How Data Mining Facebook Messages Can Reveal Substance Abusers -

Substance abuse changes people’s patterns of behavior, and this is detectable in their social media messages, say researchers.

• by Emerging Technology from the arXiv
 
• May 26, 2017

“A substance use disorder (SUD) is a condition in which recurrent use of substances such as alcohol, drugs and tobacco causes clinically and functionally significant impairment in an individual’s daily life.” So begin Warren Bickel from the Addition Recovery Research Center in Roanoke, Virginia, and a couple of pals, who study this condition.

Substance abuse is a serious concern. Around one in 10 Americans are sufferers. Which is why it costs the American economy more than $700 billion a year in lost productivity, crime, and health-care costs. So a better way to identify people suffering from the disorder, and those at risk of succumbing to it, would be hugely useful.

Bickel and co say they have developed just such a technique, which allows them to spot sufferers simply by looking at their social media messages such as Facebook posts. The technique even provides new insights into the way abuse of different substances influences people’s social media messages.

The new technique comes from the analysis of data collected between 2007 and 2012 as part of a project that ran on Facebook called myPersonality. Users who signed up were offered various psychometric tests and given feedback on their scores. Many also agreed to allow the data to be used for research purposes.

One of these tests asked over 13,000 users with an average age of 23 about the substances they used. In particular, it asked how often they used tobacco, alcohol, or other drugs, and assessed each participant’s level of use. The users were then divided into groups according to their level of substance abuse.

The results make for interesting reading. The team says its technique was hugely successful. “Our best models achieved 86%  for predicting tobacco use, 81% for alcohol use and 84% for drug use, all of which significantly outperformed existing methods,” say Bickel and co.

The technique also identified a wide range of keywords that people with substance abuse disorder are more likely to use in social media posts. “Swear words such as ‘fuck’ and ‘shit,’ sexual words such as ‘horny’ and ‘sex,’ words related to biological process such as ‘blood’ and ‘pain’ are positively correlated with all three types of substance use disorder,” say Bickel and co, referring to tobacco, alcohol and drug use. “In addition, female references such as ‘girl’ and ‘woman,’ prepositions, space reference words such as ‘up’ and ‘down’ are positively correlated with alcohol use, while words related to anger such as ‘hate’ and ‘kill,’ words related to health such as ‘clinic’ and ‘pill’ are positively correlated with drug use.”

That’s interesting work that immediately suggests a way to identify people who are at risk of substance use disorder—simply look at their Facebook posts and likes. “We believe social media is a promising platform for both studying SUD-related human behaviors as well as engaging the public for substance abuse prevention and screening,” say Bickel and co.


How Data Mining Facebook Messages Can Reveal Substance Abusers - MIT Technology Review

Washington's Princes of Paperwork Are Crushing Physicians and Bankrupting, If Not Killing, Patients

Totally neglected in the ACA and proposed AHCA is restricting the mounting paperwork burden placed on providers. This is a critical issue.  Each "improvement" which is proposed to increase quality of care, or reduce cost creates a paradoxical effect.  This is the reduction in patient care, increased non clinical paperwork and the addition of EHR and other HIT cost.

This issue must be addressed in any new health reform law.

Steve Hanke ,  

 CONTRIBUTOR

I cover economics and finance.  

Opinions expressed by Forbes Contributors are their own.

Thomas Eakins

The Agnew Clinic (1889).

In the rancorous to and fro over the repeal of ObamaCare and its possible replacement with the American Health Care Act, an elephant in the room has remained unnoticed. It’s that giant bundle of burdensome regulations that is crushing physicians, their staffs, and sending the costs of healthcare soaring.

A recent, detailed study published by the American Medical Association (AMA) sheds a common-sense light on what Washington chooses to ignore. For every hour physicians spent with patients, almost two additional hours are spent pushing papers. Even when face-to-face with patients, doctors spent 37% of their time filling out forms.

