Nationwide-Hospital Lawsuits for Overcharging

 American patients have little control over the hospital bills they receive after consenting to ambiguous admission forms before surgery. This article examines lawsuits against a plethora of hospitals across the country, for overcharging patients and insurance companies for services. And it’s not just the unfortunate folks without insurance who are being charged the inflated chargemaster prices, but fully insured people are also getting ripped off. The chargemaster is a list of prices that each hospital develops as a negotiating point with the Centers for Medicare and Medicaid and private insurers and is not based on actual reimbursements. 

Location	Hospital	Basis of the Lawsuit
California	Sutter Health, a nonprofit entity	575 million-settlement with the Attorney General of CA for overcharging (Office of the Attorney General California, 2021)
Colorado	St. Anthony North Hospital, a nonprofit entity	Patient sues under reasonableness clause for nonnetwork charges & hospital failure to disclose true cost before admission (Levenson, 2022)
Florida	North Okaloosa Medical Center, a nonprofit entity and 19 others	A 2015 review of the 50 hospitals which overcharged the uninsured the most reveals 20 sited in Florida (Post, 2015)
New York	Foundling Hospital, a nonprofit entity	Attorney General has prevailed in many lawsuits against hospitals, but the most egregious may be the 250 million settlement by Foundling Hospital for overbilling Medicaid (New York State Office of the Attorney General Press Release Archives, 2014)
North Carolina	Vidant Health, a nonprofit entity	Patient sues for being overcharged for common imaging procedures (Paavola, 2022)
Ohio	One of the state’s largest hospital groups, so either Ohio Health Corp or the Cleveland Clinic, both nonprofit entities	Supreme Court is hearing a suit brought by uninsured patients contesting the “reasonableness” clause in common-law for hospital charges (The Eisen Law Firm Co. L.P.A.)
Tennessee	Team Health, a nonprofit entity Mission Hospital-HCA, a for profit entity	Team Health sued by United Healthcare for overcharging-100 million (Healthcare Finance News.com, 2021) Mission Hospital-HCA sued for monopoly power & reduction in services
Washington	St. Mary’s, Providence Health, a nonprofit entity	Sued by WA Attorney General for unnecessary procedures which resulted in overcharging and a 22 million settlement (New York Times, Seattle Times, Walla Walla Union-Bulletin)

 Since 2004, dozens of lawsuits have been filed on behalf of patients contesting the reasonableness clause and hospitals overcharging patients, especially the uninsured, so the Supreme Court of Ohio’s reasonableness ruling will be keenly watched by consumer groups. Don’t expect hospitals to lower their price gouging charges though, the behemoth hospital corporations will just rejigger their formulas so that we pay for their legal settlements. And so it goes, as the American public continues to be abused by its pay-to-play healthcare system instead of adopting much less expensive national healthcare programs like the rest of industrialized countries.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you consent to procedures, do stipulate that for which you agree and what you decline.

 Roberta Winter is an independent healthcare analyst and journalist who accepts no money from any sector of US healthcare. This monthly column has been in continuous publication since 2007. In 2013 her guidebook to the US healthcare system was published by Rowman and Littlefield and an entire chapter was devoted to the price gouging of hospitals for the uninsured. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 References

Healthcare Finance News.com. (2021, October 29). UnitedHealth sues TeamHealth, saying it overpaid $100 million in claims. (S. Morse, Ed.) Healthcare Finance News.com. Retrieved May 22, 2022, from https://www.healthcarefinancenews.com/news/unitedhealth-sues-teamhealth-saying-it-overpaid-100-million-claims

Levenson, M. (2022, May 21). She Was Told Surgery Would Be About $1,300 Then The Bill Came: $229,000. The New YorkTimes. Retrieved May 22, 2022, from https://www.nytimes.com/2022/05/21/us/colorado-hospital-lisa-french.html

New York State Office of the Attorney General Press Release Archives. (2014, February 5). Retrieved from https://ag.ny.gov/press-release/2014/ag-schneiderman-announces-250k-settlement-ny-foundling-hospital-overbilling

Office of the Attorney General California. (2021, August 27). Attorney General Bonta Announces Final Approval of $575 Million Settlement with Sutter Health Resolving Allegations of Anti-Competitive Practices. Office of the Attorney General Press Release. Retrieved May 22, 2022, from https://oag.ca.gov/news/press-releases/attorney-general-bonta-announces-final-approval-575-million-settlement-sutter#:~:text=The%20settlement%20requires%20Sutter%20to,%2C%E2%80%9D%20said%20Attorney%20General%20Bonta.

