Physician Exclusions From Medicare, Medicaid Increasing

Federal efforts to detect Medicare fraud may be driving an increase in the number of physicians excluded from Medicare and other forms of public insurance, according to the authors of a newly published study.

The number of physicians excluded from Medicare, Medicaid, and other state public insurance programs increased on average by 20% per year, or the equivalent of 48 additional cases a year, between 2007 and 2017, said Anupam B. Jena, MD, PhD, of Harvard Medical School and colleagues. They report their findings in an article published online today in JAMA Network Open.

“There were several explanations for the observed increase in exclusions, and rates of identified health care fraud, waste, and abuse,” Jena and colleagues write. “First, this finding could be evidence that regulators, who have been aided by recent public policies targeting the reduction of fraud and waste, may be getting better at identifying perpetrators of fraudulent activity.”

Since 2011, the Centers for Medicare & Medicaid Services has used predictive analytics to detect improper billing, the authors note. In addition, the Affordable Care Act of 2010 allocated $350 million to the Department of Health & Human Services’ Health Care Fraud and Abuse Control Account. The law also increased sanctions, including allowing state Medicaid programs to halt payments and requiring that Medicare overpayments be returned within 60 days instead of 3 years.

Jena and colleagues also cite the growth in the total number of US physicians participating in public insurance as a possible cause for the rising number of exclusions.

The implementation of the Affordable Care Act of 2010 allowed more people to gain access to public insurance programs. Enrollment in any government health insurance plan increased by 12.6% total from 2013 to 2017, which is significantly greater than the 7.9% increase in private insurance enrollment, the authors note.

“We cannot exclude the possibility that the increase in physician exclusions reflects a rise in fraudulent and untoward practices by US physicians,” the authors add. “However, we are unaware of any published data that support this potential explanation.”

Overall, the researchers found that 2222 physicians, or 0.3% of US physicians, were temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017 for fraud, unlawful prescribing of controlled substances, or health crimes.

Physicians can be excluded from Medicare and other public insurance programs for a variety of reasons. Common causes include the illegal distributing, prescribing, and dispensing of controlled substances such as opioids and surgical anesthetics. Other reasons include billing for services not rendered and filing duplicate claims and providing medically unnecessary procedures.

Jena and colleagues describe their study as “the most comprehensive and contemporary effort to assess trends in physician exclusion from participation in public health insurance owing to fraud, waste, and abuse concerns, and physician characteristics associated with exclusion.”

For the analysis, they matched each physician’s unique national provider identifier to their profile in Doximity, an online networking service that collects personal and professional information about physicians.

The authors found notable variation in the rates of exclusion, which were highest in the West and Southeast. With 32 exclusions among 5720 physicians, West Virginia had the highest rate of exclusions at 5.77 per 1000. Montana, in contrast, had 0 exclusions during the study period.

“Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion,” the authors said.

Hospital Readmission Not a Good Quality Measure for Children.

Preventable readmission rates for children are lower than all-cause readmission rates, according to a new study.

“The concern that many of us have is that there is much less to be gained from a major effort to reduce pediatric readmissions because so many are due to an unpredictable disease process,” James Gay, MD, from Monroe Carell Jr. Children’s Hospital at Vanderbilt University in Nashville, Tennessee, told Medscape Medical News.

“Pediatricians try very hard to keep their patients out of the hospital in the first place,” he explained, “so a large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall, and it might actually distract from efforts in other areas, such as concentrating on patient safety.”

Dr. Gay presented the results here at the American Academy of Pediatrics 2013 National Conference and Exhibition.

Pressure is on at hospitals to reduce 30-day readmissions, which are considered by some regulators to be a metric of patient safety and quality care. The Affordable Care Act requires a hospital readmission reduction program for facilities that treat Medicare patients and imposes penalties for institutions with high rates.


A large investment of time, energy, and funds to reduce pediatric admissions may not be very beneficial overall.


Hospital administrators are therefore keen to identify preventable readmissions. Some state Medicaid programs use the 3M Potentially Preventable Readmissions grouping software; however, data on its use in pediatric readmissions are lacking, said Dr. Gay.

His team assessed 1,749,747 hospitalizations in 58 Children’s Hospital Association member hospitals. They used the 3M software to calculate all-cause readmission rates with the company’s proprietary list of 314 All Patient Refined Diagnostic Related Groups.

The software flagged 80% or more of all-cause readmissions as potentially preventable for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy. In contrast, the software suggested that more than 40% of 30-day readmissions were not preventable, including those for seizures, gastroenteritis, central line infections, urinary tract infections, and failure to thrive.

For the 20 leading patient diagnostic groups for all-cause readmissions, the software algorithm removed chemotherapy, acute leukemia, and cystic fibrosis from the list of potentially preventable reasons.

