Health Care Lawyer Blog

A Government Accountability Office report released today reveals that state and federal officials have failed to uncover millions of dollars in Medicaid prescription drug abuse. Specifically, the report covers an audit of the government-run health care assistant program in five large states – California, Illinois, New York, North Carolina, and Texas – and found approximately 65,000 instances of beneficiaries improperly obtaining prescription drugs at a cost of about $65 million during 2006 and 2007. This includes thousands of prescriptions written for dead patients, or written by individuals posing as doctors. Often, the prescriptions were written by doctors and pharmacists who had been banned from participating in Medicaid, some for illegally selling drugs.

The GAO audit focused on 10 types of frequently-abused prescription drugs, specifically painkillers and mood-altering medications.

According to the Ann Kohler, director of the National Association of State Medicaid Directors, states are working to prevent such abuse but there are “significant issues that must be addressed.” For example, tight state budgets have resulted in limited enforcement resources.

Last week drug giant GlaxoSmithKline announced a new standard for funding continuing medical education (CME) programs for health care providers – a sign that drugmakers are responding to public outcry and recent settlements involving improper marketing practices. Specifically, starting in 2010 GSK will fund only independent medical education programs that “are clearly designed to close gaps in patient care, and that demonstrate support for the optimal performance of health care professionals.”

Paying health care practitioners hefty sums to host/attend sham “continuing medical education” junkets as an inducement for prescribing pharmaceuticals has long been a standard industry practice. However, drugmakers have been slammed in recent years with False Claims Act cases alleging that pharmaceutical companies engaged in extensive “off-label marketing”, a term used to describe the practice of marketing drugs for non-FDA approved uses. Earlier this month, the Department of Justice announced the largest False Claims Act settlement in history with drugmaker Pfizer. Specifically, Pfizer will pay $2.3 billion to settle allegations that it improperly marketed numerous pharmaceuticals, including by paying physicians hefty sums for sham “speaking engagements” to induce them to prescribe drugs for off-label purposes.

According to the GSK press release, the drugmaker will invite grant applications for CME from medical education providers with “a documented track record of developing and delivering high quality medical education delivering high quality medical education programs that have a measurable impact on improved patient health. Potential grant applicants will be limited to academic medical centers and their affiliated teaching and patient care institutions, as well as national-level professional medical associations that represent healthcare professionals responsible for the delivery of patient care. All selected providers must be directly accredited by a recognized accrediting body.” GSK will also post all approved grants on its website, www.us-gsk.com.

After the jump - have the tides finally turned for Big Pharma?

Continue reading " GSK Announces New CME Standard Following Drug Industry Shake-Up " »

While scheduling a doctor's appointment recently, I advised the receptionist that I needed to update my file to reflect a new last name. As I braced myself for the torturous process of spelling out both of my equally long, hard-to-pronounce names, the receptionist instead informed me that I needed to go online and make the changes on the practice's new website.

A day later, I visited the site and discovered that not only could I update my last name, but request copies of medical records, obtain a referral, and even submit a prescription refill request. However, as I clicked over to "Update Information," I realized that I could not just make a quick name swap but had to update my complete profile and provide my husband's name, address, insurance information, primary care physician's name, and a bevy of other details. And for just a moment, I hesitated.

I'm no stranger to the Internet. Like many, I send dozens of emails daily, make eBay purchases, and use networking sites freely. I send out E-vites for big events. I check my friend's blog every day to see pictures of her babies. (As you may have noticed, I even have my own blog.) And yet, I hesitated.

While many of us tend to balk when faced with new experiences, was this REALLY a new experience? Understandably, many people have concerns about sending their health secrets into cyberspace. For example, A Wall Street Journal blog entry cites the case of a patient who was given an incorrect diagnosis after an electronic record mixup. Others believe the terminology in privacy legislation will mislead consumers about their privacy rights.

Continue reading " Online Health Care - The Final Frontier? " »

This morning Senate Finance Committee Chairman Max Baucus (D-Mont.) released a health care reform proposal, offering a peek at the pending legislation to come. Dubbed "America's Healthy Future Act of 2009", the proposal is published in the form of a "Chairman's Mark." This is intended to provide a more informal overview of the nation's current health care problems and how to fix them, instead of releasing actual legislative text.

Importantly, the "Chairman's Mark" does not provide for a government-run health plan (other than existing plans such as Medicare, Medicaid, etc.). The proposal does require individuals to purchase insurance coverage, establishes state health insurance exchanges, provides for a tax refund to help individuals and families to purchase such coverage, and contains eligibility requirements (in order to prevent illegal immigrants from accessing state exchanges).

Debate on the full committee is expected to start September 22, 2009. The 23-member Senate Finance Committee consists of 13 Democrats and 10 Republicans. The Health Care Lawyer Blog will continue to monitor such debates and provide a more complete overview of the proposal in the near future.

Last week Michigan Speaker of the House Andy Dillon (D-Redford Township) introduced legislation which, if passed, will consolidate the health benefits of all Michigan’s public employees into a single state health insurance plan. HB No. 5345, which was proposed by Dillon back in July of this year faced strong dissent from parties ranging from the Michigan Education Association to Jennifer Granholm, and is expected to be the subject of similar debate as it makes its way through the legislature.

Entitled “The Michigan Health Benefits Program Act”, the legislation creates a 13-member program board to develop a health benefit plan and determine the total premium cost for each plan to be adopted. The plan will cover all employees of “public employers” which is defined to include the state; any city, village, township, county or other political subdivision; any intergovernmental, metropolitan or local department, school district, and certain community colleges and institutions of higher education.

Any health benefits plan approved by the board may include health and wellness incentives (i.e. reward improvements in health outcomes for individuals with chronic diseases, the increased utilization of appropriate preventive health services, or reductions in medical errors), and may also provide financial incentives for the increased use of health information technology.

The full plan is available here. To date, the bill has been introduced in the House and referred to the Committee on Public Employee Health Care Reform. The Health Care Lawyer Blog will continue to monitor developments.

As lawmakers scramble to devise ways to fund the health care overhaul, a recent estimate from the Federal Bureau of Investigation shows there may be a cool $75-$250 billion floating about in the health care system.

It may not be easy to recoup, but that’s the amount that could be saved each year by eliminating fraud and abuse in public and private health care programs. The estimate, which appears as part of an article published by HHS OIG chief counsel Lewis Morris in the latest issue of “Health Affairs” (September/October 2008, Vol. 28, No. 5) also means that roughly 3-10 percent of total health spending is wrongfully siphoned away by fraudsters.

Given that Medicare is expected to cost the federal government $503.1 billion in fiscal year 2009 (and Medicaid is anticipated to cost federal and state governments $386 billion), these numbers make clear that health care fraud is not just committed by a few scattered criminals masquerading as health care providers. Instead, such fraud is pervasive and extends all the way from Pfizer boardrooms to infusion clinics.

While combating such fraud may seem daunting, the article identifies several ways in which fraud can be controlled:

Five ways to combat health care fraud after the jump:

Continue reading " 3-10% of Health Care Funding Lost to Fraud Each Year " »