Category: Daily News

CMS released a report this week showing that investments made in program integrity activities pay off. From October 1, 2012 through September 30, 2014 every dollar invested in CMS’ Medicare program integrity efforts saved $12.40 for the Medicare program. Total savings from program integrity efforts were nearly $42 billion over the two-year period covered by the report.

CMS has achieved this impact by using a multifaceted approach, ranging from provider enrollment and screening standards, to use of enforcement authorities, to use of advanced analytics such as predictive modeling. It has previously reported on various outcomes tied to specific programs.

The Department of Health and Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) are in the third year of implementing sophisticated predictive analytics technology to prevent and detect fraud. It is using the anti-fraud authorities provided in the Affordable Care Act and the Small Business Jobs Act (SBJA) of 2010,

The Fraud Prevention System (FPS) was created in 2010 by the Small Business Jobs Act, and CMS has extensively used its tools. The SBJA requires that the HHS Office of the Inspector General (OIG) certify the savings and costs of the FPS. CMS achieved certification in the second and third year of the program. For the first time in the history of federal health care programs, the OIG certified a methodology to calculate cost avoidance due to removing a provider from the program. This is a critical achievement as moving towards prevention requires a clear measurement of the future costs avoided.

Since CMS implemented the technology in June 2011, the FPS has identified or prevented $820 million in inappropriate payments by identification of new leads or contribution to existing investigations. During the third year the FPS identified or prevented $454 million in inappropriate payments through actions taken due to the FPS or through investigations expedited, augmented, or corroborated by the FPS. Total savings were 80% higher than the savings from the previous implementation year, with a nearly 10:1 return on investment.

Thus CMS’s efforts to pro actively prevent potentially fraudulent and improper payments from being made have been increasingly effective, moving its efforts away from the “pay-and-chase” method of recovering payments after they had already been made.

The primary focus of the FPS during the first two implementation years was identifying providers with the most egregious behavior for investigation by the new Zone Program Integrity Contractors (ZPICs) created to perform program integrity functions. During the third implementation year, CMS tested new and innovative ways to leverage the FPS technology and best practices to support additional fraud, waste, and abuse activities. In future years, CMS will continue to expand the FPS and the transfer of knowledge related to predictive analytics technology. For example, CMS will expand FPS edits to deny or reject more improper payments and CMS will provide technical assistance to states that decide to implement predictive analytics technology.

CMS collaborates with various partners. Assistance from its contractors, state Medicaid agencies, and law enforcement partners are also instrumental in this effort when potentially fraudulent and improper payments result from intentionally fraudulent activities. CMS welcomes input from beneficiaries, providers, suppliers, and others to inform possible future enhancements to our program integrity strategy. Please contact CMS at 1-800-MEDICARE (1-800-633-4227) or TTY: 877-486-2048 with your thoughts or to report potentially improper billing.

Around half of all major surgery in some countries is now done with robots. The US, UK, and India are among the leading proponents, but many other countries, too, are reporting statistics that would indicate that a significant proportion of surgical procedures is now robotics-assisted.

Harvard Medical School conducted a study in the US of around 500,000 cancer patients between the years of 2003 and 2010, and found that the number of surgical procedures that were robotic-assisted went from 0.7 per cent to 50 per cent over those years.

It also found that the use of robot-assisted surgery was more common among surgeons at teaching hospitals and at intermediate and large-sized hospitals, as well as at urban hospitals.

The Harvard team calculated that robot-assisted surgery increased the overall cost to the hospital, contributing to a 40 per cent increases in annual expenditures.

Dr Steven Chang, who led the study, said: “Our findings give insights on the adoption of not just robotic technology but future surgical innovations in terms of the general pattern of early diffusion, the potential impact on costs of new and competing treatments, and the alternations in practices patterns such as centralization of care to higher volume providers.”

In the UK, parts of the National Health Service (NHS) have been introducing robots into surgery over the past few years. In a study by NHS England found that robotics were used to assist surgeons in 49 to 50 per cent of the time in some types of cancer cases, such as prostate cancer. The report said it found no difference in the “operative time”, or the duration of the operation itself, “but patients having a robot-assisted procedure had shorter length of admissions”.

This is a view that is echoed by other medical professionals, such as Dr Vanita Ahuja, of the York Hospital in Pennsylvania, who produced a report partly based on a nationwide database from 2008 to 2011, and found that robotic-assisted cardiac surgery increased by 600 per cent over the four-year period.

“Robotic-assisted cardiac surgery has lower length of stay than non-robotic surgery,” Dr Ahuja said, adding: “Results of this study suggest robotic-assisted cardiac surgery may be as safe as non-robotic surgery and offer the surgeon an additional technique for performing cardiac surgery.”

