Canada contributes over U$ 11 million to PAHO’s initiative to strengthen the regional manufacturing of vaccines

Cristina Mitchell

21 Nov 2022

Summaries of the 90 audits, which examined billings from 2011 through 2013 and are the most recent reviews completed, were obtained exclusively by KHN through a three-year Freedom of Information Act lawsuit, which was settled in late September.

The government’s audits uncovered about $12 million in net overpayments for the care of 18,090 patients sampled, though the actual losses to taxpayers are likely much higher. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies.

Officials at the Centers for Medicare & Medicaid Services have said they intend to extrapolate the payment error rates from those samples across the total membership of each plan — and recoup an estimated $650 million as a result.

But after nearly a decade, that has yet to happen. CMS was set to unveil a final extrapolation rule Nov. 1 but put that decision off until February.

Ted Doolittle, a former deputy director of CMS’ Center for Program Integrity, which oversees Medicare’s efforts to fight fraud and billing abuse, said the agency has failed to hold Medicare Advantage plans accountable. “I think CMS fell down on the job on this,” said Doolittle, now the health care advocate for the state of Connecticut.

Doolittle said CMS appears to be “carrying water” for the insurance industry, which is “making money hand over fist” off Medicare Advantage. “From the outside, it seems pretty smelly,” he said.

In an email response to written questions posed by KHN, Dara Corrigan, a CMS deputy administrator, said the agency hasn’t told health plans how much they owe because the calculations “have not been finalized.”

Corrigan declined to say when the agency would finish its work. “We have a fiduciary and statutory duty to address improper payments in all of our programs,” she said.

The 90 audits are the only ones CMS has completed over the past decade, a time when Medicare Advantage has grown explosively. Enrollment in the plans more than doubled during that period, passing 28 million in 2022, at a cost to the government of $427 billion.

Seventy-one of the 90 audits uncovered net overpayments, which topped $1,000 per patient on average in 23 audits, according to the government’s records. Humana, one of the largest Medicare Advantage sponsors, had overpayments exceeding that $1,000 average in 10 of 11 audits, according to the records.

CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient.

Auditors flag overpayments when a patient’s records fail to document that the person had the medical condition the government paid the health plan to treat, or if medical reviewers judge the illness is less severe than claimed.

That happened on average for just over 20% of medical conditions examined over the three-year period; rates of unconfirmed diseases were higher in some plans.

As Medicare Advantage’s popularity among seniors has grown, CMS has fought to keep its audit procedures, and the mounting losses to the government, largely under wraps.

That approach has frustrated both the industry, which has blasted the audit process as “fatally flawed” and hopes to torpedo it, and Medicare advocates, who worry some insurers are getting away with ripping off the government.

“At the end of the day, it’s taxpayer dollars that were spent,” said David Lipschutz, a senior policy attorney with the Center for Medicare Advocacy. “The public deserves more information about that.”

At least three parties, including KHN, have sued CMS under the Freedom of Information Act to shake loose details about the overpayment audits, which CMS calls Risk Adjustment Data Validation, or RADV.

In one case, CMS charged a law firm an advance search fee of $120,000 and then provided next to nothing in return, according to court filings. The law firm filed suit last year, and the case is pending in federal court in Washington, D.C.

KHN sued CMS in September 2019 after the agency failed to respond to a FOIA request for the audits. Under the settlement, CMS agreed to hand over the audit summaries and other documents and pay $63,000 in legal fees to Davis Wright Tremaine, the law firm that represented KHN. CMS did not admit to wrongfully withholding the records.

High Coders

Most of the audited plans fell into what CMS calls a “high coding intensity group.” That means they were among the most aggressive in seeking extra payments for patients they claimed were sicker than average. The government pays the health plans using a formula called a “risk score” that is supposed to render higher rates for sicker patients and lower ones for healthier ones.

But often medical records supplied by the health plans failed to support those claims. Unsupported conditions ranged from diabetes to congestive heart failure.

Overall, average overpayments to health plans ranged from a low of $10 to a high of $5,888 per patient collected by Touchstone Health HMO, a New York health plan whose contract was terminated “by mutual consent” in 2015, according to CMS records.

Most of the audited health plans had 10,000 members or more, which sharply boosts the overpayment amount when the rates are extrapolated.

In all, the plans received $22.5 million in overpayments, though these were offset by underpayments of $10.5 million.

