The Feds have joined two lawsuits that allege that Florida’s Asad Qamar, M.D., who was Medicare’s highest-paid cardiologist in 2012, taking in $18 million in reimbursements that year, got patients to have unnecessary invasive heart testing to boost his income.
Modern Healthcare reports that in one of the lawsuits Dr. Qamar and his group ”routinely waived patients’ Medicare copayments and deductible payments so that, the suit says, ‘patients had no reason to turn down services and would oblige Dr. Qamar’s improper recommendation that they consent to all manner of procedures for which there was no medically indicated need.’ according to the lawsuit. Qamar and the institute would then bill the government for the full cost of the treatment.”
A lawyer for the cardiologist said:
“Dr. Qamar practices under the highest medical and ethical standards. Any claims to the contrary are unsubstantiated and the doctor will defend himself vigorously against these baseless allegations.”
It’s interesting that so many of alleged overbilling involve Florida physicians, but then, it does have so many people on Medicare.
Siphnian Treasury at Delphi, North frieze, c. 525 BC, detail showing gods facing right and giants facing left.
Blue Shield of California alleges that Sutter Health, which runs 23 hospitals in northern California, is charging excessive prices and doing it in sneaky ways that hide its expensiveness from the public. But Sutter, for its part, said state data show that its per-hospital-discharge prices are at or below its peers.
The Los Angeles Times reports that the legal dispute between the giants has prevented Blue Shield and Sutter from reaching a new contract that would affect many employers and consumers.
Blue Shield is telling about 280,000 health plan members that they ”might lose network coverage with Sutter doctors and hospitals” in the fight, the paper says.
Some groups have accused Sutter of sneakily imposing anti-competitive actions and illegally inflated prices.
“‘Blue Shield is demanding significant rate rollbacks as well as several changes to language that has been in our contracts for years, Sutter spokesman Bill Gleeson said. ‘Rate rollbacks of the magnitude that Blue Shield demands would have a negative impact on the level of healthcare services we offer.”‘
The Sutter case but one large example of complaints about big hospital systems’ pricing power, which has grown as they buy more and more physician practices and outpatient medical facilities. Perhaps the most famous complaints are those involving Partners HealthCare, in the Boston area.
”James Robinson, a University of California at Berkeley professor of health economics, published a study in October showing hospital ownership of physician groups in California led to 10-20 percent higher costs overall for patient care,” the Times reported.
“Consolidation can create better coordination and efficiencies in healthcare. However, it can also create opportunities for higher prices.”
Peter Zweifel raises some important questions regarding “Big Data”:
”The question of how manageable big data might be when applied to coordinated care is primarily the concern of health insurers, who have a strong incentive to invest in big data. Once insurers and medical directors agree on measures of performance, big data can be condensed so it is more manageable for both of these parties.
”However, it is doubtful whether the cost savings are sufficient to overcome the resistance of service providers who seek to retain their professional autonomy. Big data is a double-edged sword for consumers; improved coordination of care comes at the risk of a loss of privacy, which governments may be eager to exploit.”
Steve Blank, writing in MedCity News, reports on a new class of life-science/healthcare co-working collaboration space.
He says that startups seeking to commercialize new technologies should:
- Define ”clinical utility” before spending millions of dollars.
- Understand who core and tertiary customers are, and the sales and marketing process ”required for initial clinical sales and downstream commercialization.”
- Assess intellectual property and regulatory risk ”before designing and building”.
- ”Know what data will be required by future partnerships/collaboration/purchases before doing the science.”
- “Identify financing vehicles” before they’re needed.
An article in JAMA concludes:
”Among high-risk children with chronic illness, an enhanced medical home that provided comprehensive care to promote prompt effective care vs usual care reduced serious illnesses and costs.”
The aim of the study was to find out “whether an enhanced medical home providing comprehensive care prevents serious illness (death, intensive care unit [ICU] admission, or hospital stay >7 days) and/or reduces costs among children with chronic illness.”
The study’s authors had noted that regular “Patient-centered medical homes have not been shown to reduce adverse outcomes or costs in adults or children with chronic illness.”
Jonathan Merril, M.D., has joined Cambridge Management Group (cmg625.com) as a senior adviser.
Dr. Merril has devoted his career to improving provider and patient education through technology. He is currently developing a “chronic care university’’ at Partners HealthCare. The new “university’’ is an online service for patients and primary-care providers meant to improve the lives of people with chronic conditions, with the first program to be focused on multiple sclerosis.
Cambridge Management Group (cmg625.com) has increasingly worked with providers to improve care and control costs associated with patients with chronic conditions as their numbers increase with the aging of the population. Dr. Merril and his colleagues at Cambridge Management Group recognize the growing need to manage chronic diseases with innovation in diagnostics and therapeutics.
He uses mobile and simulation technology and healthcare-education expertise to work with businesses, government and non-profit organizations to create novel opportunities to enhance care.
He is also the chief executive of Astute Technology, which streams large medical conferences, including those of the American Heart Association, the American Society for Clinical Oncology and many other organizations. Dr. Merril holds many patents in the digital capture of such gatherings.
Dr. Merril has used the Internet and App technology to build some of the most widely used online (including mobile) learning resources for physicians and patients. These systems power the Partners Healthcare Office of Continuing Professional Development and some key activities (including board reviews) of various other large non-profit healthcare organizations.
He is an expert in building and integrating platforms for continuing education, maintenance of licensure and promoting best practices for hospitals and professional societies.
Dr. Merril received his M.D. degree from The George Washington University School of Medicine and Health Sciences. He did his internship in internal medicine and then completed a fellowship in medical informatics in a joint program of George Washington and Massachusetts General Hospital. Jonathan Merril is married and has three children.
Politico discusses how 2015 could be the year that Republicans, now in firm control of Congress, finally define how they would replace the Affordable Care Act.
The Supreme Court will soon hear case that threatens subsidies that form a core of the Affordable Care Act. That has Republicans putting pressure on themselves to rally around their own plan, drawing on such ideas as tax credits to buy insurance, high-risk pools and letting insurance be sold across state lines.
If the justices follow the GOP plan, subsidies ”could be abruptly cut off to millions of people in states relying on the federal health exchange. That financial assistance would be available in just the 13 states running their own exchanges.”
All this would “spill over into the rest of the U.S. health insurance system. Without subsidies in two-thirds of the states, the uninsured rate would probably rise, reversing its sharp decline. Premiums could soar if only the sickest people stick with their more expensive coverage.”
Healthcare Renewal’s Roy Poses, M.D., and the Minneapolis Star Tribune look at the controversial case of Carl Elliott, M.D., a psychiatrist and bioethicist at the University of Minnesota who challenged the University of Minnesota’s handling of the death of a patient in a clinical trial run by the university.