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Tag: 2019 News

Few Patients Benefit from Meniscus Surgery

A new study published in the British Journal of Sports Medicine suggests that surgeons are no better at determining which patients might benefit from operations to treat torn knee cartilage than if they just flipped a coin.

Researchers surveyed 194 surgeons to see whether they would recommend surgery or exercise therapy in 20 test cases with middle-aged patients who had tears in the meniscus, the cartilage that works as a cushion between the shin and thigh bones.

Overall, surgeons correctly predicted which patients would benefit from operations only half of the time. And experienced knee surgeons were no better at guessing correctly than other orthopedic surgeons.

These findings offer one reason these knee operations remain common despite a growing body of evidence suggesting many patients don’t benefit, said Dr. Victor van de Graaf, lead author of the study and a researcher at University Medical Centre, Utrecht, in the Netherlands.

“Orthopedic surgeons believe they are capable of identifying which patients may still benefit more from surgery,” van de Graff said by email. “Therefore, our findings may help to further decrease the number of unnecessary performed surgeries.”

During the operation, a surgeon makes a small incision in the knee and inserts a tiny camera called an arthroscope to view the inside of the joint, locate and diagnose the problem, and guide repairs. Sometimes surgeons remove all of the meniscus, and other times they only remove part of it.

While the procedure is minimally invasive, it’s not risk-free. Patients receive anesthesia, which in any surgery may lead to complications such as allergic reactions or breathing difficulties. In addition, this specific procedure might potentially damage the knee or trigger blood clots in the leg.

Among patients who didn’t respond to surgery, only 39% of the surgeons correctly foresaw this outcome. And among patients who didn’t respond to exercise therapy, only 29% of surgeons correctly predicted this outcome.

For patients who did benefit from surgery, surgeons correctly predicted this outcome 60% of the time. And for patients who benefited from physical therapy, surgeons correctly chose this outcome in 72% of cases.

In the same journal, a study published in June went further, concluding that it’s impossible to predict who might benefit from arthroscopic meniscus repair surgery.

Kenneth Pihl of the University of Southern Denmark in Odense and his colleagues built a model based on the real-world outcomes after one year for 641 patients who had undergone the surgery. Out of 18 preoperative factors that surgeons and the medical literature consider predictive of who will benefit, none predicted the actual results for these patients, Pihl’s team found.

Scientists Report Emerging Role of Schwann Cells in Neuropathic Pain

Neuropathic pain is a typically persistent and intractable type of chronic pain. This condition is not a symptom of a disorder but a pathological state caused by a primary lesion or dysfunction in the nervous system. Neuropathic pain caused by nerve injury or disease remains a major challenge for modern medicine worldwide.

It is certainly a challenge in the administration of workers’ compensation claims now that use of opiate medications are on the decline.

A recent review article published this year discusses emerging evidence by integrating recent advances related to Schwann cells and neuropathic pain. Their findings showed that that an improved and extended comprehension of the underlying neurobiological mechanisms of neuropathic pain would allow the development of successful targeted pain therapy.

The role of Schwann cells in pain perception has been further explored this year, and new conclusions were just published this month in the Science Journal. A new organ involved in the sensation of pain has been discovered by these scientists, raising hopes that it could lead to the development of new painkilling drugs.

Researchers say they have discovered that the special cells that surround the pain-sensing nerve cells that extend into the outer layer of skin appear to be involved in sensing pain. The scientists say the finding offers new insight into pain and could help answer longstanding conundrums.

:The major question for us now is whether these cells are actually the cause for certain kinds of chronic pain disorders,” Prof Patrik Ernfors, a co-author of the research from the Karolinska Institute in Sweden, told the Guardian.

The researchers reveal how they examined the nature of cells in the skin that, they say, have largely been overlooked. These are a type of Schwann cell, which wrap around and engulf nerve cells and help to keep them alive.

The study has revealed these Schwann cells have an octopus-like shape. After examining tissues, the team found the body of the cells sits below the outer layer of the skin, but that the cells have long extensions that wrap around the ends of pain-sensing nerve cells that extend up into the epidermis, the outer layer of the skin.

