Medicare Is Faulted on Shift to Electronic Records


From the New York Times

November 29, 2012

By 

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

The report also takes to task another federal agency that certifies the software systems used to qualify for the Medicare incentive payments, saying it should do more to ensure the systems’ reports are accurate and meet the “meaningful use” criteria.

Medicare has not audited any of the $3.6 billion payments it has made to date, according to the report, which faults the agency for its lack of prepayment review and reliance on self-reporting after money has been spent.

In their written response to the report, federal officials said they agreed with some of the inspector general’s recommendations that they clarify what hospitals and doctors need to do to qualify for the payments. But Marilyn Tavenner, the acting administrator for Medicare, strongly disagreed with the idea that the agency should do more to ensure payments are appropriate before writing a check.

Requiring an audit before paying hospitals and doctors “could significantly delay payments to providers,” she said, and these reviews “would also impose an increased upfront burden on providers.” Ms. Tavenner said Medicare took some steps to make sure providers were eligible for the payments but “does not believe prepayment audit is necessary at this juncture.” Medicare maintains that it has systems in place to verify the information being submitted.

Medicare has developed plans to audit payments it has made since the program started in 2011 and says it expects to issue additional guidance for hospitals and doctors.

The other federal agency, the Office of the National Coordinator for Health Information Technology, agreed with the inspector general’s recommendations and said officials were already working to improve the process of certifying systems.

The inspector general said Medicare should be able to review at least some payments before they were made to determine whether the hospitals and doctors actually qualified. The investigators suggest identifying a small number of providers where the information provided was inconsistent and conducting a review or audit.

 

Silent State: The Campaign Against Whistleblowers in Washington


February 11, 2012

On January 23rd, the Obama administration charged former CIA officer John Kiriakou under the Espionage Act for disclosing classified information to journalists about the waterboarding of al-Qaeda suspects. His is just the latest prosecution in an unprecedented assault on government whistleblowers and leakers of every sort.

Kiriakou’s plight will clearly be but one more battle in a broader war to ensure that government actions and sunshine policies don’t go together. By now, there can be little doubt that government retaliation against whistleblowers is not an isolated event, nor even an agency-by-agency practice. The number of cases in play suggests an organized strategy to deprive Americans of knowledge of the more disreputable things that their government does. How it plays out in court and elsewhere will significantly affect our democracy.

Punish the Whistleblowers

The Obama administration has already charged more people — six — under the Espionage Act for alleged mishandling of classified information than all past presidencies combined. (Prior to Obama, there were only three such cases in American history.)

Kiriakou, in particular, is accused of giving information about the CIA’s torture programs to reporters two years ago. Like the other five whistleblowers, he has been charged under the draconian World War I-era Espionage Act.

That Act has a sordid history, having once been used against the government’s political opponents. Targets included labor leaders and radicals like Eugene V. Debs, Bill Haywood, Philip Randolph, Victor Berger, John Reed, Max Eastman, and Emma Goldman. Debs, a union leader and socialist candidate for the presidency, was, in fact, sentenced to 10 years in jail for a speech attacking the Espionage Act itself. The Nixon administration infamously (and unsuccessfully) invoked the Act to bar the New York Times from continuing to publish the classified Pentagon Papers.

Yet, extreme as use of the Espionage Act against government insiders and whistleblowers may be, it’s only one part of the Obama administration’s attempt to sideline, if not always put away, those it wants to silence. Increasingly, federal agencies or departments intent on punishing a whistleblower are also resorting to extra-legal means. They are, for instance, manipulating personnel rules that cannot be easily challenged and do not require the production of evidence. And sometimes, they are moving beyond traditional notions of “punishment” and simply seeking to destroy the lives of those who dissent.

The well-reported case of Thomas Drake is an example. As an employee, Drake revealed to the press that the National Security Agency (NSA) spent $1.2 billion on a contract for a data collection program called Trailblazer when the work could have been done in-house for $3 million. The NSA’s response? Drake’s home was raided at gunpoint and the agency forced him out of his job.

“The government convinced themselves I was a bad guy, an enemy of the state, and went after me with everything they had seeking to destroy my life, my livelihood, and my person — the politics of personal destruction, while also engaging in abject, cutthroat character assassination, and complete fabrication and frame up,” Drake told Antiwar.com. “Marriages are strained, and spouses’ professional lives suffer as much as their personal lives. Too often, whistleblowers end up broken, blacklisted, and bankrupted,” said the attorney who represents Drake.

