Banner Prints Social Security Numbers

The Monday edition of the Arizona Republic contained a story with potential interest to our readers. On the most recent address labels of Banner Health's magazine, Smart & Healthy, the addressee's Social Security or Medicare identification numbers, which are often identical to their Social Security numbers (1). The magazine was mailed to more than 50,000 recipients in Arizona late last week.

The recipients are members of the Medicare Pioneer Accountable Care Organization, a government health-care plan that Banner serves. Banner generated its mailing list from information it received from the U.S. Centers for Medicare & Medicaid Services, which is an agency within the U.S. Department of Health & Human Services (HHS) responsible for administration of several federal health-care programs.

Although medical information has been protected by the Health Insurance Portability and Accountability Act (HIPAA) since 1996, penalties were recently increased. Civil monetary penalties were increased from a maximum of $100 to $50,000 per violation and the maximum aggregate increased from $25,000 for each violation to $1,500,000 per year. If multiple violations occur the penalties could exceed $1,500,000. Reflecting the increase in penalties, HHS fined BlueCross Blue Shield (BC&BS) of Tennessee $1.5 million in a case involving a breach that affected more than 1 million individuals (2). Locally, HHS fined a Phoenix cardiac surgery group $100,000 for posting patients' appointment information on an internet calendar that was available to the public (2).

Officials at HHS and Social Security Administration are looking into the matter (1). The $100,000 fine of the physician group in Arizona is likely a fairly sizable portion of their revenue. In contrast, the $1.5 million penalty paid by Tennessee BC&BS is less than 0.03% of their $5.6 billion revenue (3). Banner had total revenues of $4.9 billion and assets of $7.6 billion in 2012.

Richard A. Robbins, MD

References

1. Giblin P. Medicare IDs erroneously published. Arizona Republic. Available at: http://www.azcentral.com/news/arizona/articles/20140224medicare-ids-erroneously-published.html (accessed 2/27/14).
2. Anderson H. Arizona practice gets $100k HIPAA fine. Available at: http://www.govinfosecurity.com/arizona-practice-gets-100k-hipaa-fine-a-4686 (accessed 2/27/14).
3. Flessner D. BlueCross BlueShield of Tennessee earns record $221 million. Chattanooga Times Free Press Available at: http://www.timesfreepress.com/news/2013/apr/30/bluecross-earns-record-221-million/?business (accessed 2/27/14).
4. Ernst & Young. Banner Health Consolidated Financial Statements. Available at: https://www.bannerhealth.com/NR/rdonlyres/DD3E9650-00D6-4385-B12B-E96BBC4E9917/67703/_BannerHealthconsolidated201211_Final.pdf (accessed 2/27/14).

Reference as: Robbins RA. Banner prints social security numbers. Southwest J Pulm Crit Care. 2014;8(2):140-1. doi: http://dx.doi.org/10.13175/swjpcc027-14 PDF

Many Southwest Hospitals Will Receive Decreased CMS Reimbursement

More hospitals are receiving penalties than bonuses in the second year of the Centers for Medicare and Medicaid Services' (CMS) quality incentive program, and the average penalty is steeper than last year according to a report from Jordan Rau in Kaiser Health News (1). Southwest hospitals reflect that trend with New Mexico and Arizona exceeding the US average both in percentage of hospitals receiving penalties and the average size of the penalty (Table 1). Colorado approximated the national averages (Table 1).

Table 1. Hospital CMS reimbursement bonus/penalty 2014. (For individual hospitals see Appendixes for Arizona, Colorado, New Mexico, and the Mayo Clinic Minnesota).

Most hospitals are gaining or losing <0.2% but in some instances the penalties are substantial. Gallup Indian Medical Center in New Mexico, a federal government hospital on the border of the Navajo Reservation, will be paid 1.14 percent less for each patient and New Mexico’s average of a -0.31% decline in reimbursement are the largest changes nationally. 

“This program is driving what we want in health care,” said Dr. Patrick Conway, CMS’ chief medical officer. He said most hospitals have improved since the program began a year ago despite more hospitals receiving penalties than bonuses. However, even some hospitals that have gotten better are still losing money because they are not scoring as well as others or have not improved as much.