The scientists were surprised at the findings because it has long been believed that the endings of nerve cells in the epidermis were bare or unwrapped. “In the pain field, we talk about free nerve endings that are responsible for pain sensation. But actually they are not free,” Ernfors said.

Employer Supports Surgeries in Foreign Hospitals with US Physicians

The hospital costs of the American medical system are so high that it made financial sense for both a highly trained orthopedist from Milwaukee and Donna Ferguson, a patient from Mississippi, to leave the country and meet at an upscale private Mexican hospital for the surgery. Ferguson gets her health coverage through her husband’s employer, Ashley Furniture Industries.

According to the report in Kaiser Health News, Ferguson is one of hundreds of thousands of Americans who seek lower-cost care outside the United States each year, with many going to Caribbean and Central American countries. A key consideration for them is whether the facility offers quality care.

In a new twist on medical tourism, North American Specialty Hospital, known as NASH and based in Denver, has organized treatment for a couple of dozen American patients since 2017.

Its website proclaims: “The North American Specialty Hospital is committed to providing an exceptional level of quality in healthcare, with pricing that is bundled, transparent, and competitive. NASH accomplishes its mission by tapping into the finest in cross-border resources – from renowned physicians on either side of the border to state-of-the-art facilities. Headquartered in Denver, Colorado, NASH is designed to provide pre-operative and post-operative services throughout the United States, while providing clinical care in Cancun – a city connected by daily, non-stop, and year-round air service from airports located throughout the United States and the entire Western Hemisphere.

Donna Ferguson awoke in the resort city of Cancun before sunrise on a sweltering Saturday in July. She wasn’t headed to the beach. Instead, she walked down a short hallway from her Sheraton hotel and into Galenia Hospital.

A little later that morning, a surgeon, Dr. Thomas Parisi, who had flown in from Wisconsin the day before, stood by Ferguson’s hospital bed and used a black marker to note which knee needed repair. “I’m ready,” Ferguson, 56, told him just before being taken to the operating room for her total knee replacement. For this surgery, she would not only receive free care but would receive a check when she got home.

The cost to her employer, Ashley Furniture Industries, was less than half of what a knee replacement in the United States would have been. That’s why its employees and dependents who use this option have no out-of-pocket copayments or deductibles for the procedure; in fact, they receive a $5,000 payment from the company, and all their travel costs are covered.

Parisi, who spent less than 24 hours in Cancun, was paid $2,700, or three times what he would get from Medicare, the largest single payer of hospital costs in the United States. Private health plans and hospitals often negotiate payment schedules using the Medicare reimbursement rate as a floor.

Parisi, a graduate of the Mayo Clinic, is one of about 40 orthopedic surgeons in the United States who have signed up with NASH to travel to Cancun on their days off to treat American patients. NASH is betting that having an American surgeon will alleviate concerns some people have about going outside the country, and persuade self-insured American employers to offer this option to their workers to save money and still provide high-quality care.

NASH, a for-profit company that charges a fixed amount for each case, is paid by the employer or an intermediary that arranged the treatment.

The American surgeons work closely with a Mexican counterpart and local nurses. NASH buys additional malpractice coverage for the American physicians, who could be sued in the United States by patients unhappy with their results.

Medical tourism has been around for decades but has become more common in the past 20 years as more countries and hospitals around the world market themselves to foreigners.

The high prices charged at American hospitals make it relatively easy to offer surgical bargains in Mexico: In the United States, knee replacement surgery costs an average of about $30,000 – sometimes double or triple that – but at Galenia, it is only $12,000, said Dr. Gabriela Flores Teón, medical director of the facility.

The standard charge for a night in the hospital is $300 at Galenia, Flores said, compared with $2,000 on average at hospitals in the United States.

The other big savings is the cost of the medical device – made by a subsidiary of the New Jersey-based Johnson & Johnson – used in Ferguson’s knee replacement surgery. The very same implant she would have received at home costs $3,500 at Galenia, compared with nearly $8,000 in the United States.

Galenia is accredited by the international affiliation of the Joint Commission, which sets hospital standards in the U.S. But to help doctors and patients feel comfortable with surgery here, NASH and Galenia worked to go beyond those standards.

