Medicare

A Person-Centered Approach to Kidney Care

Posted by

0


Summary

Person-centered care has been advanced as an effective framework for improving patient satisfaction. By considering biopsychosocial factors — including socioeconomic status, environment, intellectual development, health, cultural factors, and social interactions — such care can help optimize treatment outcomes, advance health equity, and decrease costs. However, these factors, adopted by the medical field and labeled social determinants of health, have been inconsistently evaluated, thereby missing an opportunity to truly understand the individual needing care. Furthermore, a balance of specific social determinants of health factors and assessments of cognition and functional status can improve understanding of a patient and their context. The authors explore new possibilities with a shift in assessment methodologies, using end-stage renal disease as a model, and present a vision for a more effective person-centered assessment model, which is increasingly possible — and needed — in the modern health care environment. A surprising finding from the qualitative interviews was the importance of social connections formed during in-center dialysis. Additional key considerations include financial barriers, transportation challenges due to financial and mobility limitation, housing insecurity, insufficient knowledge of kidney disease and treatment, and limited contact with nephrologists. This article proposes potential methods for improvement of care that can simultaneously improve patient engagement and outcomes.

Editors’ note: This case study is an early release from Volume 5, Issue 2 of NEJM Catalyst Innovations in Care Delivery. It will appear alongside other issue 5.2 articles in February 2024.

Person-centered care is particularly critical for those who experience chronic health conditions such as chronic kidney disease (CKD), which affects approximately 15% of adults in the United States and disproportionately affects people of low income and communities of color.1 Complicating care, up to 90% of people with CKD are unaware they have it. This is attributed to an absence of symptoms until later stages of the disease, which increases the likelihood of progression to kidney failure and end-stage renal disease (ESRD). Current treatments for ESRD include peritoneal dialysis, hemodialysis, and kidney transplant.

Total inflation-adjusted Medicare expenditures for patients with ESRD increased from $47.1 billion in 2010 to $53.0 billion in 2019.2 Between 2010 and 2020, inflation-adjusted per-patient-per-year spending for ESRD decreased from $96,451 to $79,439. The greatest decrease was in inpatient spending, to $25,313 in 2020 from $32,886 in 2010. Outpatient spending also decreased, to $27,973 in 2020 from $30,966 in 2010.

Although transplantation has the potential to significantly improve quality of life, reduce mortality, and decrease costs, only 13% of patients are deemed eligible for the transplant list, and there are no standardized protocols for selection, potentially revealing another selection bias in survival rates.2 Certain populations are disproportionately disadvantaged when it comes to being waitlisted. The following groups are significantly less likely to be listed for transplantation and hence many fewer receive transplants: older adults; Black, Latinx/Hispanic, Native American/Alaska Native, Native Hawaiian/Pacific Islander, and Asian American people; people of low income; and people with disabilities.3–6 In addition to these selection biases, such patients are also more likely to be dually eligible, that is, those who have insurance coverage by both Medicare and Medicaid, with low income (average less than $20,000 per year) and advanced age (≥65 years) or disability, and are likely to experience very different challenges than individuals covered by Medicare alone.

Needs-Finding in ESRD

In March 2023, the authors launched a quality improvement project focused on person-centered ESRD care delivery. This project was conducted as an independent study by researchers based at Stanford University’s Clinical Excellence Research Center in conjunction with DaVita Kidney Care. We developed a survey (Appendix) and worked from a list provided by DaVita Kidney Care of dually eligible patients who were receiving dialysis. We focused on dually eligible patients because there are approximately 12.3 million people7 in the United States who are dually eligible, and more than 30% of them experience CKD. In 2020, Medicare inflation-adjusted expenditures for ESRD beneficiaries with fee-for-service Medicare was $65,817, higher for Medicare Advantage beneficiaries at $75,263, and much higher for dually eligible beneficiaries at $94,532.2

Top themes identified by individuals undergoing dialysis treatment were related to food insecurity, low rates of home dialysis, transportation barriers, mobility limitations, housing insecurity, social isolation, and cognitive decline.

A semistructured survey was prepared with primarily open-ended questions that gauged patients’ dialysis experiences with respect to barriers to care they faced, knowledge barriers in ESRD/dialysis, perspectives on the practice of home dialysis, goals of care, and highlights in their care journey that could be used to shape improved care delivery. This approach was taken by examining the literature and adapting for qualitative surveys of patients’ experience in dialysis. From a list of 48, we successfully reached 28 patients, but only nine agreed to participate (Table 1). During interviews with this group, we found that the same general themes recurred and determined that we had reached a saturation of themes. This group included participants who resided in urban, suburban, or rural neighborhoods. Interviews were conducted via telephone. The duration of each interview ranged between 29 and 153 minutes (mean [standard deviation], 51.3 [40.3] minutes).

Table 1

Demographic Characteristics of ESRD Patient Interview Participants

Qualitative interviews with dually eligible ESRD patients were conducted to understand their multifaceted social needs. Interviews were conducted until saturation of themes was reached. Top themes identified by individuals undergoing dialysis treatment were related to food insecurity, low rates of home dialysis, transportation barriers, mobility limitations, housing insecurity, social isolation, and cognitive decline (Table 2).

Table 2

ESRD Patient Interview Participants, Needs Identified

Nearly all respondents expressed a belief that they were eating healthfully, while reporting diets consisting mostly of fast foods, frozen meals, and animal-based protein. Meal choices are often dictated by what individuals can afford with food assistance programs and/or can prepare with only a microwave or a limited cooking repertoire.8 However, all interviewees reported that they had been given “kidney-friendly” diet recommendations by clinicians, who often fail to consider the reality of the patient’s unique challenges, cultural factors, and preferences. Such a one-size-fits-all approach may limit the effectiveness of treatment plans, diminish rapport between patients and providers, and compound challenges, including limited patient engagement, fragmented care coordination, and suboptimal treatment outcomes.

Approximately 90% of all dually eligible patients in the United States receive dialysis in outpatient dialysis centers despite the goal of the U.S. Department of Health and Human Services of having 80% of patients with ESRD undergoing dialysis at home or receiving a transplant.9,10 In accordance with previous literature, we found that dually eligible patients were less likely to engage in home dialysis due to challenges related to social determinants of health (SDOH), such as housing instability, lack of resources or support systems, and limited health literacy.11,12 In addition, previously reported improved outcomes for home dialysis over in-center dialysis may be applicable only to specific subgroups of patients, such as those with significant support systems, stable housing, and those in better overall health, which often excludes dually eligible patients.13,14

As with nutrition recommendations, health care–centric assumptions about quality of life with different kidney care options might contradict an individual’s preferences; therefore, treatment options warrant tailoring to nuances not routinely captured in clinical settings.