Paavola, A. (2022). Patients Are Coming After Hospital Prices. Becker Hospital Review. Retrieved May 22, 2022, from https://www.beckershospitalreview.com/legal-regulatory-issues/patients-are-coming-after-hospital-prices.html

Post, L. (2015, June 8). 50 hospitals charge uninsured more than 10 times cost of care, study finds. The Washington Post. Retrieved May 22, 2022, from https://www.washingtonpost.com/national/health-science/why-some-hospitals-can-get-away-with-price-gouging-patients-study-finds/2015/06/08/b7f5118c-0aeb-11e5-9e39-0db921c47b93_story.html

The Austin Trial Lawyer.com. (2015, April). The Austin Trial Lawyer.com. Retrieved from The Austin Trial Lawyer.com: https://www.theaustintriallawyer.com/2015/04/in-federal-case-insurance-company-sues-texas-hospital-for-tortious-interference/

The Eisen Law Firm Co. L.P.A. (n.d.). Lawsuit Alleges Hospitals Overchared Uninsured Patients. Retrieved May 22, 2022, from https://www.malpracticeohio.com/lawsuit-alleges-hospitals-overcharged-uninsured-patients-part-1/

Yates, D. (2016, June 22). Federal judge rejects Aetna’s $225M fraud claim, finds for North Cypress. Retrieved from https://setexasrecord.com/stories/510933779-federal-judge-rejects-aetna-s-225m-fraud-claim-finds-for-north-cypress

 

 

Nonprofit Catholic Hospital Group Defrauds State of Millions

 Yesterday, I read multiple articles about my local community nonprofit hospital defrauding Washington State Medicaid and the federal government for millions of dollars. This hospital encouraged neurosurgeons to perform unnecessary spinal surgeries in order to generate higher revenues for five years. (Hagar, 2022)These practitioners put patient’s health at risk for financial gain. Spinal surgeries are one of the riskiest and most controversial of all procedures with a high failure rate. One of the neurosurgeons charged in this scheme earned four million dollars in one year in a rural farming community of 38,000 people. Doesn’t sound right, does it? But the head of the hospital, St. Mary’s-Providence earned ten million dollars in the same year. That to me, was mind boggling. And these doctors are not the only ones guilty of fraud in the U.S. healthcare system, which places volume ahead of health.

To give you an idea of the scale, St. Mary-Providence only has 142 beds, which is a small hospital, by comparison, Providence Hospital in Spokane has 674 beds, which is considered large by U.S. standards. The head of a much larger hospital earned less than the head of this tiny hospital, because of the Providence incentive system which rewards increased volume in complex procedures. Not comforting to know your doctor works on a lucrative bonus plan versus the best evidence-based practices.

The overbilling occurred over a five-year-period at St. Mary’s ending in 2018, when the unethical and abusive neurosurgeons were forced to resign. But Providence did not report them to the Attorney General, for that would have ensnared them in the overbilling scheme as well. The corporate financiers were content to keep raking the money in, despite patient health risks, and higher costs for all consumers.

Fortunately, the former administrator for the neuro unit became a whistleblower and got the case started with the Washington State Attorney General, Bob Ferguson’s Office. Because of the excellent work of his team, Providence has been found guilty of fraud, will pay a twenty-two million dollar fine, and will be on a five-year-probationary review. Imagine if we looked at all of Providence’s hospitals in all seven states, how much overbilling would we find? Afterall when the Affordable Care Act passed, Providence made so much money it created its own venture capital fund rather than lower its fees for services.