Is Health Care Fraud Really This Easy???

David Williams, a personal trainer, spent years posing as a doctor and billing the nation’s top insurers, making off with millions of dollars.

Williams called himself “Dr. Dave” because he had a Ph.D. in kinesiology. But he didn’t have a medical license. Yet he wrongfully obtained, with breathtaking ease, federal identification numbers that allowed him to fraudulently bill insurers as a physician for services to about 1,000 people.

Getting one through the federal government’s Medicare program is a rite of passage for medical professionals and organizations. Without it, they can’t bill insurers for their services.

Williams discovered and exploited an astonishing loophole: Medicare doesn’t check NPI applications for accuracy. Instead, as one federal prosecutor later noted in court, Medicare “relies on the honesty of applicants.”

Williams first applied for an NPI under his own name as far back as 2008. But it wasn’t until 2014 that Williams began to ramp up his scheme, even though now he wasn’t just unlicensed, he was a two-time felon.

He got a second NPI under the company name, Kinesiology Specialists. The following year, he picked up another under Mansfield Therapy Associates. In 2016, he obtained at least 11 more, often for entities he created in the areas where he found fitness clients: Dallas, Nevada, North Texas and more. By 2017, he had 20 NPIs, each allowing him a new stream of billings.

For every NPI application, Williams also obtained a new employer identification number, which is used for tax purposes. But he never hid who he was, using his real name, address, phone number and email address on the applications. He added the title “Dr.” and listed his credentials as “PhD.” Under medical specialty he often indicated he was a “sports medicine” doctor and provided a license number, even though he wasn’t a physician and didn’t have a medical license.

Now accepting most health insurance plans,” his Get Fit With Dave website announced. He added a drop-down menu to his site, allowing potential clients to select their health insurance provider: Aetna. Blue Cross Blue Shield. United.

He began building a team, soliciting trainers from the strength and conditioning department at Texas Christian University. He met with new recruits at local fast food joints or coffee shops to set them up. To the trainers, the business appeared legit: They even signed tax forms. Before long, Williams’ network stretched throughout Texas and into Colorado, Idaho and Nevada.

He used his favorite billing code – 99215. The code is supposed to be used less often because it requires a comprehensive examination and sophisticated medical decision-making, warranting higher reimbursement. In all, Williams used the code to bill United for more than $20.5 million – without apparently triggering any red flags at the insurer. For that code alone, the insurance giant rewarded him with $2.5 million in payments.

He ran the scheme for more than four years, fraudulently billing several of the nation’s top insurance companies – United, Aetna and Cigna – for $25 million and reaping about $4 million in cash.

A case summary, prepared by the Texas Department of Insurance, shows it first learned of the Williams case in January 2015 but lacked staff to investigate.

Cigna appears to have been the quickest to intervene. In January 2015, Cigna sent Williams a letter, noting that he wasn’t a licensed medical provider and had misrepresented the services he provided. The insurer said he needed to pay back $175,528 and would not be allowed to continue billing.

Williams had more than one National Provider Identifier, so he just switched numbers and kept billing Cigna. More than a year later, in May 2016, Cigna sent another letter, saying he now owed $310,309 for inappropriate payments. In total, the company paid him more than $323,000. Williams never gave any of it back.

In October 2017, Williams’ long run came to an end when he was arrested by the FBI. After a two day trial, a jury convicted Williams of four counts of health care fraud. He was sentenced him to a little more than nine years in federal prison and ordered him to pay $3.9 million in restitution to United, Aetna and Cigna.

Opioid and Cannabis Co-Use Increases Anxiety and Depression

A researcher from the University of Houston has found that adults who take prescription opioids for severe pain are more likely to have increased anxiety, depression and substance abuse issues if they also use marijuana.

“Given the fact that cannabis potentially has analgesic properties, some people are turning to it to potentially manage their pain,” Andrew Rogers, said in describing the work published in the Journal of Addiction Medicine.

Rogers focuses on the intersection of chronic pain and opioid use, and identifying the underlying psychological mechanisms, such as anxiety sensitivity, emotion regulation, pain-related anxiety, of these relationships. Rogers is a doctoral student in clinical psychology who works in the University of Huston Anxiety and Health Research Laboratory and its Substance Use Treatment Clinic.