Table. All-Cause vs Preventable Pediatric Readmissions


All-Cause Readmissions (%)

Preventable Readmissions (%)











“There are many fewer pediatric than adult hospitalizations in the first place, and the numbers and rates of readmissions are lower in children,” Dr. Gay pointed out. According to Medicare estimates, “older adults have readmission rates of about 20% at 30 days. The overall pediatric rates are closer to 6% to 10%,” he added.

Conditions that drive hospital readmission in children, or lead to admission in the first place, are very different from those in adults, Dr. Gay said. For example, adults are more likely to be readmitted within 30 days because of a high prevalence of chronic conditions, like congestive heart failure and chronic obstructive pulmonary disease, whereas children have more acute illnesses, such as pneumonia, bronchiolitis, and asthma.

“Because of these issues, many hospital pediatricians believe that readmission rates are not a good quality measure for pediatrics,” Dr. Gay said.

Asked by Medscape Medical News to comment on this study, Mark Shen, MD, from Dell Children’s Medical Center in Austin, Texas, noted that “in this study, the single most common reason for readmission was chemotherapy. We expect these kids to come back — we’ve wiped out their immune system.”

Other children are discharged with the expectation they will return as well, he added. “Sometimes we know they’re coming back. We’re just giving them a break at home, such as children with sickle cell disease or ventricular shunts.”

This study is useful because it indicates that the rate of 30-day hospital readmission is lower for children than for adults. Further research could focus on key chronic conditions associated with more readmissions in children, which so far only have been identified in adults. “But we’re getting closer in pediatrics,” Dr. Shen added.

The study authors caution that the 3M software might not completely reflect the reasons for pediatric readmissions, and future studies are warranted to validate its use in this population. The broader issue is whether efforts to track and reduce adult hospital readmissions apply equally to pediatric patients, Dr. Gay said.

Feds Investigate Antipsychotic Prescribing in Children.

The US Department of Health and Human Services’ Office of Inspector General (OIG) has launched a probe into the prescribing of atypical antipsychotic medications to children under Medicaid.

“We will determine the extent to which children ages 18 and younger had Medicaid claims for atypical antipsychotic drugs during the selected time frame,” the office said in a summary of the plan.

“On the basis of medical record reviews, we will also determine the extent to which the atypical antipsychotic drug claims were for off-label uses and for indications not listed in one or more of the approved drug compendia.”

The time frame is a 6-month period from January to June 2011, when 84,654 children were prescribed antipsychotics in the 5 states selected for the probe, where Medicaid prescriptions are the highest — California, Texas, Illinois, New York, and Florida — said OIG spokesperson Donald White.

Psychiatric experts have been recruited to evaluate approximately 700 of the medical records as part of the ongoing effort, White told Medscape Medical News.

“We are currently conducting the medical record reviews, and the probe will likely last several months, possibly into 2014,” he said.

Lack of Funding for CBT

The probe is focusing on atypical antipsychotics such as aripiprazole (Abilify, Otsuka Pharmaceutical Co., Ltd.), risperidone (Risperdal, Ortho-McNeil-Janssen Pharmaceuticals, Inc.), quetiapine fumarate (Seroquel, AstraZeneca Pharmaceuticals LP), and olanzapine (Zyprexa, Eli Lilly and Company).

A previous probe by the OIG on the overuse of antipsychotics in nursing homes, which resulted in action by the Centers for Medicare and Medicaid Services (CMS) to reduce the use of the drugs by 15%, was launched in response to a request from Congress; however, the new probe was launched by the OIG itself, White said.

Concern over the overprescribing of antipsychotics to children in the Medicaid program is not new — a 2004 study found that children in the healthcare system from low-income families were 4 times as likely to be prescribed antipsychotics as those who were privately insured.

As reported by Medscape Medical News, a more recent study showed that the use of antipsychotic medications among Medicaid-insured children from low- or very-low-income families soared 7-fold to 12-fold between 1997 and 2006.

Among side effects of concern associated with atypical antipsychotics are weight gain and diabetes, and little is known on the long-term neurologic effects of the drugs used in early childhood.

One important reason why the prescribing of antipsychotics to children is believed to be higher among children under Medicaid coverage is that the system simply is not as accommodating to the best-known alternative — cognitive-behavioral therapy, according to Pensacola, Florida–based child psychiatrist Scott R. Benson, MD.

“The reimbursement for the kind of cognitive-behavioral therapy that could help these children is lower with Medicaid, so children who are covered by private insurance may have access to a better range of therapies,” he told Medscape Medical News.

“But part of this is our own fault on a professional level — we [psychiatrists] have not made a good enough case for the value of psychotherapy in helping children,” added Dr. Benson, who is a member of the American Psychiatric Association.

Infants, Toddlers Prescribed Atypicals

Dr. Benson said clinicians too often associate the option of cognitive-behavioral therapy with being arduous and time-consuming.