Burdened with the weight of regulatory paperwork, doctors are becoming increasingly unhappy – more paperwork, less time with patients. Indeed, in a typical day, during office hours, doctors spent only 27% of their time attending to patients face-to-face and 49.2% on electronic health records (EHR) and desk work. Even during after-hours work, doctors spent a whopping 59% of this time dealing with electronic health records.

The following table summarizes the AMA’s stunning findings. It tells the red-tape tale in horrifying detail.

Just why do regulators promulgate so many regulations and produce so much red tape? For one thing, it creates jobs for the boys (read: the Princes of Paperwork). There is no better bulletproofing for a bureau’s bloated budget than a complex maze of regulations that “must” be enforced to protect the public’s health and safety.

But, there is another, perhaps more important, reason why regulatory bureaus produce endless miles of red tape to wrap around doctors, medical staffs, and the U.S. healthcare system. Bureaucrats are conservative. They like to avoid risks, and decision making is an inherently risky activity. After all, decisions can prove to be wrong, unpopular, or both. So, to avoid the risks and responsibilities that come with discretion and decision making, regulators produce rigid rules and red tape – the more, the merrier. The regulators’ check-the-box mentality allows them to slip out from under any responsibility if something under their regulatory purview “goes wrong.” The regulators are protected, and the onus is placed on the doctors and their staffs who must check all those boxes – boxes that cover everything under the sun.

Washington's Princes of Paperwork Are Crushing Physicians and Bankrupting, If Not Killing, Patients

The Cover up of Health Care Provider Abuse.

Let's take a listen to ZdoggMD.  Zdogg is a physician who began Turntable Health in Las Vegas, as a unique direct payment model with a heavy emphasis on patient engagement and wellness.

Dr Z as he is well known also is an entertainer of some repute, with a considerable portfolio on his Youtube Channel.  His vignettes are at time serious but more often he addresses serious problems with a thick shellac of humor. Zdogg has given commencement addresses and is a nationwide speaker at medical meetings.

Here he take on the issue of dangerous assaults on first line responders, and nurses. In this case he elaborates on a case of a nurse being assaulted and raped, and the dereliction of duty by a correctional officer on the scene.  Listen to the horrific story.

It Is Time for Doctors to Fight Back

DesignPrax/Shutterstock.com

Recently a featured post on Doximity, a professional closed physician social media web site an article appeared, " Is it Time for Doctors to Fight Back?"

Matthew Hahn, MD · May 8, 2017

The American health-care system is broken, but it is not really “health-care” that is the problem. The science of medicine, the tests, and the treatments available are better than ever. It is health-care bureaucracy that is the problem. But doctors, nurses, and patients bear the brunt of the dysfunction. Medical professionals are unable to practice, and patients are denied the care they need, even though it is readily available. Careers are being ruined, and lives lost along the way. It is time to fight back.

Instead of focusing on ways to improve patient care, medical professionals today have to wade all day through a jungle of red tape just to get paid, order tests, and deliver treatments. Cumbersome government rules control the details of how we write notes, use a computer, calculate a bill, how much we can charge, who we can admit to the hospital, how long we can treat them, and much, much more.

And for everything we do, there must now be data. The bureaucracy is obsessed with data, to the detriment of everything else. It is tyranny through data. We spend so much time collecting data and running after all of these things that it is a challenge to find the time to actually care for patients! On top of that, newer health insurance policies with high premiums, high deductibles, prior authorizations, and narrow, inscrutable coverage block us from delivering the care patients need. It is health care by government and insurance company fiat. Medical professionals and patients have few choices and little control.

