The politico/media/senior conspiracy to bankrupt America

Obama, despite his talk about wanting to be responsible
about government spending and the national deficit and debt,
has shown he can talk the talk but not walk the walk,
as specifically exemplified by
his October 2012 (pre-election) expansion of Medicare
to cover in-home services to stable elderly,
an extension for which he did not even show the responsibility
to estimate the cost of.
I.e.,
he signed a blank check,
with the younger generation expected to pick up the tab,
while the current elderly gain yet another benefit
which they did not pay for,
and which they did not grant to their parents.
(Note, by the way, how such
expansion of benefits for those who did not pay for them,
which has been the norm ever since Medicare was started,
makes lying jerks
of all those lying seniors who say
“Keep your hands off Medicare: we're just getting the benefits we paid for.”)
What a disgusting example of giving away the fiscal store
by both Obama and the advocates for this expansion,
and one which neither the other politicians nor the media has seen fit,
so far as I know, to call them out on.
What a politician/media/senior conspiracy to drive America to bankruptcy
and cheat the young.


This really is an instructive example of how
the politicians, media, and spending advocates conspire
to bankrupt America.
Before an election,
they announce an expansion of benefits to senior citizens.
The trumpet the benefits the expansion will provide,
while either low-balling or omitting to describe the cost of the benefits.
The seniors vote in gratitude for the benefits showered upon them by Uncle Sugar,
not caring a whit that
they are receiving benefits
which they never paid for and
which they did not extend to their predecessors.
Meanwhile, the younger generation,
which has to pick up the tab for this largesse,
is largely ignorant of the fiscal crime that has been committed on them,
because the media reports all the benefits,
while carefully refraining from examining the costs that will be incurred.
Want an example of this?
Read the Robert Pear New York Times article.
Note how Pear, with the tacit concurrence of his editors,
reports at great length on the benefits that will be provided,
including lengthy quotes from those who lobbied for the benefit expansion,
while he does not bother to get quotes from those individuals and organizations
who might view with the greatest alarm the costs that are being incurred.
Of course there are organizations in Washington which are trying to rein in spending.
But the NYT,
which brags to potential subscribers about the breadth of its coverage,
could not be bothered to present this other side of the issue.
Well, at least not before the election.
After their electoral choice Obama is elected,
no doubt they will get around to pointing out the costs and problems.
But by then it will be too late to affect the oh-so-crucial election.
How's that for a plot?


What is the significance of failing to estimate the costs
with respect to the 2012 election, held on November 6?
What if the Obama administration had made public
an estimate of the costs of its newly granted largesse?
If the actual costs of this benefit prove to be low,
and they gave a low estimate, no problem.
But what if (as I believe is sure) the actual costs turn out to be high, in the tens of billions of dollars.
If the administration gave, when it announced the benefits, an estimate well below what they prove to be, then they look either craven (deliberately low-balling the estimate) or fools or incompetents.
On the other hand, if they offer a realistic estimate, again in the tens of billions, the question would surely be asked (one would hope!) just how does the Obama administration intend to pay for these expanded benefits.
By ignoring the costs (while announcing the benefits) they avoid both alternatives, and their responsibility.
And the media and the Romney campaign have let them get away with it.


And what might those costs plausibly be?
I am no expert on health care, but can show the unavoidable implication of various plausible (I believe) possibilities.
Suppose one million seniors need full time health care.
Suppose the cost per beneficiary needing such care is $50,000 per year.
Simple multiplication yields $50 billion per year.
What does that mean for individual taxpayers?
A useful figure to remember is that $1 billion spread evenly over roughly 300 million Americans is close to $3 per person.
So $50 billion is $150 per American citizen.
For the nominal family of four, that works out to $600 for each such family.
In other words, given those assumptions, each such family must see their taxes go up $600 per year to pay for those benefits.
And Obama has said he would not raise taxes on the middle class!
What a liar he is!
But the media and the Romney campaign have let him get away with it.
Why?
Surely the reason is that they fear the voting wraith of those who desire these benefits, i.e., the senior beneficiaries and their caregivers.