Rogers surveyed 450 adults throughout the United States who had experienced moderate to severe pain for more than three months. The study revealed not only elevated anxiety and depression symptoms, but also tobacco, alcohol, cocaine and sedative use among those who added the cannabis, compared with those who used opioids alone. No increased pain reduction was reported.

Importantly, said Rogers, while the co-use of substances generally is associated with poorer outcomes than single substance use, little work has examined the impact of mixing opioids and cannabis.

Opioid misuse constitutes a significant public health problem and is associated with a host of negative outcomes. Despite efforts to curb this increasing epidemic, opioids remain the most widely prescribed class of medications. Prescription opioids are often used to treat chronic pain, despite the risks, and chronic pain remains an important factor in understanding this epidemic.

Cannabis is another substance that has recently garnered attention in the chronic pain literature, as increasing numbers of people use it to manage chronic pain.

“There’s been a lot of buzz that maybe cannabis is the new or safer alternative to opioid, so that’s something we wanted to investigate,” said Rogers, who said the idea for the study evolved from a conversation with Zvolensky. Rogers was studying opioid use and pain management when they began discussing the role of cannabis in managing pain.

The findings highlight a vulnerable population of polysubstance users with chronic pain and indicates the need for more comprehensive assessment and treatment of chronic pain,” said Rogers.

Generic Drugmakers Accused of Stonewalling Price Probe

The head of the U.S. House of Representative’s oversight panel on Wednesday called on three drugmakers to turn over documents as part of an ongoing congressional review over generic drug price increases and accused the companies of “apparent efforts to stonewall” the probe.

U.S. House Oversight Chairman Elijah Cummings, along with U.S. Senator Bernie Sanders, the ranking member on the Senate Budget Committee, sent the letters to Mylan NV (MYL.O), Teva Pharmaceutical Industries Ltd (TEVA.TA) and privately held Heritage Pharmaceuticals, the lawmakers said in a statement.

Mylan’s shares fell 6.8% to $18.37, while Teva slumped 6.2% to $6.61 on Wednesday morning.

“Teva continues to cooperate fully with all investigations,” a spokeswoman for the company said. Mylan did not respond to Reuters request for comment.

The lawmakers first launched the probe in 2014. Earlier this year, 44 U.S. states filed a complaint in federal court alleging drug price fixing by the three pharmaceutical companies and other drugmakers, according to the statement.

Now Cummings and Sanders said they were “opening an investigation into the companies’ apparent coordinated obstruction of the investigation as revealed by,” the states’ lawsuit.

“Not only did your company’s apparent obstruction undermine our investigation, but it may have caused further harm to patients and health care providers by delaying the discovery of evidence about the companies’ price-fixing,” Cummings and Sanders wrote.

Sanders, who is among those seeking the Democratic presidential nomination for the 2020 election, has made health care and drug prices a cornerstone of his campaign.

Victorville Pharmacist to Serve 5 Years in Prison

A High Desert pharmacist who illegally distributed oxycodone by filling hundreds of counterfeit prescriptions was ordered to serve 63 months in federal prison.

Pauline Tilton, 50, of Hesperia, a licensed pharmacist and the owner of Oasis Pharmacy in Victorville, was sentenced by United States District Judge Otis D. Wright II.

Tilton pleaded guilty on April 29 to one count of distribution of oxycodone and one count of money laundering related to more than a quarter millions dollars of revenue she received from the illegal sales.

Tilton filled at least 345 fraudulent prescriptions for oxycodone during a one-year period that ended in July 2017. The prescriptions were written under the name and DEA registration number of a retired doctor. When she pleaded guilty, Tilton admitted knowing the prescriptions were fraudulent, outside the usual scope of professional practice, and without a legitimate medical purpose.

As a result of the 345 prescriptions, Tilton and Oasis Pharmacy illegally diverted approximately 62,100 tablets of oxycodone to the black market. Many of the fraudulent oxycodone prescriptions also included prescriptions for alprazolam and promethazine with codeine. Those three drugs – oxycodone, alprazolam, and promethazine with codeine – comprise the “Holy Trinity,” a frequently abused and life-threatening cocktail of controlled substances.