In India, too, surgeons are coming to similar conclusions. Dr N. P. Gupta, chairman of Medanta Kidney and Urology Institute, is claimed to have been the the first to use the robot-assisted surgical technology for radical prostatectomy in India. In an interview with The Times of India, Dr Gupta said “patients can go home in two to three days after the surgery”, partly because robots made clear and accurate, which allows suturing to suturing to be with minimum amount of damage to surrounding tissues.

Orthopedic surgery robots use the 3D imaging technology and computer navigation techniques to improve ability of surgeons to place implants with precise alignment. Many studies have shown that these techniques are safer and more effective as compared to traditional surgical techniques. David Bortel, MD, an orthopedic surgeon at MidMichigan Medical Center at Midland, says: “In reality, patients are reporting comparable mobility, functionality and quality of life”.

Though emerging technology does not guarantee better results, robotics has always been effective in hip and knee replacement surgeries. Improvements in technology and new methods of verification for implant sizing and placement are significant for patients and surgeons.

Dr. Michael Roger Chiarottino, age 68, of San Rafael, was indicted by a federal Grand Jury on September 14, 2014. He was charged with fifteen counts of distribution of controlled substances in violation of Title 21, United States Code, Section 841(a)(1).

Chiarottino pleaded guilty on March 8, 2016, to one count of distributing oxycodone, a Schedule II controlled substance, outside the usual course of professional practice and without a legitimate medical purpose.

According to his plea agreement, Chiarottino admitted that he prescribed large quantities of controlled substances (including oxycodone, oxymorphone, hydromorphone, methadone, and hydrocodone) to undercover DEA agents posing as patients in exchange for cash. On each occasion, Chiarottino failed to conduct an appropriate medical examination of, or obtain a sufficient patient medical history from, the undercover agent to support a prescription for such a large quantity of narcotics. In total, Dr. Chiarottino prescribed 46.8 grams of oxycodone (numbering 1,530 thirty-milligram pills) and admitted doing so with the intent to act outside the usual course of professional practice and without a legitimate medical purpose.

In his plea agreement, Chiarottino also admitted that he met with patients and wrote prescriptions for controlled substances at North Bay Pain Management Services and therefore maintained a premises for the distribution of controlled substances. Chiarottino also admitted that, as a licensed physician and DEA registrant, he abused a position of trust and used a special skill to intentionally prescribe controlled substances without a legitimate medical purpose.

Chiarottino was sentenced this July to three years in prison for illegally prescribing oxycodone and other controlled substances.

The sentence was handed down by The Honorable Jeffrey S. White, U.S. District Court Judge. Judge White also sentenced the defendant to a five-year period of supervised release. During this period of supervised release, Chiarottino is barred from providing medical treatment or examining any patient in the course of any employment or professional practice. Chiarottino is also forbidden from prescribing medication or controlled substances to any person and may not supervise any medical practitioner in treating any medical patient or prescribing any medication. Finally, as a condition of his supervised release, Chiarottino is required to cooperate with and not contest any administrative action to revoke or suspend his license to practice medicine or prescribe controlled substances by the Medical Board of California and the Drug Enforcement Administration. Chiarottino’s medical license is currently suspended.

The defendant will begin serving the sentence on October 20, 2016.

The prosecution is the result of an investigation by the Drug Enforcement Administration, the Livermore Police Department, the Pleasanton Police Department, and the Medical Board of California. This case is the product of an extensive investigation by the Organized Crime Drug Enforcement Task Force, a focused multi-agency, multi-jurisdictional task force investigating and prosecuting the most significant drug trafficking organizations throughout the United States by leveraging the combined expertise of federal, state and local law enforcement agencies.

Opioid abuse has come to the forefront as a serious public health issue. In fact, drug overdoses are now the leading cause of death in the United States, ahead of motor vehicle accidents and firearms. A number of federal legislative proposals have recently been introduced to address this crisis.

In near-apocalyptic terms, U.S. Sen. John Cornyn described the rising tide of American opioid abuse at a Senate Judiciary Committee hearing earlier this year. “Opioid prescription drug and heroin addiction is ripping away at the fiber of our homes and our communities in our nation,” Texas’ senior senator said. “It’s destroying families, increasing crime, making our communities less safe, hurting our economy, and robbing millions of Americans of their future.”

The National Law Review reports that while the U.S. House passed several bills on the issue, the U.S. Senate passed its own measure, S.524, the Comprehensive Addiction and Recovery Act of 2016 (CARA Act). In a bipartisan effort, both the House and Senate appointed conferees to hammer out differences. Those appointed to the Conference included 35 House members (made up of 21 Republicans and 14 Democrats) including Representatives from -key Committees including the House Energy and Commerce Committee and the House Ways and Means Committee. The Senate had seven conferees. While addressing opioid abuse is bipartisan in nature, there was disagreement on process and content throughout the legislative process. One area of debate was funding for the bill.

