requisitioning public records from CMS(Medicare) and identifying abusive billing practices by multiple clinicians. For example, the New York City osteopath who billed Medicare 2 million for family medicine, when this was not the nature of her medical practice. WSJ staffers examined the Medicare database and uncovered 25 billing codes for an array of expensive medical tests which were regularly performed by 20 other clinicians in the country. Of that group, 33% have already been convicted of fraud, have u...

Diabetes Current-State and Changes to Come Unless you are Cro-Magnon-man and just emerged from a glacial field you are probably aware of some of the 2010 health care reforms. This article reviews how the United States got to be in such poor shape, health-wise and how some provisions of the 2010 reforms will create incremental changes. Since I am nearly finished with my second book, the Russell Guide for Diabetes: Type I or Type II This Could Happen To You , let me share some mind boggling information about this scourge. The American statistics on this disease have a huge impact on government funded health plans, including Medicare and these metrics from the CDC explain why : � The proportion of diagnosed diabetics in the United States has increased by more than 50% since 2007; 17.7 million in 2007 and 25.5 million in 2010 � Fully one third of the U.S. population is expected to be diabetic by 2025; 115 million � In 2010 18.7% of the 25,564,000 U.S. residents diagnosed as diabetic were ...

Impact of the Vatican's Universal Translation of Faith, Catholic Owned Health Care Facilities and State Legislation on Health Care for Women The triad of the new stricter Vatican rules for interpretation of Catholic protocols, the trend toward Catholic organizations purchasing non-Catholic hospitals, and the furor over the proposed women's health standards for the 2014 health insurance exchanges have made this a topic which must be revisited. In order of appearance here are the players:the Vatican, Swedish Health Services, and the State of Mississippi. Vatican Rules on a Universal Translation for Catholics Beginning November 27, 2011, the Vatican has issued another edict which attempts to tighten the interpretation of the Catholic faith, by mandating a single universal translation of the faith. The church hopes to reign in the more liberal interpretation which is prevalent in the United States and other western countries. Though one might think this only affects Catholics, n...

How Primary Care Reduces Health Care Costs in the Long Run Now that the teeth gnashing over health care reforms has been ongoing for two years, before the lifelines are cut on financing health care for the forty-nine million uninsured population, let�s examine the health care continuum for the impact of a failure-to-fund the health insurance subsidies. One of the things that is missing from many discussions and assertions about the 2010 U.S. health care reforms are which systems need to be changed in order to reduce the long term cost of American health care. And when I say reduce, I mean reduce the cost increases in providing health care to an aging population. It is essential the U.S.A. get the per-capita cost of its health care in-line with other nations, as it gobbles funds that could be used for education, capital investments for industry, and other economy building activities. The country will need to make substantial investments in k-12 education as well as building a more ener...

Methods for Improving Health Care in the Hospital The Centers for Medicare and Medicaid have required hospitals to start reporting on quality criteria for reimbursement consideration as early as 2012, based on 2010 health care reforms. Major changes that clinicians and hospitals must conform to include: Value-based Purchasing- This provides greater reimbursement with an emphasis on better clinical outcomes, starting in 2013. Risk-Adjusted Reimbursement- This accounts for higher risk patients with multiple conditions and gives the doctor a higher fee to manage their care than previously, effective in 2014. Reduced Payments for Hospitals with Excessive Re-admission Rates- This is a penalty for poorer performance and is effective in 2013 for hospitals who do not perform within certain guidelines for specific diagnoses. This article reviews a report commissioned by The Commonwealth Fund to analyze some of the things the top performing hospitals, who submitted to quality surveys by the inde...

One of the chapters in my book, Unraveling U.S. Health Care, which is a guide to the health care system, addresses surgery and tips on how to vet your surgeon and find the optimal facility. Finding a Surgeon The best web site for researching surgical specialties is the American College of Surgeons, which allows consumers to look up surgeons by specialty and location. The web site for this is: www.facs.org. For instance if you need a neurosurgeon, you can enter that and voila, the universe of neurosurgeons is revealed. These specialists are typically associated with university medical centers and large trauma centers. However, it is amazing that some health care consumers still think that neurosurgeons are available at rural 25 bed hospitals. Even if they were, why would you want to have this type of surgery done at that kind of facility? Hospital Safety Rankings Secondarily, it is worth your while to review hospital patient safety ratings before deciding on the facility. Methods to d...

Government Oversight of Private Insurance: What it Means for the Cost of Your Health Insurance The plethora of health care laws passed in 2010 under the Affordable Care Act,include provisions for �rate setting� and monitoring of private sector insurance plans on a federal level. The ruling applies to all insurance plans which participate in any government funded health care program, including Medicare, Medicaid, and the soon-to-be-deployed regional insurance exchanges. This article explains how this differs from present rate monitoring and premium-setting and the ultimate impact on the consumer. The Rules Health & Human Services is charged with establishing a health insurance rate oversight committee, to assess the reasonableness of proposed health insurance rate increases starting in 2014. Since health insurance premiums have continued to grow at a rate in excess of inflation and increased 41% between 2003 and 2009, according to a Commonwealth Fund study , affordability is a conce...

Accountable Care Organizations and Medicare Shared Savings Program The federal Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS), announced proposed rules for the much vaunted Shared Savings Program for qualifying Accountable Care Organizations on March 31st. What struck me about the program, was how much of the risk management formula was taken directly from the private insurance sector, which is an indication of a public/private hybrid for program management. Since it is my belief that we can provide optimal public services through this model, I am keen to evaluate, follow, and measure the results for this revolutionary change in health care delivery for Americans. This article explains the risk sharing mechanisms in the new program and what it may mean for consumers. Private Sector Influence The Centers for Medicare & Medicaid, which administer the largest health care program in the country, have created a health c...

Discerning Hospital Quality The Center for Medicare and Medicaid Services(CMS) now requires health quality measures for specific clinical services, in order to recognize and encourage the best patient outcomes. Recognition will include greater financial reimbursement for those medical practices which conform to the CMS standards for clinical outcomes. This is yet another step in the right direction toward patient-centered-care as identified by the International Order of Medicine. This article highlights the primary hospital quality watchdogs in the United States and consumer tips on how to assess your hospital. Organizations Measuring Hospital Quality There are a number of ways to gauge your hospital�s quality, including accessing information from public sites, such as the Center for Disease Control, the Center for Medicare and Medicaid Services and the Health & Human Services Agency. There are also nonprofit organizations devoted to measuring hospital quality including; the Joint ...

Suggestions for Amending the 2010 Health Care Reforms Now that the teeth gnashing is on-going over proposed changes to the health care reforms of 2010, this article addresses some areas for potential modifications. If any of you are under the delusion that everything will be repealed, wake-up, because the Medicare changes are essential to management of that costly federal entitlement program. I am speaking of the pay-for-performance initiatives where Medicare (Center for Medicare Services) pays more money to organizations which have fewer medical errors and re-admissions for patient procedures. I am referring to the Accountable Care Act will have a major impact on how medical care is organized, models for disease interventions, and the reporting of performance metrics(I wrote about this last fall). So, that stays, but the rest of this article addresses some of the things that could go or at least be modified. Federal Insurance Purchasing Subsidies for Mandated Health Insurance A few mo...