Gov. Bruce Rauner was on the University of Illinois Springfield campus to sign an executive order forming a health care fraud investigation task force.
Brian Mackey/WUIS
April 05, 2016

New State Task Force To Search For Health Care Fraud

Gov. Bruce Rauner has signed an executive order, creating a task force to look for waste, fraud and abuse in taxpayer-funded health care programs. The panel will also try to prevent waste in state and federally funded Medicaid and employee health insurance programs. Rauner says the cost of state-run health care programs increase when no one's acting as a watchdog.

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Bernie Sanders in front of  nearly 4,000 supporters at the U of I's Activities and Recreation Center
Jeff Bossert/Illinois Public Media
March 13, 2016

Democrat Bernie Sanders Draws Crowd Of Thousands At U Of I

The Vermont Senator and Democratic presidential candidate cited his improving poll numbers, and believes a large voter turnout in Tuesday's Illinois primary will secure him a win.  About 3,600 filled the U of I's Activities and Recreation Center to hear Sanders, who reiterated a number of campaign pledges, including free tuition for college students and raising the minimum wage to $15.

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Dorothea Handron became so ill after a surgeon unknowingly pierced her bowel during a hernia operation that doctors placed her in a medically induced coma for six weeks to aid healing.
(Jim R. Bounds/AP Images for Kaiser Family Foundation)
June 23, 2014

Hospitals To Pay Big Fines For Infections, Avoidable Injuries

Medicare is preparing to penalize about 750 hospitals that have the highest rates of infections and patient injuries.

The sanctions, estimated to total $330 million over a year, will kick in at a time when most infections and accidents in hospitals are on the decline, but still too common.

In 2012, one out of every eight patients nationally suffered a potentially avoidable complication during a hospital stay, the government estimates. Even infections that are waning are not decreasing fast enough to meet targets set by federal health officials. Meanwhile, new strains of antibiotic-resistant bacteria are making infections much harder to cure.

Starting in October, a quarter of the nation's hospitals — those with the worst rates — will lose 1 percent of every Medicare payment for a year. In April, federal officials released a preliminary analysis of which hospitals would be assessed — they identified 761. When Medicare sets final penalties later this year, that list may change because the government will be looking at performance over a longer period than it used to calculate the draft penalties. (The full list of preliminary hospital scores is available here.)

The Hospital-Acquired Condition Reduction Program, created by the 2010 health law, is the third of the mandatory pay-for-performance programs established under federal health law. The first levies penalties against hospitals with high readmission rates, and the second awards bonuses or penalties based on two dozen quality measures. Both programs are in their second year.

Annual Penalties Add Up

When all three programs are in place this fall, hospitals will be at risk of losing up to 5.4 percent of their Medicare payments.

In the first year of the penalties for hospital-acquired conditions, Medicare will look at three measures. One is the frequency of bloodstream infections among patients who had catheters inserted into a vein to deliver antibiotics, nutrients, chemotherapy or other treatments.

The second measure is the rate of infections from catheters inserted into the bladder to drain urine. Finally, Medicare will examine a variety of avoidable health problems some patients experience in hospitals, including bedsores, hip fractures, blood clots and accidental lung punctures.

Over the next few years, Medicare will also factor in infections of surgical wounds and the rates of infection by one of two bacteria resistant to antibiotic treatments: Clostridium difficile, known as C. diff, and methicillin-resistant Staphylococcus aureus, known as MRSA.

"We want hospitals focused on patient safety and we want them laser-focused on eliminating patient harm," says Dr. Patrick Conway, chief medical officer of the Centers for Medicare & Medicaid Services.

Medicare's penalties are going to hit some types of hospitals harder than others. An analysis of the preliminary penalties conducted for Kaiser Health News by Dr. Ashish Jha, a professor at the Harvard School of Public Health, found that publicly owned hospitals and those that treat large portions of low-income patients are more likely to be assessed penalties. So are hospitals that are large, urban or in the West or Northeast.

According to Medicare records, preliminary penalties were assigned to more than a third of the hospitals in Alaska, Colorado, Connecticut, the District of Columbia, Nevada, Oregon, Utah, Wisconsin and Wyoming. The biggest impact may be on the nation's major teaching hospitals: 54 percent were marked for preliminary penalties, Jha found.

"Hospitals that have been working hard to reduce infections may end up in the penalty box," says Nancy Foster, vice president for quality and public safety at the American Hospital Association.

The government takes into account the size of hospital, the location the patient was treated and whether it is affiliated with a medical school when calculating infection rates. But the Association of American Medical Colleges and some experts question whether those measures are precise enough.