And now, on top of everything else, we face Medicare’s complicated new MACRA “value-based payment” program, which collects data across four categories: Quality Measures, Advancing Care Information, Performance Improvement Activities, and Cost. A physician’s annual score will be compared to the scores of other physicians to determine future Medicare pay increases or penalties. There is a huge effort being made to explain the intricacies of the new program, the first sign that it is too 

And for everything we do, there must now be data. The bureaucracy is obsessed with data, to the detriment of everything else. It is tyranny through data. We spend so much time collecting data and running after all of these things that it is a challenge to find the time to actually care for patients! On top of that, newer health insurance policies with high premiums, high deductibles, prior authorizations, and narrow, inscrutable coverage block us from delivering the care patients need. It is health care by government and insurance company fiat. Medical professionals and patients have few choices and little control.

And the sad fact is that none of this data and/or analytics has been shown to improve care or costs. Most studies have been poorly designed, and never been confirmed.

For those of you wish to dive more deeply into . Medicare, MACRA, and other regulatory issues click on these links:

And now, on top of everything else, we face Medicare’s complicated new MACRA “value-based payment” program, which collects data across four categories: Quality Measures, Advancing Care Information, Performance Improvement Activities, and Cost. A physician’s annual score will be compared to the scores of other physicians to determine future Medicare pay increases or penalties. There is a huge effort being made to explain the intricacies of the new program, the first sign that it is too complicated to be of benefit.

It Is Time for Doctors to Fight Back

More and more physicians are no longer sitting by and allowing administrators to devalue patient care and set artificial metrics for quality of care.  Quality of care now, is measure by the number of boxes checked of in an electronic health records.  Simplistic measures such
Sickcare is sick and innovation can help make it more like a healthcare system. Forces are already in play making that happen, but it will take a substantial effort still to achieve a more cost-effective, user friendly and efficient system. Overcoming the political, economic and cultural barriers of government, academia, business and sick care is indeed a Herculean task. 

Trump's policies are pressing doctors to speak out

ACA repeal efforts and other Trump administration policies are getting unprecedented pushback from the medical community.A lot is on the line. The House has passed legislation to replace the ACA in the American Health Care Act (ACHA), and the Senate is working on its own repeal bill. Funding for women’s health programs and protections for people with preexisting conditions are at risk of being cut or eliminated. The president’s budget would slash Medicaid by more than $600 billion. And Trump’s executive order on immigration threatens to curb the supply of foreign doctors.Doctors are speaking out against the administration's policies in public media, in protests, through petitions and in direct conversations with lawmakers, either in Washington or during town halls in their districts. For the most part, their employers support them. Doctors are careful to separate their patient contact from their political activity, but many view protesting as not only a right, but also an obligation.

In an opinion piece in the Washington Post, Dr. Dhruv Khullar urged Congress and the White House to ensure that no one with health insurance today would lose coverage in the future. “My patients can’t wait for policies that appeal to this political lobby or that political base,” he wrote. “Any lapse in insurance coverage affects the care they get — or don’t get — First do no harm

Doctors must toe a fine line in balancing political advocacy and their responsibilities to patients.

The American Medical Association’s (AMA) Code of Medical Ethics encourages doctors to “stay well informed” about proposed healthcare policies and “work toward and advocate for the reform and proper administration of laws related to healthcare.” However, it draws a line against mixing politics with patient care. According to Section 2.3.4, physicians should “be sensitive to the imbalance of power in the patient-physician relationship” and “refrain from political conversations during the clinical encounter.”

The American College of Physicians (ACP) encourages its members to take a stand on issues affecting healthcare. “We have been advocating very, very strongly in support of the ACA and against the AHCA,” Dr. Jack Ende, president of the ACP, tells Healthcare Dive, adding that the college focuses on policies and not political parties or politicians. “If the evidence shows that the public is better served with one program, that’s the program we support,” he says.There have also been turnouts at GOP town hall in support of the Affordable Care Act and callers expressing concerns about HHS Secretary Tom Price’s ties to healthcare companies. The public outcry puts businesses in a bind that ultimately just want to make money. Hospitals and health systems now have to consider their brand under the Trump administration.While health systems and other employers typically refrain from activism, most seem to support medical professionals’ right to protest policies they feel harm patients, so long a they do it on their own time.Care through a broader lens

