McKnight’s reported that the Trump Administration will continue the Obama Administration’s policy of discovering and punishing waste, fraud, and abuse in the nursing home industry.  However, based on Trump’s history of fraud himself, and the fact that he chose Tom Price as Secretary of DHHS, it does not appear that discovering and punishing health care fraud is on the top of the agenda.

Attorneys and former DOJ officials interviewed by Bloomberg BNA predicted that the new administration is likely to preserve several Obama-era policies in place. Those include the use of data analysis in fraud investigations, and the Yates plan to prosecute more individuals.

The department’s efforts to combat fraud in post-acute care will also likely remain a top priority, said Zane David Memeger, an attorney with Morgan, Lewis & Bockius. That may include the the DOJ’s regional nursing home task forces, launched last year to target “grossly substandard” facilities.

“We have an aging population, and nursing homes and home health, they’re vulnerable to fraud,” Memeger said.

He also indicated that fraud in the pharmaceutical and medical device industries will continue to receive DOJ scrutiny.

The Columbus Dispatch reported that Autumn Health Care of Zanesville, a nursing home operator, has been ordered to repay tens of thousands of fraudulently obtained Medicare and Medicaid dollars, after an investigation by the Ohio Attorney General’s Office. The investigation found that the owner and other employees habitually altered documents to make it appear patients were being properly cared for in order to receive government aid.

With permission from family members, investigators hid surveillance cameras in patients’ rooms, the first time such measures had been used in a state nursing-home investigation.  While the nursing home’s records reflected a high level of care, the investigation found that several patients missed treatments or were given therapy they didn’t need, the attorney general’s office said.

The corporation pleaded guilty to multiple charges in October, including forgery, tampering with evidence, Medicaid fraud, telecommunications fraud, theft and engaging in corrupt activity.

Autumn Health Care of Zanesville must pay back $53,390 to the Ohio Department of Medicaid and $75,250 to the federal Centers for Medicare and Medicaid, as well as $40,000 in investigative costs.

Its owner, Steven Hitchens, entered pleas to single counts of tampering with evidence, tampering with records and forgery. Hitchens was ordered to serve three years of community control and conduct 100 hours of community service.




Rep. Tom Price last year purchased shares in a medical device manufacturer days before introducing legislation that would have directly benefited the company, raising additional ethics concerns for President-elect Donald Trump’s nominee for Health and Human Services secretary.

Price bought between $1,001 to $15,000 worth of shares last March in Zimmer Biomet.  A few days later, the Georgia Republican congressman introduced the HIP Act, legislation that would have delayed until 2018 a Centers for Medicare and Medicaid Services (CMS) regulation that industry analysts warned would significantly hurt Zimmer Biomet financially once fully implemented.  After Price offered his bill to provide Zimmer Biomet relief from the CMS regulation, the company’s political action committee donated heavily to the congressman’s reelection campaign.
Zimmer Biomet, one of the world’s leading manufacturers of knee and hip implants, was one of two companies that would have been hit the hardest by the new CMS regulation that directly impacts the payments for such procedures.
The new revelation is the latest example of Price trading stock in a healthcare firm at the same time as pursuing legislation that could impact a company’s share price. The Wall Street Journal reported that he traded roughly $300,000 in shares over the past four years in health companies while pursuing legislation that could impact them.
 Price sat on an influential Ways and Means subcommittee that directly oversees health care policy. “This new report makes clear that this isn’t just a couple of questionable trades, but rather a clear and troubling pattern of congressman Price trading stock and using his office to benefit the companies in which he is investing,” Chuck Schumer said in a statement. “The Office of Congressional Ethics needs to conduct an immediate and thorough investigation into these potential violations of the STOCK Act before Rep. Price’s nomination moves forward.”
His stock holdings have included Aetna Inc., Pfizer Inc, Amgen Inc., Bristol-Myers Squibb Co. and Eli Lilly & Co. In recent years he has sponsored or co-sponsored 44 bills with potentially important financial impact on the U.S. health care system, insurers and the pharmaceutical industry.

The Indianapolis Business Journal had an article about the fraud and greed that led to the indictment of nursing home owner and operator James Burkhart.   In an explosive federal indictment unsealed in October, kickback money was used to buy gold bullion, casino chips, and vacation homes in a massive fraud scheme.  The fraud and kickbacks combined totaled more than $16 million, with the proceeds going to fund the men’s lavish lifestyles.

