The Ether Way

Fraud, Fraud Everywhere. Why?

First, this news item, from the BBC:

http://www.bbc.co.uk/news/world-us-canada-14831292

http://www.reuters.com/article/2011/09/07/us-usa-health-fraud-idUSTRE78669920110907?feedType=RSS&feedName=domesticNews

http://www.dailynews.com/health/ci_18848233

91 people and around $300 million in fraud.  Once again, Miami seems to be epicenter of the problem, with about half of the arrests taking place there.  If the news items are correct, these allegations represent outright fraud and theft of money, not disputes over disparities between levels of service provided and billed for.  The former is uncontroversial, the later is and will continue to be a huge headache for honest practitioners.

In this instance, there were arrests in the Chicago area:

http://www.wlsam.com/Article.asp?id=2280751&spid=

Please note: bills were apparently paid for services rendered to dead people.  This is not quite as odious as it sounds, as the modern world of medical billing can create a substantial delay between the time a service is provided and the bill for it is generated.

How does this happen?  Well, this story is informative:

http://finance.yahoo.com/news/Report-Systems-to-catch-apf-1125498258.html?x=0&.v=1&.pf=retirement&mod=pf-retirement

 So, a total of 41 people are tasked with ferreting out something like 60-90 billion dollars in fraud.  First, it is hard for me to imagine that there is that much fraud out there.  Suppose it was only $6 billion.  Suppose you had your full complement of 600 investigators.  That's $10 million in fraud per investigator per year - there is at least the potential for a huge return on your investment. Only the Feds could underinvest on this scale. 

And for those of you who are interested in the NHS IT saga from across the pond, I point out this news item:

http://www.bbc.co.uk/news/health-14378346

The article is replete with statements about the substantial sums that have already been spent, and the the real-world frustrations to implementing this apparently 'good' idea.  Outsiders have a hard time imagining what the problem.  Anyone with any real familiarity with these systems has a hard time imagining any other outcome.

 

 

 

 

 

Misplaced PA Cath

Large patient for PA cath placement.    Introducer into IJ, out IJ, thru intercostal muscles, into PA.   SG cath then placed into PA, then to RV, then  back to PA and seemed to wedge and look OK.  Clinically significant hemopericardium....(not from my hospital)

 

Wait Times – Where are we now? Where are we going?

As its budget inexorably worsens, the NHS is cutting back expenditures, and wait-times are rising.  The story from this past week is here:

http://www.bbc.co.uk/news/health-14034835

This particular story includes all sorts of claims that are difficult to reconcile.  They are most likely a consequence of different sources using different metrics, or seeing the same data from a very different perspective. For example, one paragraph states that the NHS is meeting its goals for the timely provision of services, and the next states that a third of trusts are failing (at least some of the time). ‘Most’ state that quality will not suffer, but 53% believe access will get worse. The story also alludes to elected officials attacking NHS managers for how they manage their trusts.  Of this I am certain: it is impossible for the managers in question to accomplish all of the components of their mission with the budget they have been given.  My guess is that they do a brilliant job in a difficult circumstance. The elected officials in this instance have shifted the responsibility for these hard decisions, and therefore the fallout associated with making them, to the trust management, instead of taking them on for themselves.  These decisions are intensely unpopular, and quite possibly career suicide for the manager or politician who ends up holding the bag for them.  This kind of have-your-cake-and-eat-it-too is only possible with publicly funded health care. They cannot accomplish the missions outlined in their charter with the resources allocated.  It is up to the elected officials to 1. Raise taxes (never popular) 2. Change the charter (which would require admitting that they cannot accomplish their stated mission) or 3. Assume responsibility for where the cuts will take place(and likely lose their next election).  Better to blame the NHS bureacracy and push the problem into the future for as long as possible; this is the same strategy adapted by both parties in the US for Social Security and Medicare. Individuals, small groups, and even insurance companies are far more effective at recognizing these circumstances, and dealing with them. This kind of magical thinking is the provenance of politicians and their policy analysts; the rest of us know we cannot get something for nothing.