Jews and health care

2009-12-14-Siegel-Lieberman-joes-moral-failing

Joe, Start Acting Jewish!
by Lee Siegel
Daily Beast, 2009-12-14

As Democrats give in to his health-care demands,
Lee Siegel says Lieberman’s position runs counter to his Jewish faith:
he should stop stonewalling and be a mensch.


With Democrats forgoing a Medicare buy-in,
Lieberman says he’s “ ready to vote for health-care reform.”
Lee Siegel on why the senator should stop stonewalling and start acting Jewish.


[There is a complex tradeoff between
the desire to be compassionate and
the need to be fiscally responsible.
Siegel explores how Senator Lieberman has made that tradeoff
in the context of his faith,
both how Siegel views it and how Lieberman views it.]


Joe Lieberman’s vow to vote against
any health-care bill that includes the Medicare buy-in
reminded me of a story once told me
by a Jewish girl I dated in my teens.

A kind person, she had volunteered as a “candy-striper” in a hospital.
One day,
as she was pushing an elderly Orthodox Jewish man down the hospital corridor,
he asked her if she was Jewish.
Yes, I am, she said.
Stop for a minute, he said.
Come around and let me look at you.
So she stopped pushing him and carefully locked the wheels.
Then she stood in front of him.
He took in her cute little candy-striper’s uniform
and squinted at the top of her head, which happened to be uncovered,
and he said, “You’re Jewish?”
“Yes,” she said sweetly.
He emitted a sound of disgust.
“You’re not Jewish!” he said with repugnance, almost spitting the words out.

The advantage of a fundamentalist perspective is that
you can clothe your basest motives in noble sentiments.

The strongest force driving Lieberman’s destructive contrariness
is a religious fundamentalism
that is fatally removed from moral sentiment.
His absolute certainty that he is right
makes him absolutely blind to what's wrong.

Sure, Lieberman’s heart has its other reasons.
Most obviously there are his intimate ties to the insurance industry,
based in his home state of Connecticut.
Lieberman’s defenders like to say that
he has “only” received hundreds of thousands of dollars
from the insurance companies over the last few years.
What they don’t say is that he has received more than twice as much
from the real-estate industry.
Since companies often have both real-estate and insurance divisions,
it must be hard to distinguish what is coming from where.
Make no mistake about it, Joe Lieberman is the insurance industry’s white knight.
He has to be extra nice to them especially now,
when Democratic opposition to any future political bids will be fiercer than ever.
He’ll need a fortune to fight it.
And watch as Lieberman makes stronger and stronger public statements
in support of the war in Afghanistan
and as he escalates his verbal attacks on Iran.
Lieberman has to keep the Israel lobby money pouring in, too.

Add to the need for lucre Lieberman’s rage against the Democratic Party
for abandoning him in his race for the Senate in 2006,
and—above all—
the ego-wound apparently inflicted on him by Harry Reid
when Reid endorsed Lieberman’s opponent, Ned Lamont,
for the Senate that year.
Lieberman likes his revenge not cold but piping hot.

All these sound like plausible motives for turning against
a feature of the health-care plan
that Lieberman himself has said in the past he would support.
But his amoral religiosity is what has truly deformed him.

During the past decade or so,
there has been a rising panic over
the growing influence of fundamentalist Christian precepts
on modern American politics,
but no one has said very much about Joe Lieberman’s fundamentalist Judaism.
Although he prefers to call himself an “observant”
rather than an “Orthodox” Jew,
he is in fact an Orthodox Jew.
His approach to modern life is just as uninflected
as that of his Christian counterparts.

Sure, he has proved himself flexible
on issues like gun-control, gay rights and abortion—
all instances where he has taken a standard liberal position.
But these aren’t subjects that arouse Lieberman’s passions.
What really sends him soaring are issues—health care, Israel—
that are, at the same time,
loftily resonant with moral meaning
and directly related to his material self-interest.
The advantage of a fundamentalist perspective is that
you can clothe your basest motives in noble sentiments.

