Entries in Medicare (24)


Hospitals Profit from Surgical Complications

iStockphoto/Thinkstock(NEW YORK) -- Hospitals may make more money when a surgical procedure leads to complications, according to a new study.

The research, published in the Journal of the American Medical Association, determined that hospitals experience significantly higher profit margins when complications follow surgery.

According to the study, hospitals see a 330-percent increase in profit margin when privately insured patients experience complications. Comparatively, Medicare patients who experience problems after surgery offer hospitals a 190-percent larger profit margin.

The study concluded that lower rates of surgical complications would actually cost hospitals financially.

The study analyzed hospital records from over 30,000 surgical patients from a non-profit hospital system in the southern United States in 2010. Researchers focused on 10 severe and preventable complications to determine how much the hospitals profited from each patient.

According to the study, $400 billion is spent in surgical procedures each year. Nearly 2,000 cases with at least one complication were discovered in the study.

Copyright 2013 ABC News Radio


Breast Cancer Screenings Cost Medicare $1B Annually

Comstock/Jupiterimages(NEW YORK) -- Medicare spends almost as much money screening for breast cancer as it does treating it, according to a new study published in JAMA Internal Medicine.

Breast cancer screenings cost Medicare $1.08 billion annually, lead researcher Dr. Cary Gross and his team at the Yale School of Medicine found.  Given that Medicare spends $1.36 billion a year on breast cancer treatment, Gross said he expected the screenings costs to be much lower.

"It should be a call to do further research to identify the best screening strategy," Gross said.  "If we're spending more, does it really help the patients?"

Gross said his study can't conclude whether mammograms are effective, but it does take a good look at where the money is going to prompt further study.

Gross and his colleagues also found that areas where people spent more money on breast cancer screenings didn't have better outcomes than those that didn't.  However, the study was somewhat limited because it only followed up with patients for two years.

"You could argue when it comes to screening, that if you invest more in screening, maybe you'll spend less in treatment," he said.  "But we didn't find that."

About $410.6 million of the total screening costs went toward women over 75 years old, a controversial age group because of a 2009 United States Preventative Services Task Force recommendation that said older women might not benefit from the screenings.

However, the American Cancer Society and several other medical organizations ignored the USPSTF recommendations because they drew different conclusions from the data, said Dr. John Huff, the imaging director of the Vanderbilt Breast Clinic in Tennessee.  Huff did not work on the study.

The American Cancer Society still recommends annual breast cancer screenings for women over 40.

"I think the biggest question is not so much the cost, which we certainly need to be aware of, but the question of what we get for that cost and what value we place on what we get," Huff said, addressing over-diagnosis and over-treatment.

Not unlike slow-growing prostate cancer that doesn't always require treatment, some breast cancers might not need surgery, chemotherapy and radiation, Huff said.  But before the medical community can determine whether over-diagnosis and over-treatment is at play, it must find a way to determine which patients have slow-growing breast cancers and which don't.

"There are some breast cancers that might not need aggressive treatment, but we unfortunately are currently unable to identify which ones they are," Huff said.  "So it's nice to say we might be over-diagnosing or over-treating, but until we have evidence that helps us understand which people those are, it's hard to separate those out as a group.  So we're left being a little less targeted."

Copyright 2013 ABC News Radio


Undercover Grandma Catches Medicare Fraud on Tape

ABC News(MCALLEN, Texas) -- In the wake of an ABC News undercover investigation, federal authorities in Texas are investigating how an active 82-year-old grandmother was diagnosed as homebound, with a range of ailments that she did not have, including Type 2 diabetes, opening the door to potentially tens of thousands of dollars in Medicare payments for home health care, supplies and equipment she did not need.

A hidden camera recorded the undercover grandmother's visit to a doctor in McAllen, Texas, where she told the doctor and nurses she exercised regularly and, other than some hypertension and arthritis, was in excellent health.

"I've really enjoyed good health all my life, God's been good to me," the doctor was told by Doris Ace, the grandmother of ABC News producer Megan Chuchmach.

Yet the official certification sent to Medicare for home health care services indicates she was homebound and suffered from two internal infections, incontinence and needs "assistance in all activities, unable to safely leave home, severe sob" -- an abbreviation for shortness of breath.

Ace had specifically told the doctor and her nurses she did not suffer from incontinence or shortness of breath.

On a patient referral form for home health care service, signed by the doctor, our undercover grandmother was also wrongly diagnosed with type 2 diabetes, even though she was not given a blood test which doctors say is the only way to authoritatively diagnose diabetes.

The overall diagnosis of the undercover grandmother's health could have provided the justification for what could be tens of thousand dollars a year worth of unneeded treatment and medical supplies and equipment, federal investigators said in an interview to be broadcast Thursday night on ABC News' World News with Diane Sawyer and Nightline.