Lest anyone think that access is the only strife associated with the NHS, this recent news item makes it clear that the British Medical Association and the government cannot come to terms about how the NHS will be managed going forward:

http://www.bbc.co.uk/news/health-13942819

I doubt that anyone knows what the future holds for the NHS. 

My research and reading about these topics has allowed me to stumble onto the writings of John C Goodman, who is a health policy analyst in the US.  Whether you agree or disagree, he is very much worth reading.  In this piece, appropriately titled ‘Rationing by Waiting’, he points out that physicians and hospitals do not rush to recruit patients from low-end providers. In this sense, Romney care might foreshadow how health care in the US might transform.

http://healthblog.ncpa.org/rationing-by-waiting-4/

and

http://townhall.com/columnists/johncgoodman/2011/07/09/what_difference_has_romneycare_made/page/full/

The first lesson here is that government run health care in the US has already produced the same kind of access issues that the NHS has been struggling with for decades. Access is much less of an issue for US citizens with private insurance, and are even less so for anyone, anywhere, who has the cash in their pocket to pay for what they want from a premium purveyor (e.g. the Mayo clinic). The second lesson is this: health care is like anything else, the more you pay, the more you get.  The less you pay, the less you get, and the less pleasant your experience is likely to be.  You can’t buy a Mercedes for the same price as a KIA, and you’re not going to get Mayo quality care at Medicaid rates.  Anyone who says otherwise is…..

And no, I don’t see the world the same way that Mr Goodman does.  For instance, in this column, he overstates the scope of a problem, but has an interesting solution:

http://townhall.com/columnists/johncgoodman/2011/04/16/how_safe_is_your_hospital/page/full/

This is worth a read for anyone with an interest in the topic.

Follow-up - Fraud happens, and a criminal indictment over the sale of organs.

 

First, federally administered health care is not only nidus of large scale fraud, as this news item from Chicago makes clear:

http://articles.chicagotribune.com/2011-06-17/news/ct-met-gupta-fraud-charges-20110617_1_insurance-fraud-clinics-medicaid

The details of the story are intriguing.  While the sum of $25 million is mentioned, there is no dollar figure attached to the criminal indictment.  if you've lived in Chicago over the past 10 years and listened to the radio, it was almost impossible to avoid hearing an advertisement for his services. He ran a substantial enterprise, one whose advertising outlays were enormous. Interestingly, the news item represents that the criminal indictment contains merely 3 felony charges. That's enought to obtain a warrant for his arrest as a fugitive, and to compel extradition.  Given the coverage that this story has generated, I am surprised that more counts aren't included in the preliminary indictment.  I have no doubt that the authorities are anxious to talk to the accused, after which my guess is that they would amend their indictment to include additional charges. Dozens? Hundreds? The press account gives us some basis for speculation. Dr Gupta has not been available to the authorities. To the extent that flight = guilt, it suggests that their allegations have some foundation. 

I have been waiting for more follow-up on this item from the BBC about the criminal conspiracy that supposedly bought organs for transplant:

http://www.bbc.co.uk/news/world-europe-12172901

and found this:

http://www.voanews.com/english/news/europe/Turk-Israeli-Charged-With-Organ-Trafficking-in-Kosovo-123784679.html

The VOA article suggests that neither of those who have been indicted have made themselves available to the authorities. 

There are a large number of people who advocate that people should be permitted to sell a kidney. In the view of these people Dr Sonmez is being wrongfully prosecuted, as what he did was technically illegal but not morally wrong.  It takes a lot of chutzpah to break these laws; those who do so are either very greedy or very certain that they are in the right (think Jack Kevorkian).  The apparent flight of the accused in this situation is more consistent with greed as their motivation than ideology.  I am certain that others have or will pick up where they have left off.