In return for filling the fake prescriptions, Tilton and Oasis Pharmacy received hundreds of thousands of dollars in cash payments. Between January 2016 and June 2017, Tilton deposited $268,621 of illicit cash proceeds from her illegal drug distribution into three banks accounts over which Tilton held sole signature authority.

As he imposed the prison term – and ordered Tilton to pay a $30,000 fine – Judge Wright said the defendant demonstrated a “callous disregard for her own customers’ health.”

When Tilton pleaded guilty, Oasis Pharmacy also pleaded guilty to the same drug distribution and money laundering offenses. Judge Wright today placed Oasis Pharmacy on probation for one year.

This case was the first to be charged as the result of an ongoing investigation into corrupt pharmacies dubbed “Operation Faux Pharmacy.”

This case is being investigated by the Drug Enforcement Administration; the U.S. Department of Health and Human Services, Office of Inspector General; IRS Criminal Investigation; and the California Board of Pharmacy.

Roofer Sentenced in $1M Premium Fraud Case

Paul Ronald Payne (DOB 6/21/1968), of Simi Valley, was sentenced to 365 days in the Ventura County jail and ordered to pay $1,058,058 in restitution to the State Compensation Insurance Fund for underreporting payroll and failing to pay workers’ compensation insurance premiums.

Payne operated a roofing and painting business called Paul Payne Roofing. The business involved hiring and maintaining a crew of employees to work roofing and painting jobs.

Between 2012 and 2016, Payne submitted payroll reports to the State Compensation Insurance Fund indicating that he did not have any employees and thus paid only a fraction of the workers’ compensation premiums he owed.

One of Payne’s employees reported a traumatic injury in 2016, alerting the insurer that Payne was operating his business without reporting his true payroll.

In addition to his jail sentence, Payne was placed on six years of formal probation and paid $25,000 toward restitution prior to sentencing. He was ordered to continue making monthly restitution payments.

Workers’ compensation insurance fraud is not a victimless crime. It harms local businesses that pay for workers’ compensation insurance because their costs and prices are higher than those of uninsured and underinsured businesses. Uninsured and under-insured employers also risk the safety of their workers by failing to provide them with adequate protection from on-the-job injuries.

The Ventura County District Attorney’s Office takes a vigorous stance against workers’ compensation insurance fraud and works with local and state agencies to prosecute such fraud.

Next Week – 2019 Fraud Fighting & Employment Law Conference

One week left to sign up for the Big 2019 Fraud Fighting & Employment Law Conference. The event is sponsored by the Employers’ Fraud Task Force, in Collaboration with The Law Firm of Floyd, Skeren, Manukian and Langevin. It is scheduled for August 20th & 21st, 2019 at the Morongo Hotel & Casino.

Don’t miss this exciting event, packed with information, education, plenty of networking and excitement.. Register today using the online form, or print out the PDF and return it by mail.

AGENDA Day 1 – Tuesday, August 20, 2019

7:30 a.m. Registration/Breakfast/Exhibits/Networking
8:45 a.m. Emcee -Michael Chiriatti, San Bernardino DA’s Office
8:55 a.m. Opening Remarks – Mike Hestrin, Riverside County District Attorney
9:05 a.m. Fighting Workers’ Comp Fraud -Shaddi Kamiabipour, Orange County DA’s Office
9:40 a.m. WeTip/Stop it – Fraud Reporting Solution – There’s an APP for that!
10:15 a.m. BREAK/Exhibits
10:35 a.m. Fraud Syndicates – Teena Barton, ICW Group
11:15 a.m. MPNs Facts & Fiction – What you don’t know could be costing you Big Time -Tyrone Spears, City of Los Angeles -Margaret Wagner, Signature Network Plus
12:00 p.m. LUNCH/EXHIBITS Keynote Speakers The Honorable Paige Levy Chief Judge WCAB – Eric Charlick, California Department of Insurance.
1:30 p.m. Telemedicine -Ann Schnure, Concentra
2:15 p.m. Key Tips for Employers on Conducting Workplace Sexual Harassment Investigations Bernadette O’Brien, Esq. FSML – Amanda Manukian, Esq. FSML
3:00 p.m. BREAK/Exhibits
3:20 p.m. Key Tips on Conducting the Interactive Process & Considering Accommodations for Employees with Work Related Injuries -Bernadette O’Brien, Esq. FSML- Amanda Manukian, Esq. FSML
4:00 p.m. Navigating the Employee through the Complexities of the Workers’ Compensation System from the Employer’s Perspective -John Kallas, SmartComp -Mona Garfias, DMS -Cathy Yates, MTA
5:00 p.m. RECEPTION Networking