Most winners from last year stayed winners and losers stayed losers, but there were some switches. For example, Banner Boswell Medical Center in Sun City will receive a 0.36% bonus in place of a -0.58% penalty last year. In contrast, the University of Colorado will receive a -0.35% penalty this year compared to a bonus of 0.29% last year. 

This year 45% of a hospital’s change in CMS reimbursement is based process of care measures. Patient satisfaction accounts for 30%. However, for the first time 25% of the score is based on standardized mortality for myocardial infarction, heart failure and pneumonia. CMS is planning to add new measures next year, including comparisons of charges at different hospitals and rates of medical mishaps and infections from catheters.

The maximum readmission penalties grow to 3% next year and CMS is launching a third incentive program that takes an additional 1 percent of payments away from hospitals with the most patients who suffered injury or infection during their stay. Combined, these measures have the potential to strip away as much as 5.5 percent of CMS payments from the worst performing hospitals starting next October.

As reported in the Southwest Journal of Pulmonary and Critical Care Southwest hospital charges to CMS vary widely for pulmonary and critical care DRGs (2). Also, the complications chosen by CMS do not correlate with outcomes (3). Felton et al. (4) reported higher patient satisfaction was associated with higher admission rates to the hospital, higher overall health care expenditures, and increased mortality and not the expected improvements in outcomes.

Ashish Jha (5) from the Harvard School of Public health examined the latest CMS reimbursement data and reported in his blog that hospitals in the West receiving larger penalties than other areas. Most disturbingly, public hospitals and safety-net hospitals also tended to do worse. As Jha points out these penalties are not large but the change may be relevant for a safety-net hospital operating on a small financial margin.

Richard A. Robbins, MD

References

1. Rau J. Nearly 1,500 hospitals penalized under Medicare program rating quality. Available at: http://www.kaiserhealthnews.org/stories/2013/november/14/value-based-purchasing-medicare.aspx (accessed 11/19/13).
2. Robbins RA. Variation in southwestern hospital charges for pulmonary and critical care DRGs. Southwestern J Pulm Crit Care. 2013;7(1):31-7. [CrossRef]
3. Robbins RA, Gerkin RD. Comparisons between Medicare mortality, morbidity, readmission and complications. Southwest J Pulm Crit Care. 2013;6(6):278-86.
4. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med 2012;172:405-11. [CrossRef][PubMed]
5. Jha AK. An update on value-based purchasing: year 2. Available at: https://blogs.sph.harvard.edu/ashish-jha/ (accessed 11/19/13).

Reference as: Robbins RA. Many southwest hosptials will receive decreased CMS reimbursement. Southwest J Pulm Crit Care. 2013;7(5):305-6. doi: http://dx.doi.org/10.13175/swjpcc164-13 PDF 

Bipartisan Proposal Calls for SGR Repeal

The Washington Post (11/1, Carey) reports a bipartisan group of legislators has agreed on a framework replacing the “problematic” Medicare payment formula in an attempt to end the annual Sustainable Growth Rate (SGR) or “doc fix” debate. The current system is set to reduce Medicare physician payments by approximately 25% on Jan. 1 without Congressional intervention. Senate Finance Committee Chairman Max Baucus (D-MT) and House Ways and Means Committee Chairman Dave Camp (R-MI) introduced a draft proposal that would “encourage care management services for individuals with complex chronic care needs through the development of new payment codes for such services, as well as leverage physician-developed standard of care guidelines to avoid the unnecessary provision of services”. The Committees value your feedback on this proposal. Please submit written comments to the Finance SGR comments mailbox at sgrcomments@finance.senate.gov and the Ways & Means SGR comments mailbox at sgrwhitepaper@mail.house.gov by Tuesday, November 12, 2013.

Dr. John Noseworthy, Mayo Clinic president and CEO, said in a press release he was pleased to see a bipartisan effort to replace the outdated SGR. The release went on to say that the Mayo Clinic will the initiatives and respond to Congress’ request to provide further comments.

