Governor to Cut Texas Women's Health Funds Over Abortion

Texas - The federal government will withdraw funding for a Texas program providing more than 100,000 poor women with birth control and other health services because Planned Parenthood clinics are not allowed to participate, a Health and Human Services spokeswoman said on Friday.

Health and Human Services Secretary Kathleen Sebelius announced the decision in Houston on Friday, prompting a furious response from Texas Governor Rick Perry, who called it an "egregious federal overreach."

At the heart of the dispute between the administration of President Barack Obama and Texas is the divisive issue of abortion.

The Texas legislature last year voted to cut off funding for Planned Parenthood because the network of women's health clinics performs abortions. The federal government says that this violates rules of Medicaid, the health program for the poor.

Some 130,000 low-income Texas women who get free exams and contraceptives through Medicaid could lose those benefits as a result of the dispute.

The program provides free birth control and annual exams to women of reproductive age who do not qualify for the regular Medicaid program for the poor. The federal government pays 90 percent of the cost and Texas puts up about $4 million a year.

Wisconsin, North Carolina, Tennessee and Indiana all have joined Texas trying to block Planned Parenthood from receiving taxpayer money in the last year. Several other states, including Ohio, Oklahoma and New Hampshire, are considering similar moves.

While public funds do not pay for abortions, critics of Planned Parenthood argue that hiring the organization to provide family planning to poor women helps the organization stay afloat and thus indirectly supports abortion services.

The Texas funding cut prompted Planned Parenthood to shut down 11 clinics in the state.

Perry said the decision by the Obama administration was "politically motivated," and said it was an affront that Sebelius had not informed the state of Texas before announcing the move to the press.

A spokeswoman for Sebelius had no comment beyond confirming the decision to cut off funding to Texas.
The abortion fight is the latest of a string of disputes between Obama's Democratic administration and the Republican-dominated Texas state government. The two sparred last year over disaster aid for Texas after devastating wildfires and environmental regulations Texas opposes.

States Slash Birth Control Subsidies as Federal Debate Rages

United States - Even as a national debate rages over contraception insurance, tens of thousands of low-income women and teenagers across the United States have lost access to subsidized birth control as states slash and restructure family planning funds.

Montana and New Jersey have eliminated altogether their state family planning programs. New Hampshire cut its funding by 57 percent and five other states made more modest program trims.

But the biggest impact, by far, has been in Texas.

State lawmakers last fall cut family-planning funds by two-thirds, or nearly $74 million over two years.

Within months, half the state-supported family planning clinics in Texas had closed.

The state network, which once provided 220,000 women a year free and low-cost birth control, cervical cancer tests and diabetes screenings, will now serve just 40,000 to 60,000, officials said.

Another 130,000 low-income Texas women who get free exams and contraceptives through Medicaid could lose those benefits by month's end, due to a dispute between the state and federal governments over whether Planned Parenthood should be allowed to serve women on that program.

At the People's Community Clinic in Austin, the cuts mean that many low-income patients, except the very poorest, are now charged for contraception that used to be free: $5 for a dozen condoms; $10 for a month of birth control pills; $225 for an IUD.

"I have no clue what I'm going to do," said Rhetta Pope, 22, of Austin. A stay-at-home mother of two, she lives off disability payments of less than $1,500 a month.
Pope said after paying basic living expenses, she has so little left she scrimps on electricity by keeping the lights off and takes her laundry to an aunt's house. She can't imagine how she would pay for birth control.

"I guess I'm going to have to stop using it because I don't have the money," Pope said. "I'm pretty shook up. I really am."

SAVINGS IN DOUBT

Texas legislators who backed the 66-percent family planning cuts say they had no choice - the state budget was in crisis and many worthy programs suffered.

But a budget board analysis concluded the cut would actually cost Texas taxpayers more than it saved.

The board projected that women unable to get low-cost birth control would deliver 20,500 additional babies - costing state and federal taxpayers $231 million in prenatal, maternity and infant care. The state's share would be close to $98 million - significantly more than the family planning cut savings.

