Obamacare's 2017 California Rates to Increase an Average of 13% With the Biggest Players Going Up 17.2% and 19.9%

After last year's 4% rate increase, California's Obamacare insurance exchange rates appear to be catching up to the rest of the country.

The two biggest carriers are raising rates by much more than the average 13.2% increase. Blue Shield said its average increase was 19.9% and Anthem said it would increase rates an average of 17.2%

According to the LA Times, Covered California officials blamed

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UnitedHealth's Optum Division Settles Case Alleging it Enrolled Non-Terminally Ill Patients in Hospice, Thus Risking Their Deaths Due to Treatable Illnesses

Fraudulant hospice enrollment is a uniquely dangerous practice, yet the latest cases of it have, as usual, attracted little attention.

Background

As we have discussed before, hospice care was initially designed to provide more humane treatment of the terminally ill, particularly patients with advanced cancer.  The idea was that rather than subjecting such patients to futile, but often painful or dangerous treatment, they would receive humane, palliative care.  Hospice care initally was provided in the US by small, local non-profit organizations.  But since Medicare pays for hospice care fairly well, for-profit corporations soon got into the act.  As we have discussed previously, some hospices, often but not always for-profit, began to admit patients who were not terminally ill.

The danger is that hospice care specifically excludes potentially curative care, such as antibiotics for infection or surgery for appendicitis.  So if a patient who is not terminal is in hospice and that patient develops severe bacterial pneumonia, that patient may not get antibiotics and thus may die of a potentially curable disease. 

We have been writing about this dangerous aspect of modern hospice care since 2011 (look here).  In various posts here we have detailed particular cases of non-terminal patients admitted to hospice who later died, seemingly of the neglect of treatable illness mandated by the concept of hospice care.  There have also been cases in which patients with chronic pain, but no terminal illness, may have died from hospice's overly aggressive use of narcotics .  For example, in a 2014 Wasthington Post story,

Clinard 'Bud' Coffey, 77, a retired corrections officer, did the crossword in The Charlotte Observer after breakfast every morning, pursued his hobby of drawing cartoons, talked seven or eight times a day to his son Jeff and, just two weeks before his death, told a pal that he still felt 'like a teenager.'

He did, however, have some chronic back pain, and in late March he was enrolled in hospice care 'essentially for pain management,' his doctor said. Over a two week period, he received rising doses of morphine and other powerful drugs, grew sleepy and disoriented, and stopped breathing, dying peacefully at home, according to his family and medical records they provided.

The Latest UnitedHealth/ Optum Case

The latest case of allegations of fraudulant hospice enrollment involved a very big, very profitable corporation.  As reported in detail only in the Minneapolis Star-Tribune,

A division at Minnetonka-based UnitedHealth Group is paying $18 million to settle allegations that it submitted false claims to Medicare for hospice patients who were not terminally ill.

The payment announced this week resolves a whistleblower lawsuit against Optum Palliative and Hospice Care that alleged the company tried to boost the number of patients for whom it could bill the federal Medicare program, without regard to whether they were eligible for and needed hospice services.

UnitedHealth Group's Optum subsidiary is a fairly big player in the commercial hospice world,

Optum/Evercare provides hospice care in 12 U.S. markets, including Arizona and Colorado. It does not operate in Minnesota.

The Strib provides a bit more detail about what seems to have happened.

The government alleged that false claims in the case were submitted to Medicare from Jan. 1, 2007, through Dec. 31, 2013. The lawsuit argued that Optum discouraged doctors from recommending that ineligible patients be discharged from hospice, and failed to ensure that nurses accurately and completely documented patients’ conditions.

The allegations were first raised by former employees in whistleblower lawsuits, which let private parties sue on behalf of the government and share in any recovery. The share to be awarded in the Optum case has not yet been determined, the Justice Department said in a news release.

As is now tediously typical in legal settlements involving large health care organizations, the government allowed the case to settle without any determination of guilt or innocence, and of course, without any individual who may have profited from the alleged bad behavior having to suffer any negative consequences.

'We are pleased to resolve this issue and are proud of our long record of providing high-quality, compassionate hospice care consistent with the needs of patients and supported by their doctors and family members,' Optum said in a statement. 'We believe Evercare Hospice acted properly and did not engage in wrongdoing.'

