AMA to CMS: Be Transparent About Impact of Medicare Cuts
CHICAGO – Facing a fifth consecutive year of Medicare payment reductions, the American Medical Association (AMA) issued a clarion call to the Centers for Medicare & Medicaid Services (CMS), urging the agency to be fully transparent about the impact of these payment cuts on physicians and patients.
CMS proposed in July a payment reduction of 2.8 percent. CMS also estimated that the Medicare Economic Index (MEI) – the agency’s measure of practice cost inflation—will increase by 3.6 percent.
Article on page 5
The Medicare Advantage Influence Machine
Federal officials resolved more than a decade ago to crack down on whopping government overpayments to private Medicare Advantage health insurance plans, which were siphoning off billions of tax dollars every year.
But Centers for Medicare & Medicaid Services officials have yet to demand any refunds — and over the years the private insurance plans have morphed into a politically potent juggernaut that has signed up more than 33 million seniors and is aggressively lobbying to stave off cuts.
Article on page 6
See more local news in Grand Rounds on page 8
Psych & Seniors
By BECKY GILLETTE
If you’re lucky enough to live long, you’ve been through a few things such as the death of loved ones. There can be pain leading to taking potentially addictive drugs, and challenges such as cancer, heart disease, financial problems and cognitive decline. It is easy to see how someone could end up with depression, anxiety and insomnia.
Old age is not a protective factor against mental illnesses or substance abuse, said Daniel S. Boyd, MD, a psychiatrist at Lakeside Behavioral Center in Memphis.
“People seek treatment at any age,” said Boyd, who is medical director at one of the largest free-standing psychiatric hospitals in the nation with 364-beds. “With the loss of friends and family, you can see people develop an addiction to alcohol after the age of 60 who had no previous problem. Maybe their spouse died and they turned to alcohol to deal with it. And we don’t metabolize alcohol as well when we get older.”
Older adults may be less likely to acknowledge having depression, a problem exacerbated by the social isolation of the Covid-19 pandemic. People were cut off from their families. They often also had work socialization taken away from them when they had to work at home.
As people age, social determinants get more complicated. At the same time they lose friends, family and colleagues, they get more complicated medically, too.
“That gets tricky, tricky, tricky,” Boyd said. “It is so easy to do polypharmacy with the elderly. It is like once someone of any age overdoses, everything is different going forward. You worry, ‘Could they overdose on this drug? Could they overdose on that drug? What would things look like if they overdosed on this prescription?’ You have to carefully consider what other drugs could help but might also be harmful.”
Boyd’s approach with the elderly is that every drug is guilty until proven innocent. He believes less is more. The more drugs you add to the soup, the more problems there are with drug interactions and complications like how the drug affects other medical illnesses
(CONTINUED ON PAGE 3)
Pain & Older Patients Specific Considerations in Dealing with an Aging Population
By JAMES DOWD
For more than 40 years, Dr. Moacir Schnapp has built a medical career focused on pain management. And now that Schnapp is part of the senior demographic he has treated for decades, the Memphis neurologist is even more aware of the challenges – and opportunities – facing aging patients and the medical professionals who treat them.
“When I began my career it was rare to see a lot of patients coming to our who were over 75, but seniors are a steadily growing population,” Schnapp said. “Back then, families tended to keep elderly relatives at home because there was a mindset of just accepting (CONTINUED ON PAGE 3)
Daniel S. Boyd
Moacir Schnapp
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Psych & Seniors,
and how the medical illnesses impact the metabolism of the new drug.
“It gets pretty murky,” he said. Alzheimer’s disease was the fifthleading cause of death among people age 65 and older in 2021, and the costs of caring for people living with dementia are projected to reach $360 billion in 2024 and nearly $1 trillion in 2050, according to the Alzheimer’s Association. About ten percent of people over age 65 are estimated to have Alzheimer’s, the most common form of dementia.
“Unfortunately, the drugs for dementia are so weak,” Boyd said. “The drugs for dementia got approved not because they made anyone better but because people got worse more slowly. So that is pitiful. It is pretty disappointing. I remember in the 1990s I was somewhat excited about the treatment of dementia. They came out with Cognex, which is no longer used, and they came out with Aricept, Exelon, Razadyne and Namenda. We had five drugs come out in ten years, so we thought this was going to be great. Then in the 20-year period since, there has been one disappointment after another for the treatment of dementia.
“Investors lost a lot of money funding drug trials that failed. No new oral medications have been approved. There have been some intravenous drugs approved that have been controversial about the approval process, safety risks, high cost and concerns about accessibility and effectiveness.”
Boyd said when people with mental illnesses get old, that sometimes changes the way their mental illness needs to be managed. Older people may have been on drugs that were effective for many years but no longer work.
“The drugs may work okay until they developed multiple medical problems,” he said. “So that gets tricky, as well.”
Boyd said most classes of medications prescribed for mental illnesses were invented between 1948 and 1963; pretty much everything after that has been children and grandchildren of the original drugs.
Depression is one of the most common mental health issues impacting an estimated 8.3 percent of adult Americans and an increasing number of children. Boyd said the three legs of the stool for the treatment of depression are psychotherapy, exercise and antidepressants.
“It we could put exercise into a pill, it could sell pretty well based on its benefit profile,” Boyd said. “The big daddy of all treatments for severe depression is electroconvulsive therapy. That is our ace in the hole.”
At Lakeside’s 37-acre campus, there are both inpatient and outpatient programs. Boyd said a huge part of what they do is get the diagnosis right.
“Bipolar type one is probably one of the easiest diagnoses we ever make,”
When people with mental illnesses get old, that sometimes changes the way their mental illness needs to be managed.
he said. “Bipolar type two is one of the hardest to identify or rule out. There can be low grade versions of it.”
The newest building on the campus is the geriatric building, where the number one diagnosis is dementia. The East Unit building is primarily for schizophrenia. The Landing Unit building is focused on treating depression or bipolar disease.
There is also an addiction building for people with any type of substance addictions with the most common being opiates, especially fentanyl, alcohol, and stimulants, including cocaine and crystal meth.