So Lieberman,
the Orthodox Jew who ostentatiously walks miles to Capitol Hill on the Sabbath
because of the Jewish prohibition against
operating machinery on the seventh day,
has provided himself with some very pious blinders.
An American war in Iraq will be futile, wasteful, and ultimately destabilizing?
This rational skepticism cannot hold a candle to the feeling that it would be just.
A public health-care option, or a Medicare buy-in
will solve the problem of unaffordable health care in this country?
The rational proposition sinks under the weight of the feeling that
it will increase the deficit,
and if it doesn’t add to the deficit,
it will set us on the road to single-payer serfdom,
and if it doesn’t do that, well, you feel it’s wrong.

You don’t doubt the morality of your feeling,
because you have used your strict, self-sacrificing observance of Jewish law
to prove to yourself that you are a good man.
And you are not a hypocrite,
because your observance proves that not only do you profess a belief in God,
but you act on your belief.
God on one side, your obedience to God on the other—
the result is an ironclad conviction that what you do is absolutely right.

And if you get a big fat check from the insurance lobby on the one hand,
and the Israel lobby on the other,
well, this the tribute that reality pays to virtue.
An impoverished man cannot work effectively against God’s enemies on earth.
Any thought that trading a moral position for money might be wrong
bends before the feeling that it is right.
And if you’re doing well, you must be doing good.

Here is Lieberman
on his intention to run against Ned Lamont as an independent candidate
should he lose the Democratic primary:
“I'm a loyal Democrat,
but I have loyalties that are greater than those to my party,
and that's my loyalty to my state and my country.”
Lieberman on his decision to run as an independent after losing the primary:
“For the sake of our state, our country, and my party,
I cannot and will not let that result stand."
This is Lieberman’s fundamentalist sickness in a nutshell.
He has completely submerged his self-interest
in a divine will that he has created in the image of his self-interest.
“For the sake of God’s will…”—
just fill in the blank with your favorite cause.
And then wait for someone else to fill out the check.

---

The professional Jews will whine that I am being vulgar
when I judge the Jewish Lieberman’s politics against his faith.
But Lieberman is the one
who professes his faith to be fundamental to his morality.
I am just examining the effects of his faith on his psychology.

Let me appear to be even more vulgar.
What makes Jews cringe about Lieberman’s sanctimonious opposition
to the only clause in the health-care bill that actually is worth the name “reform”
is that, to be blunt,
it is so close to an anti-Semitic caricature.
Lieberman is greedy, arrogant, venal, and vindictive.
He recalls the New Testament’s
vicious caricature of the ancient Jewish Pharisees—
who were, in reality, rational, charitable and humane.

I grew up surrounded by non-religious Jews who were guided by
the principle of rachmones, meaning “compassion.”
They were guided by feeling, too,
but it was not the absolute certitude of fundamentalist feeling.
Rather, it was the feeling that life changes fast, and that people are vulnerable.
They were gentle and ironic people.
They liked this Yiddish saying:
“God loves the poor, but helps the rich.”
They probably lost more than they won in life,
but they never fooled themselves into thinking that they were doing good
when they were merely doing well.

Let the professional Jews quote the Talmud at me,
but the way Lieberman has derived his political morality
from his religious fundamentalism,
and used both as fig leaves to cover his thralldom to money,
is ritually unclean.
Some people—for example, the sick and the crippled—
might say that it is really not Jewish at all.

[So ends Siegel's article.
As a gentile, I cannot resist a response to Siegel's basic premise.
Siegel says quite explicitly that
Lieberman's position is influenced, if not determined,
by the desire for personal gain.
Well many people have taken the same position as Lieberman did
without standing to gain the benefits that Lieberman allegedly did.
So if they can take that position, why cannot Lieberman?

Yes, it is an issue of money,
but the question ultimately, to me, is
How much health care can the nation afford?
Could Lieberman also have been concerned by that same question?]

Health care research: too much?

2015

2015-08-18-WP-scientists-are-trying-to-figure-out-the-best-ways-to-spend-money-on-science

Scientists are trying to figure out the best way to spend money on science
By Carolyn Johnson
Washington Post WongBlog, 2015-08-18

A provocative new study by two biologists appears at first glance to highlight a worrisome paradox: As the nation's investment in the science that underlies new therapies has increased over the past half century, the output that we actually care about most -- advances in health -- appears to be slipping.