For many physicians, the Trump era has sharpened the realization that staying in their office isn’t enough and that larger contextual issues play as important a role in a patient’s health as the treatments doctors prescribe.To influence the debate, Chhabra and some colleagues formed Clinician Action Network. The group now numbers about 70 physicians, many working in health policy and serving underserved populations, and studies the impact of policy decisions on patients to effectively advocate on their behalf. Obligation to speak out

Ende sees the increased activism as a reflection of a current trend to teach medical students and residents to be sensitive to problems in their workplace. If a hospital system doesn’t provide adequate nursing support or doesn’t address issues about patient experience, doctors have an obligation to speak out and try to push positive change. Speaking out on healthcare policies at the state and federal levels is a natural and logical extension of that trend.

If you are reading this and have not spoken out.  Do so now !  Call or email your congressman or senator. Better yet, visit them in person !

Trump's policies are pressing doctors to speak out | Healthcare Dive

How To Discourage a Doctor | THCB

I came across this series of articles and comments whilst researching for today's post.



The hospital is not a friend of the doctor. These stories will illuminate what many physicians face. Perhaps it is not a uniform policy, and perhaps the tide has turned with the battle being won by hospital conglomerates.  The days of the local community hospitals is about over, due to mergers and acquisitons forced by economic necessity and solvency.  For most of the hospitals who did not merge are now gone.

These are the daily battles that your physician(s) endured to care for patients. Shameful !  While there are many hospital executives that do not subscribe to these tactics a few bad apples spoil the barrel.

The details of the article are much too long to long to repeat here, these are some of the high points.

"Not accustomed to visiting hospital executive suites, I took my seat in the waiting room somewhat warily. That was when I spotted the document on an adjacent chair. Its title immediately caught my eye: “How to Discourage a Doctor.” No one else was about, so I reached over, picked it up, and began to leaf through its pages. It became apparent immediately that it was one of the most remarkable things I had ever read, clearly not meant for my eyes. 

My recollection of its contents is naturally somewhat imperfect, but I can reproduce the gist of what it said. “The stresses on today’s hospital executive are enormous. They include a rapidly shifting regulatory environment, downward pressures on reimbursement rates, and seismic shifts in payment mechanisms. Many leaders naturally feel as though they are building a hospital in the midst of an earthquake. With prospects for revenue enhancement highly uncertain, the best strategy for ensuring a favorable bottom line is to reduce costs. And for the foreseeable future, the most important driver of costs in virtually every hospital will be its medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.

“Though physician compensation accounts for only about 8% of healthcare spending, decisions that physicians strongly influence or make directly – such as what medication to prescribe, whether to perform surgery, and when to admit and discharge a patient from the hospital – have been estimated to account for as much as 80% of the nation’s healthcare budget. To maintain a favorable balance sheet, hospital executives need to gain control of their physicians. Most hospitals have already taken an important step in this direction by employing a growing proportion of their medical staff.  “Merely controlling the purse strings is not enough. To truly seize the reins of medicine, it is necessary to do more, to get into the heads and hearts of physicians. And the way to do this is to show physicians that they are not nearly so important as they think they are. Physicians have long seen the patient-physician relationship as the very center of the healthcare solar system. As we go forward, they must be made to feel that this relationship is not the sun around which everything else orbits, but rather one of the dimmer peripheral planets, a Neptune or perhaps Uranus.

“How can this goal be achieved? A complete list of proven tactics and strategies is available to our clients, but some of the more notable include the following:

“Make healthcare incomprehensible to physicians. It is no easy task to baffle the most intelligent people in the organization, but it can be done. For example, make physicians increasingly dependent on complex systems outside their domain of expertise, such as information technology and coding and billing software. Ensure that such systems are very costly, so that solo practitioners and small groups, who naturally cannot afford them, must turn to the hospital. And augment their sense of incompetence by making such systems user-unfriendly and unreliable. Where possible, change vendors frequently.