Lakeside Behavioral Center takes most forms of government and private insurance. Patients may not need to be hospitalized for a long time. For example, once patients have detoxed from a drug, they don’t need 24-hour nursing care and may progress to a residential level of care or partial hospitalization program (PHP), which is six hours a day and then later intensive outpatient (IOP) at three hours a day. PHP and IOP are offered on the main campus in Bartlett as well as facilities in East Memphis and Jackson.
With most states now legalizing medical marijuana, many older Americans have turned to cannabis for pain relief or treatment of PTSD. But there are concerns about Cannabis Use Disorder.
“Thankfully it is not scary like fentanyl, but a minority of people get psychologically addicted to it,” Boyd said. “Marijuana is much stronger than in the past, and some people get paranoid on marijuana. A problem is that people sometimes now get fentanyl or crystal meth put in their marijuana purchased on the black market. If you get crystal meth in it, it can make you psychotic. With too much fentanyl, you stop breathing. Once something is legal, people think it is safe. Tobacco and alcohol are legal, but it doesn’t mean they are safe. For that matter, cocaine used to be in Coca-Cola and at one time, heroin was over-the-counter.”
Pain & Older Patients,
chronic pain as part of the aging process. Now we see patients every day who are 90 and driving and independent, and many find that pain management allows them to remain active and functional and that is an enormous step forward in our field.”
Schnapp traces his interest in pain management to the late 1970s when he was nearing completion of a residency in neurology in Brazil. After earning his medical degree from the University of São Paulo, Schnapp came to Memphis for a fellowship in pain management at the University of Tennessee Health Science Center College of Medicine.
Schnapp remembers that in that era there were relatively few clinics that specialized in pain treatment, but there was one in Memphis that captured his attention. Following a stint back in Brazil as a medical director and associate professor at his alma mater, Schnapp returned to Memphis and joined Dr. Kit Mays in a practice dedicated to multidisciplinary pain management.
“I was always fascinated by neuropsychiatry, studying neurotransmitters and the basis of psychiatric matters and mental health, and that led me to a career in neurology,” Schnapp said. “Pain has always been puzzling, but when I was in medical school there seemed to very little interest in it within the larger medical community. I remember reading a major oncology book from that time and even though it was more 600 pages, only a few pages were devoted to pain.”
Many gains have been made in pain treatment in the last half-century, Schnapp said. When he first began practicing, doctors tended to be more conservative in treating cancer patients for pain out of a concern for potential drug dependency and the possibility of overdosing.
Determined to change the landscape, Schnapp and Mays established the pain management clinic Mays & Schnapp, which has become one of the leading pain clinics in the nation. The clinic is certified in all areas of adult pain management and rehabilitation by the Commission on Accreditation of Rehabilitation Facilities (CARF).
“There is an art to pain management and there are dozens of ways to manage pain and get comfort that benefit patients,” Schnapp said. “Patients often come to our office and they are afraid because they are in pain. The first thing they need is information delivered in a caring way because knowing what you have is the first step in determining a path for pain relief, just as knowing what you do not have can offer comfort because of the peace of mind that comes with that knowledge.”
Senior adults constitute a growing segment of his practice, Schnapp said, and that population comes with unique treatment challenges that do not usually affect younger patients. Older generations tend to be more wary of pain medication, due in no small part to the
opioid epidemic. Cultural and societal stigmas also play a role.
“Older patients grew up in an era when you just dealt with pain, you didn’t get treated for it,” Schnapp said. “I often have to convince patients to take their medications regularly and I emphasize that the small dosages are to help them manage pain, not to get high.”
Increasing life expectancies have dramatically changed the approach to pain management, Schnapp said. A couple generations ago, patients over age 65 typically slowed down and did not expect to live well beyond 80. However, as Baby Boomers continue to remain active and vibrant, many patients in their sixties can expect to live for several more decades.
The key to pain management for seniors, Schnapp said, is focusing on quality rather than quantity of years remaining. Studying a patient’s cardiovascular function along with personal or family history of cancer or strokes or other diseases helps determine treatment.
“If we know that patient will likely be alive 30 years from now then pain treatment is markedly different from patient who may have only two years to live,” Schnapp said. “Our role is to help them be as functional as possible with their time remaining.”
Age-related arthritis is one of the most common conditions Schnapp sees. Treatments may include cortisone shots and nerve blocks to allow patients to engage in activities they love such as gardening and knitting and woodworking.
And while medications, including narcotics, are often helpful for helping seniors deal with pain issues, Schnapp stresses the need for physical therapy as part of a sustainable treatment program.
“Older patients have multiple pathologies and all contribute to pain, so it’s imperative that we know every medication they’re taking to understand if there are any underlying conditions that could be attributed to medications interacting with each other,” Schnapp said. “The combination of physical therapy with medication is important because it leads to increased mobility and flexibility, which in turn helps reduce pain and allows patients to remain active longer.”
In addition to pain management treatment and physical therapy, Schnapp encourages seniors to pursue healthy lifestyles. And the obvious cautions –stop smoking, watch alcohol and salt intake – still apply because advanced as the medical field has grown, there is no magic pill to cure everything.
“I’ve been watching for a great substitute for opiates since 1979, but so far there hasn’t been anything and I don’t see anything in the near future to change that,” Schnapp said. “Part of my job is to convince people to take charge of their health and stay active through activities such as Yoga or Pilates. I pass part of the onus of pain relief onto them because if I have to do everything for them then the treatment will fail.”
AMA to CMS: Be Transparent About Impact of Medicare Cuts
By AMERICAN MEDICAL ASSOCIATION
CHICAGO – Facing a fifth consecutive year of Medicare payment reductions, the American Medical Association (AMA) issued a clarion call to the Centers for Medicare & Medicaid Services (CMS), urging the agency to be fully transparent about the impact of these payment cuts on physicians and patients.