AGENDA Day 2 – Wednesday August 21, 2019

8:30 a.m.  The Latest on Marijuana in the Workplace in Light of Legalized Recreational Use -Troy Slaten Esq. FSML – John Floyd, Esq. FSML
9:15 a.m.  Workers’ Comp Fraud Prevention and Prosecution – Operation Backlash, Largest Provider Fraud Case in the History of San Diego County-Dominic Dugo, San Diego DA’s Office
10:15 a.m. BREAK
10:30 a.m. How the Workers’ Comp System Victimizes Employers -Bill Reynolds, Argus First/Argus West Investigations
11:15 a.m. Criminal Referrals & Assembling a Compelling Case – Expectations, Timelines & Rules Southern California Workers’ Comp Fraud Consortium – Prosecutors -Jennifer Snyder, Los Angeles DA’s Office -Shaddi Kamiabipour, Orange County DA’s Office -Bill Lee, San Bernardino County DA’s Office -Michael Silverman, Riverside County DA’s Office -Andrew Reid, Ventura County DA’s Office
12:15 p.m. Adjournment & Drawings

Morongo Hotel and Casino – 49500 Seminole Dr – Cabazon, CA, 92230

Canada Forces $10B Reduction in Drug Prices

The Canadian government announced final regulations on Friday that should cut billions of dollars from patented drug prices that are among the highest in the world, overcoming heavy opposition from pharmaceutical companies who may eventually challenge the new rules in court.

The biggest reform to Canada’s drug price regime since 1987 would save Canadians C$13.2 billion ($10 billion) over a decade. The rules will save money for patients, employers and insurers including the government at the expense of drug company profits. They also could eventually cut the earnings of drugmakers in the United States, the world’s largest pharmaceutical market.

Minister of Health Ginette Petitpas Taylor said the new rules would lay the foundation for a new national drug program. Prime Minister Justin Trudeau’s government is expected to announce a program to cover the cost of prescription drugs for some or all Canadians, but the program’s scope is not yet clear.

Canada’s approach to drug pricing is unusual. Rather than bargaining prices down, the PMPRB declares that some prices are an illegal abuse of patent rights.

Drugmakers base their list prices on the agency’s published guidelines. When there is disagreement, PMPRB staff can challenge drugmakers at an internal tribunal. Most cases are settled, but appeals go to federal court and beyond.

In the past, drug companies have gone as far as the Supreme Court of Canada to challenge PMPRB guidelines. With new regulations come new guidelines, and the potential for fresh court challenges.

We anticipate a considerable uptick in litigation, at least initially, as the industry patentees test the boundaries of the new regime,” said Douglas Clark, executive director of the PMPRB, on a call with reporters. “That’s to be expected any time you substantially change rules.”

Global drugmakers, including Johnson & Johnson , Merck & Co and Amgen Inc , argued against the draft plan.

While the government’s focus is on reducing domestic patented drug prices that are among the highest in the world, the new policy could eventually have consequences south of the border.

The Trump administration in July said it would allow U.S. states and other groups to start pilot programs related to importing drugs from Canada. It has also said it may start determining what the U.S. government healthcare program Medicare pays for certain medicines based on prices in some other countries, including Canada.

Reuters reported in February that pharmaceutical lobby groups had tried to head off the Canadian reforms with an offer to give up C$8.6 billion in revenue over 10 years, freeze prices or reduce the cost of treating rare diseases. Drugmakers argue the reforms could limit Canadians’ access to new medicines.

The government said many countries with lower prices have more pharmaceutical industry investment and access to drugs that meets or exceeds Canada’s.