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Monthly Archives: October 2014

California Audit Finds Backlog Of 11,000 Nursing Home Investigations

California’s public health department has failed to adequately manage investigations of nursing homes statewide, resulting in a backlog of more than 11,000 complaints – many involving serious safety risks to patients, according to an audit released Thursday.

California State Auditor Elaine M. Howle found that the complaints had been open for a year on average – a time frame she called unreasonable and “very concerning.” Nearly 370 open complaints arose from situations that put patients in “immediate jeopardy,” meaning they caused or were likely to cause serious injury or death, according to the review, which looked at cases open as of April 2014. In the Los Angeles County district, 65 immediate jeopardy complaints were open an average of 514 days.

The public health department, which is responsible for ensuring safety for residents at more than 2,500 facilities statewide, doesn’t require investigations to be completed within a certain time, leading to wide discrepancies from office to office, according to the audit.

“Holding district offices accountable for promptly completing investigations is critical to ensuring the safety and well-being of the residents in long-term health care facilities,” Howle wrote in the 82-page report.

nursing home bed 770

State public health officials said in a written statement that they would be reporting on their progress to the auditor. “We appreciate the opportunity to improve our operation,” the statement read.

The state audit was prompted in part by Kaiser Health News reports that the Los Angeles County Public Health Department was ordering inspectors to close cases without fully investigating them. The reports, published by the Los Angeles News Group, also led to a critical county audit.

The state auditor found that the quality of investigations was inconsistent across California. For example, inspectors in the San Francisco office closed cases without having them reviewed by supervisors as required, the report said. And inspectors elsewhere failed to follow state laws requiring investigations to begin within 10 days. In one Sacramento case involving a 97-year-old resident who fell, the inspector didn’t begin the investigation until nine months later.

Mariko Yamada, a member of the state assembly who requested the audit, called the nursing home investigation process “mangled” and said the department has failed to do its job to protect some of the state’s most vulnerable residents. As many as 300,000 residents in California receive care each year in the facilities.

“There has been almost a culture of indifference,” she said in an interview.

The audit found particular problems with investigations into incidents reported to the state by the facilities themselves. In Orange County and most of Los Angeles County, for instance, the inspectors performed on-site investigations in less than 20 percent of such cases reported in 2012 and 2013.

In general, when inspectors found problems at nursing homes, they didn’t always follow up within the required time to ensure the facilities filed plans to fix the problems, according to the audit.

This KHN story can be republished for free (details).

The audit recommended that the department establish a formal process to monitor investigations into open complaints and incidents reported by the homes and that it set a time frame for their completion. The auditor also urged that the department determine how many inspectors are necessary to reduce the backlog and keep up with new complaints.  The department has repeatedly said that it lacks enough resources.

In a response to the audit, state Public Health Department Director Ron Chapman pledged to increase supervision of the district offices, noting that the state already had made improvements to its oversight of Los Angeles County. But the department said that it did not agree with the auditor’s recommendation to set a firm timeline for finishing cases, saying instead that it would work to improve timeliness.

The findings didn’t come as a surprise to Joe Rodrigues, the long-term care ombudsman for the state. Rodrigues said there has long been “questionable oversight and management” of the department’s licensing and certification division.

“It is a flawed system,” he said. “It isn’t doing everything it can do to protect residents.”

Carole Herman, president of the Foundation Aiding the Elderly, agreed. The number of open complaints is “horrific, “she said.

“How many reports are there going to have to be before the governor and the legislature pay attention?” she said.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

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Obamacare May Mean High Drug Costs For Floridians With HIV

When Tony Smith lost his job as a corporate paralegal two years ago, a state program stepped in to help him keep his health insurance — and the expensive drugs his life had depended on since his 2008 HIV diagnosis.

Now Smith,ಪ, of Coral Springs, has been told he must sign up for coverage on Florida’s federally run insurance exchange or the state will stop helping him pay his premiums.

“The landscape of healthcare has changed, and with the passage of the Affordable Care Act we have the opportunity to access and enroll in cost-effective health plans,” an official at the AIDS Insurance Continuation Program wrote in a letter to Smith and other AICP beneficiaries.