CMS proposed in July a payment reduction of 2.8 percent. CMS also estimated that the Medicare Economic Index (MEI) – the agency’s measure of practice cost inflation—will increase by 3.6 percent. Facing this widening gap between what Medicare pays physicians and the cost of delivering quality care to patients, the AMA said in a comment letter that the administration should work with Congress to enact a permanent, annual inflationbased update to Medicare physician payments. The AMA noted that other government bodies have warned about the impact on patient care.
“[This] proposed rule is silent on the impact of the growing gap between what Medicare pays for care and what it costs to provide that care. A chorus of authorities on the Medicare program has expressed concern about the ability of patients to continue receiving high-quality care as physician payments erode,” the letter said.
The Medicare Physician Payment Advisory Commission (MedPAC) and the Medicare Trustees have issued warnings about the dangers of repeated Medicare cuts and how they threaten access to care. As one of the only Medicare providers whose payment updates do not account for inflation, physicians have relentlessly advocated for this change. Medicare physician payment declined (PDF) 29% from 2001 to 2024, adjusted for inflation. The AMA and the entirety of organized medicine are working to secure a positive 2025 payment update.
The comment letter notes that the proposed cuts are self-defeating as they would reduce spending on the administration’s key policies including the cancer moonshot and maternal health programs.
“The 2025 cuts compound acrossthe-board cuts in 2021, 2022, 2023,
The Medicare Physician Payment Advisory Commission (MedPAC) and the Medicare Trustees have issued warnings about the dangers of repeated Medicare cuts and how they threaten access to care.
and 2024, and are not sustainable for physicians and their patients, and risk jeopardizing the Administration’s priorities and access to critical services,” the letter said. “We strongly urge CMS to acknowledge the negative effects of the proposed payment cut on Medicare beneficiaries in the final rule and the Biden-Harris Administration to support any congressional action to replace the cut with a positive update.”
The letter, which includes specific recommendations regarding proposed changes to the Medicare physician fee schedule, can be found at AMA.org
Caring for Aging Parents
Thanks to healthier lifestyles and advances in modern medicine, the worldwide population over age 65 is growing. In the past decade, the population of Americans aged 65 and older has grown 38% and is expected to reach 82 million in 2050. As our nation ages, many Americans are turning their attention to caring for aging parents.1,2
For many people, one of the most difficult conversations to have involves talking with an aging parent about extended medical care. The shifting of roles can be challenging, and emotions often prevent important information from being exchanged and critical decisions from being made.
When talking to a parent about future care, it’s best to have a strategy for structuring the conversation. Here are some key concepts to consider.
Cover the Basics
Knowing ahead of time what information you need to find out may help keep the conversation on track. Here is a checklist that can be a good starting point:
• Primary physician
• Specialists
• Medications and supplements
• Allergies to medication
It is also important to know the location of medical and estate management paperwork, including:3
• Medicare card
• Insurance information
• Durable power of attorney for healthcare
• Will, living will, trusts, and other documents
Be Thorough
Remember that if you can collect all the critical information, you may be able to save your family time and avoid future emotional discussions. While checklists and scripts may help prepare you, remember that this conversation could signal a major change in your parent’s life. The transition from provider to
dependent can be difficult for any parent and has the potential to unearth old issues. Be prepared for emotions and the unexpected. Be kind but do your best to get all the information you need.
"When talking to a parent about future care, it’s best to have a strategy for structuring the conversation."
Keep the Lines of Communication Open
This conversation is probably not the only one you will have with your parents about their future healthcare needs. It may be the beginning of an ongoing dialogue. Consider involving other siblings in the discussions. Often one sibling takes a lead role when caring for parents, but all family members should be honest about their feelings, situations, and needs.
Don't Procrastinate
The earlier you begin to communicate about important issues, the more likely you will be to have all the information you need when a crisis arises. How will you know when a parent needs your help? Look for indicators like fluctuations in weight, failure to take medication, new health concerns, and diminished social interaction. These can all be warning signs that additional care may soon become necessary. Don’t avoid the topic of care just because you are uncomfortable. Chances are that waiting will only make you more so.
Remember, whatever your relationship with your parents has been, this new phase of life will present challenges for both parties. By treating your parents with love and respect—and taking the necessary steps toward open communication—you will be able to provide the help needed during this new phase of life.
Chirag Chauhan, MBA, AIF®, CFP® is the managing partner of Bluff City Advisory Group in Memphis, Tennessee. For more info, please visit bluffcityadvisory.com.
Chirag Chauhan, AIF® CFP®
The Medicare Advantage Influence Machine
By FRED SCHULTE , HOLLY K. HACKER
Federal officials resolved more than a decade ago to crack down on whopping government overpayments to private Medicare Advantage health insurance plans, which were siphoning off billions of tax dollars every year.
But Centers for Medicare & Medicaid Services officials have yet to demand any refunds — and over the years the private insurance plans have morphed into a politically potent juggernaut that has signed up more than 33 million seniors and is aggressively lobbying to stave off cuts.
Critics have watched with alarm as the industry has managed to deflate or deflect financial penalties and steadily gain clout in Washington through political contributions; television advertising, including a 2023 Super Bowl feature; and other activities, including mobilizing seniors. There’s also a revolving door, in which senior CMS personnel have cycled out of government to take jobs tied to the Medicare Advantage industry and then returned to the agency.
Sen. Chuck Grassley (R-Iowa) said Medicare Advantage fraud “is wasting taxpayer dollars to the tune of billions.”
“The question is, what’s CMS doing about it? The agency must tighten up its controls and work with the Justice Department to prosecute and recover improper payments,” Grassley said in a statement to KFF Health News. “Clearly that’s not happening, at least to the extent it should be.”
David Lipschutz, an attorney with the Center for Medicare Advocacy, a nonprofit public interest law firm, said policymakers have an unsettling history of yielding to industry pressure. “The health plans throw a temper tantrum and then CMS will back off,” he said. Government spending on Medicare Advantage, which is dominated by big health insurance companies, is expected to hit $462 billion this year.
