October 19, 2021

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Pain Doctor Convicted of Over $100 Million Health Care Fraud Scheme

16 min read
<div>A federal jury in the Eastern District of Michigan convicted a Michigan doctor today for his role in masterminding and executing a complex scheme to defraud Medicare and other health insurance programs by administering medically unnecessary spinal injections in exchange for prescriptions of high doses of opioids to patients.</div>
A federal jury in the Eastern District of Michigan convicted a Michigan doctor today for his role in masterminding and executing a complex scheme to defraud Medicare and other health insurance programs by administering medically unnecessary spinal injections in exchange for prescriptions of high doses of opioids to patients.

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    Since the fall of the former Iraq regime in April 2003, the multinational force has been working to develop Iraqi military and police forces capable of maintaining security. To support this effort, the United States provided about $5.8 billion in 2003-04 to develop Iraq's security capability. In February 2005, the president requested a supplemental appropriation with an additional $5.7 billion to accelerate the development of Iraqi military and police forces. GAO provides preliminary observations on (1) the strategy for transferring security responsibilities to Iraqi military and police forces; (2) the data on the status of forces, and (3) challenges that the Multi-National Force in Iraq faces in transferring security missions to these forces. To prepare this statement, GAO used unclassified reports, status updates, security plans, and other documents from the Departments of Defense and State. GAO also used testimonies and other statements for the record from officials such as the Secretary of Defense. In addition, GAO visited the Iraqi police training facility in Jordan.The Multinational Force in Iraq has developed and begun to implement a strategy to transfer security responsibilities to the Iraqi military and police forces. This strategy would allow a gradual drawdown of its forces based on the multinational force neutralizing the insurgency and developing Iraqi military and police services that can independently maintain security. U.S. government agencies do not report reliable data on the extent to which Iraqi security forces are trained and equipped. As of March 2005, the State Department reported that about 82,000 police forces under the Iraqi Ministry of Interior and about 62,000 military forces under the Iraqi Ministry of Defense have been trained and equipped. However, the reported number of Iraqi police is unreliable because the Ministry of Interior does not receive consistent and accurate reporting from the police forces around the country. The data does not exclude police absent from duty. Further, the departments of State and Defense no longer report on the extent to which Iraqi security forces are equipped with their required weapons, vehicles, communications equipment, and body armor. The insurgency in Iraq has intensified since June 2003, making it difficult to transfer security responsibilities to Iraqi forces. From that time through January 2005, insurgent attacks grew in number, complexity, and intensity. At the same time, the multinational force has faced four key challenges in increasing the capability of Iraqi forces: (1) training, equipping, and sustaining a changing force structure; (2) developing a system for measuring the readiness and capability of Iraqi forces; (3) building loyalty and leadership throughout the Iraqi chain of command; and (4) developing a police force that upholds the rule of law in a hostile environment. The multinational force is taking steps to address these challenges, such as developing a system to assess unit readiness and embedding US forces within Iraqi units. However, without reliable reporting data, a more capable Iraqi force, and stronger Iraqi leadership, the Department of Defense faces difficulties in implementing its strategy to draw down U.S. forces from Iraq.
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    The number of financial attaches that the Department of the Treasury (Treasury) deploys overseas dropped from approximately 30 in 1981 to 7 at the beginning of fiscal year 2005. Treasury has traditionally used financial attaches to monitor and gather information on international economic and financial developments to help shape U.S. international economic policy and to promote U.S. national interests. These attaches are part of the U.S. mission overseas and are typically stationed in U.S. embassies in key countries. Since at least 1981, however, the number of financial attaches placed overseas has been declining in response to changing conditions. Due to congressional interest in these financial attaches, this report describes (1) the role of financial attaches and (2) the process Treasury uses to determine attache placement. In commenting on this report, Treasury considered our report to be fair and accurate. Both Treasury and the Department of State provided technical comments, which we incorporated where appropriate.Financial attaches represent Treasury overseas and cover economic and financial issues relevant to U.S. international economic policies and U.S. national interests, although the role and need for financial attaches have evolved. Specifically, financial attaches conduct monitoring and analysis of macroeconomic and financial issues, including those affecting the private sector. Typically, financial attaches interact with host government financial agencies such as the ministries of finance and central banks, as well as with private sector financial entities. Financial attaches typically work in conjunction with the Economic Section of the U.S. mission and usually share the information they collect with other U.S. agencies. In Afghanistan and Iraq, financial attaches are primarily involved in coordinating economic reconstruction efforts. In general, the role of attaches has evolved over time due to changing Treasury priorities, as well as factors such as technological advances in communications. To some extent, these changes have reduced the necessity for some financial attache posts overseas. Treasury has recently begun to formalize its process for determining attache placement. Previously, the placement of Treasury's attaches was accomplished through an informal process, according to Treasury officials. More recently, Treasury has taken steps to formalize its process by specifying placement criteria it will take into consideration relative to overall Treasury priorities. These criteria include whether the United States has major financial interest in a country or whether there is significant U.S. engagement in a country. However, Treasury officials stated that budget constraints have been a primary factor in determining the number of attaches in recent years. Furthermore, projected rising costs are likely to constrain the number of attaches in the future.