If the federal investment in biomedical research is really getting less efficient over time by yielding fewer new drugs and additional years of life, that would be a clear call to reexamine policy. After all, the goal of the roughly $30 billion spent by the National Institutes of Health each year isn't merely to provide jobs for scientists and create reams of erudite scientific papers, but to help people live longer and better. But the analysis, published Monday in the Proceedings of the National Academy of Sciences, raises far more questions than it answers and may in fact reveal how little we know about how to measure the bang for our buck when it comes to funding the insights and innovations that improve health.

"I remember wondering if the pace of innovation from 1950 to 1980, when we only knew a certain amount [about biology], had been faster than the pace of innovation between 1980 and 2010," said Arturo Casadevall, chair of the department of molecular microbiology and immunology at Johns Hopkins Bloomberg School of Public Health. "Thinking of all the things that were found between 1950 and 1980: blood pressure medicines, antibiotics, heart transplants… and that had been learned with only a very limited amount of knowledge compared to what we know now. And I kept thinking, could things be slowing?"

Casadevall and graduate student Anthony Bowen used a pretty straightforward technique to try and answer the question. They compared the NIH budget, adjusted for inflation, with the number of new drugs approved by the Food and Drug Administration and the increases in life expectancy in the U.S. population over the same time period.

Those crude health measures didn't keep pace with the research investment. Funding increased four-fold since 1965, but the number of drugs only doubled. Life expectancy increased steadily, by two months per year.

But Pierre Azoulay, an economist at the Massachusetts Institute of Technology Sloan School of Management who has spent several years trying to answer the same question said that although the study is well-intentioned, it is rife with limitations and assumptions. For example, new drugs or life expectancy improvements will lag the science that lays the foundation for them, often by years or even decades. So examining the NIH budget year by year and comparing it to the number of drug approvals in that same year isn't a good measure of whether the investment is working.

"The question is whether that’s an interesting thing and whether that’s a policy-relevant fact. I would say not," Azoulay said. "I would say it is possible the productivity of biomedical research expenditures has been going down over time. It’s not outside the realm of possibilities, but we’re not going to learn whether this is a fact from this study."

Azoulay pointed out a number of other limitations . Although the researchers adjusted for inflation, they didn't take into account the increased cost of doing research. They didn't look at investment by the private sector. The research team did acknowledge that gains in life expectancy are harder to make when the average lifespan has increased due to previous success. But what this study -- and a handful of others published over the past few years -- may bring to light is not a stark drop in the efficiency of the U.S. federal expenditure on biomedical science, but our stunningly imperfect understanding of how to measure the return on the investment.

"NIH agrees that it is critical to assess whether progress in biomedical research is achieving its ultimately desired outcome – better health for the nation and the world," Francis Collins, the director of the NIH, said in a statement. "That is, however, a challenging task, and previous published economic analyses of the return on investment for NIH-supported research have led to radically different conclusions."

For example, a 2009 study in the same journal that examined research funding over 50 years in separate categories. In four disease areas -- cardiovascular disease, stroke, cancer and diabetes -- as research money flowed in, the mortality rates decreased.

Casadevall and Bowen said in an interview that their data is too premature to shape policy, but both believe it is important for scientists to begin to use the tools of science to understand how to make the best possible investments.

One possible interpretation of their data, Casadevall said, is that it has gotten tougher to make gains in life expectancy or new drugs because the easier diseases have been solved, leaving the trickiest ones -- such as Alzehimer's and Parkinson's -- to be unraveled. That might suggest that more investment will be needed to make progress.

However, the broader question of whether the federal expenditure on research really leads to gains in health is a crucial and sometimes divisive one. Calls for an expansion in funding for biomedical research have become pervasive as scientists find their livelihoods threatened by years of flat funding from the federal government, and they passionately argue that funding cuts will ultimately stall advances in medicine. Some critics believe that the underlying premise -- that more research money means more breakthroughs and better health -- needs to be more scientifically examined.

"I think where we need to start is here," said Daniel Sarewitz, a professor of science and society at Arizona State University. " We’re still in the grip of this silly belief if you pour more money into knowledge creation, you’ll get more benefit. Let’s have a conversation about the kinds of institutions we really need."