New details of the government’s failure to rein in Medicare Advantage overcharges are emerging from a Department of Justice civil fraud case filed in 2017 against UnitedHealth Group, the insurer with the most Medicare Advantage enrollees. The case is pending in Los Angeles. The DOJ has accused the giant insurer of cheating Medicare out of more than $2 billion by mining patient records to find additional diagnoses that added revenue while ignoring overcharges that might have reduced bills. The company denies the allegations and has filed a motion for summary judgment.
Records from the court case are surfacing as the Medicare Advantage industry ramps up spending on lobbying and public relations campaigns to counter mounting criticism.
While critics have argued for years that the health plans cost taxpayers too much, the industry also has come under fire more recently for allegedly scrimping on vital health care, even dumping hundreds of thousands of members whose health plans proved profitable.
While critics have argued for years that the health plans cost taxpayers too much, the industry also has come under fire more recently for allegedly scrimping on vital health care, even dumping hundreds of thousands of members whose health plans proved unprofitable.
“We recognize this is a critical moment for Medicare Advantage,” said Rebecca Buck, senior vice president of communications for the Better Medicare Alliance, which styles itself as “the leading voice for Medicare Advantage.”
Buck said initiatives aimed at slashing government payments may prompt health plans to cut vital services. “Seniors are saying loud and clear: They can’t afford policies that will make their health care more expensive,” she said. “We want to make sure Washington gets the message.”
AHIP, a trade group for health insurers, also has launched a “sevenfigure” campaign to promote its view that Medicare Advantage provides “better care at a lower cost,” spokesperson Chris Bond said.
Revolving Door
CMS, the Baltimore-based agency that oversees Medicare, has long felt the sting of industry pressure to slow or otherwise stymie audits and other steps to reduce and recover overpayments. These issues often attract little public notice, even though they can put billions of tax dollars at risk.
In August, KFF Health News reported how CMS officials backed off a 2014 plan to discourage the health plans from overcharging amid an industry “uproar.” The rule would have required that insurers, when combing patients’ medical records to identify underpayments, also look for overcharges. Health plans have been paid billions of dollars through the data mining, known as “chart reviews,” according to the government.
The CMS press office declined to respond to written questions posed by KFF Health News. But in a statement,
it called the agency a “good steward of taxpayer dollars” and said in part: “CMS will continue to ensure that the MA program offers robust and stable options for people with Medicare while strengthening payment accuracy so that taxpayer dollars are appropriately spent.”
Court records from the UnitedHealth case show that CMS efforts to tighten oversight stalled amid years of technical protests from the industry — such as arguing that audits to uncover overpayments were flawed and unfair.
In one case, Jeffrey Grant, a CMS official who had decamped for a job supporting Medicare Advantage plans, protested the audit formula to several of his former colleagues, according to a deposition he gave in 2018.
Grant has since returned to CMS and now is deputy director for operations at the agency’s Center for Consumer Information and Insurance Oversight. He declined to comment.
At least a dozen witnesses in the UnitedHealth case and a similar DOJ civil fraud case pending against Anthem are former ranking CMS officials who departed for jobs tied to the Medicare Advantage industry.
Marilyn Tavenner is one. She led the agency in 2014 when it backed off the overpayment regulation. She left in 2015 to head industry trade group AHIP, where she made more than $4.5 million during three years at the helm, according to Internal Revenue Service filings. Tavenner, who is a witness in the UnitedHealth case, had no comment.
And in October 2015, as CMS department chiefs were batting around ideas to crack down on billing abuses, including reinstating the 2014 regulation on data mining, the agency was led by Andy Slavitt, a former executive vice president of the Optum division of UnitedHealth Group. The DOJ fraud suit focuses on Optum’s data mining program.
In the legal proceedings, Slavitt is identified as a “key custodian regarding
final decision making by CMS” on Medicare Advantage.
“I don’t have any awareness of that conversation,” Slavitt told KFF Health News in an email. Slavitt, who now helps run a health care venture capital firm, said that during his CMS tenure he “was recused from all matters related to UHG.”
‘Improper’
Payments
CMS officials first laid plans to curb escalating overpayments to the insurers more than a decade ago, according to documents filed in August in the UnitedHealth case.
In a January 2012 presentation, CMS officials estimated they had made $12.4 billion worth of “improper payments” to Medicare Advantage groups in 2009, mostly because the plans failed to document that patients had the conditions the government paid them to treat, according to the court documents.
As a remedy, CMS came up with an audit program that selected 30 plans annually, taking a sample of 201 patients from each. Medical coders checked to make sure patient files properly documented health conditions for which the plans had billed.
The 2011 audits found that five major Medicare Advantage chains failed to document from 12.3% to 25.8% of diagnoses, most commonly strokes, lung conditions, and heart disease.
UnitedHealth Group, which had the lowest rate of unconfirmed diagnoses, is the only company named in the CMS documents in the case file. The identities of the four other chains are blacked out in the audit records, which are marked as “privileged and confidential.”
In a May 2016 private briefing, CMS indicated that the health plans owed from $98 million to $163 million for 2011 depending on how the overpayment estimate was extrapolated, court records show.
But CMS still hasn’t collected any money. In a surprise action in late continued on page 8 >
THE MID-SOUTH'S LEADERS IN INTERVENTIONAL PAIN MANAGEMENT
ESTABLISHED FOR OVER 30 YEARS, Mays & Schnapp
Neurospine and Pain is the trusted practice for chronic pain in the MidSouth. Dr. Moacir Schnapp is a pioneer in the field, and the medical practice continues to be a leader in pain management. Patients choose Mays & Schnapp because they are treated by physicians with decades of experience, including board certifications in pain management. Our specialized team treats each individual patient and his or her pain as unique. There simply is no other place like Mays & Schnapp within 500 miles, where at its CARF accredited facility, patient treatments are specific to the individual and may include interventional treatments such as nerve blocks, radiofrequency ablation, and joint injections, as well as restorative therapies like physical therapy and behavioral therapies. You can be sure, when the problem is pain, Mays & Schnapp is the place that can help. Mays & Schnapp treats a wide variety of pain-related conditions, including back and neck pain, arm and leg pain, arthritis, sciatica, shingles, peripheral neuropathy from diabetes, multiple sclerosis, complex regional pain syndrome, and post-stroke pain.