Although in-center dialysis may pose a hardship, both in terms of time (three times a week, for several hours a day) and accessibility to patients who may have to travel 30–60 minutes in each direction to the nearest center, all of the dually eligible in-center interviewees stated that they preferred in-center dialysis for social connection; only one was open to in-home dialysis. Almost all (eight of nine) had to stop working due to dialysis, further limiting outside contact with other people. Interviewees expressed that they had formed strong friendships with staff and other patients through seeing them several times a week, over many years. For example, interviewees stated that staff would make ethnic, home-cooked meals to share; that talking with fellow dialysis patients was their social connection; and that seeing the same people multiple times a week for years was its own support group. Interviewees also stated that they utilized their dialysis time to learn about treatment options, or other tips, from fellow dialysis patients. As with nutrition recommendations, health care–centric assumptions about quality of life with different kidney care options might contradict an individual’s preferences; therefore, treatment options warrant tailoring to nuances not routinely captured in clinical settings. Ultimately, specific challenges and needs and preferences must be addressed if we are to advance kidney health for all patients.

Broadening Assessment to Include Cognitive and Functional Status

In addition to physical decline, CKD/ESRD has been linked to an increase in risk for cognitive decline, as have social isolation and loneliness, further emphasizing the importance of social engagement and the inclusion of cognitive and functional screening in addition to SDOH screening.15–17 Dually eligible individuals who experience cognitive challenges may have difficulty understanding their disease and treatment options. In interviews, some dually eligible patients (six of nine) expressed a lack of comprehension regarding what dialysis was or what dialysis entailed even after education by the dialysis center and/or clinicians, whereas others (two of eight) indicated that they preferred to be naive regarding their disease or treatments; many (six of nine) said that they hoped that providers would spend more time explaining procedures and treatments. Some (three of nine) patients expressed dismay at how dialysis has restricted their lives and daily activities. Persons living with a complicated disease such as ESRD and, in particular, those experiencing cognitive decline would uniquely benefit from increased time with clinicians so that the clinicians can check for comprehension and iterate the care plan, as needed and on a more timely basis.

A majority of interviewees (seven of nine) did not drive, which often was attributed to cognitive and mobility challenges, as well as financial and SDOH barriers. Functional difficulties with bathing, cooking, or other activities of daily living were also often reported (seven of nine). This was especially salient for those who lived alone or lacked support. Several of these patients (three of seven) relied on professional caregivers; some visited three or four times a week, which underscores the importance of understanding individual needs and barriers to engaging in critical health-promoting behaviors.

Understanding Context

Clinical, cognitive, and functional assessments can help to evaluate multidimensional risks for poor health outcomes, as well as provide opportunities for prevention and early intervention, especially for older adults who are more likely to experience a confluence of chronic conditions. Since December 2020, the Centers for Medicare & Medicaid Services (CMS) Advancing Interoperability and Improving Prior Authorization Processes Proposed Rule (85 FR 82586, which was later incorporated into the pending proposed rule CMS-0057-P), has called for accelerating the adoption of standards related to social risk factor data. In the wake of these calls to action, nearly one-quarter of hospitals are now screening for SDOH.18,19 When used in tandem with cognitive and functional assessments, these tools have shown enormous potential for identifying and serving complex, high-needs populations such as dually eligible patients with ESRD. For example, health technology companies have already effectively used functional and cognitive screening data to show how these factors are predictive of ED visits.20

One critical finding was the disparity between clinical recommendations and the lived realities of patients, especially in terms of diet and treatment options.

CMS has expressed interest in improving best practices for collecting functional, cognitive, and social risk data; new technologies should be leveraged to efficiently capture such data across a range of contexts.21 Rather than merely combining lengthy combinations of cognitive and functional assessments with SDOH indicators, new approaches aligned with the realities of telehealth, asynchronous care, and remote patient monitoring present exciting prospects for reimagining the assessment and triage process. For example, artificial intelligence–assisted telehealth, which includes routine wellness questions and evaluates responses, can easily capture important health data for patients with ESRD, potentially predicting future health issues. In addition, experimental wearable devices that assess social engagement could provide a more holistic and continuous picture of patient health, improving accuracy and outcomes without overburdening clinicians.22

To craft such integrated assessments, several prerequisites should be considered:

•

Instruments should capture functional, cognitive, and SDOH data across medical, social, and behavioral health domains, to improve health equity and promote shared decision-making.

•

Ease of use, workflow integration, and clinical and patient acceptability of these instruments must be considered and codesigned.

•

Streamlined screening instruments must be tied to modifiable outcomes of interest and be incentivized by informing standardized billing metrics.

•

Instruments must practically incorporate medical, social, and behavioral health needs to better inform clinician treatment planning.

Looking Ahead

Moving forward, the potential of this pilot qualitative study to shape care delivery for dually eligible patients with ESRD is noteworthy, particularly given the relative dearth of studies examining this unique clinical and demographic intersection. Despite the small number of interviews, the sessions lasted on average nearly 1 hour and encouraged open-ended input from participants on their experience of care. One critical finding was the disparity between clinical recommendations and the lived realities of patients, especially in terms of diet and treatment options. Individuals additionally face unique challenges such as financial limitations or lack of social support, which can hinder adherence to home-based care plans.

Based on these insights, we recommend that clinicians engage in conscientious, thorough discussions with patients at the outset of treatment — taking into account their social, cultural, and personal circumstances — to ultimately improve outcomes and drive down costs in the long term. For instance, dietary recommendations should be not only “kidney friendly,” but also realistic and achievable within the patient’s means. Similarly, decisions about dialysis modalities should involve a detailed discussion about the patient’s living conditions and support systems. These practices are not just suggestions, but important steps toward truly person-centered care, ensuring that treatment plans are medically sound as well as practically feasible and aligned with individual preferences. Thus, the findings from the current study may reinforce critical practices and ongoing shifts in kidney care, including an improved focus on the social determinants of kidney health. Further, it may open new vistas into opportunities to improve staffing, processes, or clinical/SDOH-related activities.

Our experience suggests that a thorough and empathetic understanding of the individual’s socioeconomic background, cultural influences, and personal preferences is critical.