Providence Hospitals named in the lawsuit: Providence Centralia Hospital, Providence St. Joseph Hospital, Providence Mount Carmel Hospital, Providence Regional Medical Center, Providence St. Peter Hospital, Providence Holy Family Hospital, Providence Sacred Heart Medical Center, Providence St. Mary Medical Center, Swedish First Hill Campus, Swedish Cherry Hill Campus, Swedish Ballard Campus, Swedish Issaquah Campus, Swedish Edmonds Campus, and Kadlec Regional Medical Center. Providence also operates hospitals in Alaska, Montana, Oregon, and California.

The most galling are the finance people working in hospital corporations who create these schemes and see nothing wrong with paying someone an exorbitant compensation package in a tiny rural hospital. This is one of the problems with nonprofit hospital groups, their compensation packages are often opaque, because there are no shareholders and disclosure is limited. The executive of St. Mary Medical Center is no exception in the Providence compensation, many of their executives earn ten million a year. (National Union of Healthcare Workers, 2022) And where do these finance gurus who cut clinical staff and put patients at risk come from, Amazon and Microsoft.

Providence Health was also found guilty of deceptive billing practices, because the nonprofit hospital did not make patients aware of their charity care options. In other words, the nonprofit Catholic hospital saw nothing wrong with bilking low-income people for care, as long as their venture capital fund was doing well. (Gamble, 22)

 In a previous post, I wrote about a Pennsylvania judge ruling that another nonprofit hospital group did not deliver enough uncompensated care to qualify as a nonprofit entity. [i] This is a national healthcare problem, which can only be cured by further government interventions in regulation of pricing, financial disclosure, and enforcement.

Imagine how many more nurses and mental health specialists we could have actually helping patients if we had a healthcare system which is not based on profits. The only way this abuse is ever going to end is when Americans wake up and adopt a national healthcare system and yes, that will mean hospital administrators won’t be making ten million dollars a year. And that would be better for all of us.

And this is the healthpolicymaven signing off encouraging you not to sign blanket release forms for procedures, do stipulate that for which you agree and decline.

Roberta Winter is an independent healthcare analyst and journalist who accepts no money from any sector of the U.S. healthcare system. She has been interviewed on publicinterestpodcast.com and is the author of a guidebook to the U.S. healthcare system, published by Rowman and Littlefield in 2013. https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

References

Gamble, M. (22, February 24). Beckers Hospital Review. Retrieved from Beckers Hospital Review.com: https://www.beckershospitalreview.com/legal-regulatory-issues/washington-sues-providence-over-collection-tactics.html

Hagar, S. (2022, April 13). More details emerge on Providence St. Mary Medical Center's $22.7 million insurance fraud settlement. Retrieved from Union Bulletin: https://www.union-bulletin.com/news/courts_and_crime/more-details-emerge-on-providence-st-mary-medical-centers-22-7-million-insurance-fraud-settlement/article_9ef81200-bab2-11ec-9bf3-03450d16ba13.html

National Union of Healthcare Workers. (2022, April 14). Providence St. Joseph Watch. Retrieved from NUHW.org: https://nuhw.org/providence-st-joseph-watch/executive-salaries/

 

 

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[i] https://healthpolicymaven.blogspot.com/2022/03/should-your-hospital-get-nonprofit.html

 

 

 

Financial Conflicts Among Nonprofit Advocacy Groups-Who Can You Trust

The battle between the drug-industry-controlled Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid (CMS) over its’ decision to provide only clinical trial reimbursement for Biogen’s Aduhelm, has highlighted the tentacles of the drug development pipeline in nonprofit advocacy organizations. To refresh your memory, Aduhelm, an aducanumab drug was approved by the FDA under the emergency-fast-track-approval process, without the lengthy normal vetting process for new pharmaceuticals. Biogen’s motivation for this was profit, by capturing the market for a promising, but as yet unproven drug for Alzheimer’s. This is the proverbial pants-wetter for big pharma, like Viagra, the ubiquitous male libido enhancer with universal reimbursement. This articles reviews nonprofit organizations which participate in healthcare advocacy and their funders. Only nonprofit entities are reviewed because it is assumed all for-profit advocacy is conflicted, such as lobbyists paid by their clients. This table shows nonprofit advocacy groups, their funders, and their positions on the Aduhelm approval.

