Professionals and Health Care Institutions

Professionals and Health Care Institutions Unit 2 Seminar

Massive federal sweep rounds up alleged Medicare frauds • Federal authorities said Friday they are conducting the largest Medicare fraud bust ever in five different states and arrested dozens of suspects accused in scams totaling $251 million. • Several doctors and nurses were among those arrested in Miami, New York City, Detroit, Houston and Baton Rouge, La., accused of billing Medicare for unnecessary equipment, physical therapy and HIV treatments that patients typically never received. Ninety-four suspects were indicted, and authorities said 36 people had been arrested as of Friday morning.

Massive federal sweep rounds up alleged Medicare frauds • More than 360 agents participated in Friday’s raids, announced by Attorney General Eric Holder and Health and Human Services Secretary Kathleen Sebelius at a health care fraud prevention summit in Miami. Officials said they chose Miami because it is ground zero for Medicare fraud. Authorities indicted 33 suspects in the Miami area, accused of charging Medicare for about $140 million in various scams.

Massive federal sweep rounds up alleged Medicare frauds • Cleaning up an estimated $60 billion to $90 billion a year in Medicare fraud will be key to paying for President Barack Obama’s proposed health care overhaul. Federal officials have promised more money and manpower to fight fraud, setting up strike forces in several cities. • Around the country, the schemes have morphed from the typical medical equipment scam in which clinic owners billed Medicare dozens of times for the same wheelchair, while never giving the medical equipment to patients. Now, officials say, the schemes involve a sophisticated network of doctors, clinic owners, patients and patient recruiters.

Health Care • Health care consistently ranks among the top three issues that the American public wants policymakers to address, and it is increasingly intertwined with growing worries about economic insecurity. High costs, gap-ridden coverage, and sporadic quality are the health care problems that most concern Americans.

Infrastructure • Health care depends on a highly trained, balanced, and motivated workforce; current and accurate information; and technologies that enable health professionals to use information in the right place, in the right way, and at the right time. People, knowledge, and the means for their application are the foundation upon which an efficient, high-quality health system rests.

Organization • The most effective way to address our cost and quality challenges is to confront the root cause—the chaos in everyday health care. Efforts should focus on accelerating the organization of health care providers into team-like configurations so that they can adopt systems that are likely to reduce errors of overuse, underuse, and misuse, and improve the overall coordination of care.

Quality • Improving the quality of services delivered is paramount to enhancing health system performance. Currently, an apparent contradiction exists between the fact that the United States has the highest quality health care in the world, yet also has a quality “chasm.” To truly improve the quality of the health care delivery system, policies must focus on the individual and population level.

Payment reform • Provider payment structures play an important role in how well the health care delivery system meets the goals of delivering efficient and high-quality care. Policies must work to align the desires of practitioners and health organization managers to serve patients with the incentives that come from how they are paid.

Patient activation • Polices on the demand side of the equation must focus on how best to engage individuals in their own health and care. This is increasingly important in the face of a growing chronic disease epidemic.

Population health • Improving the health care delivery system is key to improving the health of all Americans. Even if the access, quality, and cost problems in the medical system are resolved, a traditional view of the delivery system must expand to include population-wide programs in order for the system to reach its full potential.

Question • How would you handle the lack of clarity related to health care roles which may create confusion for the patient and result in care which is fragmented and not of the highest quality.

Some issues • Do we have justifiable confidence in the hospital's hiring procedures and supervision of its staff? Do administrators carefully and systematically check references, verify licenses, degrees, and internships, explore employment history, and otherwise ensure that those who work at the hospital are fully qualified to do their tasks?

Some issues • If a clinical or nonclinical worker begins behaving in a negligent, improper, or inept manner, are there adequate procedures to identify and remedy the problem and to ensure that patients do not suffer?

Some issues • In one prominent hospital, an inebriated former patient returned to shout wild accusations at a senior clinician with considerable supervisory responsibilities. The administrative and clinical staff quickly dismissed her charges—which included a variety of sexual and nonsexual dual relationships with patients—as clearly too bizarre to be credible, a function of the woman's hostility and pathology, and a slur on one of the hospital's most respected employees.