In addressing the optimal mix of care delivery methods for patients with ESRD, it is important to consider the individualized needs of each patient, particularly those who are dually eligible. Our findings underscore the need for a more nuanced approach to care delivery. For instance, although at-home dialysis offers convenience and comfort, it may not be suitable for patients facing social isolation or financial barriers that may preclude ease of application in the home. In-clinic dialysis, on the other hand, may provide essential social interaction and support, but may present transportation and mobility challenges. Lastly, although kidney transplantation is the most desirable option for many, its limited availability and eligibility criteria make it an inaccessible choice for a significant portion of patients. Therefore, we recommend a person-centered framework in which care delivery is tailored based on a comprehensive assessment of each individual’s medical, social, and personal needs. This approach would enable more effective and personalized treatment plans, enhancing both outcomes and quality of life.

In implementing a person-centered care model for ESRD, particularly for dually eligible individuals, health care providers may encounter several challenges. First, accurately assessing and integrating individual needs and preferences into care plans can be complex, given the diverse and often underrepresented backgrounds of these individuals. Our experience suggests that a thorough and empathetic understanding of the individual’s socioeconomic background, cultural influences, and personal preferences is critical. This may require additional training for health care providers in cultural competence and communication skills. Furthermore, it is critical to measure what matters and to concretely identify the full breadth of the individual experience for those who engage in dialysis.

To this end, the creation of integrated assessment instruments that more effectively capture the whole person — including the full spectrum of lived experiences, context, and behaviors — offers much promise in building person-centered care models. For clinicians, improved assessments that consider clinical, cognitive, functional, and social determinants of health can improve the identification of clinical risks without additional burden and enable earlier, upstream intervention. For health plans and the government, standardized novel data collection instruments can foster progress toward value-based care and national policy goals. For individuals, such as those with ESRD, more holistic measures and new technologies can help with the efficient capture of the full depth and breadth of an individual’s experience and better align health care with what matters most to patients.

However, challenges lie in the adoption of new technologies for patient monitoring and data collection. Although these technologies offer promising avenues for enhancing care, their integration into existing health care systems can be hindered by logistical, financial, and technical barriers. To address these challenges, we recommend collaborative efforts involving multidisciplinary teams, including IT specialists, to ensure smooth technology integration and staff training. Health care organizations should consider pilot-testing these technologies in selected patient groups to identify and address potential issues before wider implementation. Finally, maintaining consistent and open communication throughout this process is vital to ensure that needs and concerns are continually addressed, fostering trust and engagement in the care journey.

Social Risk and Dialysis Facility Performance in the First Year of the ESRD Treatment Choices Model

Posted by

0


Abstract

Importance  The End-Stage Renal Disease Treatment Choices (ETC) model randomly selected 30% of US dialysis facilities to receive financial incentives based on their use of home dialysis, kidney transplant waitlisting, or transplant receipt. Facilities that disproportionately serve populations with high social risk have a lower use of home dialysis and kidney transplant raising concerns that these sites may fare poorly in the payment model.

Objective  To examine first-year ETC model performance scores and financial penalties across dialysis facilities, stratified by their incident patients’ social risk.

Design, Setting, and Participants  A cross-sectional study of 2191 US dialysis facilities that participated in the ETC model from January 1 through December 31, 2021.

Exposure  Composition of incident patient population, characterized by the proportion of patients who were non-Hispanic Black, Hispanic, living in a highly disadvantaged neighborhood, uninsured, or covered by Medicaid at dialysis initiation. A facility-level composite social risk score assessed whether each facility was in the highest quintile of having 0, 1, or at least 2 of these characteristics.

Main Outcomes and Measures  Use of home dialysis, waitlisting, or transplant; model performance score; and financial penalization.

Results  Using data from 125 984 incident patients (median age, 65 years [IQR, 54-74]; 41.8% female; 28.6% Black; 11.7% Hispanic), 1071 dialysis facilities (48.9%) had no social risk features, and 491 (22.4%) had 2 or more. In the first year of the ETC model, compared with those with no social risk features, dialysis facilities with 2 or more had lower mean performance scores (3.4 vs 3.6, P = .002) and lower use of home dialysis (14.1% vs 16.0%, P < .001). These facilities had higher receipt of financial penalties (18.5% vs 11.5%, P < .001), more frequently had the highest payment cut of 5% (2.4% vs 0.7%; P = .003), and were less likely to achieve the highest bonus of 4% (0% vs 2.7%; P < .001). Compared with all other facilities, those in the highest quintile of treating uninsured patients or those covered by Medicaid experienced more financial penalties (17.4% vs 12.9%, P = .01) as did those in the highest quintile in the proportion of patients who were Black (18.5% vs 12.6%, P = .001).

Conclusions  In the first year of the Centers for Medicare & Medicaid Services’ ETC model, dialysis facilities serving higher proportions of patients with social risk features had lower performance scores and experienced markedly higher receipt of financial penalties.

Discussion

In the first year of CMS’ ETC model, dialysis facilities serving more patients in the highest quintile of social risk had lower performance scores and received markedly higher financial penalties. The performance differences were driven by lower home dialysis achievement, rather than transplant and transplant waitlisting, and occurred despite CMS’ incentives of rewarding improvement for the use of home dialysis and receipt of kidney transplants in addition to overall achievement. The higher financial penalization was most pronounced for facilities serving patient populations with the highest social risk. Social risk characteristics that were most highly associated with financial penalties and lower home dialysis use were the share of those who were uninsured or covered by Medicaid and were non-Hispanic Black patients. The share of patients from disadvantaged neighborhoods was most associated with lower transplant achievement and improvement. Finally, compared with for-profit facilities, not-for-profit facilities had lower use of home dialysis and were more likely to be financially penalized.

Other studies have demonstrated that pay-for-performance models can have the unintended consequence of disproportionately penalizing and transferring money away from safety-net facilities or clinicians in favor of those that serve populations with lower social risk.4,6,7,14,15,24–28 When payments are assigned without accounting for social risk, program performance may in part reflect socioeconomic case mix rather than the intended measures of quality.15 In kidney failure care, an evaluation of the 2012 ESRD Quality Incentive Program29 demonstrated that dialysis facilities that served high proportions of patients with dual Medicaid-Medicare coverage, living in low-income areas, or who were Black or Hispanic had poorer performance and were more frequently penalized than their counterparts serving lower proportions of such patients. In an effort to address these issues, CMS designed the ETC model to reward both overall achievement as well as improvement in use of home dialysis and kidney waitlisting and receipt of transplants. Our analysis of the first year of the ETC model finds that despite this approach, dialysis facilities serving patients with higher social risk experienced markedly higher receipt of financial penalties.