Overdiagnosis and overtreatment

2014

2014-02-12-NYT-Kolata-study-adds-new-doubts-about-value-of-mammograms

Vast Study Casts Doubts on Value of Mammograms
by Gina Kolata
New York Times, 2012-02-12

One of the largest and most meticulous studies of mammography ever done,
involving 90,000 women and lasting a quarter-century,
has added powerful new doubts about the value of the screening test for women of any age.

It found that the death rates from breast cancer and from all causes were the same
in women who got mammograms and those who did not.
And the screening had harms:
One in five cancers found with mammography and treated
was not a threat to the woman’s health
and did not need treatment such as chemotherapy, surgery or radiation.

The study, published Tuesday in The British Medical Journal,
is one of the few rigorous evaluations of mammograms
conducted in the modern era of more effective breast cancer treatments.
It randomly assigned Canadian women
to have regular mammograms and breast exams by trained nurses
or to have breast exams alone.

Researchers sought to determine
whether there was any advantage to finding breast cancers
when they were too small to feel.
The answer is no, the researchers report.

The study seems likely to lead to an even deeper polarization between
those who believe that regular mammography saves lives,
including many breast cancer patients and advocates for them,
and a growing number of researchers who say
the evidence is lacking or, at the very least, murky.

“It will make women uncomfortable, and they should be uncomfortable,”
said Dr. Russell P. Harris, a screening expert and professor of medicine at the University of North Carolina, Chapel Hill, who was not involved in the study.
“The decision to have a mammogram should not be a slam dunk.”

...

Dr. [Mette] Kalager [an epidemiologist and screening researcher
at the University of Oslo and the Harvard School of Public Health],
whose editorial accompanying the study was titled “Too Much Mammography,”
compared mammography to prostate-specific antigen screening for prostate cancer,
using data from pooled analyses of clinical trials.
It turned out that the two screening tests
were almost identical in their overdiagnosis rate
and had almost the same slight reduction in breast or prostate deaths.

“I was very surprised,” Dr. Kalager, said.
She had assumed that the evidence for mammography must be stronger
since most countries support mammography screening
and most discourage PSA screening.

[Interesting gender difference. What drives it?]

2014-02-12-NYT-Rabin-for-women-a-more-complicated-choice-on-mammograms

For Women, a More Complicated Choice on Mammograms
by Roni Caryn Rabin
New York Times, 2014-02-12

For women who dutifully keep their mammogram appointments year after year,
the latest results from a long-term trial in Canada,
which found no difference in death rates from breast cancer among
women who had regular mammograms and those who did not,
are bound to sow confusion, perhaps even anger.

For decades now,
the annual mammogram has been promoted vociferously and continuously
as an essential way to protect oneself from breast cancer.
Many women feel they are being irresponsible if they do not get a regular scan,
said Dr. Lisa Schwartz, a professor at
the Dartmouth Institute for Health Policy and Clinical Practice.

“For so long, we have been trying to convince people that
you’re irresponsible or not taking care of yourself
if you don’t do this,” Dr. Schwartz said.
“People were hit over the head with that message.”

...

In light of the accumulating data that
the benefits of regular mammography may be negligible for women,
and that the practice has led to false positives and overtreatment,
“it’s important for women to realize
there is a genuine decision to be made here,”
Dr. Schwartz said.

It is not a decision that medical groups are making any easier.
In 2009, the United States Preventive Services Task Force,
an influential group that makes recommendations to the federal government,
concluded that
women over age 50 should have mammograms every two years instead of annually
and that the evidence of benefit was only moderate.
The group did not recommend the screening test for younger women.

The report was met with a barrage of criticism.
Some charged that the task force was trying to save health care dollars
at the cost of human lives.

...