“The patient doesn’t necessarily have to be coming in 3 times a week over 10 years — there is plenty of evidence showing, especially for children who have been traumatized, that even short-term therapy, maybe once-a-week visits over 20 weeks, can be a very effective treatment.”

Among the more alarming figures regarding prescribing atypical antipsychotics to children are those showing prescriptions to the very young, including toddlers and infants.

As reported in a recent article in the Wall Street Journal, the inspector general’s 5-state probe found 482 children aged 3 years and younger who were prescribed antipsychotics during the 6-month period in question, including 107 children who were aged 2 years and younger.

Six children prescribed the drugs were younger than 1 year, and 1 was listed as being 1 month old.

Importantly, the records did not identify the diagnoses involved, and Dr. Benson speculated that some may have included children with certain severe disorders, such as autism.

“It’s important to remember that the majority of these prescriptions are not even written by child psychiatrists,” he said. “In the case of the very young children, these may have represented prescriptions from neurologists who were treating patients with severe autistic disorders.”

Quick Fix?

Others, however, may have been practitioners such as pediatricians, who, facing heavy patient loads, are often under pressure to make a quick diagnosis and reach for a quick fix — an antipsychotic.

“A practitioner may observe a few behaviours, say ‘that’s terrible,’ and simply prescribe something the patient doesn’t really need because there wasn’t enough time or interest in doing the kind of good, standard evaluation that all of us would expect for our children,” Dr. Benson said.

“Certainly all patients deserve that, regardless of their insurance situation.”

A complex range of psychiatric issues may cause a child to appear dysregulated, and a full evaluation is essential before writing that prescription, said Mary Margaret Gleason, MD, an assistant professor in child psychiatry and pediatrics at Tulane University in New Orleans, Louisiana.

“Especially in younger children, the causes of impulsive or disruptive behaviors can be quite broad,” she toldMedscape Medical News.

“A thorough assessment looking into psychological, environmental, and biological factors that might cause someone to look impulsive and disruptive needs to be done to know what is driving the impulsivity.”

“One of the biggest things that needs to be looked at, for instance, is if the child has been exposed to trauma, and if someone is considering using a medication that has as long a list of potential side effects as atypical antipsychotics, they do need to really be certain of what they’re treating first.”

Source: Medscape/com


Antidepressants Given Near Delivery Associated with More Postpartum Hemorrhage.

Women exposed to antidepressants near the time of delivery show an increased risk for postpartum hemorrhage, according to a BMJ study.

Researchers analyzed Medicaid data on some 100,000 women with a diagnosis of mood or anxiety disorder. They used pharmacy dispensing data to characterize exposure, with “current exposure” defined as having a supply of antidepressant medicine on hand that overlapped with the delivery date.

Compared with nonexposed women (i.e., those having no drug supply within 5 months of the delivery date), those with current exposure showed a roughly 1.5-fold increased risk for postpartum hemorrhage. The authors calculate a number need to harm of 80 for patients on serotonin reuptake inhibitors and 97 for nonserotonin reuptake inhibitors.

They speculate that the effect could be partly explained by the effect of blocking serotonin reuptake in platelets, but the association with nonserotonin inhibiting drugs is “unexpected and should be confirmed.”

Soure: BMJ 

What’s the point in restaurant calorie counts?.

There are a lot of fat people in America. More than a third of US adults are obese according to data from the Centers for Disease Control and Prevention. In 2008, medical costs associated with obesity were estimated at $147bn (£97bn; 113bn); the medical costs for people who are obese were $1429 higher than those of normal weight. Between 1988-94 and 2007-8 the prevalence of obesity increased in adults at all income and education levels. It’s a big problem, no pun intended.

So it’s no surprise that measures are progressing to reverse this problem, and one of the more recent campaigns has been a push to require chain restaurants to list calorie counts on their menus. In the Patient Protection and Affordable Care Act, the US Food and Drug Administration (FDA) began the process of requiring calorie labeling for “restaurants and similar retail food establishments that are part of a chain with 20 or more locations doing business under the same name and offering for sale substantially the same menu items.” The guidelines have been a source of controversy ever since.

The evidence over the efficacy of such moves is mixed and an understandable reluctance from various quarters of the food industry probably doesn’t greatly help the cause.

This week the BMJ publishes research that will probably only add to the uneven picture rather than solve the conundrum. Investigators researching estimations of calorie content in consumers’ meals from fast food restaurants found a routine and sizable underestimation—so far so positive for calorie labeling (doi:10.1136/bmj.f2907). But despite the conclusion that labeling “might” reduce the underestimation it was hard for them to be more concrete as they also found that “noticing calorie information in the restaurant had no effect on the accuracy of calorie estimations.”

