Month: January 2016

Goodbye to Vincent  Albert "Buddy"  Cianci, Jr. — a man who, whatever you think of him, certainly left his mark on the City of Providence. I would say that he was a Providence original if I didn't recall that though he was born in Providence he was a true son of Cranston and then, only later, the Mayor of Providence.

My absolute favorite excerpts from the eventual trial transcripts of "Operation Plunder Dome" (essentially, a RICO tapes case) were the parts discussing the selling points of various "no-show" or "low-show" jobs distributed by then Mayor Cianci. Steven Antonson, a Cianci-appointed City of Providence Building Board member, wasn't quite lucky enough to get that no-show or low-show appointment, however. Apparently, then Mayor Cianci really wanted him to show at Building Board meetings involving Providence's University Club and to wholeheartedly oppose all University Club petitions for building variances necessary for a pending re-model unless and until Mayor Cianci was offered a free lifetime membership in the University Club. What made it pure Buddy Cianci was not the apparent extortion but the ironic twist that the chief value of free lifetime membership in Providence's University Club appears to have been as payback for a rejected Buddy Cianci membership application to the Providence University Club in the early 1970's, decades earlier.

My favorite part of Buddy Cianci's sell of the Building Board appointment was Mayor Cianci's schooling of Steven Antonson on why it would be a smart move to accept it: "Remember, I appoint people to this board. You get Blue Cross. You get a check. You always said safety was important. Well, this is it."

Yes, Steven Antonson was among several would be appointees who chased the Mayor of Providence relentlessly for health insurance. Even wiseguys need health insurance. Go figure.  Or, as they say on South Coast, "Go Figah."

Steven Antonson eventually wore a wire and proved to be a fertile source of Buddy Cianci stories, many more of which you might glean from Mike Stanton's 2003 book,  The Prince of Providence: The True Story of Buddy Cianci, America's Most Notorious Mayor, Some Wiseguys, and the Feds.

x-posted at Prawfsblawg

Last week, the New York Times reported a tuberculosis outbreak in Marion Alabama so severe that TB incidence in Marion is now at a rate that exceeds TB incidence in much of the developing world. Marion is the county seat of Perry County and it is saying something when a city of roughly 3,600 people has had 20 cases of active TB diagnosed in the last two years alone, producing two TB related deaths.  Those who count TB infections do not typically  count latent infections — relatively easily if time-consumingly treated — though these have been documented in a further two dozen people.

Now, if there have been 20 active cases, the latent infection rate is likely much higher than that, but no one knows how much higher since screening for latent TB infection in the general population is not standard procedure in the United States. Why such screening for latent TB has not been pursued earlier in Alabama is a more difficult question. Long before the New York Times arrived on the scene, TB cases have been unusually high in Alabama. The number of tuberculosis cases increased in 2014 in  Alabama, but decreased nationwide. Across the nation, the number of new infections decreased by more than 2 percent. In 2014, there were 133 cases of tuberculosis in Alabama, compared to 108 the year before. The TB trajectory in Alabama has not been good for some time. 

The reasons for this are hard to parse. As the New York Times points out, there is a tradition of limited access to health care in this low income rural community where lack of reliable transportation to health care venues looms as one of the chief causes of limited health care  access. Since the data shows that those with transportation — disproportionately the insured — use that transportation to leave the community for health care, leaving the uninsured lacking transportation to seek care locally,  it is no wonder 54 of Alabama's 55 rural counties have official shortages of primary care providers. After all, good payor mix in your patient panel is one of the ingredients to successful sustainable  practice.

A people who lack the resources and opportunity to access care have a limited culture of care. The disincentives to leave the community, even when able to do so, are complicated by a general distrust of health care providers, particularly among African American residents.  Ironically, a provider-patient relationship built on trust may be the scarcest health care resource of all in Marion. 

But the situation is more complicated than this even, since the conversion rate between latent TB infection and active (or manifest) TB infection is not evenly distributed among the TB exposed population.Drug users, alcoholics, and, in particular, those who are HIV positive are particularly at risk of TB exposure converting into active TB. Drug use, particularly use of   injectables like heroin, appears to havemore than a toe hold in Marion. The Marion refrain "I don't want nobody knowing my business" in response to public health attempts at contact tracing for those with active TB may make more sense evaluated in light of access or lack thereof to drug treatment programs in Marion.

On the international stage, public health authorities struggle with the prevalence of active TB infection in injectable drug using and HIV positive  populations.  In the developing world, there is some evidence that financial incentives to promote screening and successful treatment, if required, have begun to make a dent in promoting the completion of TB treatment.  Interestingly, TB screening incentives are reported as now being offered to the entire Marion community and not exclusively to relatively high risk sub-populations such as the homeless or self-disclosed injectable drug users.

Is it that the United States Public Health Service and the Alabama State Department of Public Health as well as county public health officials  are unaware that broad screening incentives are not the norm?  Or, is it that in a community of a few thousand, the only way to screen at significant levels is to create an incentive for all to be screened in a de-stigmatized way? Whether it is folly or it is genius, only time will tell.  But if it is the syndemic of injectable drug use and TB or HIV and TB masquerading as an outbreak of TB alone that ails Marion, it will take far more than screening incentive payments and TB treatment incentive payments to right what is wrong with Marion — emblematic of so much that is amiss in rural low income America.

