Tweaking the Geographic Adjusters
Medicare's geographic adjusters for setting physician fees are valid in their fundamental design, but their methods need refinement, the Government Accountability Office reported. Geographic practice cost indices (GPCIs) are used to raise or lower Medicare physician fees depending on whether local practice costs are above or below the national average. They are based on physician work, practice, and malpractice expenses. The adjusters play a useful role by protect physicianing fees in low-cost areas from dropping to levels that could be considered unfair relative to fees in high-cost areas. On the other hand, the wage data used are not current, and the malpractice data used are incomplete, GAO said. The adjusters also seem to have little bearing on whether physicians decide to locate in rural areas, as factors other than a paycheck come into play.
'Rent-A-Patient' Fraud
Hundreds of patients from across the country had unnecessary and sometimes dangerous surgical procedures that led to the submission of tens of millions of dollars in fraudulent medical claims, according to a $30 million lawsuit filed by 12 Blue Cross and Blue Shield Plans. The suit was filed against nine California-based outpatient surgery clinics, seven medical management companies, and 34 individuals, in a Los Angeles federal district court. The Blues Plans allege that paid recruiters enlisted patients to travel to the surgical centers and undergo “needless and sometimes hazardous” surgical procedures and treatments. In return, the patients received cash payments or cosmetic surgery, and the providers submitted fraudulent insurance claims. These “rent-a-patient” tactics have resulted in significant financial losses to insurers and employee benefit plans since 1999, according to the suit.
A Plan to Reform Medicaid
Governors were unable to reach a consensus with lawmakers on Medicaid reform at their annual meeting, but they're pushing their own plan to modernize the program. In the report, “Medicaid in 2005: Principles and Proposals for Reform,” the National Governors Association recommended simplifying state plan and waiver standards and processing requirements, and allowing states to adopt policies that encourage Medicaid beneficiaries to direct their own care and share in any associated cost savings. Medicaid should also update its formula for calculating state-specific federal matching rates, while Medicare law should be amended so the federal government assumes specific responsibility for low-income Medicare-Medicaid dual eligibles, the governors said.
Discount Cards: Not Created Equal
Some discount medical cards provide value, but others have serious drawbacks such as high-pressure sales tactics, exaggerated claims of savings, inaccurate promotions, or difficulty finding participating physicians, a survey by the Commonwealth Fund concluded. The cards promise discounts for a wide range of providers, including physicians and hospitals, as well as for lab work, surgical procedures and other services. Some discount card firm are seeking to reform the market through a trade association and voluntary code of conduct. But the cards aren't regulated, so “legislative action is needed that gives state insurance departments the authority and resources to have direct oversight of the discount medical card industry,” the survey authors said. Researchers tested 5 of 27 cards advertised in the Washington, D.C. area by undergoing the application process, seeking health care services from participating providers, then canceling the cards.
Conflict-of-Interest Rules Targeted
People with direct financial conflicts of interest should not be put on Food and Drug Administration advisory committees, a coalition of public interest groups has recommended. Financial conflicts undermine “the public's faith in the fairness and credibility of the panel's work,” the Center for Science in the Public Interest, the National Women's Health Network, the U.S. Cochrane Center Consumer Coalition, and eight other groups said in a letter to Acting FDA Commissioner Lester Crawford, D.V.M., Ph.D. The groups cited the FDA advisory committee that recently reviewed the safety of cyclooxygenase-2 inhibitors, noting that 10 of the 32 members had direct financial conflicts. In addition to prohibiting scientists, physicians, and clinicians with relevant conflicts of interest from serving on advisory committees, the groups also recommended that people with any industry ties make up no more than half of a committee.
Assault on Salt?
The federal government's refusal to reveal data that it used to develop its recommendation to reduce salt intake with the goal of preventing strokes has drawn fire from the salt industry. The Salt Institute, representing salt manufacturers, sued the Department of Health and Human Services, claiming HHS refused to release the studies supporting its 2002 recommendation that Americans cut salt intake as a way to avoid hypertension and stroke. The failure to release the information was a violation of the federal Information Quality Act, the suit alleges. Under the act, parties who feel that the government is withholding information have the right to appeal to the agency in question; the institute, along with the U.S. Chamber of Commerce, did just that, but the appeal was denied. HHS says the suit is not valid because there is no provision in the act for a judicial review of a denied appeal; the court agreed and dismissed the suit. The chamber and the institute are appealing that decision.