 Who Can You Trust-Who Pays For The Advice?

Organization	Funding Source	Recent Positions
American Geriatrics Society (American Geriatrics Society, 2022)	Professional fees from its 6,000 clinician members	Submitted a letter to CMS against the approval of Aducanumab for treatment of Alzheimer’s
Alliance For Aging Research (Butler, 2022)	100% funded by pharma; 50% of annual budget designated for marketing	ACT-AD-for accelerated approval of aducanumab or similar Alzheimer’s treatments
Alzheimer’s Association (Belluck, 2022)	$485,000 from Biogen in 2021, the developer of Aduhelm; 1.6 million from other drug companies; a small portion of gross annual budget	Wants aducanumab approval for all Alzheimer’s patients even those with mild symptoms, despite scant evidence it works
National Council on Aging (Cameron, 2022)	Nonprofit funded through grants and donors	Advocate for evidence-based treatments; adopted the position that Aduhelm should be used with caution in clinical trials, against accelerated approval
Pharmed Out (PharmedOut.org, 2022)	A Georgetown University advocacy group, funded through individuals and grants	Educates individuals on the medical concerns about Aduhelm, against accelerated approval; advocates for increase rigor and value analysis before approval of drugs
Right Care Alliance (Right Care Alliance, 2022)	Mostly funded by private donors, also Resist Foundation and Ben and Jerry’s	Sponsor of petition to withdraw approval of Aduhelm, against accelerated approval for drug

 Facts

The U.S. government is the largest funder of scientific research through these National Institutes of Health Agencies: National Institute on Aging, National Institute of Mental Health, National Institute of General Medical Sciences, and National Center for Advancing Translational Science. Other federal funding comes from the National Science Foundation, Veterans Administration, Food and Drug Administration, and the Center for Medicare and Medicaid Services.  This conclusion was drawn from a scientific literature review and meta-analysis conducted in 2018 (Cummings, 2018). Though drug companies do conduct their own less risky brand research, it is on the backs of early publicly funded mostly university-led research.

Significant concerns about the FDA working too closely with the drug developer Biogen have resulted in the following investigations; congressional committees, the Health and Human Services department’s inspector general, the Federal Trade Commission and the Securities and Exchange Commission.  Such concerns reflect the process by which this drug received accelerated approval despite scant evidence it works, manipulation of research data after it was rejected by the expert review at the FDA, and the director of the FDA’s personal relationship with the drug developer. A drug which had not even completed clinical trials and has been shown to kill patients was put on a direct path to market it as an Alzheimer's cure to the public. This resulted in clinical outcry, outright banning of the use of the drug by most major medical centers, and a public movement to draw attention to the concerns, as previously published.[1] [2] As a result, the independent government agency, the Centers for Medicare and Medicaid called for and received thousands of public comments on the concerns about this drug. Additionally, CMS only approved provisional payment for this drug for patients in clinical trials, which appears prudent. This decision infuriated big pharma because they assumed anything that could be hornswoggled through the FDA was a guarantee of payment by CMS, and thus, the giant wallet of the US government, which would be responsible for most of the cost.

Conclusion, since the government conducts most of the early scientific research, shouldn’t it, as the largest purchaser of pharmaceuticals, have a right to review drug approvals, for this is exactly what private insurance companies do with their pharmacy schedules. It is not in the best interest of tax paying Americans to waste money on specious treatments and CMS is doing all of us a favor by slowing down the approval of Biogen’s Aduhelm. The pharmaceutical industry should consider this a shot across the bow as the American public is awake and livid over the continual pillaging of our pocketbooks for their profits.