State Representative Wayne Christian, a Republican, acknowledged that the cuts might be counterproductive "if you look at it from a financial cost, perhaps."

But he disputed the notion that additional babies were a cost burden. "We value a human life more than just the cost," he said.

In general, he said, the state should not try to deter births by widely distributing free contraception. If women who want birth control cannot afford it, he said, they should first seek help from families or communities.

"I'm sorry," Christian said, "but there's this thing called individual responsibility."

Some women have found ways to pay for the care they once received free, but many have not.
After losing much of its state family-planning grant, the Parkland Health & Hospital System in Dallas in January began charging most patients a flat $25-per-visit fee.

In the first two weeks of the policy, 362 women cancelled appointments because they could not make the co-pay. Only 20 percent found the money to get care within a week or two, hospital officials said.

Another 20 percent were referred to one of the two Parkland locations still providing free services. Those sites are now so busy, the first available appointment at the Irving Women's Health Center is August 21.

Most of the remaining women never came back for care after learning about the co-pay, said Paula Turicchi, a Parkland senior vice president.

BLOCKING TAXPAYER DOLLARS

In several states, including Texas, questions about birth control access are now entangled with the politically explosive abortion debate.

Planned Parenthood is the nation's largest abortion provider, with about 330,000 procedures a year. It also runs a network of urban and suburban clinics offering birth control, gynecological exams and care for sexually transmitted diseases.

The organization gets about a third of its revenue, $360 million in 2009, from government grants to provide those services to poor women.

In the past year, Wisconsin, North Carolina, Tennessee, Indiana and Texas all have moved to block Planned Parenthood from receiving taxpayer money. Several other states, including Ohio, Oklahoma and New Hampshire, are considering similar moves.

While public funds don't pay for abortions, critics of Planned Parenthood argue that hiring the organization to provide family planning to poor women helps the organization stay afloat and thus indirectly supports abortion services.

The Texas funding cut prompted Planned Parenthood to shut down 11 clinics. It also has jeopardized a $40 million family-planning program run as a Medicaid extension.

The program provides free birth control and annual exams to 130,000 low-income women of reproductive age who don't qualify for regular Medicaid. The federal government pays 90 percent of the cost; Texas puts up just $4 million a year.

About 40 percent of women in the Texas program get subsidized care from Planned Parenthood clinics, but a new state law blocks those clinics from participating. The Obama administration has said that violates federal Medicaid rules. If neither side compromises, the program will likely close by the end of March.

That infuriates Jonee Longoria, a single mother in Houston who relied on the program for free services for several years as she put herself through college. "I had one child living in poverty and I didn't want another," Longoria said.

She now works for a social service agency and refers many clients to the program for contraception. Without it, she said, "where would they go?"

Advocates of defunding Planned Parenthood say they regret any service disruptions for poor women. But they call it a necessary price to pay to take a moral stance on abortion.

"We're just doing what we think is best," said Joe Pojman, executive director of Texas Alliance for Life, which opposes abortion.

Seven Accused of Bilking $375M from Medicare, Medicaid

By Juan A Lozano and Nomaan Merchant

Dallas - A Texas doctor has been charged with running a massive health fraud care scheme with thousands of fraudulent patients and intermediaries allegedly offering cash, food stamps or free groceries, to bilk Medicare and Medicaid of nearly $375 million.

A federal indictment unsealed Tuesday charges Jacques Roy, a doctor who owned Medistat Group Associates in DeSoto, Texas, and six others in an alleged scheme to bill Medicare for home health services that were not properly billed, not medically necessary or not done.

The scheme was the largest dollar amount by a single doctor uncovered by a task force on Medicare fraud, authorities said.

U.S. Attorney Sarah Saldana accused Roy of "selling his signature" to home health agencies that rounded up thousands of patients' names and billed Medicare and Medicaid for five years.