In Kiriakou’s case, the CIA found an excuse to fire his wife, also employed by the Agency, while she was on maternity leave. Whistleblower Bradley Manning, accused of leaking Army and State Department documents to the website WikiLeaks, spent more than a year in the worst of punitive conditions in a U.S. Marine prison and was denied the chance even to appear in court to defend himself until almost two years after his arrest. Former chief military prosecutor at Guantanamo Morris Davis lost his career as a researcher at the Library of Congress for writing a critical op-ed for the Wall Street Journal and a letter to the editor at the Washington Post on double standards at the infamous prison, as did Robert MacClean for blowing the whistle on the Transportation Security Administration.

Four employees of the Air Force Mortuary in Dover, Delaware, attempted to address shortcomings at the facility, which handles the remains of all American service members who die overseas. Retaliation against them included firings, the placing of employees on indefinite administrative leave, and the imposition of five-day suspensions. The story repeats itself in the context of whistleblowers now suing the Food and Drug Administration for electronically spying on them when they tried to alert Congress about misconduct at the agency. We are waiting to see the Army’s reaction to whistleblower Lieutenant Colonel Daniel Davis, who documented publicly this week that senior leaders of the Department of Defense intentionally and consistently misled the American people and Congress on the conduct and progress of the Afghan War.

And this remains the most partial of lists, when it comes to recent examples of non-judicial government retaliation against whistleblowers.

Government bureaucrats know that this sort of slow-drip intimidation keeps people in line. It may, in the end, be less about disciplining a troublemaker than offering visible warning to other employees. They are meant to see what’s happening and say, “Not me, not my mortgage, not my family!” — and remain silent. Of course, creative, thoughtful people also see this and simply avoid government service.

In this way, such a system can become a self-fulfilling mechanism in which ever more of the “right kind” of people chose government service, while future “troublemakers” self-select out — a system in which the punishment of leakers becomes the pre-censorship of potential leakers. At the moment, in fact, the Obama administration might as well translate the famed aphorism “all that is necessary for evil to triumph is for good people to remain silent” into Latin and carve it into the stone walls of the CIA’s headquarters in Langley, Virginia, or NSA headquarters at Fort Meade, or the main office of the State Department at Foggy Bottom where I still fight to keep my job.

Silent State

I am told that, in its 223 years of existence, I am the only Foreign Service Officer ever to have written a critical book about the State Department while still employed there. We Meant Well: How I Helped Lose the Battle for the Hearts and Minds of the Iraqi People exposed what State did not want people to know: that they had wasted enormous amounts of money in Iraq, mostly due to ignorance and a desire for short-term successes that could be trumpeted back home. For the crime of writing this book and maintaining a blog that occasionally embarrasses, State Department officials destroyed my career, even as they confirm my thesis, and their own failure, by reducing the Baghdad Embassy to half its size in the face of Iraq’s unraveling.

“The State Department was aware of Mr. Van Buren’s book long prior to its release,” explains attorney Jesslyn Radack, who now represents me. “Yet instead of addressing the ample evidence of fraud, waste, and abuse in the book, State targeted the whistleblower. The State Department’s retaliatory actions are a transparent attempt to intimidate and silence an employee whose critique of fraudulent, wasteful, and mismanaged U.S. reconstruction efforts in Iraq embarrassed the agency.”

Without allowing any rebuttal or defense, State suspended my security clearance, claiming my blogging was an example of “poor judgment,” transferred me from a substantive job into a meaningless telework position, threatened felony conviction over alleged disclosure of classified information, illegally banned me from entering the building where I supposedly work, and continues to try to harass and intimidate me.

My travel vouchers from as far back as the law allows have come under “routine” re-examination. My Internet activity is the subject of daily reports. My credit reports have been examined for who knows what. Department friends who email me on topical issues have been questioned by agents of Diplomatic Security, the State Department’s internal police. My Freedom of Information Act request for documents to help defend myself and force State to explain its actions has been buried.

Without a security clearance, and with my Diplomatic Passport impounded, I will never serve overseas again, the lifeblood of being a Foreign Service Officer (FSO). A career that typically would extend another 10 years will be cut short in retaliation for my attempt to tell the truth about how taxpayer money was squandered in Iraq.

All of this has taken place in such a way that I cannot challenge it (except by writing and speaking about it in public — at additional risk). The State Department has standard disciplinary procedures that it could have invoked against me, but those leave room for public challenges and, in some cases, would allow me to force documents into the open that State would rather not share with you.

Hall Walkers: Ghosts in the Machine

Read more here

Obama: Cover Birth Control; 8 Egyptian Women Win


The Obama administration said Jan. 20 that health insurance plans must cover contraceptives for women without charge, and it rejected a broad exemption sought by the Roman Catholic Church for insurance provided to employees of Catholic hospitals, colleges and charities, reported the New York Times. But the administration said it would give some employers affiliated with churches an extra year to comply, meaning that coverage would not begin for their employees until well after the 2012 elections.

Church leaders had personally appealed to Obama to grant the exemption, and he made the final decision on the issue after hearing all points of view, administration officials said