Some issues • However, the hospital was eventually forced to abandon its position during the course of a malpractice suit when other patients reported that they had complained more quietly about the therapist but that their complaints had not been investigated; when the clinician acknowledged the accuracy of documentation (credit card receipts) showing that his "clinical work" included visits to a local motel; when the employment record he submitted on his application form was found to have been fabricated; when a letter was found in the personnel department offering him the job before he had filled out the application form; and when it was discovered that he had spent both penitentiary and jail time during past decades for charges including rape and aggravated assault of women and child abuse involving young boys and girls.

Some issues • In another hospital, a clinician was granted admitting privileges and enjoyed a good reputation among his colleagues. Later it was discovered that not only was he not licensed, he had never earned an advanced degree.

Discussion • Describe how both the aging population and the aging healthcare workforce create new and unique challenges for the delivery system, the patients and the providers.

Aging of the U.S. Population • In a speech by Federal Reserve Chairman Ben Bernanke, he stated that in coming decades, many forces will shape the U.S. economy and society, but in all likelihood no single factor will have as pervasive an effect as the aging of the population. As the first members of the baby-boom generation reach the minimum age for receiving Social security benefits, there will be about five working- age persons (between the ages of 20 and 64 yrs) in this nation for each person aged 65 yrs and older. The 65 and older cohort will constitute about 12% of the U.S. population.

Aging of the U.S. Population • These statistics are set to change rapidly, at least relative to the speed with which one thinks of demographic changes as usually taking place. For example, according to the intermediate projections of the Social Security Trustees, by 2030-by which time most of the baby boomers will have retired-the ratio of those of working age to those 65 yrs and older will have fallen from five to about three. By that year, older Americans will constitute about 19% of the U.S. population.

Aging of the U.S. Population • The outlook for Medicare is particularly sobering because it reflects not only an increasing number of retirees, but also the expectation that Medicare expenditures per beneficiary will continue to rise faster than per capita GDP. For example, the Medicare Trustees' intermediate projections have Medicare spending growing from about 3% of the GDP today to about 9\% in 2050-a larger share of national output than is currently devoted to Social Security and Medicare together.

The Changing Ethnic and Cultural Face of the U.S. Population • The population of the United States will continue to grow. As long as this country remains a magnet that attracts immigrants, growth will occur even if there is a dip in the birthrate. As of October 17, 2006, the population had reached 300,000,000. The Census Bureau projects that by 2030, there will be 363,584,000 inhabitants of the United States, by 2040 there will be 391,946,000, and by 2050 there will be 419,854,000 persons in this country; of this amount, 50% of the population will be non-Hispanic white compared with being 69% nonHispanic white in the year 2060.

Allied Health Workforce • Acute workforce shortages already exist in the United States, as exemplified by the professions of medical technology/clinical laboratory science and respiratory therapy. Even when students are attracted to a career in a health profession, the cost of obtaining an education is becoming a formidable barrier. Although state and local funding per student increased 3.5% in 2005, constant dollar funding for college and university students was at its lowest in 25 yrs, according to the annual study of state higher education finance recently released by the Association of State Higher Education Executive Officers.

The Future • The question of what health care in the United States will look like in the future leads to the following predictions. Medical technology will continue to advance and pharmaceutical breakthroughs will lead to the successful treatment of conditions that currently offer much more resistance to any interventions, such as certain forms of cancer. Meanwhile, it is likely that the poor always will be among us and that rural, isolated regions of the nation will be afflicted by inequities in the distribution of resources such as human capital in the form of the health workforce.

The Future • The use of electronic medical records is viewed as a way to improve patient care and reduce health care costs. Information technology is not as essential a part of health care as it could be. Small family-owned restaurants and dry cleaning establishments use computers in ways that are missing in the health sector of the economy. Trucking companies are able to monitor vehicles, optimize routing, and communicate with drivers. Meanwhile, in some parts of the nation it can take anywhere from weeks to months for a reportable dis ease to be communicated to public health officials.

Questions

Sources • http://www.americanprogress.org/issues/2008/10/health_care_delivery.html • http://www.insurancenewsnet.com/article.aspx?a=sa&id=77936

Professionals and Health Care Institutions