The indictment states that Burkhart, former CEO of Indiana’s largest nursing home company, and three other men orchestrated a scheme that used kickbacks and shell companies to defraud American Senior Communities which is owned by the Jackson family of Indianapolis; Health & Hospital Corporation of Marion County, which hired ASC to operate its nearly 70 nursing homes; and federal health care programs.

The defendants are former CEO James Burkhart, former Chief Operating Officer Dan Benson, Joshua Burkhart and Steve Ganote.  A 35-page indictment alleges that the four launched the brazen scheme to enrich themselves in 2009 and continued it until Sept. 15, 2015, the day FBI agents raided the nursing home company’s offices.

“The scheme was characterized by unbridled greed,” U.S. Attorney Josh Minkler said.

Herald Mail Media reported on the accusation of resident dumping by the owner/operator of five Maryland nursing homes.  The suit alleges that during a 17-month period between Jan. 1, 2015, and May 31,  Neiswanger Management Services LLC issued involuntary discharge notices to at least 1,061 residents at the five facilities it operates.

NMS and a number of its officers were named in a civil suit and charged by the state Office of the Attorney General with dumping “frail and disabled” Medicare and Medicaid residents in sham assisted-living facilities and homeless shelters, and submitting false claims to the state.

A number of dumping incidents are listed in the 62-page complaint including a woman with cancer who was driven to an unlicensed care facility in Baltimore and a woman who was left in the driveway of a relative’s home on a 95-degree day, the document said.

 “In at least 1,038 of these cases, the reason for discharge cited by NMS was the resident’s failure to pay for his or her care, or to arrange for payment by Medicare, Medicaid or another third party payor,” the suit states. By contrast, the suit noted, Maryland’s other 225 nursing homes issued about 510 such notices during that period.

NMS facilities received more than $100 million in Medicare and Medicaid reimbursements in 2015, $35 million of that from the Maryland Medical Assistance program, the suit states.

NMS preferred Medicare patients for admission because of the higher rates of reimbursement, then “aggressively seeks to evict Medicare participants as close as possible to their last covered day” without regard to their medical needs, the suit alleges.

An email from owner and former chief executive officer Matthew Neiswanger is quoted in the suit. In the email, he states, “Total of 22 empty beds! … Fill beds with Medicaid if you can’t get Medicare!!!”




Jonathan Chait for New York Magazine had a great article on the Republican strategy to repeal ObamaCare and replace it with nothing.  He argues they have no plan and no political courage to pass anything.  Below are excerpts:

The Republican Party has used health care to its advantage for the last seven years by following the same strategy: advocating an alternative plan that does not and cannot exist. During this entire time, President Obama has held power. This has afforded them the luxury of posturing against the status quo — and, indeed, doing everything in their power, at both the federal and the state level, to make it worse.

The closer they get to taking action, the more clear it becomes to Republicans that their own propaganda has trapped them and given them no escape. Railing against Obamacare was easy, but the responsibilities of power have taken all the fun out of denying medical care to the poor and sick.

A large number of Trump voters who get coverage through Obamacare “simply felt Trump couldn’t repeal a law that had done so much good for them,” reports Sarah Kliff, who spoke with many of them.

But any plan to replace Obamacare with something “terrific,” or even something almost as good as Obamacare, will violate conservative dogma. There’s no way around this. Despite the apparent complexity of the issue, it’s a very simple problem of resource allocation. In a free-market system, tens of millions of Americans will not be able to afford medical care because the cost of their treatment exceeds their income, either because they’re too poor, or because they’re too sick.

A Kaiser Family Foundation analysis finds that 52 million Americans under the age of 65 have preexisting conditions that would make it impossible for them to purchase health insurance in the individual market that existed before Obamacare.

Covering people who can’t afford to pay for their own medical care means making other people pay for it. You can do that through direct tax-and-spend transfers, or through indirect regulatory methods (like making insurance companies overcharge healthy people and undercharge sick ones). Republicans oppose these methods because they oppose redistribution in general.

And yet politics requires them to promise a plan that does not deprive Americans of access to treatment. This is the reason none of their plans has advanced beyond the white-paper concept phase —either they contain too much redistribution to be acceptable to the GOP, or too little coverage to be acceptable to the public, or both.

Republican health-care plans go much, much farther in this direction. They offer threadbare, catastrophic coverage with enormous deductibles.