The indictment alleged that from January 2006 through November 2011, Roy or others certified 11,000 Medicare beneficiaries for more than 500 home health service agencies — more patients than any other medical practice in the U.S. More than 75 of those agencies have had their Medicare payments suspended.

Roy, 54, is charged with several counts of health care fraud and conspiracy to commit health care fraud. He faces up to 100 years in prison if convicted on all counts. He appeared briefly in court Tuesday and is scheduled to have a detention hearing Wednesday. Authorities also moved to seize cash in Roy's bank accounts, cars and two sailboats.

His attorney, Patrick McLain, said authorities had contacted Roy months ago. McLain said it was too soon to comment on the case because prosecutors hadn't provided him with most of the evidence yet. Phone messages and emails left with Medistat, located just south of Dallas, were not immediately returned Tuesday.

The attorney for one of the home health agency owners, Cynthia Stiger, alleged to be part of the scheme called the charges and the dollar amounts listed overblown. Stiger pleaded not guilty Tuesday.

"They're not anywhere close to accurate," said Jeffrey Grass, Stiger's attorney.

Investigators for the U.S. Health and Human Services department noticed irregularities with Roy's practice about one year ago, officials said.

Roy had "recruiters" finding people to bill for home health services, said Saldana, the top federal prosecutor in Dallas. Some of those alleged patients, when approached by investigators, were found working on their cars and clearly not in need of home healthcare, she said.

Medicare patients qualify for home health care if they are confined to their homes and need care there, according to the indictment.

Saldana said Roy used the home health agencies as "his soldiers on the ground to go door to door to recruit Medicare beneficiaries."

"He was selling his signature," she said.

For example, authorities allege Charity Eleda, one of the home health agency owners charged in the scheme, visited a Dallas homeless shelter to recruit homeless beneficiaries staying at the facility, paying recruiters $50 for each person they found. A message was left Tuesday at Eleda's Dallas-based company, Charry Home Care Services, Inc.

Others indicted are accused of offering free health care and services such as food stamps to anyone who signed up and offered their Medicare number.

Roy would "make home visits to that beneficiary, provide unnecessary medical services and order unnecessary durable medical equipment for that beneficiary," the indictment alleged. "Medistat would then bill Medicare for those visits and services."

The indictment says Roy's business manager — identified only by his initials — recorded conversations between the two in January 2006. The business manager heard Roy describe his alleged scheme and refuse to market for patients in a legitimate way, the indictment said.

The Centers for Medicare and Medicaid Services also announced the suspension of an additional 78 home health agencies associated with Roy. The agencies were collecting about $2.3 million a month, said Peter Budetti, CMS' deputy administrator for program integrity.

The alleged fraud went unnoticed for several years. After CMS suspended Medicare provider accounts belonging to Roy and Medistat last July, Medistat's employees allegedly started billing Medicare under a different provider number under Roy's supervision, authorities said.

Until recently, HHS could not effectively track data to identify the kind of fraud now linked to Roy, who was billing beneficiaries "off the charts" for more than five years, officials said. The department's inspector general, Dan Levinson, told reporters the department's technology "has not come online as quickly as we'd like to see."

The department is now beefing up its data analysis and tracking other cases, Levinson said. It has also established task forces in several U.S. cities to track Medicare fraud, officials said.

"We're now able to use those data analytic tools in ways — in 2012 and 2011 — that no, we really could not have done in years past," Levinson said.

A spokesman for Trailblazer Health Enterprises, which paid home health claims through a contract with federal authorities, did not return a phone message Tuesday.

Health care fraud is estimated to cost the government at least $60 billion a year, mainly in losses to Medicare and Medicaid. Officials say the fraud involves everything from sophisticated marketing schemes by major pharmaceuticals encouraging doctors to prescribe drugs for unauthorized uses to selling motorized wheelchairs to people who don't need them.

"These are public programs, and we must protect them for future generations," Saldana said.