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    Why This Matters Air quality sensors are essential to measuring and studying pollutants that can harm public health and the environment. Technological improvements have led to smaller, more affordable sensors as well as satellite-based sensors with new capabilities. However, ensuring the quality and appropriate interpretation of sensor data can be challenging. The Technology What is it? Air quality sensors monitor gases, such as ozone, and particulate matter, which can harm human health and the environment. Federal, state, and local agencies jointly manage networks of stationary air quality monitors that make use of sensors. These monitors are expensive and require supporting infrastructure. Officials use the resulting data to decide how to address pollution or for air quality alerts, including alerts during wildfires or on days with unhealthy ozone levels. However, these networks can miss pollution at smaller scales and in rural areas. They generally do not measure air toxics—more localized pollutants that may cause cancer and chronic health effects—such as ethylene oxide and toxic metals. Two advances in sensor technologies may help close these gaps. First, newer low-cost sensors can now be deployed virtually anywhere, including on fences, cars, drones, and clothing (see fig. 1). Researchers, individuals, community groups, and private companies have started to deploy these more affordable sensors to improve their understanding of a variety of environmental and public health concerns. Second, federal agencies have for decades operated satellites with sensors that monitor air quality to understand weather patterns and inform research. Recent satellite launches deployed sensors with enhanced air monitoring capabilities, which researchers have begun to use in studies of pollution over large areas. Figure 1. There are many types of air quality sensors, including government-operated ground-level and satellite-based sensors, as well as low-cost commercially available sensors that can now be used on a variety of platforms, such as bicycles, cars, trucks, and drones. How does it work? Low-cost sensors use a variety of methods to measure air quality, including lasers to estimate the number and size of particles passing through a chamber and meters to estimate the amount of a gas passing through the sensor. The sensors generally use algorithms to convert raw data into useful measurements (see fig. 2). The algorithms may also adjust for temperature, humidity and other conditions that affect sensor measurements. Higher-quality devices can have other features that improve results, such as controlling the temperature of the air in the sensors to ensure measurements are consistent over time. Sensors can measure different aspects of air quality depending on how they are deployed. For example, stationary sensors measure pollution in one location, while mobile sensors, such as wearable sensors carried by an individual, reflect exposure at multiple locations. Satellite-based sensors generally measure energy reflected or emitted from the earth and the atmosphere to identify pollutants between the satellite and the ground. Some sensors observe one location continuously, while others observe different parts of the earth over time. Multiple sensors can be deployed in a network to track the formation, movement, and variability of pollutants and to improve the reliability of measurements. Combining data from multiple sensors can increase their usefulness, but it also increases the expertise needed to interpret the measurements, especially if data come from different types of sensors. Figure 2. A low-cost sensor pulls air in to measure pollutants and stores information for further study. How mature is it? Sensors originally developed for specific applications, such as monitoring air inside a building, are now smaller and more affordable. As a result, they can now be used in many ways to close gaps in monitoring and research. For example, local governments can use them to monitor multiple sources of air pollution affecting a community, and scientists can use wearable sensors to study the exposure of research volunteers. However, low-cost sensors have limitations. They operate with fewer quality assurance measures than government-operated sensors and vary in the quality of data they produce. It is not yet clear how newer sensors should be deployed to provide the most benefit or how the data should be interpreted. Some low-cost sensors carry out calculations using artificial intelligence algorithms that the designers cannot always explain, making it difficult to interpret varying sensor performance. Further, they typically measure common pollutants, such as ozone and particulate matter. There are hundreds of air toxics for which additional monitoring using sensors could be beneficial. However, there may be technical or other challenges that make it impractical to do so. Older satellite-based sensors typically provided infrequent and less detailed data. But newer sensors offer better data for monitoring air quality, which could help with monitoring rural areas and pollution transport, among other benefits. However, satellite-based sensor data can be difficult to interpret, especially for pollution at ground level. In addition, deployed satellite-based sensor technologies currently only measure a few pollutants, including particulate matter, ozone, sulfur dioxide, nitrogen dioxide, formaldehyde, and carbon monoxide. Opportunities Improved research on health effects. The ability to track personal exposure and highly localized pollution could improve assessments of public health risks. Expanded monitoring. More dense and widespread monitoring could help identify pollution sources and hot spots, in both urban and rural areas. Enhanced air quality management. Combined measurements from stationary, mobile, and satellite-based sensors can help officials understand and mitigate major pollution issues, such as ground-level ozone and wildfire smoke. Community engagement. Lower cost sensors open up new possibilities for community engagement and citizen science, which is when the public conducts or participates in the scientific process, such as by making observations, collecting and sharing data, and conducting experiments. Challenges Performance. Low-cost sensors have highly variable performance that is not well understood, and their algorithms may not be transparent. Low-cost sensors operated by different users or across different locations may have inconsistent measurements. Interpretation. Expertise may be needed to interpret sensor data. For example, sensors produce data in real time that may be difficult to interpret without health standards for short-term exposures. Data management. Expanded monitoring will create large amounts of data with inconsistent formatting, which will have to be stored and managed. Alignment with needs. Few of the current low-cost and satellite-based sensors measure air toxics. In addition, low-income communities, which studies show are disproportionally harmed by air pollution, may still face challenges deploying low-cost sensors. Policy Context and Questions How can policymakers leverage new opportunities for widespread monitoring, such as citizen science, while also promoting appropriate use and interpretation of data? How can data from a variety of sensors be integrated to better understand air quality issues, such as environmental justice concerns, wildfires, and persistent ozone problems? How can research and development efforts be aligned to produce sensors to monitor key pollutants that are not widely monitored, such as certain air toxics? For more information, contact Karen Howard at (202) 512-6888 or HowardK@gao.gov.