Left to right: Cindy Tiu, DO, Matthew Kangas, MD, Moacir Schnapp, MD, and Andrew Dudas, MD
The Medicare Advantage,
January 2023, CMS announced that it would settle for a fraction of the estimated overpayments and not impose major financial penalties until 2018 audits, which have yet to get underway. Exactly how much plans will end up paying back is unclear.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said CMS has largely failed to rein in billions of dollars in Medicare Advantage overpayments.
“It is reasonable to think that pressure from the industry is part of the reason that CMS has not acted more aggressively,” Kronick said.
CMS records show that officials considered strengthening the audits in 2015, including by limiting health plans from conducting “home visits” to patients to capture new diagnosis codes. That didn’t happen, for reasons that aren’t clear from the filings.
In any case, audits for 2011 through 2015 “are not yet final and are subject to change,” CMS official Steven Ferraina stated in a July court affidavit.
“It’s galling to me that they haven’t recovered more than they have,” said Edward Baker, a whistleblower attorney who has studied the issue.
“The government needs to be more aggressive in oversight and enforcement of the industry,” he said.
Senior CMS official Cheri Rice recommended in the October 2015 email thread with key staff that CMS could devote more resources to supporting whistleblowers who report overbilling and fraud.
“We think the whistleblower activity could be as effective – or even more effective – than CMS audits in getting plans to do more to prevent and identify risk adjustment overpayments,” Rice wrote.
But the handful of cases that DOJ could realistically bring against insurers cannot substitute for CMS fiscal oversight, Baker said.
“Unfortunately, that makes it appear that fraud pays,” he said.
Spending Surge
In December, a bipartisan group of four U.S. senators, including Bill Cassidy (R-La.), wrote to CMS to voice their alarm about the overpayments and other problems. “It’s unclear why CMS hasn’t taken stronger action against overpayments, despite this being a longstanding issue,” Cassidy told KFF Health News by email.
In January, Sen. Elizabeth Warren (D-Mass.) and Rep. Pramila Jayapal (D-Wash.) called for CMS to crack down, including by restricting use of chart reviews and home visits, known as health risk assessments, to increase plan revenues.
Cassidy, a physician, said that
continued from page 6
“upcoding and abuses of chart review and health risk assessments are wellknown problems CMS could address immediately.”
Advocates for Medicare Advantage plans, whose more than 33 million members comprise over half of people eligible for Medicare, worry that too much focus on payment issues could harm seniors. Their research shows most seniors are happy with the care they receive and that the plans typically cost them less out-of-pocket than traditional Medicare.
Buck, the spokesperson for the Better Medicare Alliance, said that as the annual open enrollment period starts in mid-October, seniors may see “fewer benefits and fewer plan choices.”
The group has ramped up total spending in recent years to keep that from happening, IRS filings show
In 2022, the most recent year available, the Better Medicare Alliance reported expenses of $23.1 million, including more than $14 million on advertising and promotion, while in 2023, it paid for a Super Bowl ad featuring seniors in a bowling alley and left viewers with the message: Cutting Medicare Advantage was “nuts.”
Bruce Vladeck, who ran CMS’ predecessor agency from 1993 through 1997, said that when government officials first turned to Medicare managed care groups in the 1990s, they quickly saw health plans enlist members to help press their agenda.
“That is different from most other health care provider groups that lobby,” Vladeck said. “It’s a political weapon that Medicare Advantage plans have not been at all reluctant to use.”
The Better Medicare Alliance reported lobbying on 18 bills this year and last, according to OpenSecrets. Some are specific to Medicare Advantage, such as one requiring insurers to report more detailed data about treatments and services and another to expand the benefits they can offer, while others more broadly concern health care costs and services.
Proposed reforms aside, CMS appears to believe that getting rid of health plans that allegedly rip off Medicare could leave vulnerable seniors in the lurch.
Testifying on behalf of CMS in a May 2023 deposition in the UnitedHealth Group suit, former agency official Anne Hornsby said some seniors might not “find new providers easily.” Noting UnitedHealth Group is the single biggest Medicare Advantage contractor, she said CMS “is interested in protecting the continuity of care.”
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism.
GrandRounds
Baptist Memorial and Fayette County Board Agree to Establish New Hospital in Fayette County
The Fayette County Board of Commissioners and Baptist Memorial Health Care have agreed to establish a new hospital in Fayette County. This would be the only hospital in the county and would serve much of West Tennessee along the I-40 corridor between Arlington and Jackson.
Fayette County consists of 11 incorporated cities and has a population of more than 41,000 people according to the 2020 census. The county is near BlueOval City, Ford’s automotive manufacturing ecosystem that will produce the next generation of electric trucks and is seeking to fill 6,000 positions in West Tennessee.
Baptist Memorial and Fayette County expect the new construction project to cost about $24 million and take about 24 months to complete. Integrated into the Baptist Memorial Health Care system, the new hospital will include eight emergency rooms staffed by physicians who are board certified in emergency medicine, eight acute care inpatient beds, outpatient imaging and lab services.
The new hospital will be centrally located in Fayette County at the northwest corner of Highway 64 and Warren Road near Tennessee Tractor.
“This hospital will significantly improve access to emergency and trauma care in Fayette County,” said Glenn Miller, director of Emergency Medical Services for Fayette County.
Semmes Murphey Clinic Welcomes Two New Neurologists
Memphis-based brain and spine care provider Semmes Murphey Clinic recently hired two general neurologists – Dr. Caitlin Brockenshire and Dr. Neha Kumar.
Western Reserve University/Cleveland Clinic Foundation and completed her residency at Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School, where she served as Chief Resident in her final year. She then completed a fellowship in vascular neurology at Boston Medical Center. She is an active member of the AAN and the American Stroke Association.