"That's fraud," said Tim Menke, senior adviser for investigations in the Inspector General's office at the Department of Health and Human Services.

"Our Medicare system is an honor system," said Menke after viewing the files and the ABC News undercover tape of the doctor's office visit.  "And there's not much honor left in the system when you see things like that."

McAllen is considered a hotbed of Medicare fraud by the Inspector General's office, which has already brought cases against a number of doctors and health care agencies and has many others under investigation.

"The fraud indicators are off the charts," said Menke of McAllen and surrounding towns in the Rio Grande Valley.  "We have ten of the top physicians who have billed nearly $200 million in one specialty last year alone."

Nationwide, the Inspector General's office estimates that $60 billion dollars of taxpayer money is lost to unchecked Medicare fraud every year.

"We've seen it in Miami, Detroit and now in McAllen and it's very, very common," he said.

"They're lying in order to steal from you and me and the taxpayers," he added.

The McAllen doctor, Dr. Padmini Bhadriraju, declined to comment to ABC News, but denied any wrongdoing through her lawyer.

The lawyer, John Rivas, said the doctor acknowledged an "error" in the diabetes diagnosis for ABC News' undercover grandmother on the patient referral form, but said, "this section was filled out by someone other than Dr. Bhadriraju," even though he confirmed the doctor did fill out the majority of the form and signed it in her handwriting.

Her signature served as certification that "my clinical findings support that this patient is homebound."

The doctor's lawyer said neither the doctor nor others in her office knew who filled in the incorrect diabetes diagnosis.

Rivas also said the doctor played no role in the official certification form sent to Medicare, although records show she billed Medicare for the review of the form and its plan of care.

"The records provided by ABC News do not support any allegations of fraud.  It would be irresponsible journalism to air a story on Medicare/Medicaid fraud using this referral as an example when there is clearly no evidence of fraud," he added in a letter to ABC News.

ABC News ended the undercover investigation before any medical supplies or equipment could be billed to Medicare based on the false diagnosis. 

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Copyright 2012 ABC News Radio


Budget Crisis Could Mean $123 Billion in Medicare Cuts Over 10 Years

Getty Images(WASHINGTON) -- The partisan divide that doomed the congressional “supercommittee” threatens to trigger automatic spending cuts that would weigh heavily on public education, housing and other programs that Americans rely on daily.

Unless members of Congress come up with a budget solution, an automatic cut known as “sequester” will kick in for the fiscal year 2013, cutting about $1.2 trillion from the budget in 10 years. The sequester would reduce annual spending by $109 billion, starting Jan. 2, 2013. The cuts are divided equally between the Defense Department and social programs.

Two sectors where Americans are likely to see a direct negative impact are public education and public housing. The sequester would cut more than $3 billion cut from the Department of Education, and mean a more than $3.5 billion decline in funding for housing and urban development programs.

Less money would trickle down to states because of cuts, affecting people who have children in public schools and those who live in public housing. Much of the drop in the housing sector is in community development block grants, according to an analysis by the Federal Funds Information for States.

Medicare, community and migrant health centers, and health services for American Indians would be trimmed by 2 percent. That amounts to $123 billion in a 10-year time period for Medicare alone. Most of the cuts would come from reducing the amount of reimbursements the federal government gives to health care providers, not directly from Medicare recipients. But it would make it more challenging for the elderly to find doctors, some experts say.

The Special Supplemental Nutrition Program for Women, Infants and Children would see a $600 million reduction. At a time when poverty and hunger are at a record high, many advocates say, the cuts are likely to be detrimental to thousands of families reliant on federal aid.

The sequester would also hamper the government’s ability to implement the Affordable Care Act by reducing the amount of money that’s needed to enact some programs.

Some of the most important parts of the health care law are set to go into effect after 2014, including expanded coverage for Medicaid, mandatory employer coverage and insurance exchanges, a marketplace in which people could shop for and compare insurance plans.

Entitlement programs such as Medicaid and Social Security, however, would remain sheltered, as would funding for veterans programs, income tax credits and food stamps. Funding for these safety net programs is considered mandatory and would not be affected by the sequester.

Copyright 2011 ABC News Radio


Medicare Patients Get Costly Surgery before Death

Jupiterimages/Thinkstock(NEW YORK) -- Nearly one of every three Americans on Medicare undergoes surgery in their last year of life, according to a new study. Those numbers are leading some to question whether pursuing these costly and invasive procedures is the right thing to do for dying patients.

The study, published in The Lancet, analyzed more than 1.8 million claims for Medicare patients who died in 2008, and found that 32 percent of them had an operation in the year before they died. Nearly one in five had a surgical procedure in the last month of life and one in 10 went under the knife in the last week of life.