But it is not clear that ACA insurance plans will be cheaper — or even affordable — for those with HIV and AIDS, according to patient advocates.

This copyrighted story comes from the Miami Herald, produced in partnership with KHN. All rights reserved.

Last spring, two nonprofit groups filed a federal civil rights complaint alleging that some Florida insurers were discriminating against people with HIV by charging “inordinately high” rates for HIV medication on ACA plans.

In their complaint, the AIDS Institute and the National Health Law Program singled out CoventryOne, Cigna, Humana and Preferred Medical for discouraging people with HIV “from enrolling in those health plans — a practice which unlawfully discriminates on the basis of disability.”

The ACA prohibits insurers from discriminating against consumers because of preexisting medical conditions. The four companies all offered 2014 plans in Florida, including in Miami-Dade and Broward counties, and plan to do so again in 2015, with the exception of Preferred Medical in Broward.

It is an important issue for Florida, which has the third-highest rate of HIV infection in the nation, and for Broward and Miami-Dade, which have the highest rates statewide. Almost 95,000 people in Florida have been diagnosed with HIV. Many of them have coverage for the first time thanks to the health law, activists say. But without proper regulation, high drug prices could act as a de facto form of discrimination, said Carl Schmid, deputy executive director of the Tampa-based AIDS Institute, one of the groups that filed the civil rights complaint.

In a statement to the Miami Herald last week, Coventry spokesman Walt Cherniak said the insurer’s 2014 plans provided access to HIV care “that follows the latest Department of Health and Human Services guidelines and evidence-based practices.” Humana, Preferred Medical and Cigna also issued statements to the Herald denying any discrimination. Humana said it places HIV drugs on its highest — and most expensive — tier because of their cost and clinical complexity.

The details of 2015 insurance plans on the federal exchange in Florida will not be announced until early November, leaving Smith and other Floridians with HIV in limbo. Open enrollment will begin Nov. 15.

“I’m drowning in paperwork trying to figure out what sort of plan I’ll need,” Smith said. “And I’m really worried that I’m just going to be stuck if enrollment opens and there aren’t any I can afford.”

And what if Healthcare.gov, the enrollment website, is again derailed by the kinds of problems that marred its introduction, preventing people from signing up for coverage for months? “I don’t even want to think about that,” Smith said.

HHS said the complaint, filed in May, is still under review by its Office for Civil Rights, which protects consumers from discrimination. The complaint asked the OCR to prevent the four companies from offering plans with discriminatory costs.

Harvey Bennett, a spokesman for the Florida Office of Insurance Regulation, said the state was also investigating whether the plans were “unfairly discriminatory.”

Not all insurers on the exchange are being accused of discrimination. Aetna, Ambetter and Molina placed most of their HIV drugs on less-expensive tiers. Florida Blue, the state’s largest health insurer, listed all but one HIV drug on lower tiers requiring monthly co-pays of $10 to $70.

But the market has seen a general trend toward plans with high deductibles and high co-insurance models for expensive drugs, including those for hepatitis C and multiple sclerosis, according to Steven Ullmann, director of the Center for Health Sector Management and Policy at the University of Miami’s School of Business Administration.

Ullmann said cost-sharing presents a moral dilemma. “It’s one thing if you’re dealing with an elective pharmaceutical, but it’s another where you’re looking at drugs and treatment plans that affect one’s ability to sustain quality of life,” Ullmann said. “But insurance companies are businesses, as well, and one recognizes their incentive structure: to avoid taking on too much risk.”

Ullmann said companies that offered low-cost HIV drugs last year may change their behavior this year based on the plans of their competitors. That means that until insurers reveal their rates for 2015, Smith and others with HIV will not know whether plans will place HIV drugs in high- or low-cost tiers.

“What we’re really worried about is a race to the bottom,” said Wayne Turner, a staff attorney at the National Health Law Program, which helped file the civil rights complaint. Turner said he fears the high-cost plans may have “skewed the market” and that in order to avoid having their risk pool burdened by people with expensive health needs, competitors may increase what they charge for HIV drugs.