References

American Geriatrics Society. (2022, April 6). Where We Stand-Letter to CMS Commissioner on Aducanumab. Retrieved from https://www.americangeriatrics.org/: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/viewer.html?pdfurl=https%3A%2F%2Fwww.americangeriatrics.org%2Fsites%2Fdefault%2Ffiles%2Finline-files%2FAmerican%2520Geriatrics%2520Society_Letter%2520to%2520FDA%2520Biogen%2520Drug%2520for%2520Alzheimer%

Belluck, P. (2022, April 6). Inside a Campaign to Get Medicare Coverage for a New Alzheimer’s Drug. Retrieved from https://www.nytimes.com/2022/04/06/health/aduhelm-alzheimers-medicare-patients.html?smid=url-share

Butler, J. (2022, April 5). The Alliance For Aging Research-Fronting For Pharma. PharmedOut.org. Retrieved April 6, 2022, from https://mailchi.mp/georgetown/april-2022-newsletter-update

Cameron, K. (2022, April 6). What you need to know about aduhelm. Retrieved from National Council on Aging: https://www.ncoa.org/article/what-you-need-to-know-about-aduhelm

Cummings, J. R. (2018, June 13). The price of progress: Funding and financing Alzheimer's disease drug development. doi:https://doi.org/10.1016/j.trci.2018.04.008

PharmedOut.org. (2022, April 6). Aduhelm. Retrieved from PharmedOut.edu: https://georgetown.edu/pharmedout/advocacy/aduhelm?authuser=0

Right Care Alliance. (2022, April 6). Withdraw Approval of Aduhelm Petition. Retrieved from Right Care Alliance: https://rightcarealliance.org/

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you agree to inpatient treatments, do stipulate that for which you agree and that you decline.

 

Roberta Winter is an independent healthcare analyst who accepts no money from any sector of the U.S. healthcare system. She is the author of a guidebook to the healthcare system which was published in 2013 by Rowman and Littlefield. https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html

 

 

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[1] https://healthpolicymaven.blogspot.com/2022/01/high-cost-of-single-unproven-drug.html

 

[2] https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html

Should Your Hospital Get Nonprofit Status If It Doesn't Provide Enough Health Care for the Poor?

Nonprofit 501C-3 hospitals can lose their nonprofit status if they do not contribute enough of their revenue to charitable care in the communities they are supposed to serve. In 2017, a nonprofit hospital lost its tax-free status because it did not provide enough community benefit according to the Affordable Care Act Standards. The hospital, which was not named by the IRS, was deemed to have willfully flaunted the requirement that it maintain nonprofit status. (Wyland, 2017) Worse yet, this hospital was designated a disproportionate share facility, a designation which receives further federal government funding because they are located in communities with large populations of impoverished people. Disproportionate share hospitals are found in inner cities and include; Cook Hospital in Chicago, Harborview in Seattle, and Bellevue Hospital in New York City. Unfortunately, in this situation a nominal fine of $50,000 was levied to this hospital group, because that is all the statue allowed, which is coffee money for hospital corporations. Opportunism in large hospital corporations is a growing trend, but at least the Affordable Care Act finally provided some standards of proportionality for charitable care in order to actually be a nonprofit, nontax paying entity.

 Tracking Your Nonprofit Hospital’s Community Benefit

Boston-based Lown Institute even publishes an index that ranks community investments from hospitals and its’ latest report shows 72% of the 3.641 nonprofit hospitals  which participated actually received tax benefits in excess of their charity care and community investment. (Toleos, 2021) To determine how your local hospital ranked go to their site at https://lownhospitalsindex.org/rankings/

Lown Institute Rankings for Community Investment and Charitable Care (Lown Institute , 2022)

Standards	Hospital	Location
Most Charitable	Paradise Valley Hospital	National City, CA
2nd Most Charitable	Elmhurst Hospital Center	Elmhurst, NY
3rd Most Charitable	Queens Hospital Center	Jamaica, NY
3rd Least Charitable	University CA Medical Center	San Francisco, CA
2nd Least Charitable	New York Presbyterian Hospital	New York, NY
Least Charitable	Cleveland Clinic	Cleveland, OH

 Affordable Care Act Requirements for Nonprofit Hospitals

Under ACA mandates, hospitals must conduct a community health needs assessment (CHNA), create an action-based plan to meet objectives identified in the report, and widely disseminate the plan once it is approved. Additionally, the Internal Revenue Service has added section 501 (1) to the revenue code which has requirements for nonprofit hospital reporting and standards to demonstrate nonprofit status. (Internal Revenue Service, 2022) These requirements prohibit lobbying, political contributions, and election year issues. Further, if compensation paid to hospital executives is deemed excessive, they are taxed a 25% excise tax on each excess benefit, of which the executives are personally liable. The compensation deemed an excess must be paid back and if it is not, a 200% tax penalty is levied. A 10% tax may also be levied on the manager of the person(s) who are deemed to have received an excess benefit as well.  These penalties at least provide some teeth in the Revenue Service’s enforcement of tax code provisions which provide generous exclusions for nonprofit hospitals.