Saint Francis Medical Partners Welcomes New Interventional Cardiologist
Saint Francis Medical Partners recently welcomed Zulfiqar Baloch, MD, an interventional cardiologist, to Saint Francis Cardiology Associates. His office
PUBLISHER
Pamela Z. Haskins pamela@memphismedicalnews.com
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Brockenshire will diagnose, treat and manage patients’ conditions affecting the blood vessels in the brain and spinal cord. Prior to joining Semmes Murphey, she attended medical school at the University of Tennessee Health Science Center, where she also completed her residency. She graduated from Auburn University where she received her Bachelor of Science in biomedical studies. She is an active member of the American Academy of Neurology and the American Heart Association.
Kumar will diagnose, treat and manage conditions affecting patients’ brain, spinal cord and nervous system. Prior to joining Semmes Murphey, she attended medical school at Case
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Caitlin Brockenshire
Neha Kumar
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is located on the Saint Francis Hospital-Bartlett campus.
Baloch provides peripheral vascular, general cardiology and interventional cardiology services, pacemaker and defibrillator services, and vascular/circulation medicine. He performs cardiac catheterizations and stents, stent implantations for blocked arteries, and pacemaker and implantable cardioverter defibrillation implantations.
He is board-certified by The American Board of Internal Medicine, The American Society of Echocardiography, The American Society of Nuclear Medicine, The American Board of Cardiovascular Medicine, and is a Registered Physician in Vascular Interpretation (RPVI).
Regional One Health Implements New EvidenceBased Program for Childbirth
Regional One Health’s Labor & Delivery Center has implemented a new program called TeamBirth, an industrystandard process that sets specific steps during childbirth designed to support open communication among patients, their support people, nurses and doctors. The program helps ensure every family who delivers at Regional One Health has a safe, positive birth experience that results in a healthy mom and baby.
Maternal fetal medicine physician Kerri Brackney, MD, and clinical nurse specialist Bonnie Miller are spearheading TeamBirth.
“The goal is to involve patients in their own care, give them a voice, and really put them in the center of it all,” Dr. Brackney said. “The patient should be the focal point, and we should be the team that supports them.”
There are two key components to TeamBirth: communication huddles and a planning board in each patient’s room.
“During the huddles, the patient and their support people, nurse, provider and other key players talk about decisions that need to be made at that point in the patient’s care,” Dr. Brackney said. “Anybody on the team can call a huddle at any point, including the patient.”
The first huddle occurs soon after the patient is admitted. The team discusses the patient’s goals and preferences, develops a plan for the birth, and makes sure everyone is on the same page. After that, huddles take place by request or whenever there is a big decision to make.
The second component of TeamBirth, the planning board, is also aimed at communication. Each patient room has a dry erase board that lists everyone on the medical team, the patient’s specific preferences, and an
outline of the birth plan.
The next step is to expand the TeamBirth program to antepartum and postpartum units.
Visit www.regionalonehealth.org/ womens-services/labor-and-delivery/ for more information about Regional One Health’s childbirth services.
College of Nursing Expands Doctor of Nursing Practice to Develop Nursing Executives
The University of Tennessee Health Science Center College of Nursing
has opened a new Doctor of Nursing Practice (DNP) degree track to educate aspiring nurse executives.
“Bringing our nurse executive DNP online expands our opportunity to build nurse leaders, something for which the college is well-known,” said Dean Wendy Likes, PhD, DNSc, APRN-BC, FAAN, FAANP. “This degree is perfect for a registered nurse aspiring to serve as a chief nursing officer, chief executive officer, director of nursing, or in a leadership role for a governmental agency or non-profit organization.”
UT Health Science Center is the
largest producer of doctorally prepared nurses in Tennessee. According to U.S. News & World Report, the College of Nursing’s DNP program ranks No. 16 nationwide among public universities with DNP programs. Among public and private schools nationwide, the college’s DNP program ranks No. 25.
Applications for the new degree are open. Nurses who hold a Bachelor of Science in Nursing (BSN), a Master of Science in Nursing (MSN), or a DNP in another area qualify for the program.
The DNP for nurse executives at UT
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Zulfigar Baloch
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Health Science Center is unique in that it offers a greater emphasis on crisis communications and strategy. “Events over the past few years have demonstrated the need for nurse executives to have the tools to provide leadership and communication strategies during times of crisis,” said Assistant Dean of Graduate Programs Bobby Bellflower, DNSc, NNPBC, FAANP, FNAP.
More information about the nurse executive DNP and how to apply is available on the College of Nursing’s website.
West Cancer Foundation Grant to Fund Oncology Education at UT Health Science Center College of Nursing
The University of Tennessee Health Science Center’s College of Nursing has received a $144,469 grant from the West Cancer Foundation that will support innovative educational opportunities to prepare nurses and nursing students to meet the specific needs of oncology patients.
The project, Providing the Oncology Workforce Education and Resources (POWER) for Nursing Program, will enhance oncology education in nursing in four ways. It will fund a Distinguished Visiting Professorship in Oncology Nursing; it will support the development of an oncology elective in the Bachelor of Science in Nursing (BSN) program at UT Health Science Center; and it will fund two students as oncology nurse scholars and two students as oncology research nurse scholars.
The Oncology Scholars programs are one-year courses open to traditional BSN students, which will take place in the last year of their BSN degrees. Students in the Oncology Scholars programs will have paid clinical or research opportunities in diverse oncology settings in the Mid-South. They will also do oncology coursework to gain more knowledge in the field and agree to work in an oncology setting upon graduation, said College of Nursing Dean Wendy Likes, PhD, DNSC, APRN-BC, FAAN, FAANP. West Cancer Foundation’s mission is to break through barriers to cancer
care and improve patient outcomes by providing accessible patient resources, early detection and education, and research to improve health inequities.
The grant to UT Health Science Center is the latest among 17 grants West Cancer Foundation has awarded to the university totaling just under $2.2 million.
The BSN oncology elective and both Oncology Scholars programs are scheduled to go into effect in 2025. The Bernie Crook Distinguished Visiting Professorship in Oncology Nursing will take place at 5:30 p.m. on February 3, 2025, at the FedEx Event Center. The free event will offer continuing education units, and a registration link will soon be available at cenow.uthsc.edu
Methodist Healthcare Foundation Welcomes Memphians Chirag Chauhan and Lori Patton to Board of Directors
and received his Retirement Planning Specialist designation from the Wharton School of Business at the University of Pennsylvania.