Extensive research has demonstrated significant disparities in access to optimal kidney failure care across the US.1,4,30–32 Structural barriers such as institutional and interpersonal racism, residential segregation, and neighborhood poverty are influential in driving these care gaps.1,33 Furthermore, non-Hispanic Black, uninsured, Medicaid-covered, and socioeconomically disadvantaged patients are highly concentrated within dialysis facilities that have lower use of home dialysis and receipt of transplants. Although the financial margins on Medicare dialysis payments are highly variable (approximately <0.5% on average),29,34 facilities that serve high proportions of patients who are uninsured or are covered by Medicaid likely operate on particularly narrow margins. The magnitude of the ETC model’s 5% to 10% penalty on all Medicare reimbursements, larger than previous quality kidney failure programs,29 may threaten the solvency of these safety-net centers. Their closures would likely have harmful consequences, including extended travel and missed sessions.

Beginning in 2022, CMS applied a new health equity adjustment to the modality performance score, which accounts for the proportion of Medicare beneficiaries per aggregation group who are dually insured or low income.16 Our analysis demonstrates social risk factors like race, ethnicity, and neighborhood disadvantage are associated with model performance yet will not be directly addressed in the new scoring system. Furthermore, this study found that only 57 facilities (2.6%) in the sample may be eligible for the future health equity adjustment, when approximated using a proxy for the stratum cutoff proposed by CMS (>50% dually insured or low income). Only about 10% of the cohort with the highest social risk score (≥2) and 17.6% of those currently penalized met this threshold. These findings suggest that relatively few facilities serving patients with substantial social disadvantage may benefit from this adjustment, given that the 50% or higher threshold is substantially greater than the national proportion of patients with kidney failure who are eligible for both Medicaid and Medicare.5 CMS could consider defining a broader construct of social risk, rather than exclusively focusing on eligibility for Medicaid or low-income subsidies or revising the proposed stratum cutoff to be the median proportion of patients who are dually insured or low income. In 2021, the first year after the 21st Century Cures Act expanded Medicare Advantage enrollment to persons with kidney failure, nearly 1 in 4 dual beneficiaries with kidney failure switched to Medicare Advantage coverage.35 Given this disproportionate shift ,36 smaller proportions of dialysis facilities may qualify for CMS’ health equity scoring adjustment going forward.

Limitations

This study has 4 limitations. First, the use of historical (2017-2020) data on incident patients to characterize facilities’ 2021 social risk may lead to misclassification. However, it is likely that the sociodemographic characteristics of a facility’s population in 2021 are strongly associated with the composition of patients who initiated dialysis in that facility over the prior 3 years. Second, the approach to identifying facilities eligible for the health equity scoring adjustment used the proportion of patients who were uninsured or were covered by Medicaid at initiation, but CMS uses the proportion of prevalent traditional Medicare patients with dual coverage or who are eligible for a low-income subsidy. Third, CMS assesses outcomes and provides data at the aggregation-group level and then attributes performance and applies payment adjustments to all member facilities. Therefore, although the analyses in this study align with CMS’ approach, it was not possible to assess facility-level variations in home dialysis and transplant waitlisting or transplant rates. Fourth, although not-for-profit facilities had received substantially higher financial penalization driven by lower use of home dialysis, the small number of such facilities (n = 130) precludes more extensive analyses. The experience of not-for-profit facilities under the ETC model should be closely monitored in future work.

Conclusions

In this observational study of 2191 dialysis facilities, those serving higher proportions of patients who were non-Hispanic Black or Hispanic, living in a highly disadvantaged neighborhood, or were uninsured or covered by Medicaid at dialysis initiation received lower performance scores and had experienced more financial penalization, driven primarily by lower use of home dialysis. These findings, coupled with the escalation of penalties to as much as 10% in future years, support monitoring the ETC model’s continued impact on dialysis facilities that disproportionately serve patients with social risk factors, as well as its influence on outcomes and disparities in care among patients treated in these sites.

Older Adults Want Medicare, Insurance to Cover Obesity Drugs

Posted by

0


Weight-loss drugs should be covered by Medicare and by other health insurance, according to a poll of US adults aged 50-80 years.

Among more than 2600 polled, 83% say that health insurance should cover prescription weight-loss drugs that have been approved by the US Food and Drug Administration (FDA), and 76% say Medicare should cover such drugs. However, only 30% would be willing to pay higher Medicare premiums to have these medications covered.

Among the 27% of respondents who say they are overweight, 63% are interested in taking such medications, as are 45% of those with diabetes, regardless of weight.

The University of Michigan (U-M) National Poll on Healthy Aging was published online on December 13, 2023.

High Awareness

The findings come at a time when injectable glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as Ozempic, Wegovy, Zepbound, and Mounjaro, are receiving a lot of public attention, the university noted.

Overall, 64% of survey respondents had heard of at least one prescription medication used for weight management. 

By brand name, 61% had heard of Ozempic, approved for the treatment of type 2 diabetes but prescribed off label for weight loss; 18% had heard of Wegovy; and 13% had heard of the anorexiant drug phentermine.

Very few respondents (3% for each) had heard of the GLP-1 RA Saxenda, Qsymia (phentermine plus the anticonvulsant topiramate), and the opiate antagonist Contrave. 

Zepbound, the obesity-specific form of the diabetes drug Mounjaro, received FDA approval after the poll was taken and was not included in survey questions.

Among respondents who had heard of at least one prescription medication used for weight management, 58% had heard about them through the news (eg, TV, magazines, newspapers) and 53% had heard about them from an advertisement on TV, the internet, or radio. Only 11% heard about them from their healthcare provider.

Respondents more likely to be interested in taking a prescription medication for weight management included women, those aged 50-64 years, Black persons, Hispanic persons, those with household incomes of less than $60,000 annually, those with lower levels of education, those in fair or poor physical or mental health, and those with a health problem or disability limiting their daily activities.

Spotty Coverage

The GLP-1 RAs can cost more than $12,000 a year for people who pay out of pocket, the university noted. 

A Medicare Part D law passed in 2003 prohibits Medicare from covering medications for weight loss, although currently it can cover such drugs to help people with type 2 diabetes manage their weight. 

Medicaid covers the cost of antiobesity drugs in some states. 

Most private plans and the Veterans Health Administration cover them, but with restrictions due to high monthly costs for the newer medications.

The American Medical Association recently called on insurers to cover evidence-based weight-loss medications.

The strong demand for these medications, including for off-label purposes by people willing to pay full price, has created major shortages, the university noted. 

“As these medications grow in awareness and use, and insurers make decisions about coverage, it’s crucial for patients who have obesity or diabetes, or who are overweight with other health problems, to talk with their healthcare providers about their options,” said poll director Jeffrey Kullgren, MD, MPH, MS, a primary care physician at the VA Ann Arbor Healthcare System and associate professor of internal medicine at U-M.