The actual state of the relevant legal and regulatory systems is far less perfect than most outsiders realize, as is documented in this NPR story:

http://www.npr.org/2011/06/02/136885472/foreign-policy-strict-laws-perpetuate-organ-theft

The NPR story makes several interesting claims, the most interesting of which are that 10% of transplants take place on the black-market(citing a WHO report, link in the story), and that the anonymity of the organ procurement system enables the criminals who sell organs.  First, the WHO report states that money changes hands in 10% of kidney transplants.  It seems that this is legal, or not obviously illegal, in several jurisdictions(Romania, Moldova, Egypt, and Turkey according to the story).  Secondly, those intent upon breaking the law and earning huge sums of money can and will exploit the features of any system.  In this instance, the perpetrators would simply make up a name....Nevertheless, the NPR story is fascinating, consider reading it.

Several of the above items allude to a more sinister operation during the Kosovo war, in which the organs of Serbian POWs were allegedly harvested for tranplantation. There is no disputing that this one is a heinous crime.  The EU has commisioned a special task force to investigate these allegations.  The alleged crimes happened in 1999. The wheels of justice are grinding slowly and not especially surely here. If these crimes happened, their perpetrators are likely to be dead or dying of old age before they are brought to justice, as was the case with both Nazis and the Khmer Rouge. 

 

 

 

ACADEMIC ANESTHESIOLOGY DEPARTMENT BLUEPRINT

Academic Anesthesiology Department--A Blueprint

Executive Summary 

W. Andrew Kofke

 May 26, 2011

 

Executive Summary

 

The mission of the   Department of Anesthesiology is to advance the science and practice of anesthesia through the integration of medical and graduate education, patient care, and research in a single academic community.

My vision of an academic anesthesiology department encompasses development and maintenance of excellent programs in clinical care, education, and research.  All subspecialties of anesthesiology are practiced with increasing involvement in external remunerative activities.   Residency and medical student experience is of the highest quality, including use of simulation.  The research program  includes clinical and laboratory research with identified areas of excellence with external funding.

 

Blueprint

 

Clinical service will be based in multisubspecialty practice in perioperative medicine with the core competencies remaining in the OR, ICU, and pain clinic.  Anesthesiologists have multiple tasks and challenges relating to operating room anesthesia.  These include running an efficient preop evaluation clinic, solving manpower issues with respect to direct provider caregivers and faculty, supporting trauma services, providing anesthesia at multiple remote sites, and developing and implementing ideas for cost containment.  The surgical intensive care unit should be staffed by faculty from anesthesiology and surgical services with interdisciplinary coordination at the faculty and housestaff level with a meaningful role for critical care nurse practitioners.  The pain service will ensure minimal perioperative pain and provide leadership in the management of chronic pain and palliative care.  An information management system should be in place to facilitate cost containment initiatives, increase efficiency of caregivers, and improve quality of care.   Such a system can be helpful in documenting the excellence of clinical care provided by the institution. Decision support systems are available to manpower decision makers to enable performance of “what-if” analysis of various scenarios and application of evidence based medicine as applicable..

 Research activities are multiple faceted.  Research is primarily driven by clinical problems, involving the complementary expertise of basic scientists and clinicians.  One important mechanism to foster and support clinically relevant research is through disease-oriented program development.  Such programs, composed of clinicians from diverse specialties and basic scientists, can effectively focus their members’ varying perspectives to most expeditiously solve clinical problems.  A clinical trials program is set up in the department or the institution to facilitate negotiations with industry to perform research studies.  The department’s most finite and valuable resources, time and academic funds are fairly allotted through a seed grants mechanism. Department faculty can act as advisors to undergraduates and  high school students wishing to gain an exposure to medical research.  A bioengineering program can effectively add another dimension to the research and business efforts of the department.   The traditional ways of funding research, while still useful are very elusive for clinical faculty who are subjected to increasing clinical and administrative demands.   Options for funding research include grants and contracts, institutionally or insurance supported cost effectiveness research, industry-sponsored specific product evaluation, moonlighting (internal or external) to augment funds for an individual faculty for research, and increasing the revenue stream to the department through external business activities.  A program in education research is based on the controlled conditions available in the simulator. New faculty start up remains a difficult problem and several options  are available for a given situation.