He is a member of the Methodist Germantown Hospital Advisory Council. In addition, the Chauhan family has supported Methodist Le Bonheur Healthcare for more than 15 years through annual giving and special projects like the Germantown Historic Church Restoration, and a memorial to Dr. Dinesh N. Chauhan with an update to the Mothers Room at The Women’s Pavilion at Methodist Germantown.
seven to 14 beds, increasing the ICU’s footprint to 17,000 square feet. Moving from the first floor to the second floor, the new ICU will replace former shelled space and unused rooms on the second floor of the hospital. Once the ICU renovations are complete, the emergency department will be expanded into the former ICU space on the first floor, increasing the ER by 4,732 square feet.
Baptist Collierville’s expansion project is largely funded through a $5.5 million grant from the Tennessee Department of Health’s Healthcare Resiliency Program.
The Methodist Healthcare Foundation recently welcomed two long-time Memphians to its board of directorsChirag Chauhan, financial advisor and managing partner with Bluff City Advisory Group, and Lori Patton, co-owner of Roadshow BMW/MINI and trustee of the Jerry and Nina Patton Family Foundation.
Patton is a Christian Brothers University alumna, receiving the Distinguished Alumni Award in 2010. She currently serves as chair of the Girl Scouts Heart of the South Board and serves on the Tennessee Nonprofit Network and Memphis Child Advocacy Center Boards. In 2010, she completed the Leadership Memphis Executive Program.
“Lori and Chirag are both incredible leaders and health advocates in our community, and they truly exude our Foundation’s mission to enhance the health of the communities we serve through a vision of healing and hope,” said Zach Pretzer, President of the Methodist Healthcare Foundation.
Chauhan, a Rhodes College graduate, is involved with the National Association of Insurance and Financial Advisors, Medical Group Management Association and the Memphis Estate Planning Council. He earned a master’s degree from the University of Memphis
Through Roadshow BMW, the Patton Family has supported Methodist Le Bonheur Healthcare for a decade through Roadshow BMW’s Ride for A Cause for breast cancer prevention and Bowl n Bash and Sips for Sickle Cell to raise awareness and funds for the Methodist Comprehensive Sickle Cell Center.
Baptist Collierville Set to Make $10 Million-plus ICU and ER Expansion
Baptist Memorial HospitalCollierville will soon begin construction on a $10 million-plus project to expand the hospital’s intensive care unit and emergency department.
The expansion will double the capacity of Baptist Collierville’s ICU from
Construction on the ICU is scheduled to last approximately 12 months and should be completed in fall 2025. The emergency department expansion will be completed a few months later. During construction, scaffolding and a temporary air handler may block some parking spaces on the hospital campus. The expansion was designed by ESa architectural firm, and Flintco Construction is handling construction management and services.
OrthoSouth Welcomes Two New Spine Surgeons to the Team
OrthoSouth, the region’s leading orthopedic practice, is thrilled to announce the addition of two distinguished spine neurosurgeons, Dr. Raul J. Cardenas and Dr. Jason Andrew Weaver, to its multidisciplinary spine team.
Cardenas, boardcertified neurosurgeon and a native Memphian, brings with him over a decade of expertise in minimally-invasive and complex spine surgery. Dr. Cardenas has led a rich and productive career, including roles at the University of Tennessee Health Science Center and Semmes-Murphey Clinic. His
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Chirag Chauhan
Lori Patton
Raul J. Cardenas
Jason Andrew Weaver continued
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innovative approach to minimally-invasive spine surgery has helped patients across the Mid-South find relief from painful conditions.
He has performed charitable operations with his father in Mexico to care for the underserved. Dr. Cardenas is not only a leader in the field but also a dedicated educator, shaping future surgeons through his roles at multiple prestigious medical institutions, including University of Texas Health Science Center in Houston and Louisiana State University Health Science Center.
Weaver is a board-certified neurosurgeon. He brings 20 years’ experience in minimally invasive spine surgery and complex spine surgery to OrthoSouth. He is also fellowship-trained in spine tumor surgery at MD Anderson Cancer Center with a focus in complex reconstructive surgery of the spine. He has a particular focus in outpatient surgery and utilizing the latest advancements to his patients’ benefit.
Weaver has served the Memphis community notably through his previous affiliations with the Semmes-Murphey Clinic and the University of Tennessee. He has also held the position of Team Neurosurgeon for a number of Memphisbased professional and collegiate sports teams.
Dr. Cardenas and Dr. Weaver are now accepting new patients at OrthoSouth’s offices in East Memphis, Germantown, and Southaven. For more information or to make an appointment, please visit https://orthosouth.org
Campbell Clinic Physicians Named to Newsweek’s Inaugural List of America’s Best Spine Surgeons
Two of Campbell Clinic’s spine surgeons, Dr. Keith Williams and Dr. Kirk Thompson, were the only two spine surgeons in the Memphis regional area to be named to Statista and Newsweek’s first annual ranking of America’s Best Spine Surgeons.
“The ranking includes an evaluation of the surgeons’ performed procedures based on Medicare data, an online survey of more than 30,000 medical experts, a quality-of-care rating by peers of each spine surgeon and a consideration of their American Board of Orthopaedic Surgery certifications,” noted Newsweek’s Global Editor in Chief, Nancy Cooper in a letter outlining the list’s methodology.