Also,

'The claims resolved by the settlement are allegations only, and there has been no determination of liability,' the Justice Department said in a news release.

As is also usual in these cases, the monetary value of the settlement, while it might appear large to a middle-class lay-person, is tiny compared to the revenue of UnitedHealth. For example, according to Google Finance, the corporation's 2015 total revenue exceeded $157 billion.

All that would be bad enough if the case only involved financial fraud.  Again, as noted above, it is possible that some patients without terminal disease who were enrolled in UnitedHealth's Optum hospice could have died of treatable conditions.  Yet this possiblility was not addressed by the limited press coverage of this case, or even by the US Department of Justice's news release about the settlement. 

Other Recent Cases

In 2016, there have been nearly anechoic media reports of cases of smaller hospices at least alleged to have deliberately enrolled non-terminal cases.  Perhaps because these organizations involved were not "too big to jail," some of these cases involved findings of guilt.

Home Care Hospice

In February, 2016, according to the Philadelphia Business Journal,

Nearly three years after fraud charges against a Philadelphia nurse first surfaced, a jury found 68-year-old Patricia McGill guilty for her role in scamming Medicare out of $9.32 million.

McGill was the director of professional services for Home Care Hospice for roughly three years beginning in 2005. During that time, she authorized and supervised the admission of patients for hospice services that they did not need or were not eligible for, according to court records.

This was not the first finding of guilt in this case involving a small, local for-profit hospice.

Alex Pugman and Matthew Kolodesh, the owners of the defunct Home Care Hospice – at one time located along Grant Avenue in Northeast Philly – were previously convicted for their part in the crime. Kolodesh, of Bucks County, was sentenced to 14 years in prison after being found guilty on more than 30 separate counts.

Note that the sentences were severe, but as far as I could tell, not based on the possible danger to patients without terminal illness created by their admission to hospice.

Horizon Hospice Subsidiairy of  JourneyCare

As reported by the Pittsburgh Post-Gazette in March, 2016,

The former top executive at Horizons Hospice in Monroeville is set to enter a guilty plea Friday in connection with charges of scheming to send patients to the center who weren’t terminal so she could bill Medicare and Medicaid.

She was not the first person to be found guilty in this case.

One of the key witnesses was expected to be Oliver Herndon of Peters, the medical director at Horizons from 2008 to 2012.

Herndon was sentenced in July to 33 months in prison after pleading guilty to certifying patients for hospice care who weren’t terminal and keeping them there longer so Horizons could continue billing the government.

Again, the possible danger to the fraudulantly enrolled patients was not discussed in the media accounts. Note that Horizons Hospice is a subsidiary of JourneyCare, which appears to be a non-profit organization.

Multiple Michigan Hospices

As reported in April, 2016, by the Washington Free Beacon,

Five individuals who have donated to Democratic politicians pleaded guilty to a scheme that drained Medicare out of $33 million dollars.

Two physicians and three owners of hospice and home care companies based out of Detroit, Mich., were charged on June 18, 2015 as part of the largest Medicare fraud case in history for submitting fraudulent claims for home health care and hospice services that were either not provided or deemed medically unnecessary.

The elaborate operation revolved around Muhammad Tariq, Shahid Tahir, and Manawar Javed—the owners of the home health care and hospice companies—paying kickbacks and bribes to physicians for referrals to their companies that included A Plus Hospice and Palliative Care, At Home Hospice, and At Home Network Inc.

While the reporting of this case focused on the apparent political leanings of the individuals involved, it also ignored any danger to non-terminal patients.


Discussion

The problem of fraudulant enrollment of non-terminal patients in hospice continues, despite our efforts over five years to make the problem more public.  The latest case involved a very big, very wealthy for-profit health care corporation which has had its share of troubles in the past.  Yet the latest case is as anechoic as earlier ones, including smaller cases this year.

These enrollments may be motivated by the desire for more money, but they put patients at risk.  Nonetheless, such abuses by hospices get little press coverage, seemingly are ignored by health care regulators and law enforcement, and are almost completely anechoic in the health care, medical and health policy literature.

If a measure of society is how it cares for the most vulnerable patients, the US laissez faire approach to for-profit hospices suggests a society in decline.

