Wednesday, February 29, 2012

NHS Reform & Scamming: Unnecessary Rx & Fraud

As England tried to cope with possible fraud of A4E causing the most untimely embarrassment to the Prime Minister, it pales when compared with:

Latest Medicare Fraud  Dallas, Texas, USA.

Federal authorities announced charges Tuesday in the largest healthcare fraud scam in the nation's history, indicting a Dallas-area physician on charges that he bilked Medicare of nearly $375 million and accusing him of sending "recruiters" to scoop up patients and get them to sign for treatments he never provided.

Prosecutors said Roy and his office manager in DeSoto, Teri Sivils, who was also charged, sent healthcare "recruiters" door-to-door asking residents to sign forms that contained the doctor's electronic signature and stating that his practice had seen them professionally in their own homes.
They also dispatched "recruiters" to a homeless shelter in Dallas, paying the recruiters $50 every time they coaxed a street person to a nearby parking lot and signed him up on the bogus forms.

Even when officials suspended his Medicare license last June, they said, Roy found a way around that by shifting his business to another company.

Could we find a B4E soon or C4E!

In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.

I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.

The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.

By how much? In the US:
26 OCT 2009

The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.

The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.

"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.

UNNECESSARY CARE (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
FRAUD (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”

“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.

Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
deceased patients
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid  recipients with drug addictions enrolling in multiple states.

ADMINISTRATIVE INEFFICIENCY (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
HEALTHCARE PROVIDER ERRORS (12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
PREVENTABLE CONDITIONS (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
LACK OF CARE COORDINATION (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

BBC 20 May 2008
A dentist and his wife who stole more than £30,000 from the NHS by claiming money for treatment never given to patients have been jailed.
Newton Johnson, 52, and his wife Judith, 51, also claimed for treatment for "phantom" patients, which included the name of a family pet dog.

UK Dental Fraud: 2007200820102011


Tuesday, February 28, 2012

Obama Health: Under One Roof

Obama Health & The NHS: Patients Trading
It would be interesting to see how universal health insurance will pan out in the Obama health care reform.

It made sense that insurers should not be allowed to “cherry pick”. The Cockroach Catcher just realised that perhaps there now will be a new commodity: patients.

The financial world has been about risks and derivatives were designed to minimise risks. All very laudable until some smart ones realise that much money could be made from such instruments.

Health Insurers are a special group of such financial institutions and no doubt they will want to minimise the risks. In the past, it is very simple: exclude risky patients.                    Reuters: Insurer targeted HIV patients to drop coverage
President Obama signed the budget reconciliation bill containing a package of revisions to the big health care legislation after giving a speech at Northern Virginia Community College, a setting aimed at drawing attention to the education component of the bill.

“Today we mark an important milestone on the road to health insurance reform and higher education reform,” Mr. Obama said. “But more broadly, this day affirms our ability to overcome the challenges of our politics and meet the challenges of our time.”

He continued, “When I took office, one of the questions we needed to answer was whether it was still possible to make government responsive to the needs of everyday people, middle-class Americans, the backbone of this country, or whether the special interests and their lobbyists would continue to hold sway like they’ve done so many times before. And that’s a test we met one week ago, when health insurance reform became the law of the land in the United States of America.”

In his speech, Mr. Obama also sought to temper some expectations. “The health insurance reform bill I signed won’t fix every problem in our health-care system in one fell swoop,” he said. “But it does represent some of the toughest insurance reforms in history. It represents a major step forward toward giving Americans with insurance and those without a sense of security when it comes to their health care. It enshrines the principle that when you get sick you’ve got a society there, a community that is going to help you get back on your feet. It represents meaningful progress for the American people.”

It was a courageous president to have taken on the might of Health Insurers the way President Obama did with his Health Reform, it is time that England should seriously consider passing legislation to rein in on Health Insurers. Many consider it too late to prevent private bodies taking over our once efficient NHS. By 2014, Health Insurers in the US will not be allowed to "cherry pick". Is that why so many of them are poised to cross the pond? Only time will tell. In the mean time legislation similar to those in the US will at least prevent the kind of things that are happening now over there.
All the insurers have notified the state Department of Insurance of their intention to resume sales.

“……There is plenty at stake. California's private insurance market — where individuals and small businesses buy coverage — generated $17 billion in revenue last year. The market is only expected to grow as millions of uninsured Californians buy coverage, beginning in 2014, through a new marketplace exchange set up as part of the federal healthcare law.”

“Regulators from the California Department of Insurance have been trying to prod insurers to start selling child-only policies once again since they announced their departure shortly before Sept. 23, when the federal healthcare law would have required them to accept all children with preexisting conditions. On Wednesday, officials sent the companies two pages of "guidance" to help them interpret the new state law.”

Guidance? Really!

Perhaps our new government is the one that needs guidance. The sooner they rein in the insurers the better:

No exclusion of pre-existing conditions and no rescission and definitely no dumping.