Dr. Ashish Jha, the study's author and an associate professor of health policy at the Harvard School of Public Health, said it's well known that patients get lots of health care at the end of their lives, but this study is the first to show how many of them are getting costly, invasive surgery, and then dying.

"This level of surgical intensity doesn't seem to be having much in the way of benefit for the population," Jha said. "Our sense is that there are probably lots of unnecessary procedures that go on at end of life."

The study found that a patient's likelihood of getting surgery varied greatly depending on their age and where they lived. Surgery was more common for 65-year-olds than for patients in their 80s and 90s. Operations also became more likely in regions with greater availability of hospital beds and higher levels of Medicare spending.

All this surgery didn't necessarily prolong life. Areas where doctors did lots of operations had higher patient death rates.

Ken Thorpe, a professor of health policy at Emory University, said doctors and health care systems should reevaluate the kinds of interventions they give to patients who may not live long enough to really benefit from their treatments.

"Researchers are finding that these aggressive procedures have the same outcomes as less invasive, less expensive treatments," he said. "This study shows us there's an enormous opportunity to basically save money and provide less intervention, and still have the same quality of care and life expectancy."

The study also suggests that more dying people have surgery not because they want it or need it to save their lives, but because American medical culture encourages aggressive care like surgery, even at the end of a patient's life.

Jha said it's impossible to tell from the Medicare claims analyzed in the study whether or not surgery was really necessary or whether patients and their families wanted an operation. But he said it underscores a general hesitation by doctors to discuss a difficult subject with their patients: that they might die.

"A lot of physicians struggle to talk about prognosis, whether people are going to live or die. Instead they focus on trying to make little things better," Jha said. "Some of these procedures are a distraction from what might really be important for patients, like being able to spend time with family, being able to say goodbye to people they love, or what their quality of life will look like."

Experts say this study highlights the need for doctors and patients to talk about palliative care options as well as more aggressive treatments like surgery.

"We need to provide patients options for how aggressive they want to be toward the end of life," Thorpe said.

Copyright 2011 ABC News Radio


Medicare Fraud Bust Nets 91 People, Including Doctors and Nurses

PhotoAlto/Frederic Cirou/Thinkstock(WASHINGTON) -- The Justice Department announced on Wednesday that 91 people allegedly scammed $295 million from Medicare by falsely billing the entitlement program.

To make matters worse, some of the suspected crooks are doctors, nurses and other medical professionals, according to Attorney General Eric Holder.

In announcing the charges, Holder said they were "based on a variety of alleged fraud schemes involving various treatments and services that were not medically necessary -- and, oftentimes, were never even provided."

The crackdown netted 11 doctors, three nurses and 10 licensed health professionals.  The charges were filed in Baton Rouge, Louisiana; Brooklyn, New York; Chicago; Dallas; Detroit; Houston; Los Angeles and Miami.

Half of the defendants came from South Florida, the reputed national leader in Medicare fraud.

Copyright 2011 ABC News Radio


$15 Million Medicare Fraud Owner Sentenced to Prison 

Stockbyte/Thinkstock(DEARBORN, Mich.) -- The operator of a phony health center who scammed the government out of $15 million will spend 48 months in jail.

Court documents show the Sacred Hope Medical Center and Dearborn Medical Rehab Center collected millions from medicare for phony treatments, over several years, and paid kickbacks to phony patients, who claimed they were getting health care.

The owner of the bogus centers, Jose Rosario, has now been sentenced by a federal judge in Michigan to 48 months in prison and ordered to pay more than $10 million in restitution after the justice department's medicare fraud strike force and the FBI shut down the operation.

Copyright 2011 ABC News Radio


Government Spending on Hospice Care More than $12 Billion 

Comstock/Thinkstock(WASHINGTON) -- The amount of money Medicare spent on hospice care increased more than 53 percent between 2005 and 2009 to $12 billion, according to a government report.

Hospice care is provided at the end of a person's life and focuses on providing comfort in a patient's final days, not a cure for any disease.  Medicare covers certain hospice care costs provided a person has a terminal illness, six months or less to live, and receives care in an approved facility.

The rise in spending is largely due to a big increase in the number of people who utilize hospice services.  In 2009, more than one million people received hospice care, a 25 percent increase over 2005.  People can receive this type of care at home, in a long-term care facility, in hospitals or in facilities that specialize in hospice care.

In addition to a boom in the number of people who receive it, the number of facilities that provide end-of-life care services also increased.

According to the Department of Health and Human Services, more than half of hospices in 2009 were for-profit.  These same hospices received more money from Medicare than non-profit and government-owned hospices, even though there are far fewer of them.

Although the government paid more money to profit-making providers, Medicare pays the same rate to all hospices.