“Promote a sense of insecurity among the medical staff. A comfortable physician is a confident physician, and a confident physician usually proves difficult to control. To undermine confidence, let it be known that physicians’ jobs are in jeopardy and their compensation is likely to decline. Fire one or more physicians, ensuring that the entire medical staff knows about it. Hire replacements with a minimum of fanfare. Place a significant percentage of compensation “at risk,” so that physicians begin
to feel beholden to hospital administration for what they manage to eke out.

“Transform physicians from decision makers to decision implementers. Convince them that their professional judgment regarding particular patients no longer constitutes a reliable compass.

“Subject physicians to escalating productivity expectations. Borrow terminology and methods from the manufacturing industry to make them think of themselves as production-line workers, then convince them that they are not working sufficiently hard and fast. Show them industry standards and benchmarks in comparison to which their output is subpar. On the off chance that their productivity compares favorably, cite numerous reasons that such benchmarks are biased and move the bar
progressively higher, from the 75th

“Increase physicians’ responsibility while decreasing their authority. “Above all, introduce barriers between physicians and their patients. The more directly physicians and patients feel connected to one another, the greater the threat to the hospital’s control.

How To Discourage a Doctor | THCB

A patient’s budding cortex — in a dish? | National Institutes of Health (NIH)

Frankenstein----in a petri dish

A patient’s budding cortex — in a dish? 

The modern version...Franken-dish does not have a bolt through it's head.

Budding brain-like “human cortical spheroids” growing in a petri dish. Sergiu Pasca, M.D., Stanford University

A patient tormented by suicidal thoughts gives his psychiatrist a few strands of his hair. She derives stem cells from them to grow budding brain tissue harboring the secrets of his unique illness in a petri dish. She uses the information to genetically engineer a personalized treatment to correct his brain circuit functioning. Just Sci-fi? Yes, but...

An evolving “disease-in-a-dish” technology, funded by the National Institutes of Health (NIH), is bringing closer the day when such a seemingly futuristic personalized medicine scenario might not seem so far-fetched. Scientists have perfected mini cultured 3-D structures that grow and function much like the outer mantle – the key working tissue, or cortex — of the brain of the person from whom they were derived. Strikingly, these “organoids” buzz with neuronal network activity. Cells talk with each other in circuits, much as they do in our brains.

Neurons and supporting cells in the spheroids form layers and organize themselves according to the architecture of the developing human brain and network with each other.Sergiu Pasca, M.D., Stanford University

Sergiu Pasca, M.D.(link is external), of Stanford University, Palo Alto, CA, and colleagues, debut what they call “human cortical spheroids,” May 25, 2015 online in the journal Nature Methods.

For further details:

A patient’s budding cortex — in a dish? | National Institutes of Health (NIH)

Personalized Medicine, The Dog whose Bark was much worse than it's bite.

Eric Topol M.D., soon followed by Barak Obama coined the term 'personalized medicine' (PMx).  It’s been about 16 years since Genentech launched Herceptin, a drug for breast cancer patients with a specific genetic mutation. At the time, Herceptin seemed to usher in a revolution for how drugs would be developed and patients would be cured.

In that new version of care, drugs could be tailored to a patient’s specific biochemical profile, dramatically improving efficacy rates and reducing the system-wide costs and complications associated with one-size-fits-all medications. For pharmaceutical manufacturers, this approach had the potential to improve sales and profits through a radically new business model: differentiated products for segmented populations (see “A Strategist’s Guide to Personalized Medicine,” by Avi Kulkarni and Nelia Padilla McGreevy, s+b, Winter 2012).


But despite the occasional success story, PMx is largely seen today as the dog that did not bark. With a few exceptions, such as Herceptin, there are few PMx success stories. This is true for several reasons. 