Richard A. Robbins MD

Reference as: Robbins RA. Bipartisan proposal calls for SGR repeal. Southwest J Pulm Crit Care. 2013;7(5):278. doi: http://dx.doi.org/10.13175/swjpcc147-13 PDF

Helman Defends Decision to Pull VA Sponsorship of Veterans Day Parade

Sharon Helman, Phoenix VA Director, defended her decision to cancel VA sponsorship of the annual Phoenix Veterans Day Parade in a 4/10/13 email to VA employees. Helman said that VA sponsorship was cancelled because of “…priorities in the organization (specifically access), and heightened awareness over liability concerns which VA Legal Counsel brought forward”. She concluded her letter by warning “… that all media inquiries should be forwarded to Paul Coupaud, Acting Public Affairs Officer”.

VA officials initially said fear of litigation prompted the review of VA support. Last year, a float carrying wounded Veterans in a Midland, Texas, parade collided with a freight train, killing four and injuring 17. Crash victims and their families filed lawsuits in Texas against Union Pacific Railroad and the float owner. The VA was not a defendant, and the VA has not issued any national directives on liability as a result of the tragedy.

In past years, the VA did not contribute cash for the parade. Instead, it served as lead sponsor by providing staging areas at its medical center and allowing Paula Pedene, the former Director of Public Relations at the Phoenix VA, to serve as coordinator. It also provided other support and hosted award events, an essay contest and banquets. Pedene was demoted in the wake of her testimony to the VA Office of Inspector General against former VA administrators. Pedene testified that the Phoenix VA suffered from leadership run amok. She said that agency bosses intimidated employees and created a hostile workplace.

Phoenix VA employees had provided volunteer support on their own time for the Phoenix Veterans Day Parade. No mention has been made of clinical VA employees who participated in parade activities during regular working hours instead of providing care. It is difficult to understand how cancelling sponsorship of the Phoenix Veterans Day Parade will provide increased access to healthcare for Veterans. However, wasting clinical staff time with lengthy and extraneous emails such as the one sent out 4/10/13 or Ms. Helman’s equally lengthy and extraneous weekly e-mails to employees will compromise access. As Helman said in her letter the VA must focus on “bringing additional staff on board” to care for the 81,000 Veterans enrolled at the Phoenix VA. If true, the alleged pattern of abuse, discrimination and retaliation at the Phoenix VA will jeopardize the hiring and retention of the necessary clinical staff to provide Phoenix Veterans access to quality healthcare.

Richard A. Robbins, MD*

*Dr. Robbins was the chief of pulmonary and critical care at the Phoenix VA from 2003-11.

Reference as: Robbins RA. Helman defends decision to pull VA sponsorship of Veterans day parade. Southwest J Pulm Crit Care. 2013;6(4):180. PDF

In Aftermath of Financial Investigation Phoenix VA Employee Demoted after Her Testimony

A previous Southwest Journal of Pulmonary and Critical Care Journal editorial commented on fiscal mismanagement at the Department of Veterans Affairs (VA) Medical Center in Phoenix (1). Now Paula Pedene, the former Phoenix VA public affairs officer, claims she was demoted for testimony she gave to the VA Inspector General’s Office (OIG) regarding that investigation (2). In 2011, the OIG investigated the Phoenix VA for excess spending on private care of patients (3). The report blamed systemic failures for controls so weak that $56 million in medical fees were paid during 2010 without adequate review. The report particularly focused on one clinician assigned by the Chief of Staff to review hundreds of requests per week and the intensive care unit physicians for transferring patients to chronic ventilator units (1,3). After the investigation, the director and one of the associate directors left the VA and the chief of staff was promoted to chief medical officer in one of the VA’s networks. The other associate director was appointed as director of another VA medical center in 2010 before the investigation.

According to the Arizona Republic, Pedene was interviewed in May 2011 by the OIG to probe the misspending along with allegations of sexual harassment and a hostile workplace (2). Pedene testified that the Phoenix VA suffered from “leadership run amok” (2). She said that agency bosses intimidated employees and that then-Director Gabriel Perez threatened her with banishment to a basement workspace, making it clear he did not want a woman — or someone with a service-connected disability — as the VA’s public-affairs officer. The OIG report makes no mention of intimidation, sexual harassment or a hostile workplace in their report (3).