Other weight-management strategies that respondents think should be covered by health insurance include sessions with a registered dietitian or nutritionist (85%); weight-loss surgery (73%); gym or fitness facility memberships (65%); apps or online programs to track diet, exercise, and/or behavior change (58%); and sessions with a personal trainer (53%).

The randomly selected nationally representative household survey of 2657 adults was conducted from July 17 to August 7, 2023, by NORC at the University of Chicago for the U-M Institute for Healthcare Policy and Innovation. The sample was subsequently weighted to reflect population figures from the US Census Bureau. The completion rate was 50% among those contacted to participate. The margin of error is ±1 to 5 percentage points for questions asked of the full sample and higher among subgroups.

The poll is based at the U-M Institute for Healthcare Policy and Innovation and supported by AARP and Michigan Medicine, the University of Michigan’s academic medical center.

Physician Exclusions From Medicare, Medicaid Increasing

Posted by

0


Federal efforts to detect Medicare fraud may be driving an increase in the number of physicians excluded from Medicare and other forms of public insurance, according to the authors of a newly published study.

The number of physicians excluded from Medicare, Medicaid, and other state public insurance programs increased on average by 20% per year, or the equivalent of 48 additional cases a year, between 2007 and 2017, said Anupam B. Jena, MD, PhD, of Harvard Medical School and colleagues. They report their findings in an article published online today in JAMA Network Open.

“There were several explanations for the observed increase in exclusions, and rates of identified health care fraud, waste, and abuse,” Jena and colleagues write. “First, this finding could be evidence that regulators, who have been aided by recent public policies targeting the reduction of fraud and waste, may be getting better at identifying perpetrators of fraudulent activity.”

Since 2011, the Centers for Medicare & Medicaid Services has used predictive analytics to detect improper billing, the authors note. In addition, the Affordable Care Act of 2010 allocated $350 million to the Department of Health & Human Services’ Health Care Fraud and Abuse Control Account. The law also increased sanctions, including allowing state Medicaid programs to halt payments and requiring that Medicare overpayments be returned within 60 days instead of 3 years.

Jena and colleagues also cite the growth in the total number of US physicians participating in public insurance as a possible cause for the rising number of exclusions.

The implementation of the Affordable Care Act of 2010 allowed more people to gain access to public insurance programs. Enrollment in any government health insurance plan increased by 12.6% total from 2013 to 2017, which is significantly greater than the 7.9% increase in private insurance enrollment, the authors note.

“We cannot exclude the possibility that the increase in physician exclusions reflects a rise in fraudulent and untoward practices by US physicians,” the authors add. “However, we are unaware of any published data that support this potential explanation.”

Overall, the researchers found that 2222 physicians, or 0.3% of US physicians, were temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017 for fraud, unlawful prescribing of controlled substances, or health crimes.

Physicians can be excluded from Medicare and other public insurance programs for a variety of reasons. Common causes include the illegal distributing, prescribing, and dispensing of controlled substances such as opioids and surgical anesthetics. Other reasons include billing for services not rendered and filing duplicate claims and providing medically unnecessary procedures.

Jena and colleagues describe their study as “the most comprehensive and contemporary effort to assess trends in physician exclusion from participation in public health insurance owing to fraud, waste, and abuse concerns, and physician characteristics associated with exclusion.”

For the analysis, they matched each physician’s unique national provider identifier to their profile in Doximity, an online networking service that collects personal and professional information about physicians.

The authors found notable variation in the rates of exclusion, which were highest in the West and Southeast. With 32 exclusions among 5720 physicians, West Virginia had the highest rate of exclusions at 5.77 per 1000. Montana, in contrast, had 0 exclusions during the study period.

“Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion,” the authors said.

Radiologists Did Most Stroke Thrombectomy In Early Days

Posted by

0


But most had neurointerventional training in Medicare data up to mid-2015

As clinical trial evidence turned the corner for mechanical thrombectomy in 2015, what few procedures were done remained solidly the province of radiologists, a study of Medicare data showed.

Looking at a nationally representative 5% sample of Medicare beneficiaries between January 1, 2009, and September 30, 2015, only 555 thrombectomy procedures for acute ischemic stroke were done among nearly 78,000 stroke hospitalizations.

While 61.4% of them were done by radiologists, an equally high proportion of operators had dedicated neurointerventional fellowship training (66.1%), albeit of unknown type or quality, Hooman Kamel, MD, Weill Cornell Medical College in New York City, and colleagues reported here at the International Stroke Conference and online in JAMA Neurology.

Neurologists and neurosurgeons roughly split the rest not done by radiologists — 19.8% and 16.4%, respectively — along with a sliver (2.4%) done by an assortment of other physicians.

“Clinician characteristics did not change significantly after December 17, 2014, when the first trial to show a clinical benefit for thrombectomy was published,” the researchers noted in the paper.

Early in 2015, a subsequent series of trials confirmed that, with advanced imaging-selection of patients, mechanical thrombectomy held a significant outcome benefit for large vessel strokes, kicking off a rapid uptake in the procedure.

How the workforce doing these procedures might have changed since the end of the study period isn’t clear.

Kamel’s group pointed to arguments “that a workforce shortage exists that could be filled by non-neuroscience clinicians with expertise in catheter-based procedures. Neurointerventionalists have countered that they are available to most U.S. patients, but vascular neurologists have nevertheless raised concerns about a shortage.”

“I know in my own institution right now, radiologists aren’t doing the procedures,” commented Ralph Sacco, MD, of the University of Miami, and president of the American Academy of Neurology.

“Radiologists are phenomenally good at working with catheters and often they are part of a team,” he told MedPage Today, “but it’s hard to say, and I’ve never seen differential data regarding outcomes by radiologists, a neurologist, or even interventional neurosurgeon.”

A lot of the future landscape may be up to trainees, Sacco noted. “It’s hard to say what the landscape will look like in the future. But our belief is that more neurologists will become interventional neurologists … Obviously, the demand for more people to do interventional procedures is rapidly rising.”

The researchers suggested that their study may help “inform plans for optimizing systems of acute stroke care across the United States.”

Medicare Is Getting A Serious Makeover

Posted by

0


Medicare wants to shift away from paying doctors according to number of visits, procedures, hospitalizations, and tests — and toward paying for performance.

This week, Medicare officials unveiled an ambitious plan to do just that. The nearly thousand-page report proposes an opt-in track for doctors called the “merit-based incentive payment system” (MIPS), designed to reward or penalize them based on their performance. The proposal would also pay doctors to try out Medicare’s alternative payment models — non-traditional (and hopefully money-saving) new ways for the public health program to reimburse doctors.