Dentist Pleads Guilty to Wrongful Dentristry Practice

New Bedford, Massachusetts – A dentist accepted a guilty plea to Medicaid fraud and several other charges related to the use of paper clips instead of stainless steel posts in root canals.


Dentist Michael Clair's other charges include defrauding 130-thousand dollars from Medicaid, assault and battery, illegally prescribing prescription drugs, and witness intimidation.


Although he was suspended in 2002 by Medicaid, he kept filing claims from 2003 to 2005 via the use of local area dentists' names.


His use of the paper clips in place of steel posts may possibly have caused pain and infection in some of his patients.

Update:  Michael Clair has received a year in jail for his medical malfeasance.  Prosecutors were hoping to get a sentence of five to seven years.

One victim's tooth turned black.  The victim's mother, who witnessed Clair's sentencing was outraged the former dentist only got a year in prison. He was also ordered to stay away from his victims and seven of his employees. 


"He put my kids in pain for months...I hope he rots there," she told reporters.


The reason for the light sentence was that he had, in Judge Richard Moses' words is "a lack of a criminal record and certain mental health issues" but didn't elaborate.

State Cuts to Medicaid Affect Patients, Providers

ATLANTA — Just as Medicaid prepares for a vast expansion under the federal health care overhaul, the 47-year-old entitlement program for the poor is under increasing pressure as deficit-burdened states chip away at benefits and cut payments to doctors.

Nearly every state has proposed or implemented a plan in its current budget to rein in costs, and many are considering additional cuts in the year ahead.

For the tens of millions of poor and disabled who rely on the program — approaching nearly one in five Americans — the cuts translate into longer waits for doctors, restrictions on prescription drugs, a halt to vision and dental care, staff cuts at nursing homes and dwindling access to home health care.

Ruth Wohlforth, 70, is among those feeling the effects.

Her $700 monthly income qualifies her for both Medicare and Medicaid, but she says her benefits have been reduced, she's being forced her to make co-pays for the first time on prescription drugs, and she now has to drive about 30 minutes from her home near the southern tip of New Jersey to see a doctor. Some of her friends have been assigned to doctors in Philadelphia. 

She said she feels lawmakers are not aware of the real-world consequences of their spending cuts.

"I've seen so many people in tears, and they don't know what to do," Wohlforth said. "People that are older than I am, and are in worse shape, they get befuddled by the whole thing. They don't know where to go for help; they just feel they're not being listened to."

States are reshaping the Medicaid landscape even as the need has grown along with joblessness during the recession.

The $427 billion-a-year program, a combination of state and federal funding, also had been targeted for additional cuts at the federal level this year as members of Congress sparred over how to reduce the nation's debt. But funding seems safe for now after a special committee failed last month to reach an agreement on how to cut overall spending.

Already, many changes at the state level have been dramatic and are testing the legal bounds of what Medicaid must provide:

— Arizona, for a time, eliminated life-saving transplants for Medicaid patients, and hospital officials in the state blame at least one death on the halt in coverage. Gov. Jan Brewer restored transplants but is prohibiting thousands of low-income, childless adults from entering the program and has added fees on those who smoke and the obese.

— New Jersey Gov. Chris Christie is pushing a plan under which only the poorest would qualify. A parent of two making more than $103 per week would no longer be eligible for coverage.

— The U.S. Supreme Court will decide whether California has the right to continue cutting payments to physicians and other Medicaid providers to help close the state's ongoing budget deficit.

Cuts to provider fees, as in California, have been the most frequently used tactic by states to save Medicaid costs. A recent survey by the National Association of State Budget Officers found that 33 states wanted to reduce provider rates and another 16 sought to freeze them.

California was granted permission by federal officials to make broad cuts to reimbursement rates to its Medicaid program, known as Medi-Cal, in October. The cuts include a 10 percent reduction to payments for outpatient services for doctors, clinics, optometrists, dental services, medical equipment and pharmacy. They are intended to save the state an estimated $623 million.