Health insurers remain unconvinced of PMx’s merits. One would expect these companies to push hard for personalized medicine, considering that they are the main beneficiaries of more efficient healthcare. Yet most payors seem to believe that the economic benefits of PMx are relatively small. The few PMx-based therapeutics now on the market are much more expensive than conventional therapies—and the prices don’t always translate to proportionately better outcomes, such as higher survival rates. For example, Bristol-Myers Squibb released a new metastatic melanoma therapy called Yervoy in the U.S. in 2011. Yervoy costs US$120,000, but in Phase III trials, it added only about 3.7 months of survival time.

In addition, many pharma companies have been hesitant to make the necessary investments in personalized medicine. The steep costs required, including best-in-class PMx development and commercialization capabilities, seem out of proportion to the small markets for each drug. Cancer drugs are the exception, but pharmaceutical companies have focused less on the genetic causes of other diseases. That makes PMx a costlier and riskier proposition.

Finally, the reason success stories are so rare is a notable reluctance among physicians to adopt PMx. Medicine is a cautious discipline, understandably, and in some cases PMx requires practitioners to dispense diagnoses and treatments based on complex molecular changes. For example, in the 10 years since Genomic Health launched its pivotal Oncotype DX test, which can determine the recurrence risk of breast cancer and assess the likely benefit of certain types of chemotherapies, it has faced steep resistance from the medical community. Even though Oncotype DX has been proven as medically relevant technology, and been widely reimbursed by payors, analysts estimate that it is used on only half of all eligible patients.

Despite the promise of fewer and less serious complications than toxic chemotherapy using PMx to treat malignancy, they have other and even more serious side effects causing heart, and liver disorders.

There is much more to be done until this methodology enters the main stream.

A Diagnosis for Personalized Medicine

Consumer oriented Genomics and Ancestry.com

Ancestry.com takes DNA ownership rights from customers and their relatives

A word to the wise: Read the complete terms of service.

Read the fine print before you send in your sample to Ancestry.com .  The bottom line is you consent to give ownership of your genetic information to Ancestry.com . Ancestry.com can use your genotype for anything it wants.  They can use methods to copy it, transcribe it, modify it and use it for whatever purposes they want and gain profit from it.

There are three significant provisions in the AncestryDNA Privacy Policy and Terms of Service to consider on behalf of yourself and your genetic relatives: (1) the perpetual, royalty-free, world-wide license to use your DNA; (2) the warning that DNA information may be used against “you or a genetic relative”; (3) your waiver of legal rights.

So, you still own your DNA, however Ancestry.com also owns it. It is not a partnership.  Normally when a company owns something that they don't own they pay a royalty payment each time it is used. Essentially you are paying them to use your DNA.  What do you get in return ?  Their marketing literature explains it.

The AncestryDNA service promises to, “uncover your ethnic mix, discover distant relatives, and find new details about your unique family history with a simple DNA test.”

For the price of $69 dollars and a small saliva sample, AncestryDNA customers get an analysis of their genetic ethnicity and a list of potential relatives identified by genetic matching. Ancestry.com, on the other hand, gets free ownership of your genetic information forever. Technically, Ancestry.com will own your DNA even after you’re dead.

Specifically, by submitting DNA to AncestryDNA, you agree to “grant AncestryDNA and the Ancestry Group Companies a perpetual, royalty-free, world-wide, transferable license to use your DNA, and any DNA you submit for any person from whom you obtained legal authorization as described in this Agreement, and to use, host, sublicense and distribute the resulting analysis to the extent and in the form or context we deem appropriate on or through any media or medium and with any technology or devices now known or hereafter developed or discovered.”

Basically, Ancestry.com gets to use or distribute your DNA for any research or commercial purpose it decides and doesn’t have to pay you, or your heirs, a dime. Furthermore, Ancestry.com takes this royalty-free license in perpetuity (for all time) and can distribute the results of your DNA tests anywhere in the world and with any technology that exists, or will ever be invented. With this single contractual provision, customers are granting Ancestry.com the broadest possible rights to own and exploit their genetic information.