Fellowship-trained spine surgeon Dr. Keith Williams has been with Campbell Clinic since 1992 and currently practices out of its Wolf River Boulevard location in Germantown. He is board-certified by the American Board of Orthopaedic Surgery and is also a member of various professional societies including the American Academy of Orthopaedic Surgeons, the American Medical Association, and the North American Spine Society, in addition to
serving as an Associate Professor for the University of Tennessee-Campbell Clinic Department of Orthopaedic Surgery. For more information on Dr. Williams, visit https://www.campbellclinic.com/ physician/keith-williams/
Dr. Kirk Thompson, a fellowshiptrained spine surgeon, joined the Campbell Clinic team in 2020 and also practices out of its flagship Wolf River location. He is board-certified by the American Board of Orthopaedic Surgery and is also involved in a number of professional societies and academic interests such as serving as an Assistant Professor for the University of Tennessee-Campbell Clinic and serving as a reviewer for the Global Spine Journal in addition to being a member of the North American Spine Society, the American Academy of Orthopaedic Surgeons and the Tennessee Medical Association. For more information on Dr. Thompson, visit https://www.campbellclinic.com/physician/kirk-m-thompson/
Regional One Health Legal Leader to Lead Tennessee Bar Association’s Health Law Section
Imad Abdullah, senior vice president and chief legal officer for Regional One Health, is the incoming Chair for the Tennessee Bar Association’s Health Law Section.
Abdullah advanced from Vice Chair to incoming Chair during the organization’s recent annual meeting. The Health Law Section works to further the knowledge of its members in federal, state, and local health care law.
Abdullah joined Regional One Health in 2014. As the principal attorney and general counsel for the health system, he is responsible for managing all aspects of legal affairs and risk management.
Dr. Brendan Tunstall Gains National Support for Opioid Dependence Research
Brendan Tunstall, PhD, assistant professor of pharmacology in the College of Graduate Health Sciences at the University of Tennessee Health Science Center, was recently awarded $423,500 from the National Institute on Drug Abuse for his exploration of a new approach to treat opioid dependence, a pressing global health issue.
Tunstall, the sole principal investigator on the project, is focusing on Neuropeptide S (NPS), a brain chemical known for its unique profile of reducing anxiety while promoting wakefulness. When NPS interacts with its receptor, Neuropeptide S Receptor 1 (NPSR1), it can calm anxiety without causing drowsiness or sedation, which are common side effects of many current anxiety
medications.
“My proposal is based on the idea that activating the NPSR1 receptor in the brain could help counteract stress signaling in the brain and thereby reduce anxious states that are a common feature of opioid dependence, particularly evident during opioid withdrawal,” Tunstall said. “My lab’s work is guided by the premise that if we could alleviate the negative emotional states experienced in opioid dependence, then we would remove a major contributing factor to the motivation to seek and use opioids.”
By working to identify new mechanisms that could be targeted to modulate brain chemistry without severe side effects, Tunstall hopes his work will eventually provide much-needed relief for those battling opioid dependence.
Tunstall’s ultimate goal is to improve the range of treatments available for opioid use disorder and the often-overlapping disorders of anxiety and pain.
Regional One Health Brings High-Risk Pregnancy Services to Rural West Tennessee Communities
Regional One Health is using a $3 million grant the hospital received from the Tennessee Department of Health to make high-risk pregnancy services available for families living in rural West Tennessee communities who otherwise would not have access to maternal fetal medicine.
The grant will be used to create and implement our Stork 901 program that will make high level prenatal care more accessible and equitable
Stork 901 will offer a number of services including highly detailed ultrasounds, management of chronic conditions, consultations through telehealth, and referrals when needed for women facing high-risk pregnancies.
The funds from the grant will be used to purchase two mobile obstetrics imaging units that will provide access to advanced prenatal screenings. Highlytrained sonographers will identify any birth defects or abnormalities in the screenings for patients in targeted areas in over 20 rural West Tennessee counties including McNairy, Obion, Hardeman, Tipton, Haywood, Weakley, Henry, Hardin, and Crockett.
“This grant gives us the opportunity to elevate obstetric care for families living in rural areas in targeted communities in West Tennessee. It will have a huge impact on improving outcomes for moms and babies,” said Kerri Brackney, MD, who specializes in maternal fetal medicine at Regional One Health and is an assistant professor in the College of Medicine – Memphis at UTHSC.
Dr. Brackney says West Tennessee has the lowest detection of congenital heart defects in the state. She says the specially trained sonographers who will be using the advanced detailed anatomy ultrasound technology aboard the
mobile units will be able to identify fetal congenital heart defects sooner. This program will allow patients to remain close to their homes which makes it easier for families to stay together and avoids additional costs of staying in another community.
WGU Launches $10M Scholarship to Benefit Nursing Students
Western Governors University (WGU) has announced the launch of a new $10 million scholarship fund that could impact its nursing students in Tennessee.
The Heartbeat of Healthcare is aimed at supporting registered nurse (RN) students across the country who are pursuing WGU’s Bachelor of Science in Nursing (RN-to-BSN) or Master of Science in Nursing (RN-to-MSN) programs at the Michael O. Leavitt School of Health (LSH). This initiative, which is available through June 2025, is intended to increase access to affordable nursing education, helping to address the state’s critical need for highly trained nurses.
The Heartbeat of Healthcare scholarship provides two tiers of support to eligible students:
• Tier 1: Full tuition for up to two terms, awarded to 100 recipients nationwide
• Tier 2: $2,500 per recipient, divided across two terms ($1,250 per term)
In Tennessee, WGU currently has nearly 5,200 students, including 598 in its LSH. Over the past 12 months, WGU has awarded more than $1.1 million in scholarships in Tennessee.
Employers across Tennessee, including major healthcare providers like HCA Healthcare and Ascension, are increasingly seeking nurses with advanced education. According to the AACN, more than 28 percent of employers now require nurses to hold a bachelor’s degree, while 72 percent strongly prefer it.
Tennessee RNs who have an associate degree or nursing diploma and are looking to advance their careers into roles like public health nurse, flight nurse, nurse case manager or staff nurse are encouraged to apply for these scholarships. The RN-to-BSN and RN-to-MSN programs are designed to be completed within one year, allowing working professionals to efficiently continue their education while maintaining their current roles.
The program is evidence-based, with updated content that aligns with the AACN Essentials: Core Competencies for Professional Nursing Education. For more information about the Heartbeat of Healthcare scholarship or to apply, visit https://www.wgu. edu/financial-aid-tuition/scholarships/ general/heartbeat-of-healthcare-rn-bsnscholarship.html