To repeat what I wrote the last time for-profit hospices were (barely) in the news for enrolling the wrong patients,...

 In my humble opinion, we should return control of direct patient care, especially of the most vulnerable patients, to health care professionals and if necessary small non-profit community organizations.  We ought to give strong consideration to banning corporate hospices, and banning all forms of the corporate practice of medicine and corporate health care "delivery."

Given how many insiders make so much money from the current version of laissez faire capitalism in health care, however, I would expect strong resistance should such apparently "radical," but actually conservative proposals actually get any mainstream attention.

But in an election season now often dominated by ridiculous hyperbole and outlandish statements, maybe such vitally (literally) important issues should start getting some attention.     

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Kentucky College of Optometry about to open in Pikeville

Artist's rendering of Kentucky College of Optometry, Pikeville

The University of Pikeville says it is about to open the nation's largest optometric college in terms of floor space, the Kentucky College of Optometry.

"Dr. Andrew Buzzelli, vice president for optometric education and the college’s founding dean, said that, at 130,000 square feet, KYCO is the largest optometry college in the country," Josh Little reports for the Appalachian News-Express in Pikeville. "The cost to build the college is $55 million, plus $9 million for equipment."

Students at the college will perform optometric services for local residents, under the supervision of doctors of optometry. "Pikeville Medical Center will still continue to be the main provider in the area, but they only have two providers, so the care is in here," Buzzelli said. "In the other schools around the country, care is all around the city, that’s not true here. ... This will be for our specialty clinics, such as laser surgery." He said The college will offer electrophysiological tests, which now require residents to travel to Lexington or Huntington, W.Va.

The university is already home to the School of Osteopathic Medicine.

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Hearing loss can lead to cognitive decline or even dementia, but is often unaffordable, and financial aid for it is shrinking

By Trudy Lieberman
Rural Health News Service

Nearly two-thirds of adults over age 70 have hearing loss that doctors consider “clinically meaningful.” In plain English that means as people age, they are likely to become hard of hearing. Many of those people, however, don’t get the help they need, often because they simply cannot afford it.

“The prevalence of hearing loss almost doubles with each age decade of life,” says Dr. Frank Lin, an otolaryngologist at Johns Hopkins University, but for older people, he adds, “there are multiple barriers that prevent individuals from getting their hearing loss addressed.”

Lin spoke about the subject to a group of journalists in a recent phone conference sponsored by a Washington, D.C., advocacy group the National Committee to Preserve Social Security and Medicare. He is a co-author of a June report issued by the National Academies of Sciences, Engineering, and Medicine that recommends better access and support for treating hearing loss.

Lin told the group that although hearing loss is a normal part of the aging process, “hearing care is inaccessible” to many seniors. He said studies over the last five years have shown that such loss “can increase the risk of cognitive decline.”

Using data from a longitudinal study (one that tracks data from the same people repeatedly over many years or decades) that began in 1958, Lin and his colleagues at Johns Hopkins found that those with hearing loss had a higher probability of developing dementia. The more severe the loss, the more likely the dementia.

Photo from howmanyarethere.net

That isn’t the only problem. Hearing loss is also associated with a greater risk for falls and other accidents because a person can’t hear traffic or a smoke alarm in their home. Furthermore, those with hearing loss often feel isolated and shun normal social contacts because they can’t hear others speak. That’s a blow to productive aging, the goal promoted by the late Dr. Robert Butler, a well-known gerontologist who fought against ageism.

So why, then, is hearing care so inaccessible? Cost may be the major barrier. Nearly all expenses for hearing care must be paid out-of-pocket, and for many seniors on fixed incomes, that’s sometimes hard to do. Lin told me the average cost of two hearing aids is $4,700 and rarely covered by insurance.

Medicare doesn’t cover hearing exams, hearing aids, or exams for fitting hearing aids. It does cover diagnostic hearing and balance exams, but only if your doctor orders those tests to see if you need medical treatment. In that case, if a person has traditional Medicare and a Medicare supplement policy, often called a Medigap, he or she has to pay 20 percent of the approved amount for the exam. Some Medicare Advantage plans may include hearings tests as part of the extra benefits they offer.