Insatiable

It seems the desire to constantly expand
the range of things which need to be "cured"
is insatiable.
Here is an example:

2012-04-09-WP-Butler-aging-makes-people-more-vulnerable-to-depression-but-the-problem-can-be-treated

Aging makes people more vulnerable to depression,
but the problem can be treated
By Carolyn Butler
Washington Post Health Section, 2012-04-09

Health care fraud

@Wikipedia: Health care fraud
@Wikipedia: Medicare fraud
www.stopmedicarefraud.gov/

2012

2012-03-19-NYT-new-medicaid-inspector-general-supports-less-adversarial-audits

Under Pressure, New York Moves to Soften Tough Medicaid Audits
By NINA BERNSTEIN
New York Times, 2012-03-19

New York State was paying for the medical care of dead people
when Gov. George E. Pataki and the State Legislature
created the Office of the Medicaid Inspector General
to curb billions of dollars in fraud and misspending by health care providers.

The turnaround was startling.
Within four years the state had recouped $1.5 billion in Medicaid overpayments,
the highest recovery rate in the nation.
Other states rushed to create inspectors general like New York’s.

But a backlash from the politically powerful health care industry
has erased broad support for the crackdown.
Last year, amid a crescendo of provider complaints
of overzealous, nitpicking audits and unfair tactics,

Gov. Andrew M. Cuomo [D]
quietly dismissed the state’s first Medicaid inspector general, James G. Sheehan,
and directed Mr. Sheehan’s successor, James C. Cox,
to collaborate with providers on changes to the agency’s policies and auditing methods.

In an interview, James Introne, Mr. Cuomo’s deputy secretary for health,
expressed the state’s new view.

“An audit need not be an adversarial enterprise,” Mr. Introne said.
“To the extent that an audit turns into an adversarial affair,
it may not be conducted properly.
An audit is successful when people agree.” [!!!!!]

The Cuomo administration said that enforcement was as vigorous as ever,
and that Mr. Cox was on target
to avoid $1.1 billion in improper Medicaid spending this year,
even more than his predecessor.
But veterans of Medicaid policing pointed to
important audits that were started by Mr. Sheehan
but have not been released,
and said the inspector general’s office was at a difficult crossroads,
caught between

the Legislature’s allegiances to campaign contributors from the health care field
and
the governor’s plans to cut Medicaid costs,
which depend on the goodwill [???] of
nursing homes, hospitals and home health agencies.

“An industry that’s regulated doesn’t love the regulator unless the regulator isn’t doing much,”
said Arthur A. Levin, the longtime director of
the Center for Medical Consumers, a nonprofit advocacy organization,
who admired Mr. Sheehan.
“Asking the regulator and the regulated party
to sit down and come to some sort of consensus
on how the regulation should be —
to me, it makes no sense.”

Michael A. Zegarelli,
a past president of the national association of Medicaid oversight officials
and a senior regulator in New York until 2003,
said that by definition,
an audit that found overbilling, fraud or waste
was “going to be adversarial.”

“Sheehan’s successor will have a short leash,” Mr. Zegarelli said.
“Will that be for the benefit of the program, or to keep Cuomo’s constituency happy?”

New York’s Medicaid program, jointly financed by federal, state and local taxpayers,
is the nation’s largest, at $53 billion.
In 2005, an investigation by The New York Times found that
Health Department regulators had uncovered only 37 cases of suspected fraud
in 400 million annual claims,
overlooking red flags like
a storefront dentist whose billings spiked to 991 procedures daily and
a nursing-home operator who took in $1.5 million in salary and profit
the same year he was fined for neglecting the home’s residents.

The 2006 overhaul spurred by that investigation was financed by
a $1.5 billion payment from the federal government with tough terms:
the state had to recoup the money by September 2011 or pay back the shortfall.
To take charge, Gov. Eliot Spitzer in 2007 appointed Mr. Sheehan,
who had prosecuted health care fraud for 20 years
as an assistant United States attorney in Philadelphia.

Mr. Sheehan exceeded recovery targets.
Over all, the state reclaimed 1.2 percent of its total Medicaid spending,
the nation’s highest rate.

But complaints from providers mounted, and were taken up by legislators.
The providers charged that under pressure to meet the federal target,
Mr. Sheehan treated paperwork errors like fraud.
At one legislative hearing, he was accused of “gangster tactics”
for demanding that providers settle with the state
or risk having to pay more based on findings extrapolated from statistical samples.

“Jim Sheehan was able to make up his own rules,”
said Richard J. Herrick, president of the New York State Health Facilities Association,
a nursing-home trade group.
“It wasn’t for purity, it was where can we find money to recoup.”