Missed Surgical Nick Triggers Nasty Infection

Medicare assigned a preliminary penalty to Northwestern Memorial Hospital in Chicago, for instance, but Dr. Gary Noskin, the chief medical officer, says hospitals that are more vigilant in catching problems end up looking worse unfairly. "If you don't look for the clot, you're never going to find it," he says.

It took, for example, five days for doctors to identify the infection Dorothea Handron picked up when a surgeon unknowingly pierced her bowel in 2009. By the time they operated on her again, she was so weakened that she was placed in a medically-induced coma at Vidant Medical Center in Greenville, North Carolina.

Under the scores released by Medicare in April, Vidant was assigned a preliminary penalty. Joan Wynn, who is in charge of safety at Vidant, says the hospital has taken many steps to reduce complications. The prospect of penalties is "difficult when you know how much your performance is improved," Wynn says.

Among its improvements, Vidant has added patients to internal committees, and now reveals on its website the total number of medication errors, infections, falls, and bedsores that patients at the hospital experience.

Vidant also asked Handron, who happens to be a retired nursing professor, to tell her experience to the hospital's trustees and to make a video for the medical staff.

Handron continues to advise the hospital. "I know they're going in the very right direction," Handron says. "I would have absolutely zero concern about myself or a family member going to Vidant for anything now."

This new effort by Medicare is just the latest campaign to get hospitals to lower rates of injuries to patients. In 2008 Medicare started refusing to reimburse hospitals for the extra cost of treating patients who suffered complications that the hospital could have prevented. A subsequent study by Harvard researchers found no evidence that the change led to lower infection rates.

"With infections, we are moving in the right direction," says Lisa McGiffert, who directs the patient safety program at Consumers Union. "But I would not say we are anywhere near where we need to be."

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Hundreds in California rushed to get health insurance just before the deadline.
(Justin Sullivan/Getty Images)
April 16, 2014

Is Obamacare A Success? We Might Not Know For A While

After months of focusing on how many people have or haven't signed up for health insurance under the Affordable Care Act, we now have a rough total (7.5 million), and everyone's keen to get to the bigger questions: How well is the law working? How many of those who signed up have paid their premiums and are actually getting coverage? How many were uninsured before they signed up? And just how big has the drop been in the number of uninsured people?

Unfortunately, the answers to some of these questions simply aren't knowable — or, at least, not knowable yet.

"It's very challenging," says Linda Blumberg, a senior fellow at the Urban Institute's Health Policy Center. "People want answers right away, and the best data sets we have obviously come out with a lag."

What's So Complicated?

That's partly because of the enormous size and complexity of the health system and the law. But it's also because the insurance industry is mostly private and regulated by the states.

"The impacts that all of these changes are going to have on the marketplace are going to play out differently all across the country," says Robert Zirkelbach, spokesman for the trade group America's Health Insurance Plans. "Simply looking at national data doesn't tell you what's going to happen in a particular market in a particular state."

Still, it's worth taking a closer look at some of those questions.

How Many Folks Are Paying Their Premiums?

First, how many people have actually paid their premiums for insurance they've chosen through the health exchange? That's the final and arguably most important part of the sign-up process. Most insurers report numbers in the 80 to 85 percent range. You might assume the people not paying are deadbeats. But that's hardly the case.

"This is not at all surprising," says Ken Jacobs, who heads the Center for Labor Research and Education at the University of California, Berkeley. The labor center just published a study of who's signing up for coverage in California. The research predicts that fully half the people who enroll in a plan through the California health exchange won't keep it for a full year.

That's always the case in the individual market, Jacobs says. It's transient.

"We have people who are starting in the nongroup market, and they get a job with job-based coverage and they leave," Jacobs says. "Or their income goes down and they end up going into Medicaid." Meanwhile, some others who have Medicaid experience a boost in income during the year and don't qualify anymore, "so they go into the exchange," Jacobs says, "or they get a job with job-based coverage and they leave the exchange."

In the case of the Affordable Care Act, he says, that transience was multiplied by lots of people who signed up in October and November and December — well before they had to pay their premiums.

"By the time they needed to pay," he says, "life had changed and they no longer needed that coverage."

Are There Really Fewer Uninsured?

Then there's the question of how the law is affecting people without insurance. But Jacobs says that asking whether people signing up had insurance previously is actually the wrong question — because of that same churning that affects the payment of premiums.

People move in and out of insurance all the time, he says, "and what the new marketplaces do is provide a place where people go rather than becoming uninsured during those times. And so you may have people who had insurance — job-based coverage — [then] lost their job, and now they're going into one of the marketplaces rather than becoming uninsured."