The National Committee and other advocacy groups are campaigning to add a hearing benefit to Medicare’s benefit package. Their campaign is bucking a trend in Washington to cut Medicare benefits by raising the age of eligibility, making richer seniors pay more, and requiring those with traditional Medigaps to have more skin in the game.

Politicians have already begun redesigning Medigap policies to make seniors pay more out of pocket for their care. Beginning in 2020, for example, insurers will not be allowed to sell Medigap policies that cover the deductibles for Medicare Part B that pays for physicians’ services, lab tests and hospital out patient care. The theory behind this shift is that seniors will pay more and the government less, thus helping to save Medicare money.

I asked Dan Adcock, the National Committee’s policy director, about the chances of adding benefits to treat hearing loss, or for that matter vision and dental care, when the focus has been on cutting benefits of all kinds. He said one major source of funds to pay for hearing aids could come from lowering the price of what Medicare pays for drugs. The 2003 legislation that gave seniors a drug benefit also prohibited the government from negotiating prices for the drugs it buys. Drug makers strongly oppose such negotiations.

Adcock said he remains hopeful. If better hearing means a decrease in dementia, falls and accidents, fewer people would need treatment for those conditions. The savings could potentially “pay” for the hearing aids, he said.

For now, though, seniors and their families are on their own. The National Academies offer an "Action Guide for Individuals and Families" that suggests actions people can take to prevent hearing loss, and strategies for families to cope with it when it occurs. It’s available at www.nas.edu/hearing.

What experiences have you or a family member had with hearing loss and obtaining treatment? Write to Trudy at trudy.lieberman@gmail.com.

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Ben Chandler, who as AG filed lawsuit that led to creation of Foundation for a Healthy Kentucky, will be its president and CEO

Ben Chandler (AP photo)

Ben Chandler, who as state attorney general filed the lawsuit that led to the creation of the Foundation for a Healthy Kentucky, was named president and CEO of the foundation Monday.

Chandler, 56, was state auditor in 1992-95, attorney general in 1996-2003 and Sixth District representative in Congress from 2004 to 2012, when he lost a bid for re-election. He lives near Versailles and has been executive director of the Kentucky Humanities Council.

As attorney general in 1997, Chandler sued Anthem Blue Cross Blue Shield of Kentucky to recover the charitable assets Anthem received after merging in 1993 with non-profit Blue Cross. In 1999 Anthem Inc. agreed to put $45 million into an independent, charitable foundation that would address the unmet health needs of Kentuckians. The Foundation for a Healthy Kentucky was created and had its first board meeting in 2001.

Chandler succeeds Susan Zepeda, who has been president and CEO since 2005 and announced last year that she would retire at the end of the year. Zepeda came to Kentucky after serving as CEO of The HealthCare Foundation for Orange County in California, and before that as head of the health agency and hospital in San Luis Obispo County.

Chandler said in a press release, “Having fought so hard for a healthier Kentucky during my time as attorney general, I am beyond thrilled to be invited to build on the good work of Susan Zepeda and her team and to lead the foundation to even greater impact. The health challenges in our state are very real, but so is the commitment to a healthier future for all our citizens.”

Foundation Board Chair Chris Roszman, who chaired the search committee, said, “Ben’s past experiences as a bipartisan leader in championing health policies through collaboration and effective consensus-building will serve the foundation well as we continue to address the unmet healthcare needs of Kentuckians.”

Search committee member Robert Slaton, a former state health commissioner who chairs the foundation’s Community Advisory Committee, said in the release, “Sixteen years ago Ben had a vision. To welcome him to continue that vision today is very exciting.”

The nine-member search committee consisted of business and health leaders from across the state, the press release said. All were current or former members of the board or the Community Advisory Committee. "In an extensive, six-month process, the search embraced a broad array of potential contenders from across the commonwealth and from 21 other states and the District of Columbia," the release said.

Chandler earned both his B.A. and J.D. degrees from the University of Kentucky. He studied at the University of London and Trinity College in Dublin, including an internship in the British Parliament. He practiced law with Brown, Todd & Heyburn, specializing in health-care law, and later with Reeves & Graddy in Versailles. He and his wife, Jennifer, have three children, live on the family farm and attend Pisgah Presbyterian Church, where he is a trustee.

