Hospice Administrator Sentenced for Role in Hospice Fraud Scheme

The administrator of a Southern California hospice was sentenced Thursday to 30 months in prison for his role in a multimillion dollar hospice fraud scheme.

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    What GAO Found GAO's analysis of 2020 data found that, for 20 selected brand-name prescription drugs, estimated U.S. prices paid at the retail level by consumers and other payers (such as insurers) were more than two to four times higher than prices in three selected comparison countries. The U.S. prices GAO estimated for comparison reflect confidential rebates and other price concessions, which GAO refers to as net prices. Publicly available prices for the comparison countries were gross prices that did not reflect potential discounts. As a result, the actual differences between U.S. prices and those of the other countries were likely larger than GAO estimates. The price differences varied by drug. Specifically, while estimated U.S. net prices were mostly higher than the gross prices in other countries (by as much as 10 times), some were lower. The following figure illustrates comparisons for two of GAO's selected drugs. GAO found similar differences in estimated prices paid by final payers at the manufacturer level. Estimated U.S. Net Prices and Selected Comparison Countries' Gross Prices at the Retail Level for Two Selected Drugs and Package Sizes, 2020 GAO's analysis found consumers' out-of-pocket costs for prescription drugs varied across and within all four countries but likely more within the U.S. and Canada where multiple payers had a role setting prices and designing cost-sharing for consumers, and not all consumers had prescription drug coverage. In Australia and France, prescription drug pricing was nationally regulated and prescription drug coverage was universal; thus, consumers' out-of-pocket costs within these countries for each drug were generally less varied. For example, in Australia, consumers typically paid one of two amounts for prescription drugs—either about 5 or 28 U.S. dollars in 2020. In the U.S., potential out-of-pocket costs for consumers could have varied much more widely depending on the type of coverage they had. For example, for one drug in GAO's analysis, considering only a few coverage options, consumers' out-of-pocket costs in 2020 could have ranged from a low of about 22 to a high of 514 U.S. dollars. GAO provided a draft to the Department of Health and Human Services for review and incorporated the Department's technical comments as appropriate. Why GAO Did This Study While spending on prescription drugs continues to grow worldwide, studies indicate the U.S. spends more than other countries. However, various factors—such as country-specific pricing strategies, confidential rebates to payers, and other price concessions—may obscure the actual prices of prescription drugs. GAO was asked to review U.S. and international prescription drug prices. This report (1) examines how prices at the retail and manufacturer levels in the U.S. compare to prices in three selected comparison countries—Australia, Canada, and France, and (2) provides information on consumers' out-of-pocket costs for prescription drugs in these countries. GAO analyzed 2020 price data for a non-generalizable sample of 41 brand-name drugs among those with the highest expenditures and use in the U.S. Medicare Part D program in 2017. Twenty of these drugs had price data available in all four countries. For U.S. prices, GAO estimated the net prices paid using data from various sources, including estimates of Medicare Part D rebates and other price concessions, and commercially available data. Prices for the selected comparison countries were obtained from publicly available government sources. National prices were not available for Canada, so GAO used the prices from Ontario, Canada's most populous province, as a proxy for Canadian prices. GAO also reviewed country-specific guidance and other relevant information and interviewed researchers, manufacturers, and government officials. For more information, contact John E. Dicken at (202) 512-7114 or dickenj@gao.gov.