The Act passed in the Senate by 90-2 after Democrats followed their colleagues in the House of Representatives and dropped calls for the legislation to include additional funding. Senate Majority Leader Mitch McConnell, called for Senate Democrats to pass the measure, citing support for the legislation by the National Association of Counties, the National League of Cities, the Fraternal Order of Police and more than 200 other groups.

CARA includes several provisions concerning the need for expansion of prevention and education on the misuse of prescription pain killers and heroin. Law enforcement agencies and first responders are permitted to distribute naloxone for the reversal of overdose. Evidence-based treatment and intervention programs for incarcerated individuals and those across the country will be implemented. There will be safe disposal sites for prescription medications to diminish the opportunity for ill use. The Act creates a medication assisted treatment program for pain management and expands states’ drug monitoring programs to eliminate doctor shopping.

Now that CARA has passed and has been signed into law by the President, stakeholders will be watching closely for implementing rules, regulations, changes to incentive-based patient surveys, as well as any grant opportunities.

Further discussion of funding may arise as Congress discusses budgetary options in 2017and beyond.

“This is a historic moment, the first time in decades that Congress has passed comprehensive addiction legislation, and the first time Congress has ever supported long-term addiction recovery,” said Sen. Rob Portman, a chief author of the legislation. “This is also the first time that we’ve treated addiction like the disease that it is, which will help put an end to the stigma that has surrounded addiction for too long.”

The U.S. Department of Justice and attorneys general from multiple states and the District of Columbia filed litigation to block Anthem’s proposed acquisition of Cigna and Aetna’s proposed acquisition of Humana, alleging that the transactions would increase concentration and harm competition across the country, reducing from five to three the number of large, national health insurers in the nation.

The department and state attorneys general filed these two merger challenges in the U.S. District Court for the District of Columbia; The complaints allege that the two mergers – valued at $54 billion and $37 billion – would harm seniors, working families and individuals, employers and doctors and other healthcare providers by limiting price competition, reducing benefits, decreasing incentives to provide innovative wellness programs and lowering the quality of care.

Eleven states – California, Colorado, Connecticut, Georgia, Iowa, Maine, Maryland, New Hampshire, New York, Tennessee and Virginia – and the District of Columbia joined the department’s challenge of Anthem’s $54 billion acquisition of Cigna; Eight states – Delaware, Florida, Georgia, Iowa, Illinois, Ohio, Pennsylvania and Virginia – and the District of Columbia joined the department’s challenge of Aetna’s $37 billion acquisition of Humana.

The suit against Anthem and Cigna alleges that their merger would substantially reduce competition for millions of consumers who receive commercial health insurance coverage from national employers throughout the United States; from large-group employers in at least 35 metropolitan areas, including New York, Los Angeles, San Francisco, Denver and Indianapolis; and from public exchanges created by the Affordable Care Act in St. Louis and Denver. The complaint also alleges that the elimination of Cigna threatens competition among commercial insurers for the purchase of healthcare services from hospitals, physicians and other healthcare providers. The merger would eliminate substantial head-to-head competition in all these markets, and it would remove the independent competitive force of Cigna, which has been a leader in the industry’s transition to value-based care.

The lawsuit against Aetna and Humana alleges that their merger would substantially reduce Medicare Advantage competition in more than 350 counties in 21 states, affecting more than 1.5 million Medicare Advantage customers in those counties. Before seeking to acquire Humana, Aetna had pursued aggressive expansion in Medicare Advantage. Aetna, the nation’s fourth-largest Medicare Advantage insurer by membership, has nearly doubled its Medicare Advantage footprint over the past four years. Humana is the nation’s second-largest Medicare Advantage insurer by membership. The lawsuit also alleges that Aetna’s purchase of Humana would substantially reduce competition to sell commercial health insurance to individuals and families on the public exchanges in 17 counties in Florida, Georgia and Missouri, affecting more than 700,000 people in those counties. The lawsuit alleges that by buying Humana, Aetna would eliminate one of its strongest and most capable competitors in these markets.

Anthem, Inc. is headquartered in Indianapolis, Indiana. It is the nation’s second-largest health insurer and the largest member of the Blue Cross and Blue Shield Association. It holds the Blue Cross license in 14 states and provides health insurance to 39 million people. In 2015, Anthem reported over $79 billion in revenues.

Cigna Corp. is headquartered in Hartford, Connecticut. It is the nation’s fourth-largest health insurer. It operates in every state and the District of Columbia and provides health insurance to 15 million people. In 2015, Cigna reported $38 billion in revenues.

Aetna Inc. is headquartered in Hartford, Connecticut. It is the nation’s third-largest health insurer. It operates in every state and the District of Columbia and provides health insurance to 23 million people. In 2015, Aetna reported $60 billion in revenues.

Humana Inc. is headquartered in Louisville, Kentucky. It is the nation’s fifth-largest health insurer, operates in every state and the District of Columbia and provides health insurance to 14 million people. In 2015, Humana reported $54 billion in revenues.