There’s no doubt that on an anecdotal level some people do find calorie labeling helpful, but if we’re tackling a public health problem and the population level data show questionable benefit, is this part of the Affordable Care Act worth the continuing controversy?

The implementation of the Affordable Care Act is one of the big ongoing topics of 2013 and this week we also publish an international view on it from four visiting academics, currently researching in the US (doi:10.1136/bmj.f3261). Their conclusions on the challenges facing Medicaid expansion hardly make for a walk in the park either, but then, if health reform were straightforward, it would have been done already.

Source: BMJ

The “Oregon Experiment” at 2 Years.

A lottery for Medicaid enrollment simulates a randomized trial.

In 2008, Oregon modestly expanded its Medicaid program through a lottery. From a list of 90,000 names on a Medicaid waiting list, 30,000 were drawn randomly; ultimately, about 10,000 of the lottery “winners” applied for state Medicaid services and were enrolled. Eligibility was based on age (19–64) and financial need (income, <100% of the federal poverty level; assets,

Researchers compared selected 2-year outcomes for about 6000 people who acquired Medicaid coverage through the lottery and for 6000 controls (people who entered the lottery but weren’t selected). Data were acquired by questionnaires and by limited cardiovascular risk assessments. The following statistically significant outcomes were noted in the Medicaid group, compared with controls:

  • Lower prevalence of positive depression screens (21% vs. 30%)
  • Better self-reported health-related quality of life
  • Fewer financial hardships due to medical expenses
  • Better access to medical care
  • More Pap smears and mammograms completed
  • More outpatient visits but not hospital admissions

Mean blood pressure, lipid levels, and glycosylated hemoglobin (HbA1c) levels were similar in the two groups.

Comment: One month ago, I saw an uninsured 45-year-old woman who had noted an enlarging breast mass for 9 months. She had not sought medical attention because “it wasn’t the cost of the mammogram or biopsy that concerned me . . . it was the cost of what would happen next if I have cancer.” Unfortunately, a biopsy showed breast cancer.

This case exemplifies a key reason for medical insurance — it enables people to access medical care when they need it, without fear of financial ruin. By that standard, the Oregon experiment is a success for Medicaid expansion. The lack of difference in cardiovascular risk factors is not important, given the short follow-up and the relatively normal values: Mean blood pressure, total cholesterol levels, and HbA1c in both groups were about 120/75 mm Hg, 200 mg/dL, and 5.3%, respectively.


Source:Journal Watch General Medicine


Azithromycin Does Not Increase Cardiovascular Mortality in the General Population.

The excess cardiovascular mortality previously observed with azithromycin use is attributable to the infection being treated, not the antibiotic, a New England Journal of Medicine study finds.

Using Danish registries, researchers compared 1.1 million episodes of azithromycin use with either 1.1 million episodes of no antibiotic use or 7.4 million episodes of penicillin V use among adults.

The risk for cardiovascular death was roughly three times higher with current azithromycin use than with no antibiotic use. However, cardiovascular death rates did not differ between azithromycin and penicillin. This indicates, the authors write, that “the increased risk … observed in the comparison with no antibiotic use was entirely attributable to the risk of death associated with acute infection” or some other risk factor in patients receiving antibiotics.

The authors add that while previous research showed a link between azithromycin and cardiovascular mortality in a higher-risk (Medicaid) population, the current study “shows that this effect is not present in the general population.”

NEJM commentators still highlight the potential risk for QT prolongation with use of macrolides and emphasize caution in their use for patients with preexisting cardiovascular conditions.

Source: NEJM 

Medicaid Expansion Appears to Lower 5-Year Mortality.

Data hint that bolstering the system benefits even those already enrolled.

One of the provisions of the Affordable Care Act, scheduled to take effect in 2014, will allow states to expand Medicaid to include all adults with incomes near the federal poverty level. Researchers tried to predict health benefits from this measure by examining outcomes in three states that have enacted similar Medicaid expansions already.

Adjusted all-cause mortality in the Medicaid-expansion states (New York, Arizona, and Maine) declined by 6.1% in the 5 years after expansion, which is a significant difference compared with mortality in adjacent states used as controls (Pennsylvania, Nevada, New Mexico, and New Hampshire). The differences were greatest among nonwhites, residents of poor counties, and 35- to 64-year-olds. A smaller (but also significant) mortality difference (2.6%) was observed in adults older than 65, along with a significant decline in cost-related delays in care.

Comment: This “natural experiment” addresses a long-debated statistic in the health policy world, in which Medicaid coverage has been associated with worse rather than better health outcomes among adults. This study shows that when confounders are removed, the association is more likely inverse. Although this study had a variety of statistical caveats to consider, its results are consistent with both mortality benefits of Medicaid already established for infants and children, and preliminary results of a randomized, controlled trial of Medicaid expansion in Oregon.

Source: Journal Watch General Medicine