Education activities are mostly focused on resident education with important consideration given to medical students, fellows and others.  An organized didactic schedule covers material needed to become board certified.  High quality residents are presently rather difficult to attract.  A variety of strategies are employed to facilitate resident recruitment and retention.  A residency academic track is available for residents interested in pursuing an academic career.  A T32 or equivalent research education grants are available or are sought.

Outreach activities are an essential component of a department’s marketing plan.  Such activities  are done to maintain the excellent reputation of the department in the medical center, in the region, and nationally using described outreach tools, publications, and selective use of visiting professors.  Anesthesiology faculty are encouraged to participate in outreach of other health system programs, particularly if they are members of multidisciplinary disease-oriented programs.

Business  activities should be fostered to support the academic mission of the department.  University affiliated business activities, as warranted by available markets, can be developed in areas relevant to faculty expertise such as monitoring, pain management, locum tenens, respiratory therapy, critical care transport,telemedicine,  legal consultation, or academic peer review for publishing houses.

 

The full treatise can be viewed at

   Download Bprt Generic

 

 

More on Fraud and misconduct

Florida seems to be the epicenter of criminal medicare fraud AND problematic prescription of opiate painkillers, at least according to these two news items:

http://news.yahoo.com/s/nm/20110413/ts_nm/us_usa_healthcare_fraud

http://news.yahoo.com/s/ap/20110419/ap_on_he_me/us_pill_mills_us_response

The first elaborates on a theme that has been clear from previous news items and posts on real medicare fraud: Florida seems to be an epicenter. It may be a consequence of better surveillance, more aggressive investigation, or it just may be that there is more medicare fraud in Florida than in much of the rest of the US.  This is an enforcement effort that is welcomed by everyone else in the health care system, including physicians and patients, as fraud on this scale sucks resources from the system sufficient to make providing real care to real patients more difficult. The first news item does make it clear that, historically, it has been fairly easy to defraud medicare. 

The second news item deals with one of the dark underbellies of medicine: the rampant abuse of prescription opiates(interestingly, benzodiazepines are not presently on anyone's radar).  As with medicare fraud, it seems that this is also an activity for which Florida is an epicenter. While Florida has a disproportionate number of elderly residents, I doubt that this alone explains the fact that 85% of all oxycodone in the US is prescribed there. Unlike outright medicare fraud, it is easy for a private practice doc, especially a pain doc, to fall into the trap of running  a pill mill. Why? There is no objective evidence of pain: you have to accept what your patient self-reports. Pain treatment is often not covered by insurance, hence many pain patients pay cash on the barrel for monthly visits, which is very attractive in a world awash in insurance paperwork and payment denials. Patient satisfaction drives prescription as well: patients, including drug-seekers, give very low marks to physicians who undertreat or don't treat their pain.  Being liberal with opiates can only help your satisfaction scores, being stingy can only hurt them.  Sadly, all of this has produced a situation where physicians, especially those who specialize in pain, legally prescribe to drug-seeking individuals opiates that they previously obtained illegally.  If what my colleagues tell me is true, then there are physicians out there who run pill-mills, knowing full well that a large percentage of their 'patients' are full of BS, and that much of what they prescribe is being diverted. It only takes a few such pill-mills to generate huge problems. These bad actors are likely to make life ever more difficult for the honest pain docs in the next few years, especially as enforcement efforts like this ramp up.

  It is difficult, and usually impossible, for the prescribing physician to tell which of their patients is diverting, and which among them simply has terrible pain.  In an era where pain is the 5th (or 6th) vital sign, being liberal with opiates to treat it (as all authorities have exhorted all physicians to do) can put practitioners in regulatory and legal peril.  And yet, in our midst are physicians whose business and ethics are indistinguishable from a street-corner drug dealer. 

What do the numbers mean?

This is a very cogent and thought provoking news item about the NHS from the BBC:

http://www.bbc.co.uk/news/health-13130678

Wait times are at a 3 year high. Wait times, which correlate with patients seeking care, must of course vary over time, over days, weeks, months, and years.  Everyone inside and outside the NHS is aware that its wait-times have been a patient-care issue and political football for a long time.  So why is this news?