 Judge Ruled Hospital Corporation Is Non-Charitable Entity

Local communities have started to sue large hospital corporations and in Pennsylvania, a Chester County judge ruled that three local nonprofit hospitals, owned by Tower Health were not tax-exempt charities and thus subject to property taxes. This judge found these hospitals did not meet the 1997 statute for Institutions of Purely Public Charity Act. Further the court stipulated they did not provide adequate uncompensated care and declaring undercompensated care as charity care is not valid. This is a line in the sand which will reverberate throughout all nonprofit hospital groups, because they too use the undercompensated care standard tied to their “chargemaster.” This judge also decreed the chargemaster is meaningless because it has nothing to do with actual contracts or payment for services. (Johnson, 2022) As a former hospital finance department employee, I can state unequivocally that no one pays the charge master prices. Even the uninsured, who could be charged those rates can apply for charitable care or negotiate discounts. The chargemaster is in fact, a starting point in swap meet negotiation and hospitals never expect to receive reimbursements at those rates.

 Many municipalities and school districts are interested in taxing wealthy nonprofit organizations, whom may have extensive property in their communities. For example, in my state, the University of Washington is one of the largest real estate owners and landlords in pricey Seattle. Even in tiny Walla Walla, Whitman College is also one of the largest land owners in town. In the case of both of these educational institutions, they were established before Washington became a state and merely held onto their land grants.

 Communities can and should use the courts to redress exorbitant healthcare prices from hospital groups which pay no taxes and received a plethora of government financing. Perhaps when enough of the settlements cost enough money these money gouging hospital groups will start to care about the people in their communities more than their pocket books.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when agreeing to health care procedures, do stipulate that for which you consent and for which you decline. Roberta Winter is a healthcare analyst and freelance journalist who accepts no money from any sector of the healthcare industry for publication of this column.

 Works Cited

Internal Revenue Service. (2022, March 3). Non-profit Charitable Organizations Exemption Requirements. Retrieved from IRS.gov: https://www.irs.gov/charities-non-profits/charitable-organizations/exemption-requirements-501c3-organizations

Johnson, B. K. (2022, January 7). Non-Charitable Nonprofit Hospital Ordered to Start Paying Property Taxes. Retrieved from Bloomberg News.com: https://news.bloombergtax.com/tax-insights-and-community/non=charitable-nonprofit-hospital-ordered-to-start-paying-property-taxes

Lown Institute . (2022, March 3). Lown Institute Hospitals Index-2021 Rankings . Retrieved from Lown Hospitals Index.org: https://lownhospitalsindex.org/rankings/compare/?hospitals=050024,330128

Toleos, A. (2021, July 11). Most U.S. nonprofit hospitals neglect community investment obligation, analysis reveals. Retrieved March 3, 2022, from Lown Institute: https://lowninstitute.org/press-release-most-us-nonprofit-hospitals-neglect-community-investment-obligation-analysis-reveals/

Wyland, M. (2017, August 18). Hospital Loses IRS Tax Exemption for Noncompliance with ACA. Retrieved from Becker's Hospital Review: https://nonprofitquarterly.org/hospital-loses-irs-tax-exemption/

 

High Cost Of Single Unproven Drug Forces Medicare To Increase Premiums by 13% for All Seniors

The Centers for Medicare and Medicaid should NOT approve Aducanumab (branded Aduhelm), because it is posing as an effective treatment for Alzheimer’s which hasn’t been proven. All of the clinicians who served on the FDA review board for this drug resigned when FDA leadership overruled their recommendation to deny approval. Further the drug is linked to heightened risk for falls and brain bleeds. Finally, the astronomical cost of the drug has forced the Centers for Medicare and Medicaid to increase its’ Part B premium by 13%, the largest rate increase it has ever had, which impacts low-income seniors disproportionately. CMS is a separate agency from the Food and Drug Administration for a reason and it has a long history of stewarding improvements in public health. The non-inclusion of Aducanumab by CMS for Medicare enrollees represents an effective method for it to soundly manage the Medicare budget and reinforce scientific methods for approval of treatments by a government agency. This conflict represents a unique opportunity for the Centers for Medicare and Medicaid to put the needs of the general public ahead of the interests of pharmaceutical companies.