And a limit of say no more than double the best rates.
With the passing of the health care bill in the US, one must congratulate President Obama for achieving the impossible and he will no doubt be ranked with the greatest presidents.

A few weeks ago, Obama and health reform were doomed and Obama was not up to the job. In the coming days, we will see a jubilant Obama on the cover of newsmagazines. He will be lionized as a giant-killer. His approval ratings will rise, both because more Americans are paying attention to the beneficial features of the bill as opposed to the Republican caricatures and because Americans love a winner.

"And the health bill itself only begins the long task of wresting control of the health care system from callous insurance and drug companies. We still have to fight for a real public option that is the first step towards national health insurance."   Huffington Post

The Obama Health reform is dealing a big blow to Health Insurers as by 2014 they will have to take all comers and cannot exclude pre-existing conditions not to say dumping someone like my Anorexia Nervosa patient. Until then, the State or the Federal Government steps in.

Gov. Arnold Schwarzenegger of California, a Republican gave a rousing endorsement of President Obama’s health plan.  New York Times reported today.

The new government in a week’s time should take the first step in legislating against Health Insurers “dumping” patients because of psychiatric diagnosis or so called chronic conditions. That way, private hospitals and insurers can fight it out amongst themselves. At least  the small pot of NHS cash would be safe. That would be a first step.

I doubt if any government would follow Obama’s extremely courageous move of legislating against excluding pre-existing conditions but we could watch what happens in a few year’s time. If we can at least secure the position of those already insured we could save the NHS a great deal of money.

Unlike the US we have a safety net: the NHS.

Let us protect it. 

NHS Reform & Health Insurers: True Choice & Competition

A very personal view indeed:

 ©2005 Am Ang Zhang

Our NHS is not without faults and often the faults were to do with government. Impossible targets set up by successive governments have one aim: limit access to health care.

I wrote in 2008 in The Cockroach Catcher:

The doctor’s position had over the last ten years moved nearer the bottom end with no such counter moves by politicians. Some argued that the rot started with Shipman and the move to check on doctors’ competence will soon become law. The sad truth is that incompetence was not Shipman’s problem as he was able to shield the deaths that he created with his expert medical knowledge.  The incompetence was with those that regulated him. He was probably more up-to-date with medicine than most, and expert at euthanasia. Recent scandals relating to Cleveland, Bristol, Alder Hey, Kent Authority, and MMR  all help to erode people’s trust in their doctors and their regulator, the GMC.

Then we have Mid-Staffordshire & Baby P amongst others that demonstrated how if you try hard to meet targets patients died and if you whistle-blow, you die professionally. Successive governments tried to pretend that the problems have nothing to do with their main aim: cutting funding to Health Care of the citizens of the land in the form of covert rationing.

So, a new sales pitch came in: Choice & Competition to improve the quality of health care plus let us involve the privateers as they are good.

Good at what!

Making money: for themselves. Remember Southern Cross and now A4E?
Then we have world class cancer hospital and third world cancer survival. No it did not make any sense at all.

So the decision was to get rid of the NHS as it was but retain the name as a brand.

Many consider it too late to prevent private bodies taking over our once efficient NHS.

But!!! And a very big BUT!!!

Why not legislate to rein in Health Insurers?
  • Ends discrimination against people with pre-existing conditions.
  • Limits premium spread to normal, high risk and healthy risk to say under 20% either way of normal.
  • Limits premium discrimination based on gender and age.
  • Prevents insurance companies from dropping coverage when people are sick and need it most.
  • Caps out-of-pocket expenses so people don’t go broke when they get sick.
  • Eliminates extra charges for preventive care.
  • Contribute to an ABTA style cover.
We could legislate that Insurers will have to pay for any NHS treatment for those covered by them. It will stop Insurers “gaming” NHS hospitals. This will prevent them saving on costly dialysis and Intensive Care. Legislate for full disclosure of Insured status.

Insurers cannot drop coverage or treatment after a set period and even if they do they will still be charged if the patient is transferred to an NHS Hospital.

This will eliminate problems like PIP breast implants.

It will indeed encourage those that could afford it to buy insurance and in any case most firms offer insurance for their employees including the GMC.

To prevent gaming of Insurers by individual patients (I look after their interest too), the medical fee should be paid up front by the patient and then deduction taken from premiums. Corporate clients like those with the GMC should not be gaming Insurers.

Imagine the situation where those with “individual personalised budget” being able to “buy” their own insurance!

In fact, to save money, government can buy insurance for the mental patients and the chronically ill.

This way their will be real choice and insurers will be competing with each other to provide the worst deal.


What Health Insurer will want the business? 

Perhaps they will go back to the US and we will have our own NHS back.

“……The principle of care for all from cradle to grave is worthy and wonderful. But the current reality is a cradle rocked by accountants who are incapable of even counting the number of times that they have rocked it……..” These are the very same people we pay market rate or they will go elsewhere!!!