First, as demand increases and budgets are cut, extra funds that were once used to surge in times of increased demand are no longer available.  The strategy of setting aside funds to respond to fluctuations in operational tempo was a very smart strategy for the NHS; it mimics supply-demand in a system that would otherwise be completely unresponsive to cycles in activity. As the budget problems in the NHS worsen, wait times, especially during upswings in demand, are certain to become worse than they are now.  In short: less overtime = longer wait times.

As you would expect, there is a large gap between what independent (but not necessarily politically non-partisan) experts represent as the wait time and what they government reports.  In this instance,the outsiders say that 15% of patients wait more than 18 weeks for specialty care, while the government claims that only around 10% do.  This is a huge gap. Spin? Propaganda? Everyone knows that government agencies have an enormous incentive to represent their performance in the most favorable possible light. Over time, they can adopt methods for reporting data that are consistent, reproducable, precise, and completely divorced from reality.  There are plenty of instances of this from the various levels of government in the US. Orwell could not have imagined someone like Baghdad Bob, or how statistics that translate into misery, suffering, and death can be transformed and reported by political agendas.

The other interesting part of the news item is that various trusts have very smartly decided to utilize clinical criteria to change the position of individual patients on a list.  This is wise in that it accounts for details that no master-list schedule of criteria possibly could; it is hazardous in that it invites corruption and shennanigans en-masse. Absent a policy of random or comprehensive review, the pockets of the list-keepers will soon be lined with gold.

Within the NHS, there is intense interest in making the best of the substantial changes that are occurring. If I had the time and the money, I would attend this meeting:

http://www.hsj-patientexperience.com/

The lessons I might learn there could be helpful in years to come in the USA.

 

Fraud, Waste, and Abuse

Fraud and Abuse continues to be discovered on a massive scale; and that Pay-for-Performance (intended to improve the quality of care) still doesn’t work.  Why? Because both of these are far more complex, intractable problems than the public policy discussions have admitted.

A widely publicized US crackdown:

http://news.yahoo.com/s/nm/20110217/ts_nm/us_usa_healthcare_fraud

 As is often the case, it is difficult to judge the substance of the charges from the news item, which is sourced from the government agencies making the allegations. Nevertheless, if the allegations are as reported, then most of this is outright fraud, and on a massive scale. The involvement of organized crime is disconcerting, as it suggests that defrauding the US government has been either more lucrative or safer than any other crime they could commit.

and an admission of the scope of the problem:

http://news.yahoo.com/s/ap/20110205/ap_on_re_us/us_health_care_fraud_most_wanted

Years ago, I could not have imagined that health care fraud would have become such a problem that it would require its own Most-Wanted list, and that the list would be crowded.  Ineresting times indeed.

This is a news item about How Pay-For-Performance (P4P) doesn’t:

http://www.reuters.com/article/2011/01/26/us-incentives-idUSTRE70P6GY20110126

This last article is interesting, as it makes apparent that in spite of an exhaustive analysis of the data, they could not find even a hint of benefit from P4P.  This matters, as a lot of ‘health care reform’ in the US is to be built on this, which at present appears to be a house of cards.  If there is any benefit from P4P, it has been elusive, and cannot be easily or consistently demonstrated. 

Why did I put these items side-by-side? They’re both about fraud. One is fraud perpetrated against the government, the other perpetrated by the government against health care providers. It is within the power of the government to extinguish one of these completely.

 

 

The Good and Bad of the NHS

 

The Bad

Many advocates of government administration of health care point to the potential efficiencies that can arise from centralizing some functions.  The sad truth is that centralizing some functions simply allows for failure to occur on an even larger scale.