"Reimbursement is all the same -- it's the same dollar amount per day," said Don Schumacher, president and CEO of the National Hospice and Palliative Care Organization, a non-profit organization that represents hospice and palliative care programs and professionals nationwide.

Information on Medicare's website shows the current rate is $146.63 for daily routine home care.

Robert Field, a professor of health management and policy at the Drexel School of Public Health in Philadelphia, explained the main reason for-profits made so much more money is because of that per diem payment system.

"Medicare pays in a way that incentivizes overuse," he said.  "Providers get a certain rate per day, and the longer patients stay in, the more they make.  The incentive is to enter patients into hospice before they really need it and to keep them there beyond the time they may no longer need it -- they may no longer be on the verge of dying in many cases."

Critics of for-profit hospices say the current reimbursement structure could lead facilities to hand-pick certain patients who cost less medically but require longer stays, maximizing profits.

Copyright 2011 ABC News Radio


Should Medicare Move to Cheaper Drugs?

Creatas Images/Thinkstock(WASHINGTON) -- If there are two drugs that achieve the same result but one costs $2,000 per dose and the other costs $50, should Medicare opt to cover the cheaper one and not the more expensive one?

That’s the question senators on the Special Committee on Aging aimed to answer Thursday at a hearing on reducing prescription drug costs -- costs that are expected to double between 2008 and 2019.

The drugs in question are Lucentis and Avastin. Both are produced by the same company, Genentech, and both prevent blindness caused by wet age‐related macular degeneration, the leading cause of blindness in people over 50.

Lucentis, the more expensive option, is FDA-approved and has few known side effects. Along with one other drug, Lucentis accounts for 16 percent of the $12.5 billion Medicare Plan D spent on prescription drugs last year.

Avastin, the less-costly option, is a newer drug that has not yet been approved by the FDA. Some studies show that the drug may increase the risk of stroke and death, but no conclusive evidence has yet been produced.

Medicare covers both drugs, and despite more doctors prescribing Avastin, the “vast majority of the spending is for Lucentis,” said Jonathan Blum, the director of the Center for Medicare.

As of 2008, about 60 percent of physicians had started prescribing the “off-label” drug instead of Lucentis to save money for their patients, said Phillip Rosenfeld, a professor of ophthalmology at the University of Miami Miller School of Medicine. The move toward Avastin saved Medicare $800 million in 2008 alone, he said.

At a time when lawmakers are looking to slash budgets and decrease deficits, cost-saving measures like choosing low-cost drugs over similar but significantly more expensive ones may be part of the answer to closing huge budget shortfalls in programs like Medicare and Medicaid.

Tunis argued that the price Medicare pays for a drug should be linked with the drug’s effectiveness in relation to other drug options. In the case of Lucentis and Avastin, that would mean Medicare would pay a similar price for both drugs.

But under current law, Medicare is powerless to negotiate a price structure like that. The Medicare Modernization Act of 2003 requires Medicare to pay six percent more than the average sale price for prescription drugs, no matter the alternatives.

The downside of opting for low-cost alternatives to high-priced, brand-name drugs is that it would decrease funding for research and development, Tunis said. The Lucentis development program, for example, was one of the most expensive in Genentech’s history, said Anthony Adamis, the global head of ophthalmology at Genentech.

Lucentis’ clinical trials alone cost $1.1 billion, spanned 11 years and involved 7,100 patients.

Adamis said that because the vast majority of the drugs that go through clinical trials fail, the few that make it to market have to pick up the tab for all the failures.

Tunis argued that with research and development grants, innovation would not suffer, but the overall cost of prescription drugs could be reduced.

“It would be a very important way for Medicare to spend less on drugs and not harm beneficiaries at all,” he said.

Copyright 2011 ABC News Radio


Medicare to Cover Costly Prostate Cancer Drug

Paul Tearle/Thinkstock(WASHINGTON) -- The Centers for Medicare & Medicaid (CMS) says it will cover the cost of the pricey drug Provenge, recently approved for men with metastatic prostate cancer.

Provenge is said to extend patient survival by an average of four months, but costs about $93,000 per patient.  A CMS administrator said Thursday that the agency wants to assure patients can get the treatment they need according to their wishes.

"We are optimistic that innovative strategies may improve the experience of care for our beneficiaries who have cancer," said Dr. Donald M. Berwick, a CMS administrator. "CMS is dedicated to assuring that these patients can seek the treatments they need in accordance with their wishes."

Although research says that Provenge can lengthen survival time for men with prostate cancer that has spread beyond the prostate, experts note the drug is a therapeutic treatment and not a preventative one.   

Provenge has also reportedly presented fewer side effects in patients, researchers say.

Copyright 2011 ABC News Radio

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