A coalition of trade associations representing doctors, pharmacists and chain drug stores has filed a lawsuit seeking to stop the cuts. Doctors who care for Medi-Cal patients say they already have been subjected to multiple pay cuts, and some say they no longer will be able to serve the state's neediest patients.

About 70 percent of Dr. Douglas Tolley's practice in Yuba County is covered by Medi-Cal. The 64-year-old obstetrician, who practices in a largely agricultural region about 40 minutes north of the state capital, said he is the old-school sort of doctor who "was brought up in a time when doctors took care of all comers."

Yet he has seen his income steadily drop over the last 18 years — down one-third from what it was when he started.

"Everybody understands that doctors are basically small business people, and we have to meet our cost plus make a living." Tolley said. "Just meeting our cost doesn't mean staying in business."

Even more state cuts could be on the horizon. In Maine, Gov. Paul LePage recently proposed removing 65,000 residents from the program, citing a state Medicaid shortfall estimated to reach $221 million through mid-2013. The Republican governor says he will not consider tax increases to make up the difference.

State officials, who are required to balance their budgets, argue they have no choice but to cut into Medicaid after four straight years of budget deficits. With state and federal funds combined, Medicaid makes up 22 percent of total state spending, the largest single portion of most state budgets, according to the National Association of State Budget Officers.

Critics say the moves are shortsighted.

Joan Alker, co-executive director of the Center for Children and Families at Georgetown University, said slashing Medicaid will not stop the sick from seeking care, sending them to emergency rooms and ultimately inflating private medical insurance premiums.

"At the end of the day, for the children, the individuals with disabilities, the seniors in nursing homes, their health care needs are not going to go away just because someone cuts the Medicaid program," Alker said.

Jerry Kemmer, a former Democratic state assemblyman in New York, said Medicaid has long been an issue lawmakers did not want to touch. Now, they simply have no choice.

"It's ballooned to the extent that it's just become a budget-buster," he said.

Six million people have joined the Medicaid rolls since the recession began in late 2007. Enrollment nationally topped 50 million for the first time in June 2010, a number that is projected to keep rising, especially as the nation's unemployment rate remains high.

Billions of dollars from the federal stimulus program helped avoid deep Medicaid cuts through the worst of the recession, but the last of that money dried up this year.

In Florida, Medicaid reimbursement rates were reduced this year by 12 percent for most hospitals, although rural and children's hospitals were cut just 3 percent, and rates for nursing homes were cut 6.5 percent.

But the start of the next legislative session in January already has some people worried about additional cuts.

Debra St. Fleur, 25, of Miami, is covered by Medicaid, along with her 1-year-old son. Many of her neighbors in the city's Little Haiti section are on Medicaid, too, and she worries what would happen if services continue to be eroded.

"It's really scary," she said. "If they can't get their medicine, what's going to happen? They're going to die."

The Obama administration is concerned enough about the widespread Medicaid provider cuts that it has introduced a rule that would make it harder for states to slash the rates. The move is designed to ensure that those eligible for Medicaid are not denied access due to a shortage of 

health care resources.

Medicaid reimbursement rates already trail those physicians receive for treating Medicare patients and those with private insurance. A study by the nonpartisan Center for Studying Health System Change found that on, average, Medicaid would reimburse a doctor $39 for 45 minutes for a new patient hospital visit, compared to $63 for Medicare.

Physician groups say that has left more and more doctors declining to see Medicaid clients. Some providers are trying to find other ways to make up for the cuts.

In Columbia, S.C., Julie Ann Avin, executive director of the private, nonprofit Mental Illness Recovery Center Inc., has decided not to fill staff vacancies and also cut back on some rehab services because of Medicaid's new authorization process. The center serves about 650 people annually, close to 60 percent of whom are on Medicaid.

"We accept folks regardless," Avin said. "Everything that we do is not based just on a reimbursement."

Molly Collins Offner, director of policy development for the American Hospital Association, said emergency rooms must accept Medicaid clients, as well as those without insurance.