Congressional staffers tell Philip Klein, a staunch Obamacare critic, that they plan to repeal the law quickly, and then replace it not all at once but with a series of “legislative changes that could be enacted in a series of shorter bills … for instance, one bill could theoretically be passed to address individuals with preexisting conditions.” This plan is so laughably hopeless it’s difficult to believe Republicans would attempt it. It’s impossible to gauge the impact of one change to the health-care system without knowing what other changes will be enacted. None of the stakeholders in the health-care system is going to support any discrete changes that could dramatically alter their business models without knowing what other changes may or may not follow.

Preexisting conditions are an obvious example of this problem. If insurers will be required to provide below-cost plans to people with expensive medical needs, they need to know what other measures will be put in place to compensate them: Subsidies? Regulations on healthy customers? Hospitals need to know how many uninsured patients they should expect to show up in their emergency rooms. In particular, popular parts of health-care reform (like benefits people get) need to be attached to unpopular parts (like ways to pay for it).

If Republicans blow up Obamacare, “the media and the left will blame the repeal vote for any turmoil in insurance markets,” editorializes The Wall Street Journal, “Republicans will own health care, like it or not.”

John Goodman, a conservative health-care-policy activist, concedes, “It’s not going to be politically possible to throw 20 million people out on the street without health insurance.”

Repeal-and-delay is the ultimate backhand acknowledgement that the party has no answers.

If Republicans repeal Obamacare without creating a replacement, insurers will have little reason to stay in the marketplace. They’ll start canceling plans immediately, and the news will be filled with stories of Americans being thrown off their medication and, in some very real cases, dying.

Repeal-and-delay will actually require taking additional action to prevent a meltdown. Insurers have begun negotiating behind-the-scenes with Republicans in Congress for concessions that would allow them to continue to cover their existing customers.

Hospitals are also warning Republicans that blowing the system up without a replacement would expose them to massive financial risk.

The most likely answer is that Republicans never craft a replacement. They repeal Obamacare, but delay the effective date of the repeal, and then Obamacare becomes a “cliff” that Congress votes to keep extending.

There is no majority in Congress behind any one specific plan to replace Obamacare, but there is probably a majority against blowing it up immediately.

If Republicans truly believed Obamacare creates more victims than beneficiaries, they would blow it up immediately. And if they really had an alternative that was more popular, they would wait to write it before they eliminated it. Repeal-and-delay proves that neither one of these is true. They have no better plan. All they can do is promise some better plan lies over a horizon that will never arrive.


The L.A. Times reported that millions of Americans are scrambling to get insurance coverage through ObamaCare before the Republicans attempt to replace the successful health care law.  As of Dec. 24, more than 11.5 million people had enrolled in a health plan through one of the insurance marketplaces created by the law according to federal data. The coverage expansion has recorded historical gains in the last three years, as more than 20 million previously uninsured Americans obtained health insurance and the nation’s uninsured rate dropped to the lowest level ever recorded.

“Nationwide demand for health coverage is higher than ever, as Americans prove again that marketplace coverage is vital to them and their families,” Health and Human Services Secretary Sylvia M. Burwell said.

More than 10 GOP senators have publicly questioned the current push to repeal the law now and develop an alternative sometime in the next several years.  Republicans have never coalesced around an alternative or even submitted one to review by congressional committees or independent budget analysts.


Buzzfeed reported on the sordid politics of Georgia Republican Tom Price who has been chosen to lead the DHHS.  Price has long criticized federal spending as excessive unless it directly benefited his campaign donors.  Price has been a go-to congressman for medical special interests sparring with safety regulators or facing budget cuts. In other cases, he has gone to bat for companies whose executives and employees have generously contributed to his campaigns and political action committees.  He has won significant campaign support over the years from drug firms and physician groups.

Over the past decade, he has waded into issues related to specific drugs and medical devices, making 38 inquiries with the FDA, according to federal records obtained through the Freedom of Information Act. He questioned the FDA on his constituents’ behalf about matters as minute as a device for sperm analysis and an ingredient in pain creams.

In recent weeks, Price has come under criticism for his unethical and possibly illegal stock trading in drug companies, including an Australian firm that plans to seek US approval for a new drug.  The Australian firm Innate Immunotherapeutics said in an annual report that it plans to bring its key multiple sclerosis drug to the FDA for approval. Several months ago, Price purchased between $50,000 and $100,000 worth of stock in the company, according to a routine financial disclosure required of Congress members.




An overwhelming majority of people disapprove of Republican lawmakers’ plan to repeal the Affordable Care Act without having a ready replacement for the health care law.  NPR reported on a poll released by the Kaiser Family Foundation finds that 75 percent of Americans say they either want lawmakers to leave Obamacare alone, or repeal it only when they can replace it with a new health care law. Only twenty percent of those polled say they want to see the law killed immediately.