Some of the ACA plans have other drawbacks, such as limiting patients to a Ǿ-day supply of medicine instead of a 90-day supply and requiring prior authorization from insurers before every refill. A 2012 study conducted by the pharmacy chain Walgreens and published by the Centers for Medicare and Medicaid Services, which regulates plans sold on the exchange, found that patients with 90-day supplies took their medicine more regularly and had greater cost savings than those with 30-day supplies.

Turner said that with the confusion of the exchange’s launch out of the way, the time was right “for the federal government to send a strong message to plans that they can’t design their benefits in a way that discriminates against people with HIV.”

In a statement to the Miami Herald, Aaron Albright, a spokesman for CMS, called the law’s anti-discrimination provisions “effective” and said the federal government was investigating complaints of discrimination.

Smith said he wouldn’t mind switching to the ACA if he knew that plans with sufficient coverage were waiting for him.

But he knows he will be in trouble if all of the plans look like one Humana plan from last year mentioned in the complaint. The terms of the “silver,” or mid-range, plan would require him to meet a $1,500 prescription deductible and then pay 50 percent of his total drug costs. For his Atripla prescription, a once-daily anti-retroviral, that would mean a monthly payment of around $1,000 until he hit his $6,300 out-of-pocket limit.

“That’s just such a crazy jump from what I’m paying now,” said Smith, who is currently covered by an off-exchange Cigna plan. “I’m already trying to save by not going to the doctor for minor stuff.”

Right now, AICP, the program that helped Smith keep his insurance when he was laid off, pays $750 of his $803 monthly premium. He is responsible for a monthly $110 co-pay for medication. Without insurance, Atripla costs more than $6,300 every three months. AICP, Smith said, “saved my life.”

The program receives about half of its funding from the federal Ryan White HIV/AIDS Program, which helps provide medical care for about 500,000 HIV-positive people nationwide. By federal law, the Ryan White program is the “payer of last resort,” meaning many Floridians who can get cheaper coverage from another source, such as an ACA exchange, will now be required to do so.

Other HIV-positive patients will also be funneled to the exchange, including some clients of the state-administered AIDS Drug Assistance Program, which helps pay for HIV drugs for people who have low incomes or little or no insurance. The program receives 90 percent of its funds from the Ryan White program, meaning that those whose medication costs can be reduced by going onto an exchange will have to do so.

Nathan Dunn, a spokesman for the Florida Department of Health, said that this year about 4,000 of the 14,000 people enrolled in ADAP will have to sign up for federal marketplace coverage. The state would be in danger of losing its Ryan White program funding if it did not move people onto the exchange.

At the Legal Aid Society of Palm Beach County, which helps Ryan White program clients, staff attorney Vicki Tucci said many consumers with HIV who enrolled last year were unhappy with their plans. Tucci counseled about 30 people with HIV who said they discovered too late that the insurance plans they had purchased either didn’t offer enough coverage to make their HIV medicines affordable or didn’t include long-time healthcare providers in their network.

“These were people who were often signing up for health insurance for the first time,” said Tucci, who served as a marketplace “navigator” assisting new enrollees last year. She said she was able to help about half of the 30 clients who came to her switch plans.

For his part, Smith is trying to educate himself about the best way to pick a health insurance plan.

He has learned that low premiums are often accompanied by high deductibles and high co-insurance rates, and he plans to talk with a navigator who can guide him through the system. But he worries that others with HIV might not be as well-prepared.

“There are people out there who, if they don’t do their homework, they’re really going to get sucker-punched [next year] when they start paying their bills,” Smith said.

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Viewpoints: Ebola Errors; McConnell’s Mixed Message; Shifts In Mental Health Care

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Research Roundup: The Effects Of ACOs; Declines In Medical Liability Payments

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State Highlights: Ga. Official On Insurer’s Contract With Docs; Calif. Nursing Home Audit

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Florida Medicaid Lawsuit Delayed Again

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Candidate Credentials Hinging On Health Law

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Debate Heats Up Over Mandatory Quarantines For People Who Are Not Sick

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Aging Baby Boomers Spark High-Tech Health Innovation

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HHS Watchdog Criticizes Medicare Rule That Allows Drug Purchases After Patient’s Death

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