In June, Mr. Sheehan was dismissed with a month’s notice
in a phone call from Mr. Cuomo’s director of operations.

“He said, ‘We’ve decided to go in a different direction,’ ”
recalled Mr. Sheehan,
who has since been hired as the chief integrity officer and executive deputy commissioner for the Human Resources Administration, which oversees Medicaid in New York City.

A spokesman for the Cuomo administration
would not specify the reasons for the decision,
and Mr. Sheehan said that
as a political appointee, he had no problem with it.
But he disputed providers’ accusations, saying that

the real issue was
his challenge to a powerful industry that is a large employment engine.

“Medicaid is to New York what corn is to Iowa,” he said.
“It’s a heavy lift.”

He said that audits of nursing homes, for example, found that
some had inflated their profits
by needlessly sending every patient to physical therapy
during the month when annual reimbursement rates were calculated.

The nursing-home trade group sought an injunction to stop the audits.
A court dismissed the association’s argument
that Mr. Sheehan had exceeded his jurisdiction.

Mr. Herrick said that the decision was on appeal,
and that his association was revising audit protocols with Mr. Cox,
the new inspector general.
“I have no personal knowledge that facilities followed the practice alleged,”
he said,
“and as a practical matter find it highly unlikely.”

In home health care agencies, Mr. Sheehan said auditors found widespread patterns that violated Medicaid requirements linked to quality of care.

“Nurses are supposed to review the work and design the plan of the home health aides, but there were cookie-cutter plans,” he said, citing one plan that failed to mention that the patient was an amputee or to explain how the aide was to care for the stump.

“Home health aides would not show up, or would be in two places at once,” he added. “One entity billed us 500 times for home health care while patients were in the hospital.”

Mr. Sheehan would not name audited agencies, but two of his former managers said the largest audit was of Visiting Nurse Service of New York, a $1 billion nonprofit group. That audit gained attention a year ago, when an internal report citing tens of millions of dollars in overpayments was leaked to The Wall Street Journal. At the time, the agency’s chief executive was on a task force advising the new governor on how to redesign Medicaid to trim costs.

Richard Rothstein, a spokesman for Visiting Nurse Service, said that under an agreement with the inspector general’s office, he could not talk about the audit, which started in 2008 and has not been released. But he added, “There is absolutely no discussion about fraud,” only “errors in paperwork.”

One example cited in the preliminary report was a bill for an eight-hour-long sponge bath. Mr. Rothstein said that there had been no intent to cheat Medicaid and that the aide who started the sponge bath had forgotten to report that a nursing crisis had intervened before she finished it hours later.

Many providers welcomed Mr. Sheehan’s exit, but Richard J. Mollot, executive director of the Long Term Care Community Coalition, which advocates for nursing-home residents, did not.

“It was politics at its worst to see him leave,” Mr. Mollot said. “They put enormous pressure on that office to sustain their budget, so to then turn around and say they were too aggressive is the height of hypocrisy.”

After Mr. Sheehan’s dismissal, lawmakers unanimously passed a bill curbing the office’s authority. It cut the government’s time to reclaim overpayments to three years from six and let providers submit corrected bills rather than repay.

Mr. Cuomo, an aggressive prosecutor of Medicaid fraud as attorney general, vetoed the bill. “The provider community, as a whole, plays a critical role,” his veto message said, “and many of their concerns reflected in this bill are legitimate.” But, he added, the bill “would potentially allow fraudulent and abusive activity to go undetected or unprosecuted.”

Instead, he ordered Mr. Cox to review policies with “a working group comprised of representatives of provider associations and others.”

Mr. Cox’s confirmation last week, after a nine-month wait, underscored the change in climate. At genial committee hearings, state senators said they were receiving positive feedback from providers, but one warned that the vetoed bill would be resubmitted “if we hear otherwise.”

Mr. Introne, the deputy health secretary, said that Medicaid providers followed rules better now than they did five years ago. Mr. Sheehan agreed, and said his successor was well-qualified. But he noted that dozens of city audits he had asked to start or to release in his new job were still awaiting Mr. Cox’s approval.