A separate study released projects that a straight repeal of the law could kill 3 million jobs across the country by 2021. Total business output could be cut by as much as $2.6 billion over four years, the report says.

Health care providers, hospital groups, consumer advocates, and the insurance industry have made it clear that they want to see a replacement for the Affordable Care Act in place before Congress repeals the current law.

A report released Dec. 6 by the American Hospital Association and Federation of American Hospitals warned that a repeal could cost hospitals hundreds of billions and said “any reconsideration of the ACA should be accompanied at the same time by provisions that guarantee similar coverage to those who would lose it.”

A letter sent Tuesday from the American Medical Association urged lawmakers to release details of their Obamacare replacement before repealing the current law.

There has been a lot of discussion and misinformation about the success and failures of the Affordable Care Act.  Several articles have appeared recently discussing the difficulty in repealing the Act and how to replace it with something that will be affordable and provide better quality of care.

New York Magazine had an article explaining that enrollment has spiked despite Trump’s vague promise to repeal and replace.

About 6.5 million more people have signed up for health insurance next year under the Affordable Care Act.  The new sign-ups — an increase of 400,000 over a similar point last year — mean the health care coverage of millions of consumers could be taken away by Trump. Consumers still have until the end of January to enroll.

Salon reported that a new report from Standard & Poor’s projected that 2017 will actually be a good year for the ACA and for insurers participating in the marketplaces, “with more insurers getting close to break even or better.” What the insurers want from the Obamacare marketplaces is for more healthy people to sign up and pay for coverage. This report suggests that might happen.

As for those who’ve already benefited from the ACA, the Urban Institute just put out a big study breaking down what kinds of people have gained coverage over the past few years. It found that there’s been a nearly 40 percent drop in the national uninsured rate since 2010, and that “men and women of all ages and across race, ethnicity, and education levels benefited from gains in coverage.” Significantly, the report found a major disparity in coverage gains when comparing states that cooperated with ACA implementation and those that did not: “States that expanded Medicaid under the ACA saw larger percentage reductions in their number of uninsured residents than did states that chose to not expand Medicaid (45 percent compared with 29 percent).”

This rash of year-end data provides ammunition for the law’s supporters to make a plausible counterargument: More people are signing up for coverage, the marketplace outlook is getting better, and many millions of people have already benefited.

NPR explained the difficulty with repealing ObamaCare for one big reason: Republicans have pledged to repeal the taxes that Democrats used to pay for their health law. Without that money, Republicans will have far less to spend on whatever they opt for as a replacement.

The health law’s subsidies to individuals buying insurance and the Medicaid expansion are funded by two big pots of money.

The first is a series of taxes, including levies on individuals with incomes greater than $200,000, health insurers, makers of medical devices, brand-name drugmakers, people who use tanning salons, and employer plans that are so generous they trigger the much-maligned “Cadillac Tax.” Some of those measures have not yet taken effect.

The other big pot of money that funds the benefits in the health law comes from reductions in federal spending for Medicare (and to a lesser extent, Medicaid). Those include trims in the scheduled payments to hospitals, insurance companies and other health care providers, as well as increased premiums for higher-income Medicare beneficiaries.

CBO estimated in 2015 that canceling the cuts would boost federal spending by $879 billion from 2016 to 2025.  However, the Congressional Budget Office estimated in early 2016 that repealing those provisions would reduce taxes by an estimated $1 trillion over the decade from 2016-2025.

“Repealing all the ACA’s taxes as part of repeal and delay only makes a true replacement harder,” wrote Loren Adler and Paul Ginsburg of the Brookings Institution in a white paper out Monday. It “would make it much more difficult to achieve a sustainable replacement plan that provides meaningful coverage without increasing deficits.”

Republicans will have two options if and when they try to replace the ACA’s benefits — not paying for them at all, thus adding to the federal deficit or cutting Medicare and Medicaid leaving millions of Americans without any coverage.

ObamaCare’s core elements remain highly popular including protection for people with pre-existing conditions and the availability of financial assistance for people who can’t afford coverage on their own ― which, in a Henry J. Kaiser Family Foundation poll, 80 percent of Americans said they support.

The same Kaiser Foundation poll found that roughly half of Americans want to keep Obamacare in place or expand what it does. Another 17 percent merely wants Congress to scale it back, while just over a quarter want full repeal ― and even that enthusiasm wanes when respondents learn that repeal might mean eroding the law’s consumer protections.