Auditors scrutinize 30 contracts a year, a small sample of about 1,000 Medicare Advantage contracts nationwide.

UnitedHealthcare and Humana, the two biggest Medicare Advantage insurers, accounted for 26 of the 90 contract audits over the three years.

Eight audits of UnitedHealthcare plans found overpayments, while seven others found the government had underpaid.

UnitedHealthcare spokesperson Heather Soule said the company welcomes “the program oversight that RADV audits provide.” But she said the audit process needs to compare Medicare Advantage to original Medicare to provide a “complete picture” of overpayments. “Three years ago we made a recommendation to CMS suggesting that they conduct RADV audits on every plan, every year,” Soule said.

Humana’s 11 audits with overpayments included plans in Florida and Puerto Rico that CMS had audited twice in three years.

The Florida Humana plan also was the target of an unrelated audit in April 2021 by the Health and Human Services inspector general. That audit, which covered billings in 2015, concluded Humana improperly collected nearly $200 million that year by overstating how sick some patients were. Officials have yet to recoup any of that money, either.

In an email, Humana spokesperson Jahna Lindsay-Jones called the CMS audit findings “preliminary” and noted they were based on a sampling of years-old claims.

“While we continue to have substantive concerns with how CMS audits are conducted, Humana remains committed to working closely with regulators to improve the Medicare Advantage program in ways that increase seniors’ access to high-quality, lower cost care,” she wrote.

Billing Showdown

Results of the 90 audits, though years old, mirror more recent findings of a slew of other government reports and whistleblower lawsuits alleging that Medicare Advantage plans routinely have inflated patient risk scores to overcharge the government by billions of dollars.

Brian Murphy, an expert in medical record documentation, said collectively the reviews show that the problem is “absolutely endemic” in the industry.

Auditors are finding the same inflated charges “over and over again,” he said, adding: “I don’t think there is enough oversight.”

When it comes to getting money back from the health plans, extrapolation is the big sticking point.

Although extrapolation is routinely used as a tool in most Medicare audits, CMS officials have never applied it to Medicare Advantage audits because of fierce opposition from the insurance industry.

“While this data is more than a decade old, more recent research demonstrates Medicare Advantage’s affordability and responsible stewardship of Medicare dollars,” said Mary Beth Donahue, president of the Better Medicare Alliance, a group that advocates for Medicare Advantage. She said the industry “delivers better care and better outcomes” for patients.

But critics argue that CMS audits only a tiny percentage of Medicare Advantage contracts nationwide and should do more to protect tax dollars.

Doolittle, the former CMS official, said the agency needs to “start keeping up with the times and doing these audits on an annual basis and extrapolating the results.”

But Kathy Poppitt, a Texas health care attorney, questioned the fairness of demanding huge refunds from insurers so many years later. “The health plans are going to fight tooth and nail and not make this easy for CMS,” she said.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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The centre, which is being constructed on lands located at Maxfield Park Children's Home in St Andrew, is "90-odd per cent complete" and should be open before the fiscal year ends in March, according to Rosalee Gage-Grey, head of the Child Protection and Family Services Agency (CPFSA) which will operate the entity.

Cabinet in May last year had given approval for the construction of the $117.1-million facility, the contract for which was awarded to Alfrasure Structures and Roofing Limited. The scope of work involved the building of a 650m2 model therapeutic care centre for children, "with a series of rooms for consultation, observation, operations and administration". This was to be constructed over six months according to the bid document seen by the Jamaica Observer.

"We are a little behind schedule because it should have been done in six months, but you know construction in this country. But, the building is up, they are doing some of the finishing work to the interior and, like, parking and those kinds of finishes. We are very anxious to have it open because it is very well needed," Gage-Grey expressed.

According to statistics, there are more than 800,000 children in the island's 14 parishes, nearly 120,000 of whom may have a mental disorder and with 40,000 suffering from a severe mental disorder. Child guidance clinics islandwide, of which there are 20, tend to 3,500 Jamaican children but experts believe that more than 95 per cent — or just over 110,000 children and adolescents with mental disorders — are slipping through the cracks and not benefiting from the government-provided services.

There are 30,000 children in the Kingston and St Andrew region alone who need psychosocial intervention. It would take at least another five to seven clinics to provide services to even two-thirds of them.

Gage-Grey said while the centre is predominantly for children in the care of the State, other children will be able to access the services.