The proposal is the first step toward what could be the biggest update to Medicare in its 50-year history. It’s part of a bigger plan to tie as much as half of doctor payments to patients’ health outcomes by 2019.

Proponents of the proposed “pay-for-performance” system say that Medicare’s traditional “fee-for-service” system is too costly and encourages waste. Under fee-for-service, doctors are paid a flat free for every test or procedure they perform, regardless of whether those services actually improve their patients’ health. As a result, doctors may administer expensive medical tests even when there’s little chance these tests will find a tumor or disease — and taxpayers end up footing the bill.

Medicare wants to save taxpayer dollars by penalizing wasteful doctors, but doctors have been known to fight tooth and nail against what Medicare considers wasteful. Facing criticism last year, Medicare had to abandon its proposal to penalize doctors for ordering routine prostate-cancer exams for their patients. On the one hand, prostate exams have led an estimated one million mento be treated for cancer that would never have bothered them — again, with taxpayers footing the bill. Yet, even the very authors of that study, doctors themselves, opposed Medicare’s proposal.

“[We] are not comfortable rewarding doctors for withholding a test that could help some men,” the two doctors wrote in the New York Times. They added that Medicare should not penalize doctors, but should raise patient deductibles for screenings it deems unnecessary.

The American Medical Association (AMA), the largest and most powerful group of doctors in the nation, has also criticized Medicare, calling its past attempts to implement pay-for-performance “burdensome, meaningless and punitive.” But Wednesday’s proposal got the AMA’s stamp of approval.

“Our initial review suggests that CMS has been listening to physicians’ concerns,” Steven Stack, the association’s president, said in a statement. “It is hard to overstate the significance of these proposed regulations for patients and physicians.”

The second way the proposal tries to save money and promote quality care is through “alternative payment models.” Under one common alternative model — the bundled payment model — Medicare pays doctors for all care in connection with a single “episode” of sickness or, for instance, a single knee replacement procedure. All the doctors in a given region get the same flat fee for a procedure based on the average cost of the procedure in that region. The model encourages pricey health care providers to bring down costs like their more cost-efficient neighbors.

Other models promote doctor innovation. For example, doctors can be part of a health home — “where doctors can help patients understand prevention and wellness,” the Center for Medicare and Medicaid Services explains in a video. “They can try innovative approaches like tele-health or nutrition classes.”

Patrick Conway, CMS’s chief medical officer, emphasized that the new payment system is opt-in, giving doctors “the opportunity to participate in a way that is best for them, their practice, and their patients.” Even so, CMS expects the vast majority of doctors to opt in.

The comment period for the proposal is open for the next two months.

Does Sodium Intake Affect Mortality and CV Event Risk?

Posted by

0


Sodium intake may not be associated with mortality or incident cardiovascular events in older adults, according to a study published Jan. 19 in the JAMA: Internal Medicine.

In the Health, Aging and Body Composition (Health ABC) Study, initiated in 1997, researchers assessed self-reported sodium intake from 2,642 Medicare beneficiaries, ages 71-80 years old. Participants were excluded for difficulties with walking or activities of daily life, cognitive impairment, inability to communicate, and previous heart failure (HF). At the first annual follow-up visit, researchers recorded food intake as reported by participants, specifically examining sodium intake. After 10 years, 34 percent of patients had died, while 29 percent and 15 percent had developed cardiovascular disease and HF, respectively.

The results of the study showed that there was no association between participant-reported sodium intake and 10-year mortality, incident HF or incident cardiovascular disease. Further, there was no indication that consuming less than 1,500 mg/d of sodium benefitted participants any more than consuming the recommended amount (1,500-2,300 mg/d). However, the study showed a slight potential for harm when participants had a sodium intake of greater than 2,300 mg/d, especially in women and African Americans.

The authors note that while the food frequency questionnaire used by participants at the first annual follow-up has limitations in its accuracy, “self-reported adoption of a low-salt diet was not associated with significantly higher risk for [any] events.” They conclude that moving forward, there is a need for further research and stronger evidence in order to create better recommendations for older adults.

– See more at: http://www.acc.org/latest-in-cardiology/articles/2015/01/16/15/47/does-sodium-intake-affect-mortality-and-cv-event-risk-acc-news-story?wt.mc_id=fb#sthash.vE0R3iGF.dpuf

Hospital Readmission Not a Good Quality Measure for Children.

Posted by

0


Preventable readmission rates for children are lower than all-cause readmission rates, according to a new study.

“The concern that many of us have is that there is much less to be gained from a major effort to reduce pediatric readmissions because so many are due to an unpredictable disease process,” James Gay, MD, from Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News.

“Pediatricians try very hard to keep their patients out of the hospital in the first place,” he explained, “so a large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall, and it might actually distract from efforts in other areas, such as concentrating on patient safety.”

Dr. Gay presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Pressure is on at hospitals to reduce 30-day readmissions, which are considered by some regulators to be a metric of patient safety and quality care. The Affordable Care Act requires a hospital readmission reduction program for facilities that treat Medicare patients and imposes penalties for institutions with high rates.

 

A large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall.

 

Hospital administrators are therefore keen to identify preventable readmissions. Some state Medicaid programs use the 3M Potentially Preventable Readmissions grouping software; however, data on its use in pediatric readmissions are lacking, said Dr. Gay.

His team assessed 1,749,747 hospitalizations in 58 Children’s Hospital Association member hospitals. They used the 3M software to calculate all-cause readmission rates with the company’s proprietary list of 314 All Patient Refined Diagnostic Related Groups.

The software flagged 80% or more of all-cause readmissions as potentially preventable for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy. In contrast, the software suggested that more than 40% of 30-day readmissions were not preventable, including those for seizures, gastroenteritis, central line infections, urinary tract infections, and failure to thrive.

For the 20 leading patient diagnostic groups for all-cause readmissions, the software algorithm removed chemotherapy, acute leukemia, and cystic fibrosis from the list of potentially preventable reasons.

Table. All-Cause vs Preventable Pediatric Readmissions

Day

All-Cause Readmissions (%)

Preventable Readmissions (%)

7

4.9

2.5

15

8.5

4.1

30

13.0

6.2

 

“There are many fewer pediatric than adult hospitalizations in the first place, and the numbers and rates of readmissions are lower in children,” Dr. Gay pointed out. According to Medicare estimates, “older adults have readmission rates of about 20% at 30 days. The overall pediatric rates are closer to 6% to 10%,” he added.