The AncestryDNA terms also requires customers to confirm that, “You understand that by providing any DNA to us, you acquire no rights in any research or commercial products that may be developed by AncestryDNA that may relate to or otherwise embody your DNA.” Essentially, you still own your DNA, but so does Ancestry.com. And, you can commercialize your own DNA for money, but Ancestry.com is also allowed to monetize your DNA for millions of dollars and doesn’t have to compensate you.

Although AncestryDNA customers provide voluntary consent to have their DNA used in commercial research projects, customers are free to withdraw consent, with a few exceptions. First, “data cannot be withdrawn from research already in progress or completed, or from published results and findings.” In those cases, Ancestry.com has access to data about you indefinitely.

Secondly, if a customer withdraws their consent, Ancestry.com will take 30 days to cease using their data for research. Finally, withdrawing consent, “will not result in destruction of your DNA Sample or deletion of your Data from AncestryDNA products and services, unless you direct us otherwise.” Customers must jump through additional hoops if they want their DNA sample destroyed or their data deleted from AncestryDNA products and services. The Ancestry.com policy does not specify what “additional steps” are required. U.S. customers must contact Ancestry.com customer service at 1–800–958–9124 to find out. (Customers outside the United States must call separate customer service numbers.)

Their marketing literature posted on their web site is rather seductive about the wonderful genomic science that will allow you to discover where your relatives come from or even connections with other members of your family.  It however, other than the legal disclosures when you  sign up says nothing about their legal claim to your genetic data. BEWARE !

https://thinkprogress.org/ancestry-com-takes-dna-ownership-rights-from-customers-and-their-relatives-dbafeed02b9e

UnitedHealth Doctored Medicare Records, Overbilled U.S. By $1 Billion, Feds Claim | California Healthline

The complexities of billing Medicare in Medicare Advantage Programs is leading to fraudulent claims.

Advantage plans are paid by Medicare according to a risk sharing formula and payments can vary from year to year.

By Fred Schulte

In a 79-page lawsuit filed in Los Angeles, the Justice Department alleged that the insurer made patients appear sicker than they were in order to collect higher Medicare payments than it deserved. The government said it had “conservatively estimated” that the company “knowingly and improperly avoided repaying Medicare” for more than a billion dollars over the course of the decade-long sche

UnitedHealth Doctored Medicare Records, Overbilled U.S. By $1 Billion, Feds Claim | California Healthline

Medicare pays the health plans using a complex formula called a risk score, which is supposed to pay higher rates for sicker patients than for people in good health. But waste and overspending tied to inflated risk scores has repeatedly been cited by government auditors, including the Government Accountability Office. A series of articles published in 2014 by the Center for Public Integrity concluded that improper payments linked to jacked-up risk scores have cost taxpayers tens of billions of dollars.

Tuesday’s court filing argues that UnitedHealth repeatedly ignored findings from its own auditors that risk scores were often inflated — and warnings by officials from the Centers for Medicare & Medicaid Services (CMS) — that it was responsible for ensuring the billings it submitted were accurate.

All but two of 37 Medicare Advantage plans examined in a 2007 audit were overpaid — often by thousands of dollars per patient. Overall, just 60 percent of the medical conditions health plans were paid to cover could be verified. The 2007 audits are the only ones that have been made public.

Audits in these cases are difficult to trace. One factor may be due to inaccurate coding and/or incomplete medical records from providers notes in either a chart or in an EHR.   This may be due to time pressures  and inadequate time allotment for providers to complete their CPT and ICD coding.

While the feds are focused on the insurance companies, part of the blame may rest on providers themselves...insulated now by another level of bureaucracy.  In an effort to reduce CMS cost, CMS has shifted the burden to Advantage plans.  The blame game comes into operation in this case.

The current complexity of billing is such that it encourages omissions and faulty record keeping. CMS audits numbers, codes for CPT and ICD, in a digital manner, not an analog manner.

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This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.