In the meantime she said the centre will not be residential, as had been originally planned, however, children in crisis situations who need to be relocated will be given temporary housing on the grounds.

Gage-Grey was unable to say whether the project had been completed within budget.

Child and adolescent psychiatrist Dr Ganesh Shetty, at the onset, had described the plans for the facility as "a step in the right direction". He, however, told the Observer that based on the number of children in Jamaica suspected of suffering from mental health issues, one such facility per parish is what it will take to even make a dent in the situation.

Chief among his concerns are the children who are suffering in silence, their conditions undetected rendering them prime targets for gangs and criminal activities.

According to research, in the United States two out of three such children do not receive help, in Canada four out of five children do not get assistance, while in Jamaica 19 out of 20 children suffer the same fate.

“Grenada’s history and traditional wealth is based on being an agrarian nation where agriculture and agro-processing were key drivers”

View the full post Agro Processing, Agriculture 2.0 on NOW Grenada.

An influence on all areas of health care and life, health literacy is one of the first things that our health-care workers learn. It impacts ourselves, our families, our communities, and our environments. Therefore, being health literate is not solely the responsibility of our health-care system and public officials. As individuals, being health literate can make a world of a difference as we aim to live healthy, long lives.

On a personal level, health literacy can be understood as the ability to understand what your doctor or health-care provider is communicating to you about your illness. According to official data, approximately 1,845,296 Jamaicans can read and write, meaning approximately 88.6 per cent of the population is literate. Literacy rates complement health literacy rates directly. If you are unable to read and write it is likely you may not have a high health literacy. Jamaica's lower literacy rate likely means there is a low health literacy rate, even though this number has not been precisely documented.

There are several other socio-economic factors which affect health literacy rates, including:

● low income

● lack of formal education

● age (the elderly are less likely to have high health literacy rates)

● health (those who are unwell may have lower levels of health literacy rates)

Good health literacy keeps you on track with what type of check-ups you may need for your age (for example Pap smears, mammograms, prostate checks); how to manage your illness; and the effect of your medications on your daily life, just to name a few. Your health-care providers are important in helping you become more health literate and communicating your health status to you in ways that you should understand.

Being able to answer the following questions may determine how health literate you are:

•What condition do I have, if any?

•Do I understand what's happening in my body to develop the condition I have?

• How do I treat the conditions I have?

• What medications can I or can't I take? What are the possible side effects of these medications?

•How do I monitor my illness?

•How often should I visit the doctor?

• How can my day-to-day life practices help my illness?

While you can read books, talk to knowledgeable people and search the Internet, telemedicine serves as a useful resource in creating a means of instant communication between you and your health-care providers to help you understand your health and stay healthy to the best of your ability.

How telemedicine can support health literacy

•Reducing the need to travel. This allows those living in remote areas, those who have mobility issues, and those who have hectic schedules to still be able to reach out to their doctors through telemedicine to address any questions or concerns that they may have about their illnesses, medications, among others.

• Accessibility Options. Speaking to a doctor online while taking advantage of accessibility options on devices, such as reading selective text (great for blind patients) and using charts, videos, graphics, and other visual aids (great for younger patients and visual learners), are two great ways that accessing health-care online can support patients in accessing information in a way that they will receive and understand well.

•Provides a Safe Environment. Medical offices may be a bit intimidating for some people. Telemedicine allows you to speak to your provider remotely through call, text, or video call wherever you are most comfortable. Platforms, such as MDLink, will enable you to be at home, in your car, or wherever while being able to chat with your doctor and learn about your illness and treatment. It's essential that you are in optimum conditions to learn and understand your health.

A healthy population is one that understands its health. Understanding our health includes understanding the many resources readily available to us to be educated. In a technological world, resources, such as telemedicine, fit the mould for encouraging and facilitating a Jamaican population knowledgeable and prepared to tackle illness and disease to live a healthy, long life.

Dr Ché Bowen, a digital health entrepreneur and family physician, is the CEO & founder of MDLink, a digital health company that provides telemedicine options. Check out the company's website at www.theMDLink.com. You can also contact him at drchebowen@
themdlink.com.

The
Global Wellness Institute defines wellness as the active pursuit of activities, choices, and lifestyles that lead to a state of holistic health.