This is a story from the BBC from last summer:

http://www.bbc.co.uk/news/health-10740225

It’s important to note that the sums involved are somewhere between substantial and massive.  The NHS is leaving very large sums of money on the table, money that it could use to provide higher quality or more timely service to the populace.  How can this happen? Because those tasked with collecting this money likely have no incentive to do this well.  If they got even 2% of the money involved as a bonus, they would very likely be relentless in collecting every last penny.  The more energetic among them could become richer than the queen.  This is likely what happens when government bureaucrats see this as a paperwork problem instead of a way to create resources for their organization.  Instead, the NHS is a reliable source of windfall revenues to the pharmaceutical companies that supply these drugs. Ironically, these companies almost certainly invest a majority of their windfall into future product development, which will ultimately benefit the NHS and its patients.

The Good

There are few benefits to centrally administered or regulated health care.  One of them (theoretically at least) is that the regulators can study the performance of the system, and make changes that will predictably improve outcomes.  This is talked about much, much more than it happens. Why? Political considerations shape the options available to regulators. The universe of the politically possible is far smaller than the universe of the theoretically possible. Why so? Because governmental and regulatory power ultimately derives from political power and politics. Nevertheless, every once-in-a-while, a regulating body will study and analyze what it is doing, and come to a very smart decision about how to proceed. This story, also from the BBC, is a narrative of a very wise decision by the NHS to concentrate very complex pediatric cardiac surgery to a few centers of excellence.  The US system has many strengths, but among its weaknesses are that it is presently completely incapable of doing something similar.

http://www.bbc.co.uk/news/health-12462913

There is a back-story to this decision. The events that compelled it that are outlined in the associated BBC stories.  It is enough to say that doing pediatric cardiac surgery well is a very, very difficult undertaking.

This is an outstanding decision, and deserves to be recognized as such. I am flummoxed at the lack of interest in and coverage of this, in both the lay press and medical media.

--------------------------------------------------------------------------------------------------------------------------

This is an interesting item about a problem of our times:

http://www.nhsonline.net/news/article.asp?CategoryId=2&ArticleId=5080

The decision to only selective deploy the ability to transport the morbidly obese is an interesting one, as it seems that one ambulance crew will end up having to summon another.  My guess is that, over time, every ambulance in the UK and the US will have this capability.

Major Changes are coming to the NHS

Inasmuch as the NHS has been highly touted in the ongoing discussions about the US health care system, it is worth noting that circumstances have compelled a MAJOR reorganization:

http://www.bbc.co.uk/news/health-12217668

If passed, all 151 primary care trusts (PCTS) and strategic health authorities will be disbanded. The resources of the system would be allocated to consortia of primary care providers, who would in turn go to market to procure the services required by those under their care. They would control about 80% of of the NHS budget, which must shrink substantially over the next few years. This contraction of resources is occurring simultaneously with the aging of their population.  Sound familiar? It is worthwhile to note that the US solution is not hugely different - pay less.  In both instances, the decision making is likely to be opaque to everyone outside the decision loop, most especially the doctors and their patients.  The only question is why the primary care docs, instead of the patients themselves, should control the funds. Whether this particular re-organization comes to pass or not, it is clear that the leadership of the NHS confronts a problem very similar to the US: a burgeoning population of elderly and contracting contributions to their system. Importantly, the structure they already have cannot deliver the care required.

The IT infrastructure of the NHS also continues to flounder.  There are a variety of news items that have covered this, but none is more succinct than these:

http://www.telegraph.co.uk/finance/newsbysector/supportservices/8174715/No-more-mega-IT-contracts-Government-tells-suppliers.html

http://blogs.computerworlduk.com/the-tony-collins-blog/2010/12/the-end-of-it-mega-contracts-and-a-state-welcome-for-smes/index.htm

Given the size and scope of the UK investment, it is hard to imagine how the paltry sums allocated by the US for similar projects have any chance of success.  If there is any hope, it may be a consequence of a more free market, and the absence of 6000 page policy and procedure manuals.  History will know the answer, we are left guessing as to what it might be.

The ability of CHIT to generate information overload is likely to be akin to military systems. See this recent article in the New York Times:

http://www.nytimes.com/2011/01/17/technology/17brain.html