 

x-posted at prawfsblawg

 

For the past several months, a series of announced hospital settlements with the U.S. Department of Justice  under the Federal False Claims Act has been gathering momentum and interest.   Reported to be the product of years of investigative work, the 450 plus hospitals that have settled with the government for more than$250 million dollars are rumored to yet be only the tip of the iceberg of a nationwide investigation into the suspected overuse of implantable cardiac devices. These ICDs are spendy, costing about $25,000 each in comparison to a more conventional pacemaker that might cost less than 50 percent as much. It has been noted elsewhere that, "[c]ardiovascular disease remains one of the largest cost drivers in medicine."

Anything involving more than 450 American hospitals ought to be of interest and an investigation involving a rumored twice that number of American hospitals out to be riveting.  The fact that HCA has 42 hospitals, to date, involved in these settlements (though scores more, reportedly, involved in the investigation) also ought to be of interest. HCA's troubled history with overuse of lucrative cardiac treatments is the stuff of legend. HCA is a hospital behemoth, particularly in the disproportionately Medicare enrolled population of Florida.  An estimated two thirds of the entrants on this 2014 list of the most profitable hospitals in the United States are HCA facilities.  A full five percent of all U.S. hospital services take place at an HCA facility. 

In addition, the subterranean dispute beneath all this concerning  the role of Medicare National Coverage Determinations in the area of cardiac rhythm management also matters.  None of the three biggest hospital systems involved in the settlement agreements, to date, have conceded liability. Community Health Systems (31 settling facilities to date) delicately noted, in an October 2015 statement, that "[t]he issue involved a highly technical interpretation of a Medicare national coverage determination that was the subject of strong disagreement in the medical community."  But that is the rub, the Medicare National Coverage Determination on cardiac rhythm management and ICDs was not highly technical or particularly highly technical for a technical field.

It was controversial, however. It is worth thinking about why it was controversial. A Medicare National Coverage Determination is arguably one of the few restraints the Medicare system explicitly places on  provider discretion to determine the scope of Medicare coverage for a certain diagnosis. Medicare's general mandate to provide to its beneficiaries what is reasonable and necessary for the diagnosis or treatment of an illness or injury sets scant limit, in and of itself, on what may be covered. Medicare National Coverage Determinations are infrequently made and, to the extent they cluster in areas of high-cost arguably low-value care, they are always controversial.  They are, surprisingly,  non-transparent to  those, arguably, most interested in the scope of what Medicare might cover: Medicare beneficiaries. 

So, just what happened at these facilities? ICDs, apparently,  were implanted in many cardiac rhythm management patient Medicare beneficiaries that were not Medicare coverage reimbursable, falsely representing to the U.S. Government that they were (by billing for them and their implantation costs  through the Medicare program) and by representing to the individual Medicare beneficiary patient/implantee that they were within the Medicare scope of coverage for each of them.   

Was this the product of  dismal provider ignorance of the revised Medicare National Coverage Determination in this area? Was it confidence that the Medicare National Coverage Determination in this area would not be enforced so long as any conflicting practice protocol could be cited? Was it awareness that Medicare Coverage Determinations have, historically, been difficult to audit for compliance combined with a telling  lack of awareness that new Medicare data and data search capabilities would make it possible for whistle blowers — including two cardiac healthcare reimbursement consultants — to search out those hospitals and those individual providers implanting ICDs before the 40-day post heart attack milestone, for example, where a significant percentage of cardiac patients may no longer need something like an ICD?  Perhaps it was all of these things and more.

One thing we do know:  physicians billed for 70,969 of these devices under Medicare in 2008 and 51,052 in 2013, so somebody's reading the Medicare National Coverage Determinations now, at any rate. Now, that's a shock to the system. 

 

x-posted at Prawfsblawg

I have been following Vermont's all-payer claims database litigation, Gobeille v. Liberty Mutual Insurance Co. — argued at the U.S. Supreme Court on December 2, 2015. Perhaps you have as well. There is absolutely nothing like a good ERISA preemption dispute to to remind me of the force of Bill Sage's observation that is a case like this that reminds you why  you must explain "to every class of Health Law students… that ERISA [is] the most important law affecting private health insurance in the United States."

Strictly as an ERISA preemption case, Gobeille is interesting for how it may force the Court to parse yet again and yet further whether the collection of health care data by a state interferes with a core ERISA function belonging to the U.S. Secretary of Labor or whether state by state variable all-payer claims database reporting requirements are arguably unduly burdensome on the reporting entities and firms.   If you've read this far, I know you are fascinated by preemption, but even more importantly, such a decision would test whether or not the gradual movement of the states to mandating reporting of all-payer claims data has legs.

It is early days, but there is some evidence that the all-payer claims data has begun to influence health care cost to consumers and health care consumer decision making in New Hampshire (under its Comprehensive Healthcare Information System established by state law in 2007). The claim of price transparency triumphant, of course, is also balanced by arguments about adverse affects of health care  price transparency because limited research may also indicate that it causes rates to narrow and average costs to rise.

All of this is based on fairly little experimentation with health care cost transparency in the U.S. of the sort that may be developed from  all payer claim databases.  So just what is it that we would rather not know, rather not test empirically, about the competitive effects of the disclosure of this kind of information?

 

x-posted at Prawfs Blawg