There are six to 12 dimensions of wellness. These include emotional, physical, mental, social, and environmental wellness. A nation that believes in the wellness of its people is on the road to great development and growth.

The global reset resulting from the novel coronavirus pandemic has forced the world to experience a new quality of living and positive experiences. Wellness is the word on the lips of global tourism, and Jamaica needs to identify this and create the avenue to earn. This shift to wellness will help guests enjoy the unique experience that a country, its culture, and people have to offer. It stands to engage their physical, emotional, psychological state to awaken a new quality of living and not just existing.

The Global Wellness Report further states that wellness tourism was valued at $4.4 trillion in 2020, and based on the Global Wellness Report of February 2022, Jamaica ranked 107. Our neighbour Cuba earns US$2.7 billion and is ranked 76 in the world for wellness tourism.

Of note, Jamaica has natural resources we can explore without exploiting and over commercialising and still contribute to the gross domestic product earning opportunity for the country. Against that backdrop we need to realise that other countries have white sand beaches, rum, spectacular hotels, too, and music, plus a greater integration of our local holistic treatments. Take, for example, a popular global wellness tourism option – thermal spring treatments. In Europe, these are large earners for specialised spa and thermal clay retail stores. We have the Bath Fountain in St Thomas and Milk River Bath in Clarendon, which have the potential to be major earning opportunities. Bath Fountain's water has healing properties that can help with acne, pain management, and others ailments. Milk River Bath can offer thalassotherapy, which is unique. With structure and proper training, design, and leadership, these can be large earning opportunities for St Thomas and Clarendon.

We have to look at wellness not only as exercising and diet but as a form of real estate and perhaps a beauty product and take seriously the earnings it can bring to the people of this country, how it can improve quality of life, and increase the life expectancy.

It's not too late for Jamaica to be one of the earners in this multi-billion dollar global wellness market. Let's diversify the tourism experience with authentic Jamaican spa treatments and beauty products, marrying them with our natural Jamaican hidden gems so that tourists can experience the true culture and spaces that truly make us a unique destination.

Richard Martin is a certified massage and general beauty therapist who worked in construction and wastewater management before transitioning into the beauty and wellness industry. He trained the first cohort of visually impaired massage therapists in this hemisphere and is the first male spa educator to be certified by the America Hotel Lodging Institute as a certified hospitality educator in Jamaica.

South Africa: A recent case report published in JAAD Case Reports, reports the case of an African woman with frontal fibrosing alopecia (FFA) in whom pleural, pericardial effusion and anasarca developed three weeks following low-dose oral minoxidil (LDOM) therapy.

For many years, topical minoxidil has been used for treating androgenic alopecia and other hair disorders. The mechanism of action of minoxidil is not clearly understood. Still, animal studies have shown that it affects the hair growth cycle by reducing the telogen phase and prolonging the anagen phase. Lately, there has been increasing evidence to support the successful use of LDOM for treating various types of alopecia. The dosing regimens vary from 0.25 to 5 mg daily to twice daily; side effects are reportedly dose-dependent.

The case in question is of a 40-year-old, healthy, Black South African woman with no comorbidities. She presented with a 2-year history of hairline loss involving the frontal and temporal hairlines. A dermatoscopic examination and histologic findings confirmed the clinical diagnosis of frontal fibrosing alopecia. The patient was given the following treatment:- 5% topical minoxidil, clobetasol propionate ointment, tacrolimus ointment 0.1%, twice daily 100 mg of doxycycline, and 0.25 mg of oral minoxidil (OM) daily. She was informed about the adverse effects of all the medications.

Following three weeks of the treatment, there was swelling in both lower extremities of the patient, which progressively spread to the upper extremities and face; she was advised to discontinue oral minoxidil and present for follow-up; she was admitted to the hospital for additional workup and further management by a cardiologist.

Following various assessments, the authors excluded other causes of anasarca and pericardial effusion in the previously healthy young woman, concluding that low-dose oral minoxidil was responsible for clinical presentation.

Ncoza C. Dlova, University of Kwazulu Natal, KwaZulu-Natal, South Africa, and colleagues stated in their study, "to the best of our knowledge, the occurrence of pleural, pericardial effusion and anasarca with the LDOM use for alopecia has not been reported in the literature."

"Our extensive workup of the patient did not indicate any obvious underlying cause; thus, we conclude that the woman's presentation was a rare side effect and should be documented to alert other clinicians to be careful about this uncommon adverse effect of LDOM."