Pedene, the Veterans Day Parade coordinator since 1997, was accused of having her husband take photographs of the Veterans Day Parade. Pedene, who is blind, then allowed her husband to upload the photos onto the VA website using her password (2). Pedene’s legal advisers and VA records indicate the dispute stems from a larger controversy involving years of mismanagement, squandered funds, discrimination, sexual harassment and retaliation at the Phoenix VA. Pedene was notified of her transfer in a Dec. 10 letter from Associate Director Lance Robinson. He wrote that she was the subject of a “very serious” allegation, and he issued a gag order prohibiting public disclosures.  

Former Maricopa County Attorney Rick Romley, who chairs the parade-sponsoring Veterans Commemorative Committee of Phoenix, said he authorized Pedene to hire her husband as a photographer and cannot understand VA administrators’ response to a seemingly minor transgression  (2). “Quite frankly, this is peanuts in the security world,” said Romley, who in 2006 served as special security adviser to the secretary of Veterans Affairs in Washington (2).

Pedene had been called as a witness in the case. The investigation was initiated after complaints by employee Sheila Cain, who in 2010 was assistant chief of the Phoenix VA’s Health Administration Services. Cain had sought to repair problems with the Phoenix VA’s budget and fee-payment systems. According to VA reports, her efforts led to infighting over blame and responsibility. Cain filed a series of grievances alleging that she was subjected to false accusations, denied due process, stripped of authority and isolated in a basement workspace for six months. Cain endured sexual remarks, threats, improper touching, public humiliation and other abuse more than 30 times. In one instance, she alleged that Dr. Christopher Bacorn, then Phoenix VA Associate Director, hit her rear end with a spatula in front of a fellow employee (2).

Documents obtained independently by the Arizona Republic show Cain also was victimized by unlawful access to her medical records (2). An investigation of that patient-confidentiality breach resulted in the discipline of at least nine employees of the health system, some of whom left the VA. Cain remains with the VA but not under the supervision of Phoenix administrators. In the meantime, Pedene became a target of similar treatment under new bosses. Her reassignment to the hospital library, initially set at 30 days, is in its third month.

Employee-relations consultant, Roger French, who at one time represented Pedene and has represented about 40 VA employees in grievances, said he has seen a pattern of abuse, discrimination and retaliation in the Phoenix VA (2). He said Pedene was criticized for her blindness, and administrators dismantled a public-relations program once considered among the nation’s best. Recently, he added, Pedene’s name was redacted from the VA’s online employee directory, and her awards were removed from a display case at the Phoenix VA. “She stood up and told the truth,” French said. “It cost (administrators) their jobs, and they threatened to destroy adversaries and families.”

French has asked Department of Veterans Affairs Secretary Eric Shinseki to launch a new inquiry. French’s Feb. 12 letter accuses the present Phoenix VA administration of nepotism, retaliation and improper downgrading of evaluations. “I have never seen the hostility, cavalier violations of regulations and laws (or) lack of dignity and respect for employees,” French wrote to Shinseki. Shinseki did not respond, French said.

Unfortunately, if Shinseki does act, it will likely be through another investigation by the OIG which inadequately investigated the previous allegations of mismanagement (1). Instead of focusing on the administrators responsible for budget control, the OIG attempted to place the blame on clinicians acting in the best interests of the patients (1). Furthermore, if the Arizona Republic report is correct, the OIG ignored accusations of sexual harassment and a hostile workplace made at the time of their original investigation. If French’s accusations regarding the present Phoenix VA administration are true, a whitewashing with resignation of some and promotion of other present Phoenix VA administrators is likely to result, as it did in the original investigation (1).

Richard A. Robbins, MD*

References

1. Robbins RA. Mismanagement at the VA: where's the problem? Southwest J Pulm Crit Care 2011;3:151-3.
2. Wagner D. VA official in Arizona demoted after her testimony. Arizona Republic. Available at http://www.azcentral.com/news/arizona/articles/20130314va-official-arizona-pedene-demoted-after-testimony.html accessed 3/29/13.
3. http://www.va.gov/oig/pubs/VAOIG-11-02280-23.pdf (accessed 3/29/13).

*Dr. Robbins was the Chief of Pulmonary and Critical Care at the Phoenix VA from 2003-11.

Reference as: Robbins RA. In aftermath of financial investigation Phoenix VA employee demoted after her testimony. Southwest J Pulm Crit Care. 2013;6(3):151-3. PDF