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    In U.S GAO News
    GAO has reported on the Department of Veterans Affairs' (VA) use of research to identify and add new illnesses to its list of presumptive conditions for both Gulf War Illness and Agent Orange—a tactical herbicide used extensively during the Vietnam Era. VA entered into agreements with the National Academy of Sciences to assess the link between certain exposures and illnesses experienced by veterans, and uses the Academy's findings to inform its lists of presumptive conditions. GAO also reported in 2017 that VA did not have a single set of uniform criteria to define Gulf War Illness (a case definition) that could improve research, clinical diagnosis, and treatment of Gulf War veterans. GAO recommended that VA prepare and document a plan to develop a single case definition. In response, VA convened a group of subject matter experts from VA and the Department of Defense to create a multi-step plan to develop a case definition. According to VA, it is in the final stages of the plan and will bring together experts in 2021 to review new research and work toward delineating a definition. Further, according to VA, the department continues to support research on conditions related to Gulf War service as well as Agent Orange exposure and will use the findings to consider future presumptive conditions. In 2017, GAO reported on challenges that VA faced in processing complex, presumptive disability claims for veterans who served in the Gulf War—claims that were being denied at higher rates than other disability claims. At the time of GAO's review, VA officials stated that Gulf War Illness claims may be denied at a higher rate, in part, because they are not always well understood by VA staff, and veterans sometimes do not have medical records to adequately support their claims. The challenges we identified included: Inconsistent requests for disability medical exams. VA claims processors can request that a veteran undergo a disability medical exam to help determine whether the conditions in the claim exist and are linked to service. GAO found that claims processors were inconsistent in asking for an exam, in part, due to confusion about the guidance. VA issued training on the topic and in April 2017 completed a review of Gulf War claims to assess the effectiveness of the training and help ensure future consistency. Inconsistent disability medical exam reports. Veterans Health Administration disability medical examiners did not always complete medical exam reports properly and sometimes offered a medical opinion when one was not necessary. GAO recommended that VA require all examiners to complete Gulf War medical exam training before conducting these exams, and VA implemented this recommendation. Since our 2017 report, VA has allowed contracted medical examiners to complete these exams, and in 2018 GAO found VA was not monitoring whether all contractors completed required training. GAO recommended VA improve its oversight of training, but the department has not fully implemented this recommendation from GAO's 2018 report. VA provides disability compensation to millions of veterans with service-connected disabilities. Veterans are generally entitled to these benefits if they can prove their injuries or illnesses were incurred or aggravated by active military service. For certain claims, VA presumes a condition is due to a veteran's service. For example, VA can provide benefits to any veteran with certain symptoms, from respiratory disorders to gastrointestinal issues, who served in Southwest Asia from 1990 to the present, without the veteran needing to prove cause. GAO refers to these as Gulf War Illness claims. In 2017, GAO issued Gulf War Illness: Improvements Needed for VA to Better Understand, Process, and Communicate Decisions on Claims ( GAO-17-511 ), which identified needed improvements in VA's processing of Gulf War Illness claims. In 2018, GAO issued Agent Orange: Actions Needed to Improve Accuracy and Communication of Information on Testing and Storage Locations ( GAO-19-24 ). This statement summarizes information from these reports on how VA determined certain presumptive conditions and challenges VA faced with processing Gulf War Illness claims. In GAO's 2017 report, it recommended that VA develop a plan to establish a single case definition of Gulf War Illness and make Gulf War Illness training mandatory for medical examiners. VA implemented the recommendations. For more information, contact Elizabeth Curda at (202) 512-7215 or curdae@gao.gov.
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    In U.S GAO News
    The Department of Education (Education), the Department of Health and Human Services (HHS), and the Office of National Drug Control Policy (ONDCP) manage six key federal grant programs that can support drug prevention activities in schools. The flexibility of these grants supports a variety of drug prevention education programs. The agencies generally monitor grantees' compliance with grant requirements through periodic reporting. The aim of the National Drug Control Strategy (Strategy) is to reduce drug misuse, but HHS, and ONDCP have not fully defined how several key grant programs support the Strategy. ONDCP's guidance directs agencies to report, for each grant program, performance measures that relate to the Strategy's goals. However, some performance measures for several programs did not relate to drug prevention, did not link directly to the Strategy's prevention goals, or were not reported at all. For example: A $372 million set-aside for HHS's Substance Abuse Prevention and Treatment Block Grant program must be used on drug prevention, but HHS did not link the program's performance measures to the Strategy's prevention education goal.   ONDCP did not report on any performance measures in the Strategy or document how its $100 million Drug-Free Communities Support program contributes to achieving specific goals in the Strategy. GAO also found that the approximately $10 million grants to states component of Education's School Climate Transformation Grant program could more fully provide performance information related to the Strategy's prevention education goal. Fully understanding these programs' contributions to the goals of the National Drug Control Strategy could help Congress and the public better understand and assess how the nation's significant investments in drug prevention education programs help address the drug crisis. Most people who develop a substance use disorder begin using substances as adolescents. To reach adolescents, drug prevention programs are frequently provided in schools. Education, HHS, and ONDCP manage most federal programs that support school-based drug prevention activities. This report (1) describes how Education, HHS, and ONDCP support drug prevention activities in schools, and monitor those efforts and (2) examines the extent to which these agencies identify how their prevention activities support the National Drug Control Strategy. GAO reviewed agency documentation, the 2019 and 2020 National Drug Control Strategy documents which ONDCP identified as being most relevant to our review including the fiscal year 2019 drug control budget, ONDCP guidance, relevant federal laws, and GAO's prior work on attributes of successful performance measures that can help achieve agency goals. GAO also interviewed federal and state officials. GAO is making four recommendations, including that Education, HHS, and ONDCP clarify how grants that can include drug prevention education programs support related goals of the National Drug Control Strategy. HHS and ONCP agreed with the recommendation and Education partially concurred, saying it would explore collecting and reporting related performance data. For more information, contact Jacqueline M. Nowicki at (617) 788-0580 or nowickij@gao.gov.
