Here’s a breakdown on two stories I had this week about two different Medicare-funded programs.
The first story, was about the HPSA, or Health Professional Shortage Area. These areas are supposedly reviewed and blessed by federal Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services, based on states’ health data.
The shortage areas (HPSAs) play a key role in luring primary care docs and psychiatrists to rural or poorer areas in the United States that have little regular access to health care.
Makes sense. If the government wants to improve something, say health care, it’s a good ideal to pinpoint population areas where health care is non-existent.
There’s a handful of incentives to get primary care doctors to consider working in a HPSAs.
Physicians can qualify for medical school loan forgiveness if they relocate to a HPSA. If they’re a foreign doctor, the J-1 visa requirement that they return home, is waived.
And then there’s this: for each Medicare claim they file while working in the HPSA, they get a 10 percent bonus. Per claim, filed. Not per claim, reimbursed.
While interviewing a fraud investigator for another story I am working on, he mentioned the bonus program to me. Never heard of it. Tell me more. He referred me to a few documents.
The first, available online is here. I’ve also Scribd-ed it to my docs page on this tumblr. It’s a 2005 HHS OIG report on rural clinics and explains, there on pages 2-3, in the introduction, how HPSAs work.
“HRSA designates shortage areas for the purpose of directing placement of providers or program funding for nearly 30 departmental programs focused on alleviating access problems in such locations.”
The HPSA (shortage area) program began in 1978. But in this document and another, the HHS OIG noted problems with HRSA not updating the areas.
No updates means those areas that have overcome their medical access issues siphon off benefits they may no longer qualify for.
In the Rural Clinic audit, that problem surfaces by page 8:
“Sixty-one percent (169) of these RHCs are located in areas that HRSA has not designated as shortage areas. The remaining 39 percent (110) are located in urbanized areas defined by Census.”
Then there’s this Sept. 26, 2011 HHS OIG memo - (not available online and there really is no good reason for that) to the HHS deputy secretary. It essentially points out that, this lack of updating what areas are medically needy, is costing money via Medicare bonuses.
The HHS OIG memo quickly points out that because there’s no timely updating of HPSAs, areas doctors in areas once considered medically needy are working in areas that have become so urbanized they no longer qualify for the HPSA and subsequently the bonus program. By the HHS OIG’s own accounting an estimated $64 million has been overpaid to docs in Hidalgo County, which no longer qualifies. Two months later, Hidalgo and 310 other areas were stripped of their HPSA status.
However, Hidalgo is still a HPSA based on a lack of mental health services.
Now onto today’s story which is all about another costly Medicare acronym: PHPs
Partial Hospitalization Programs, or PHPs were designed to be an intensive alternative to a psychiatric hospital stay. Here’s how TrailBlazer Health Services, the billing contractor for the Centers for Medicare and Medicaid Services, explains it:
“Psychiatric partial hospitalization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care, designed to provide patients having profound or disabling mental health conditions with an individualized, coordinated, intensive, comprehensive and multidisciplinary treatment program not provided in a regular outpatient setting.”
In Texas, neither a PHP nor its stand-alone cousin, the for-profit Community Mental Health Center, are facilities regulated by the Texas Department of State Health Services (DSHS).
However, Medicare requires that PHPs be offered either by a hospital or at a clinic affiliated with a hospital. The Texas health department requires only that hospitals with PHPs, tell them they have a PHP.
Hospitals are not required to tell Texas DSHS where their PHP (the physical address) is housed or located.
And that’s become a problem in Houston, where many clinics have sprung up offering PHPs, but not clearly stating which hospital they are affiliated with.
In the past year, I’ve seen more PHPs that were housed in the equally fuzzy - and unlicensed - Medicare entity known as a CMHC, now call themselves a hospital-based PHP and shed the CMHC from their name. That appeared to be the case of the Hornwood clinic run now by Westbury Community Hospital.
In 2010, when I first started work on what became the Chronicle’s series on private ambulances, the Hornwood clinic was owned by Continuum Health Services and it was classified as a CMHC. By 2011, it had a new name (Westbury) but the owners were the same. And it was no longer called a CMHC.
Stay tuned. We’ll see more on this issue, this year.
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