 In September, I posted an article about the Biogen Aducanumab (Aduhelm) FDA approval controversy. https://healthpolicymaven.blogspot.com/2021/09/is-fda-too-politicized-to-make-sound.html The Centers for Medicare and Medicaid’s decision not to approve Aduhelm for payment reimbursement under any of its plans was a landmark rebuke of the FDA. This is the first time CMS has denied payment for a drug approved by the Food and Drug Administration. This decision speaks to the fact the FDA overruled the recommendations of the clinical experts who voted against approval of Aduncanumab for treatment of Alzheimer’s as it has not been proven to work. Currently CMS will only pay for this drug for those participating in further study via clinical trials. The FDA and CMS are separate government agencies for a reason and one should not serve as a rubber stamp for the other, yet this is the first time CMS has denied a drug for payment. This incidence does provide hope that our government agencies which are responsible for public health policies which impact us all are demonstrating leadership. Biogen, the maker of Aducanumab, branded as Aduhelm is furiously working to roll back this decision, because after all, their profits and bonuses are at stake. Yet our public advocacy efforts, led by the Right Care Alliance have been effective.. https://rightcarealliance.org/we-say-no-to-aduhelm-heres-why/ 

Here are the actions Biogen was forced to take when we made our collective voices known: 

1. Slashed the price of the unproven Aduhelm by 50% from $56,000 to $28,200

2. Aduhelm is currently only approved for payment for patients in clinical trials

3. Centers for Medicare and Medicaid have initiated a public comment period on Aduhelm through February 10th

4. Biogen’s stock has nosedived 40% because of the questions regarding the validity of the drug and the united clinical outcry against it

 Advocacy Works

The fact a group of scrappy healthcare reform advocates could incite these actions is evidence that efforts by the public can work to roll back some of the ineffective and costly treatments approved by the Food and Drug Administration. It is important to note the drug companies have been allowed to conduct their own testing to certify whether their drugs work without third party validation since 1992. No conflict of interest there- “Heh guys, I don’t like these results can you rejigger the data so it makes my drug appear more favorable?”

 Next Steps

Make your voice heard by taking these actions today:

1. Go to the Centers for Medicare and Medicaid site and post your comment here

https://www.cms.gov/medicare-coverage-database/view/national-submit-public-comment.aspx?DocID=305&commentDocType=nca&fromPage=tracking&error=Your%20comment%20has%20been%20submitted%20successfully,%20and%20your%20confirmation%20email%20se

2. Contact your senators and tell them you do favor the CMS decision not to approve Aduhelm for payment, because it has not been proven to work. This is no cure for Alzheimer’s.

 The FDA should require pharmaceutical companies to have independent third-party validation of the effectiveness and safety of their drugs before approval is given. The U.S. government needs to spend more money to oversee the drug approval process, not turn it over to profiteering drug companies. The pharmaceutical industry should not be financing 44% of the FDA’s annual budget. In 1906, when the agency was founded, the government paid 100% of its funding. Public safety and public interest for our health and our wallets are at stake.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when you consent to medical procedures, do stipulate that for which you agree and decline.