The real question then is whether the overall number of people without insurance goes down.

One presumes we'd begin to get a handle on that when the Census Bureau puts out its annual numbers in the fall. Except officials have decided to change the way they ask their health insurance questions for the Current Population Survey. (That's the study that produces the annual uninsured number.)

Those tweaks to the survey mean that, going forward, the uninsured numbers won't really be comparable to those of past years. That has produced some significant upset in the research community.

"It is a very unfortunate set of decisions in my opinion," says Blumberg of the Urban Institute. "We have all used the Current Population Survey for trends for measuring insurance coverage ... forever, it seems like, and we're not going to be able to do that because of the question changes."

Eventually, researchers say, the impact of the law will become more clear as more data become available. But "eventually" is likely to be well after this year's elections — and possibly after the presidential contest of 2016.

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A 2011 GAO report that sampled data from a handful of states suggests that, even before Obamacare, patients got the denial overturned 39 to 59 percent of the time when they appealed directly to the insurer.
(iStockphoto)
April 14, 2014

Patients Often Win If They Appeal A Denied Health Claim

Federal rules ensure that none of the millions of people who signed up for Obamacare can be denied insurance — but there is no guarantee that all health services will be covered.

To help make sure a patient's claims aren't frivolously denied, the Affordable Care Act creates national standards that allow everyone who is denied treatment to appeal that decision to the insurance company and, if necessary, to a third party reviewer.

For Tony Simek, a software engineer in El Mirage, Arizona, appealing was the only way he was able to get treatment for sleep apnea, which, though mild for many people, had become life-threatening for Simek.

"I had actually gotten to a place where I had fallen asleep while driving a vehicle," Simek says. "That's something that would normally have never ever happened to me."

Simek's doctor recommended he go a lab to undergo another sleep study test to see if his night-time breathing machine needed adjustment. But his insurance company denied the test.

"I was rather surprised," Simek says, so I reached out to my doctor to find out why. My doctor had been told [by the insurance company] that it was 'not medically necessary' in their judgment of my health condition."

Simek spent hours on the phone with the health plan, trying to get approval for the test. The insurance company sent him four denial letters. Simek has job-based health insurance through a California employer, so he filed an appeal with the California Department of Insurance.

"I have never had a problem with health insurance prior to this," Simek says.

Capital Public Radio analyzed data from California and found that about half the time a patient appeals a denied health claim to the state's regulators, the patient wins.

The picture is similar nationally. A 2011 GAO report sampling data from a handful of states suggests that even before the new standardization for appeals was implemented under the Affordable Care Act, patients were successful 39 to 59 percent of the time when they appealed directly to the insurer. When appealing to a third party (such as the state insurance commissioner), patients also were frequently successful in getting the service in question – patients won 54 percent of such decisions in Maryland, in the GAO sampling, and 23 percent in Ohio.

 

Until a few years ago, Fish-Parcham says, the rules regarding such appeals varied by state and employer.

"Insurers often get it wrong the first time," she says. "So if you've been denied a health care service, it might be because the plan didn't understand why that service was needed and why it fit their guidelines."

Administrative errors are the source of many denials, says Peter Kongstvedt, a senior health policy faculty member at George Mason University.

"It can be an error on the health plan side," he says. "Maybe they put somebody in the system wrong and they don't know that [he or she is] eligible yet. Or a data entry error occurs, and the computer says, 'Oh, we don't pay for this service on that diagnosis,' — that type of thing."

Other denials, like Simek's sleep test, are based on judgments of medical necessity. Insurers may consider a treatment experimental. Kongstvedt, a former executive in the managed health care industry, says such decisions require human discernment.

 

"The computer doesn't — usually doesn't — make that decision," he says. "It simply flags it and then it gets reviewed — first by a nurse reviewer who then presents it, usually, to a medical director," he says.

Insurers say medical studies support their decisions.

"The more evidence that's available about the appropriateness and effectiveness of a particular drug or treatment or technology — that's what drives what's covered," says Robert Zirkelbach, of America's Health Insurance Plans, the trade group representing insurers.

Zirkelbach says only about three percent of claims are denied. And, he adds, insurers support the new strengthening of the appeals process.

"Health plans are committed to getting it right," he says.

Appealing the denial was the right thing for Tony Simek. Ultimately, a California regulator overruled his insurer, and Simek got the test.

"I have been sleeping well ever since," he says.

The federal law requires insurers to notify patients of their right to appeal. But Fish-Parcham says many patients are not exercising that right as frequently as they should.

This story is part of a reporting partnership with NPR, Capital Public Radio and Kaiser Health News.


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