Audit figures released by the state show that Mr. Cox’s findings of overpayments have fallen steeply since Sept. 30, when the state met the deadline for the $1.5 billion federal target.

Mr. Cox, a 23-year veteran of audits for the Health and Human Services inspector general, said he involved government lawyers and providers at the outset of an audit and examined every audit himself to make sure its findings could withstand a court challenge. That has held up some audits, he acknowledged, including that of Visiting Nurse Service, which is “still being reviewed and discussed with the entity and its lawyers to see what areas we agree on or disagree on.”

“We’re all about fighting fraud,” he said, and “also about improving program integrity, quality of care, and saving taxpayer dollars. That’s our mission, and we’re sticking with it.”

2012-05-02-WP-more-than-100-charged-in-massive-medicare-fraud-busts-in-7-cities-in-scams-totaling-455-mil

More than 100 charged in massive Medicare fraud busts in 7 cities in scams totaling $452 mil
By Associated Press, 2012-05-02

Cf. DOJ Press Release:
Medicare Fraud Strike Force Charges 107 Individuals
for Approximately $452 Million in False Billing

MIAMI —

Federal authorities charged 107 doctors, nurses and social workers in seven cities
with Medicare fraud Wednesday
in a nationwide crackdown on unrelated scams
that allegedly billed the taxpayer-funded program of $452 million —
the highest dollar amount in a single Medicare bust in U.S. history.

It was the latest in a string of major arrests in the past two years
as authorities have targeted
fraud that’s believed to cost the government
between $60 billion and $90 billion each year.
Stopping Medicare’s budget from hemorrhaging that money
will be key to paying for President Barack Obama’s health care overhaul.

[I would put that differently.
Stopping that fraud is essential to help balance the budget,
irrespective of whether Obamacare is implemented or not.]

...

---

Cracking the codes
Thousands of doctors and other medical professionals
have steadily billed higher rates for treating elderly patients on Medicare
over the last decade —
adding $11 billion or more to their fees
and signaling a possible rise in medical billing abuse,
an investigation by the Center for Public Integrity has found.

[A sample article from this series:]

Growth of electronic medical records eases path to inflated bills
...
In the rush to get the program off the ground, though,
federal officials failed to impose strict controls over billing software,
despite warnings from several prominent medical fraud authorities.
Now that decision could come back to haunt policy makers and taxpayers alike,
a Center for Public Integrity investigation has found.
...

2013

2013-07-01-CPI-Schulte-medicare-fraud-outrunning-enforcement-efforts

Medicare fraud outrunning enforcement efforts
By Fred Schulte
Center for Public Integrity, 2013-07-01

Official: agency failed to investigate 1,200 complaints due to staff shortages,
and more cuts coming

2013-07-25-CPI-Schulte-obamacare-oversight-among-health-watchdog-cuts

ObamaCare oversight among health watchdog cuts
by Fred Schulte
Center for Public Integrity, 2013-07-25

Budget squeeze, staff departures force HHS inspector general
to trim investigative targets

...

The cuts are “deeply regrettable,” said Malcolm Sparrow,
a professor at Harvard University’s John F. Kennedy School of Government and health fraud expert.
“We’d save a huge number of taxpayer dollars
by doubling the size of these operations.”

Sparrow said fraud artists are adept at quickly figuring out
how to exploit new health care initiatives
and that officials have an obligation to “stay ahead” of them.
“Otherwise three years from now we’ll be saying,
‘how could we not have predicted this mess?’ ”

Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association,
said that OIG audits not only stem financial losses,
but also can protect patients from harm.
Money spent on these efforts “pays for itself many times over,”
he said in an email.

OIG officials contend their investigations typically return $8 for every dollar invested.
They reported fiscal 2012 expected recoveries of about $6.9 billion
and more than 1,100 criminal and civil investigations of individuals or health care businesses.

...

“OIG will not be able to keep pace with the ACA (Affordable Care Act) expansion,
maintain/expand our highly successful Medicare Fraud Strike Forces,
or keep pace with the expanding Medicare and Medicaid enrollment
and the expected need for growth to combat on-going health care fraud,”
an agency document states.