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    The Department of Defense (DOD) has not routinely assessed climate-related risks faced by its contractors as part of its acquisition and supply processes, through which DOD obtains contracted goods and services. DOD's acquisition process includes long-term planning activities such as life-cycle sustainment planning. Its supply chain process includes steps to identify and assess potential disruptions, such as severe storms affecting transportation or energy systems, in order to mitigate risk. However, these processes in general do not systematically identify and consider climate-related risks to materiel acquisition and supply or the acquisition of weapon systems, according to Office of the Secretary of Defense (OSD) and military department officials. DOD's climate change adaptation directive indicates that OSD and the military departments should include climate considerations in acquisition and supply and integrate those considerations into relevant policy and guidance. However, GAO's review of DOD and military department guidance on acquisition and supply found that the guidance did not implement DOD's climate change directive by including consideration of climate change or extreme weather. Until DOD and the military departments include these considerations in their guidance on acquisition and supply chain processes, they risk continuing to develop acquisition strategies and managing supply chains without building climate resilience into these processes and potentially jeopardizing their missions. DOD guidance requires consideration of climate-related risks as part of the mission assurance process, when appropriate. However, GAO found that the department has not assessed risks—including those associated with climate change or extreme weather—to commercially owned facilities, which can support DOD installations as well as weapon systems, as part of this process. Assessing risks to commercial facilities has been a longstanding challenge for DOD, with the department noting in 2012 that it had paid inadequate attention to challenges outside of DOD-owned facilities and citing a limited understanding of supply chain risks as a pervasive problem. DOD's mission assurance guidance includes minimum requirements for assessments of certain non-DOD-owned facilities, such as completion of an all-hazards threat assessment. However, DOD officials stated that they had not conducted such assessments. The officials noted that DOD is limited in its ability to conduct such assessments, as it does not have the same access to commercial facilities as it does to its own facilities. While DOD officials stated that they are exploring alternative ways of assessing risks to commercial facilities, they noted that these efforts are in the early stages. Without determining what approaches may be feasible for assessing risks to commercial facilities as part of the mission assurance process and issuing or updating guidance accordingly, DOD may not fully evaluate the risks to critical commercial facilities as part of the mission assurance process, leaving gaps in its knowledge of potential risks—to include climate and weather-related risks—to its ability to fulfill key missions dependent on such facilities. Since 2010, DOD has identified climate change as a threat to its operations and installations. The department relies on contracted goods and services for its mission and installations. Climate change is projected to have broad effects that could affect DOD's supply chains, and any associated risks to contractors can have an impact on DOD. One way DOD assesses risk to its missions is through mission assurance, which is a process to protect or ensure the function of capabilities and assets critical to its missions. GAO was asked to review potential threats to national security from the effects of climate change on defense contractors. GAO examined the extent to which DOD assesses the potential effects on its operations from climate change and extreme weather risks faced by its contractors through the department's (1) acquisition and supply processes, and (2) mission assurance process. GAO reviewed DOD acquisition, supply, and mission assurance documents and interviewed relevant DOD officials and contractor representatives. GAO is making six recommendations, including that DOD incorporate climate adaptation into its acquisition and supply guidance and issue or update guidance on mission assurance-related assessments for commercial facilities. DOD concurred with three recommendations and partially concurred with three. GAO continues to believe that DOD should fully implement its recommendations. For more information, contact Elizabeth A. Field at (202) 512-2775 or fielde1@gao.gov.
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