Conditions that drive hospital readmission in children, or lead to admission in the first place, are very different from those in adults, Dr. Gay said. For example, adults are more likely to be readmitted within 30 days because of a high prevalence of chronic conditions, like congestive heart failure and chronic obstructive pulmonary disease, whereas children have more acute illnesses, such as pneumonia, bronchiolitis, and asthma.

“Because of these issues, many hospital pediatricians believe that readmission rates are not a good quality measure for pediatrics,” Dr. Gay said.

Asked by Medscape Medical News to comment on this study, Mark Shen, MD, from Dell Children’s Medical Center in Austin, Texas, noted that “in this study, the single most common reason for readmission was chemotherapy. We expect these kids to come back — we’ve wiped out their immune system.”

Other children are discharged with the expectation they will return as well, he added. “Sometimes we know they’re coming back. We’re just giving them a break at home, such as children with sickle cell disease or ventricular shunts.”

This study is useful because it indicates that the rate of 30-day hospital readmission is lower for children than for adults. Further research could focus on key chronic conditions associated with more readmissions in children, which so far only have been identified in adults. “But we’re getting closer in pediatrics,” Dr. Shen added.

The study authors caution that the 3M software might not completely reflect the reasons for pediatric readmissions, and future studies are warranted to validate its use in this population. The broader issue is whether efforts to track and reduce adult hospital readmissions apply equally to pediatric patients, Dr. Gay said.

Residential exposure to aircraft noise and hospital admissions for cardiovascular diseases: multi-airport retrospective study.

Posted by

0


Abstract

Objective To investigate whether exposure to aircraft noise increases the risk of hospitalization for cardiovascular diseases in older people (≥65 years) residing near airports.

Design Multi-airport retrospective study of approximately 6 million older people residing near airports in the United States. We superimposed contours of aircraft noise levels (in decibels, dB) for 89 airports for 2009 provided by the US Federal Aviation Administration on census block resolution population data to construct two exposure metrics applicable to zip code resolution health insurance data: population weighted noise within each zip code, and 90th centile of noise among populated census blocks within each zip code.

Setting 2218 zip codes surrounding 89 airports in the contiguous states.

Participants 6 027 363 people eligible to participate in the national medical insurance (Medicare) program (aged ≥65 years) residing near airports in 2009.

Main outcome measures Percentage increase in the hospitalization admission rate for cardiovascular disease associated with a 10 dB increase in aircraft noise, for each airport and on average across airports adjusted by individual level characteristics (age, sex, race), zip code level socioeconomic status and demographics, zip code level air pollution (fine particulate matter and ozone), and roadway density.

Results Averaged across all airports and using the 90th centile noise exposure metric, a zip code with 10 dB higher noise exposure had a 3.5% higher (95% confidence interval 0.2% to 7.0%) cardiovascular hospital admission rate, after controlling for covariates.

Conclusions Despite limitations related to potential misclassification of exposure, we found a statistically significant association between exposure to aircraft noise and risk of hospitalization for cardiovascular diseases among older people living near airports.

What is already known on this topic

·         Noise has been associated with hypertension, myocardial infarction, and ischemic heart disease

·         Aircraft noise in particular has been associated with several hypertension outcomes

·         Few studies, however, have investigated the relation of aircraft noise to cardiovascular disease, in part because studies surrounding a small number of airports are not typically adequately powered

What this study adds

·         Long term exposure to aircraft noise is positively associated with hospitalization for cardiovascular disease

·         The association between aircraft noise and hospitalization for cardiovascular disease is not confounded by air pollution, road density, or area level socioeconomic status

·         There may be a threshold for the association between aircraft noise and hospitalization for cardiovascular disease

·         Source:BMJ

Physician Gave Chemo to Patients Without Cancer..

Posted by

0


Hematologist-oncologist Farid Fata, MD, in suburban Detroit, Michigan, was arrested August 6 and charged with Medicare fraud in a federal case that stands out from dozens of others recently brought against healthcare providers.

For one thing, the dollar amount of alleged fraud — $35 million — is higher than most for individual providers charged by the government. The potential physical harm to patients described by prosecutors also is far more substantial. In a criminal complaint filed in a federal district court in Detroit, prosecutors said that the 48-year-old Dr. Fata ordered toxic chemotherapy for patients who did not have cancer or whose cancer was in remission. Doing this “is simply poisoning the patient,” prosecutors said in a later court filing.

And something else happened in Dr. Fata’s case that is unusual: Rather than keeping their heads down, some employees at Dr. Fata’s high-profile practice challenged his actions before he was arrested, according to the government.

One employed oncologist, for example, told agents from the FBI and the Department of Health and Human Services that he discovered that Dr. Fata had ordered chemotherapy for a patient whose cancer was in remission. The oncologist said he advised the patient to get a second opinion and not return to Dr. Fata’s practice.

This oncologist and other employees also reported that Dr. Fata ordered intravenous immunoglobulin (IVIG) for patients whose antibody levels did not warrant the therapy. One nurse practitioner (NP) told federal agents that she pulled the charts for 40 patients scheduled for IVIG therapy and saw that 38 had neither low antibody levels nor a recurrent infection, which is another indication for the treatment. The NP consulted 2 other employees about the issue, and the 3 of them canceled the IVIG therapy for the 38 patients.

Dr. Fata’s employees had internally challenged other practices they considered unethical, such as fabricating cancer diagnoses in patient records to justify insurance claims for chemotherapy and positron emission tomography (PET) scans, according to interviews conducted by federal agents. Some employees quit over these issues. The employed oncologist, who had considered quitting, described working with Dr. Fata as “living with this hell.”

Dr. Fata has not yet had his day in court to refute these charges. “He vehemently denies all the allegations,” said Christopher Andreoff, the physician’s attorney, in an interview with Medscape Medical News.

Andreoff faulted federal prosecutors for failing to review patient files “to determine the propriety of diagnoses and subsequent treatment.” He also said that the federal charges do not identify the current and former employees of Dr. Fata cited in the criminal complaint. They may be “disgruntled,” he said.

“People shouldn’t race to make a judgment,” said Andreoff. “There’s still the presumption of innocence.”

On Thursday, US Magistrate Judge David Grand ruled that Dr. Fata could get out of jail once he posted a $170,000 bond. Prosecutors appealed the judge’s decision but lost, according to newspaper accounts of yesterday’s court proceedings. Grand said that Dr. Fata must not practice medicine or bill anyone for the time being as conditions of his release.