The Cockroach Catcher on Amazon Kindle UKAmazon Kindle US

Friday, February 24, 2012

Private & NHS: Choice & Competition for same Consultants

It is amazing that the debate on the NHS Reform continues and the emphasis is on choice and competition that will in turn improve quality!

"But, excuse me, did I not just see you at the NHS Clinic?"

The above is still the most common exchange when one gets persuaded to see a consultant at a Private Clinic on the belief that you might get your hip earlier and wait, "better" treatment.

But private clinics and hospitals need to make a profit and that means less money for treating patients when we started sending NHS patients to private clinics. 

Please Mr Lansley, explain to me the good of the AQP of your new world order!

In the new world order of our NHS, private provider (AQP)for commercial reasons need not let the public have access to information about their activities etc, and even the doctors they provide.

Just look at one of the OOH, one doctor for 950,000 population!  As they say, be very afraid.

Even as we like our NHS as much as our woods: looks like private providers for public services is in the PM's mind. Sometimes it is public (taxpayer) money for private failures: catastrophic failures when it is someone's life.

Wait, most of the time they are the same doctors so introducing competition is not going to improve anything.

Choice? Really!!!

Anyone who cared to Google Private Health Insurers will find that many conditions are excluded from their "comprehensive" Health Care. The full list is too long and I might be infringing their copyrights. See if dialysis and intensive care treatment are covered. What kind of "comprehensive" Health Care is it to exclude both.

Check out the John Lewis Hospital, sorry Circle. Same story: exclude baby intensive care, dialysis and mental health.  

Just try not to get this funny E. Coli. As when you need dialysis you may have to choose NHS. But then, you might be so ill and unconscious.....mmm interesting thought. How does one choose when very unwell? 

According to the NAO:

In 2009 the total value of the market for PH(Private Healthcare) in the UK was estimated at just over £5.8 billion. Private hospitals and clinics account for the largest part of the overall PH market, generating an estimated £3.75 billion in revenue during 2009. Fees to surgeons, anaesthetists and physicians generated an estimated £1.6 billion in 2009.

The total number of UK citizens with Private Insurance is estimated to be around 90,000. It is not difficult to work out what good value the NHS has always been.

The NHS was not perfect, far from it and yet successive attempts at fixing it has produce the opposite effect: it needs more fixing.

If you read that line again from the NAO report, it was clear where the problem was: fees to surgeons, anaesthetists and physicians!!!

Yes, that was the main recipient of Private Health income.

To become a Consultant in the NHS used to be prestigious and even those aiming to doing mainly private work will have to wait till they achieve Consultant status in the NHS.

The NHS for all its sins tried to keep every consultant as close to the MAYO ideal by insisting on the same pay-scale.

Several levels of Distinction Awards were used to keep some professors and top consultants happy. Later the name of the Awards was changed and yet it was still the same soup.

If Consultants were prepared to give up one session of pay, then there is no limit as to the private work they can take on. It was a safe way to start your private work and you keep the rather nice NHS pension.
What is generally not talked about is that you keep one foot in your NHS hospital and one in your private one.

So far so good and yet this is where the problem starts.

It does not need a genius to work out that people worry about their health and do not want to wait for a suspicious lump to stay in their body too long. They will pay. We need not even mention the manipulation of waiting lists, etc. Then big companies realise that they can attract staff by offering Health Insurance and the rest is as they say history.

Then the rules changed and every consultant can do a maximum of 10% of their NHS pay in private work without having to give up anything. Some hospitals even allow you to use their facilities for a small fee.

Why not, more private patient means less expenditure for the NHS.

Private Insurers discovered that too and they started offering a small fee if you can wait for your operation at your free NHS hospital.

There has never been any control of Health Insurers and I suspect if was not even because they have a strong lobby: just the feeling that the NHS was for everybody so no one could be excluded.

But Health Insurers are cleverer, they exclude chronic conditions, many psychiatric ones belong to that group and often they will exclude after a while.

Cherry picking without extra labour.
Cherry picking soon©2007 Am Ang Zhang 

So, indeed it was a clever move by the present government to simply hand over a portion of money to the GPs and say: get on with it, the best price or better still, why not treat them yourself. You are all doctors, forgetting one of their own just had neurosurgery done at Queen Square.

Until, now Consultants are to be excluded from the consortia. Most are not making too much noise for a very good reason.

There just are not enough of us Consultants and the reform is really COVERT rationing by any other name.

How else could the government continue to claim that competition will improve standard and bring down cost.

Private or NHS, they are the same Surgeons, Anesthetists and  Physicians. 

It is so simple: Private Providers need to make a profit so there is going to be less money for patient care, not more.

Mark Porter: Chairman of the British Medical Association's consultants committee.

NHS services in some parts of England could be "destabilised" by private firms taking advantage ……….to win contracts for patients with easy-to-treat conditions. This could lead to some hospitals no longer offering a full range of services and ultimately having to close.

The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.

The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.

The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porter. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned.

NHS & Market Forces: Fund Holding & Medical Ethics