They added, "we have since advised patients to initiate alternate days of LDOM for one month and, after that, increase it to daily dosages. This case report alerts clinicians to be mindful of this potential side effect."

Reference:

Dlova NC, Jacobs T, Singh S. Pericardial, pleural effusion and anasarca: A rare complication of low-dose oral minoxidil for hair loss. JAAD Case Rep. 2022 Aug 11;28:94-96. doi: 10.1016/j.jdcr.2022.07.044. PMID: 36117778; PMCID: PMC9478873.

PAHO/WHO supports Belize in the aftermath of hurricane Lisa

Cristina Mitchell

18 Nov 2022

Issuing direction to the authorities to cooperate with each other and issue advertisement for these posts at the earliest, the top court bench comprising of Justices Sanjay Kishan Kaul and Abhay S. Oka further clarified that if the UP Public Service Commission and the State fails to sort out the issue by the next date, the court might give the responsibility of recruiting doctors to a separate organization.

"We note with deep regret the manner in which the State Government of Uttar Pradesh has proceeded as also the obvious lack of communication with the Uttar Pradesh Public Service Commission, where a ping pong is going on. In view of the vacancies un-filled, a large number of 2382 posts were required to be carried forward," observed the bench as it slammed the State and UPPSC for their lack of coordination in filling up the vacant posts of specialist doctors.

"We deprecate the conduct of both the authorities and reject the time period given by the Commission. The two authorities will cooperate and inform whether all information is ready or not for issuance of the advertisement by the next date, failing which we may consider referring this recruitment to a separate organization, if both of them are not capable of doing it," warned the bench.

These observations were made by the bench while it was considering a bail plea filed in connection of the death of a patient who died due to the lack of a surgeon at the Sambhal district hospital. Medical Dialogues had earlier reported that while considering the matter, the top court bench back in March, 2022 had slammed the UP Government over the huge vacancies in its District hospitals.

Back then, the Apex court bench comprising  of Justices Sanjay Kishan Kaul and M.M. Sundresh had taken note of the fact that even though last year the State Government had tried to fill up 3620 posts of doctors through the State Public Service Commission, only 1881 doctors could be selected, leaving a vacancy of about a little under 1800 doctors, while some of the doctors may have retired over the last one year.

Emphasizing on the point that ensuring the presence of adequate medical facilities at the district levels is among the primary functions of the State Government, the top court had also given the State Government some suggestions for meeting the requirement of doctors in the Hospitals.

During the hearing of the case concerning the recruitment of specialized doctors throughout the State of Uttar Pradesh, the top court bench noted that on 10.06.2022, the State had requested UPPSC to re-advertise the vacancies. However, the Commission took altogether four months time for responding to that letter. Even when the Commission finally responded through a letter dated 19.10.2022, it sought further information from the Government.

Referring to this, the Supreme Court bench noted, "This is the position of the working of the commission when the matter is being monitored by this Court, reflecting on their inefficiency levels."

Following this, on 20.10.2022, the State sent a letter for the same posts and once again the Commission responded on 04.11.2022 pointing out the deficiencies regarding lack of provision for horizontal reservations, lack of subcategorization of physically handicapped category and lack of equivalent criteria for degree/diploma awarded by different bodies.

At this outset, the court took note of the submission that it is only on the submission of the necessary information that an advertisement for selection of vacant posts can be published by the Commission. 

Referring to this huge delay, the Court observed, "The schedule given by the Commission takes us almost to the end of next year. We deprecate the conduct of both the authorities and reject the time period given by the Commission."

Directing both the State and UPPSC to cooperate with each other and inform if all the information is ready or not for issuing the advertisement by the next date, the bench also warned that "failing which we may consider referring this recruitment to a separate organization, if both of them are not capable of doing it."

"The solution should be found in a joint meeting to be held from Monday onwards next week, if they are capable of doing so," the bench noted at this outset.

The matter has been listed on 02.12.2022 for further hearing and the Court has directed the authorities "to report back whether all issues for proceeding with the issuance of advertisement have been sorted out or not."

To read the court order, click on the link below:

https://medicaldialogues.in/pdf_upload/supreme-court-on-up-doctor-vacancies-191289.pdf

Also Read: Supreme Court slams UP govt over massive 1800 vacancies in District Hospitals, directs measures