 "More and more, you are seeing ER's becoming primary care docs," she said.

She said deep cuts rippling through the Medicaid system will only exacerbate that.

New Fee Coming for Medical Effectiveness Research

WASHINGTON — Starting in 2012, the government will charge a new fee to your health insurance plan for research to find out which drugs, medical procedures, tests and treatments work best. But what will Americans do with the answers?

The goal of the research, part of a little-known provision of President Barack Obama's health care law, is to answer such basic questions as whether that new prescription drug advertised on TV really works better than an old generic costing much less.

But in the politically charged environment surrounding health care, the idea of medical effectiveness research is eyed with suspicion. The insurance fee could be branded a tax and drawn into the vortex of election-year politics.

The Patient-Centered Outcomes Research Institute — a quasi-governmental agency created by Congress to carry out the research — has yet to commission a single head-to-head comparison, although its director is anxious to begin.

The government is already providing the institute with some funding: The $1-per-person insurance fee goes into effect in 2012. But the Treasury Department says it's not likely to be collected for another year, though insurers would still owe the money. The fee doubles to $2 per covered person in its second year and thereafter rises with inflation. The IRS is expected to issue guidance to insurers within the next six months.

"The more concerning thing is not the institute itself, but how the findings will be used in other areas," said Kathryn Nix, a policy analyst for the conservative Heritage Foundation think tank. "Will they be used to make coverage determinations?"

 The institute's director, Dr. Joe Selby, said patients and doctors will make the decisions, not his organization.

"We are not a policy-making body; our role is to make the evidence available," said Selby, a primary care physician and medical researcher,

But insurance industry representatives say they expect to use the research and work with employers to fine-tune workplace health plans. Employees and family members could be steered to hospitals and doctors who follow the most effective treatment methods. Patients going elsewhere could face higher copayments, similar to added charges they now pay for "non-preferred" drugs on their insurance plans.

Major insurers already are carrying out their own effectiveness research, but it lacks the credibility of government-sponsored studies.

Not long ago, so-called "comparative effectiveness" research enjoyed support from lawmakers in both parties. After all, much of the medical research that doctors and consumers rely on now is financed by drug companies and medical device manufacturers, who have a built-in interest in the findings. And a drug maker only has to show that a new medicine is more effective than a sugar pill — not a competing medication — to win government approval for marketing.

The 2009 economic stimulus bill included $1.1 billion for medical effectiveness research, mainly through the National Institutes of Health. It was not considered particularly controversial. But things changed during the congressional health care debate, after former GOP vice presidential candidate Sarah Palin made the claim, now widely debunked, that Obama and the Democrats were setting up "death panels" to ration care.

As a result, lawmakers hedged the new institute with caveats. It was set up as an independent nonprofit organization, with a .org Internet address instead of .gov. The government cannot dictate Selby's research agenda. And there are limitations on how the Health and Human Services department can use the research findings in decisions that affect Medicare and Medicaid.

Selby says the institute is taking seriously the term "patient-centered" in its name. Patients will not be merely subjects of research; they and their representatives will be involved in setting the agenda and overseeing the process.

"We are talking about patients as partners in the research," said Selby. Findings will be presented in clear language — a kind of Consumer Reports approach — so that patients and doctors can easily draw on them to make decisions.

"Our goal, our hope, is that over time, by involving patients in research, two things will happen," said Selby. "One is that we will start asking questions in a more practical fashion, so the results would speak more consistently to questions that patients want to know the answers to. And two is that, by our example of involving patients in the research, trust will rise." He expects to unveil the institute's proposed research agenda in the next few weeks.

Former Medicare administrator Gail Wilensky says that agenda should focus on high-cost procedures and drugs on which the medical community has not developed a consensus, and which have widely different patterns of use around the country. A Republican, Wilensky believes opposition to the institute's work is shortsighted.

"This just strikes me as a component of finding ways to treat better and spend smarter," she said.