References

Centers for Medicare and Medicaid. (2021, November 12). CMS Announces 2022 Medicare Part B Premiums. Retrieved from Centers for Medicare and Medicaid: https://www.cms.gov/newsroom/press-releases/cms-announces-2022-medicare-part-b-premiums

Centers for Medicare and Medicaid. (2022, January 11). CMS Proposes Medicare Coverage Policy for Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease. Retrieved from Centers for Medicare and Medicaid Press Release: https://www.cms.gov/newsroom/press-releases/cms-proposes-medicare-coverage-policy-monoclonal-antibodies-directed-against-amyloid-treatment

 Roberta Winter is a freelance healthcare journalist who has been publishing this column since 2007 and accepts no money from any sector of the healthcare industry. She is the author of a guidebook to the US healthcare industry, published by Rowman and Littlefield in 2013. 

https://www.amazon.com/Unraveling-U-S-Health-Care-Personal/dp/1442222972

 

 

 

 

Healthcare Crimes Related to Covid-19

 

Healthcare Criminals-2021 

In March of 2021, the Department of Justice announced a coordinated law enforcement Covid-19 Task Force to bring pandemic charlatans to justice and charges for nearly 2 billion have been filed, for doctors, laboratories, and pharmacies. (United States Department of Justice, 2021) The scams fall into three primary areas, telemedicine fraud, running unnecessary tests, and prescription fraud. The United States Attorney’s Office has convicted many people for pandemic related healthcare crimes from 2020 and this is a brief anthology of the more egregious convictions. (United States Department of Justice, 2021) . Though special mention goes to the ethically bankrupt Sackler family, which was not pandemic related and is therefor, not included in the table. It is important to note that ethical people still exist because internal whistleblowers were responsible for 73% of these convictions leading to the recovered funds. The U.S. government was able to claw-back over a billion dollars from corporate healthcare entities, including multinationals, and two-hundred-sixty-four million from individual grifters. (Land, 2021)

 Financial Recovery of Healthcare Fraud-2020 Convictions

Company	Crime	Restitution
Novartis	Payments (bribes) to doctors to prescribe their drugs	$ 591,000,000
Practice Fusion	Accepted payments from Purdue Pharma to increase opioid use	$ 145,000,000
Novartis	Illegally paid copays for their drugs through a foundation, with the appearance of independence; as an inducement	$ 148,000,000
Universal Health Services	False claims for mental health services	$ 117,000,000
Oklahoma Center for Orthopedic and Multi-specialty Surgery	Hospital-paid kickbacks to physicians for referrals	$   72,000,000
UTC Laboratories (RenRX)	Kickbacks for lab referrals	$   41,600,000
ResMed Corp	Paid kickbacks for medical equipment suppliers, sleep labs, and health care providers	$   37,000,000
Subtotal		$1,151,600,000
Individual Assessments	Crime	Restitution
Health Management Associates	Hospital group convicted of false billing and kickbacks	$ 260,000,000
Glen Kline, DO, Community Surgical Associates	Kickbacks from HMA (one of the nation’s largest for-profit hospital groups) for surgeries	$     4,250,000
Subtotal		$   264,000,000
Grand Total Recovered		$1,415,6000,000

 Human suffering is never complete without the opportunists and charlatans. I note that HMA, one of the nation's largest for-profit hospital groups, was previously convicted of one of the largest Medicare frauds in US history, and of course, theformer head of that company is now a Senator from Florida. And this is the healthpolicymaven signing off wishing you a healthy new year!

 This column has been in continuous publication since 2007. Roberta Winter is an independent healthcare journalist who accepts no money from any healthcare, pharmaceutical, insurance, or medical device entity. She encourages you not to sign blanket release forms when agreeing to medical procedures, do stipulate that for which you agree and which you decline.

 References

Land, H. (2021, January 15). DOJ Recovers 1.8 billion in healthcare fraud settlements, judgements in 2020. Retrieved from Fierce Health.com: https://www.fiercehealthcare.com/tech/feds-recover-1-8b-from-false-claims-act-cases-2020

United States Department of Justice. (2021, May 26). Coordinated Task Force to Combat Healthcare Fraud Related to Covid 19. Retrieved December 31, 2021, from Department of Justice: https://www.justice.gov/opa/pr/doj-announces-coordinated-law-enforcement-action-combat-health-care-fraud-related-covid-19

United States Department of Justice. (2021, September 17). National Health Care Fraud Enforcement Action Results in Charges Involving over $1.4 Billion in Alleged Losses. Retrieved from United States Department of Justice: https://www.justice.gov/opa/pr/national-health-care-fraud-enforcement-action-results-charges-involving-over-14-billion