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If you read a story saying pasta isn't fattening and can help you lose weight, you may not have gotten the whole story

By Steve Wilson
The Paducah Sun

Newspapers are often faulted for not printing enough good news, and a reader lodged a fresh complaint along that line last week.

"Why didn't you have a story about the study that found eating pasta is good for you? TV had it, and it was all over social media. We spaghetti lovers would appreciate reading something good about a food that's gotten a lot of criticism."

I said I hadn't heard about the study and would look into it. What I learned is that despite all the cheerful sound bites and headlines it generated ("Pasta isn't fattening and can help you lose weight") the study provides a prime example of how slapdash reporting can mislead more than inform.

It's no mystery why the study was widely reported, especially by media that are fond of "click bait" and measure success by the number of eyeballs they attract online.

Pasta sales have dropped in the past decade as low-carbohydrate diets have gained favor. Many nutritionists disparage the food as "empty calories" without much benefit, especially for people wanting to lose weight. . . . 

Buried far down in a couple of the stories were these facts:

• A traditional serving of pasta in Italy is no more than three ounces, far smaller than what most people eat in the U.S., and less likely to have a high-calorie sauce. It's usually served as a light first-course.
• Italians in the study were likely to follow the healthful Mediterranean diet, which is rich in olive oil, fish, fresh fruits and vegetables and whole grains.
• Italian pastas have more whole grains than most American white-flour varieties. They're higher in nutrients and fiber, making them beneficial in giving a sense of fullness that helps control calorie intake.
• The study was partly funded by Barilla, a leading pasta-maker.

. . . While the Italian study is less than a ringing endorsement for filling up on pasta, it's good to see evidence that moderate consumption is healthy and can even help people lose weight.

What's unhealthy are media reports that skim the surface of a study and misrepresent its findings.

This is a condensed version of the article. The full version is here but behind a paywall.

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Needle exchanges slowly spread as locals conclude they're better than HIV and hepatitis outbreaks, injuries from discarded syringes

Needle exchanges may be difficult for some people to accept, but they are better than outbreaks of hepatitis and HIV or accidental injury from discarded needles, officials in Kentucky counties that have established the exchanges told Bill Estep of the Lexington Herald-Leader.

"Programs allowing intravenous drug users to exchange dirty syringes for clean ones are spreading in Kentucky as communities confront growing heroin abuse and concerns over the potential for disease outbreaks caused by addicts sharing needles," Estep reports. "So far, health departments and local governments in 13 counties have approved needle exchanges, and 11 are in operation, according to the state Cabinet for Health and Family Services and local officials."

Kentucky leads the nation in hepatitis C cases and has 54 of the 220 counties that the federal Centers for Disease Control and Prevention considers most at risk for HIV or hepatitis outbreaks from shared needles, based on "statistics such as numbers of overdose deaths, per capita income, unemployment and sales of painkillers," Estep notes. "Kentucky had 18 counties that the CDC calculated to be more vulnerable than Scott County, Indiana, to a disease outbreak among IV drug users, with Wolfe County considered at greatest risk in the nation."

A version of this map appeared on Kentucky Health News May 5. This one adds needle-exchange sites.

Some local officials "said they’ve faced concerns that giving needles to drug users enables or condones illegal drug activity, or will make the local drug problem worse," Estep reports. Republican Judge-Executive Mike Malone of Carter County "said he shared those concerns when officials from the health department brought up the idea. Malone said he changed his mind because of the potential for the program to head off disease and get addicts into treatment.

“It’s not about enabling them to take drugs. It’s about stopping the spread of disease,” Malone said. “The more you learn about it, the more you’ll understand it’s the right thing to do.”

Estep reports, "Health officials said they understand some people don’t like the idea of providing drug users with needles at public expense, but they argue the potential cost to taxpayers of not doing so is far worse."

Needle exchanges are operated by local health departments with approval of the county health board, the fiscal court and the city where the exchange is located, under a law passed by the 2015 General Assembly.

UPDATE, July 22: "Clark County’s needle exchange opened a week ago with one client." Fred Petke reports for The Winchester Sun. "Local officials are good with that." Clark County Health Department director Scott Lockard told Petke in an email, “Some of the health departments had their exchanges open several weeks before having their first client.”

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