Federal prosecutors wanted Dr. Fata behind bars while he awaits trial. They argued in a court filing that he poses a flight risk and possesses the means to return to his native Lebanon because the taxable estate for him and his wife exceeds $40 million. Although the government has begun to seize some of his assets, others are at Dr. Fata’s disposal, prosecutors said. Andreoff countered that his client is a naturalized American citizen who has traveled only once to Lebanon since 2001.

Prosecutors also emphasized the severity of the charges against Dr. Fata in their arguments to keep him locked up. They said that if convicted, Dr. Fata faces substantial time in prison, especially if unwarranted chemotherapy has injured or killed any patients. They noted that some of his patients already have complained to a local newspaper that they suffered mistreatment. The Oakland Press quoted the father of one deceased patient as saying that his son had been “tortured” with needless chemotherapy.

An Otherwise Shiny Career

Regardless of whether Dr. Fata is found innocent or guilty, his arrest on August 6 stands in jolting juxtaposition to an otherwise shiny career.

Dr. Fata completed a hematology-oncology fellowship at Memorial Sloan-Kettering Cancer Center in New York City. In 2005, he founded Michigan Hematology Oncology (MHO), which now has 60 employees and 7 locations throughout suburban Detroit. According to the MHO Web site, Dr. Fata’s research has been published in peer-reviewed journals such as Cancer, the Journal of Clinical Oncology, and the Annals of Internal Medicine. A search of medical literature through PubMED unearthed 20 articles in which Dr. Fata is a coauthor and sometimes the lead author. The MHO Web site also states that Dr. Fata often lectures at hospitals in southeast Michigan and functions as principal investigator on cancer protocols funded by the National Institutes of Health.

Dr. Fata also has made a name for himself as the founder of Swan for Life, a nonprofit organization that provides “support, education and resources to cancer patients and their families,” according to the group’s Web site. Swan for Life programs range from support groups and educational workshops for patients to fee-based medical services such as acupuncture and clinical massage. The nonprofit has raised money through fashion shows, a gala ball, and an annual 5k run, the most recent one on August 4.

Dr. Fata was listed as president of the foundation, and his wife Samar Fata as treasurer, on the group’s tax return for 2011, the latest on file with GuideStar, an online database on nonprofits. The tax return put 2011 revenues at $595,904 and expenditures and disbursements at $267,836. Revenue included a $300,675 contribution from a tax-exempt trust called Fata 2011 Grantor Charitable Lead Annuity with the same address as Dr. Fata’s home in Oakland Charter Township, Michigan. Total assets for Swan for Life at the end of 2011 were valued at $950,954.

Head-Injured Patient Had to Receive Chemo Before ED Trip

The criminal complaint filed against Dr. Fata on Tuesday said that his practice, MHO, billed Medicare $35 million over the course of 2 years. Of that amount, roughly $25 million was billed specifically by Dr. Fata. Almost all of that $25 million was for drug infusions, the highest amount billed for those services by any hematologist-oncologist in Michigan.

It is not clear how long federal authorities have scrutinized Dr. Fata. One court document filed by prosecutors called the investigation “very brief.” The complaint suggests that the government has moved with extreme urgency. The allegations against Dr. Fata come from 8 current or former employees, all of whom were interviewed earlier this month. Only 7 such individuals, all unnamed, are mentioned in the complaint, however. Of these, 6 were interviewed the day before Dr. Fata was arrested as federal agents raided his home and office.

“Our first priority is patient care,” said US District Attorney Barbara McQuade in a news release. “The agents and attorneys acted with a great attention to detail to stop these allegedly dangerous practices as quickly as possible.”

Many of the allegations center on Dr. Fata’s use of chemotherapy, and in particular, administering it to patients who did not need it. One NP told federal agents that “Dr. Fata falsified cancer diagnoses to justify cancer treatment” and that blood cancers were easier to falsify than tumors because physicians have more discretion to interpret blood tests. This NP and other employees also said that patients whose cancer was in remission were put on “maintenance” doses of chemotherapy. A medical assistant quoted Dr. Fata as telling patients that once they had chemotherapy, “they had to have it for the rest of their lives.”

Dr. Fata also ordered chemotherapy for all patients with advanced cancer who would not benefit from it, according to the employed oncologist interviewed by federal agents. “No other physician would do this and would let the patients die in peace,” the complaint quotes the oncologist as saying. In April 2012, the American Society of Clinical Oncology said that administering chemotherapy to patients with advanced cancer who would not benefit from it is 1 of 5 practices that oncologists must abandon.

The current and former employees paint a picture of a physician who was obsessed with administering chemotherapy, no matter the circumstances. “A male patient fell down and hit his head when he came to MHO,” the complaint alleged. “Dr. Fata directed [an NP] that he must receive his chemotherapy before he could be taken to the emergency room.” Dr. Fata’s order was carried out. The man eventually died from the head injury.

In another alleged incident, a patient with extremely low and potentially fatal levels of sodium was given chemotherapy before he could go the emergency department, as ordered by Dr. Fata.

Doses of chemotherapy were excessive as well, according to the employed oncologist at MHO. For example, Dr. Fata would order 56 doses of rituximab (Rituxan, Genentech) over the course of 2 years for a patient with non-Hodgkin’s lymphoma compared with 12 doses that a “normal oncologist” might order.

Dr. Fata Owned Firm That Did PET Scans, Complaint Says

Current and former employees of Dr. Fata describe other practice patterns that are hallmarks of Medicare fraud cases:

  • Unusually high patient volume: One employee said Dr. Fata saw 30 to 60 patients per day. Three other employees put the count at 50 to 70. Several said that Dr. Fata could sustain this pace because he used unlicensed foreign physicians to conduct examinations that typically lasted several hours. Then Dr. Fata would pop in at the end.
  • Upcoding: One NP told federal agents that Dr. Fata “bills every patient at the highest possible code, even though he only spends 3 to 5 minutes with them.”
  • Interlocking services: The criminal complaint states that Dr. Fata incorporated a company called United Diagnostics in November 2012. According to a business office employee interviewed by federal agents, all the PET scans ordered by Dr. Fata were performed at United Diagnostics. Another employee said that the percentage of Dr. Fata’s patients who received PET scans increased from 30% to 70% once United Diagnostics opened for business. Likewise, Dr. Fata started a pharmacy in 2012, and he instructed MHO employees to make it their sole source for oral chemotherapy drugs.

In addition, the complaint alleges problems that could be classified as simply careless medicine.

  • Dr. Fata performed bone marrow biopsies assisted by medical assistants who were not wearing gloves.
  • Patients sometimes received the wrong medicine, or medicines out of sequence, because of poor record-keeping.
  • At one time, patients received chemotherapy without a physician present.

Source: http://www.medscape.com