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    Literature GAO reviewed indicated that private insurance payments for anesthesia services on average were more than 3-1/2 times those of Medicare payments. This payment difference increased from what GAO reported in 2007—average private insurance payments for certain anesthesia services in 2004 were about 3 times those of Medicare. While Medicare rates for anesthesia services are set by the Centers for Medicare & Medicaid Services (CMS), private insurance rates are set through negotiations between providers and private insurers. GAO identified three recent studies with analyses of private insurance and Medicare payments for anesthesia services: Researchers from Yale University calculated that private insurance payments were 3.67 times Medicare payments, on average, for services provided by anesthesiologists for one large private insurer in 2015 operating across all 50 states and the District of Columbia. The Health Care Cost Institute calculated that in 2017 private insurance payments ranged from 2 to 7 times Medicare payments, on average, across six common services provided by anesthesiologists in 33 states. Wide state-to-state variation within specific services was reported. The American Society of Anesthesiologists reported that private insurance payments were 3.46 times Medicare payments, on average, based on a survey of its members in 2019. According to studies GAO reviewed and stakeholders GAO interviewed, market factors likely enhanced anesthesia providers' negotiating position and allowed them to secure higher private payments. For example, several studies and stakeholders cited market concentration as a key factor that increased private payments for anesthesia services. In a market with high provider concentration—or relatively few providers in a given market—there is little competition between providers, enabling the providers within that market to negotiate for higher payments from private insurers. Studies also indicated that specialists, including anesthesia providers, could negotiate higher in-network payment rates because they were able to leave an insurer's network with little risk of losing patients or revenue. In addition, when anesthesia providers are not a part of a private insurer's network, they are typically able to bill for a higher amount than the insurer would pay for an in-network provider, known as out-of-network billing. This dynamic decreases providers' incentives to participate in insurer networks because it creates an attractive alternative to network participation. GAO's interviews with stakeholders, literature review, and review of agency data generally did not indicate that the supply of anesthesia providers was insufficient for Medicare beneficiaries. CMS data indicate that the number of active anesthesia providers per 100,000 Medicare beneficiaries increased from 2010 through 2018 and that a very small number of anesthesia providers opted out of the Medicare program. Furthermore, researchers and stakeholders GAO interviewed were not aware of any issues with access to anesthesia services for Medicare beneficiaries, including those in traditionally underserved rural areas. In 2018, Medicare paid over $2 billion for anesthesia services, such as general anesthesia administered to beneficiaries undergoing surgical or other invasive procedures. The joint explanatory statement for the Further Consolidated Appropriations Act, 2020 included a provision for GAO to update its 2007 report and examine how differences in payment rates for anesthesia services have changed since that time. In 2007, GAO reported that Medicare payments in 2004 for certain anesthesia services provided by anesthesiologists were on average 67 percent lower than private insurance payments in certain geographic areas—indicating that private payments were about 3 times more than Medicare payments at that time. This report describes what is known about (1) recent trends in differences between Medicare and private payments for anesthesia services, and (2) the sufficiency of the supply of anesthesia providers for Medicare beneficiaries. GAO reviewed literature and available published data on payment differences for anesthesia services, published in the United States since 2010. GAO also reviewed data from CMS on the number of anesthesia providers from 2010, 2018, and 2020. GAO also interviewed a nongeneralizable selection of three research groups, two beneficiary advocacy groups, and five stakeholder groups, including those representing anesthesiologists, nurse anesthetists, and hospitals, to obtain their perspectives on these issues. The Department of Health and Human Services provided no comments on this report. For more information, contact Jessica Farb at (202) 512-7114 or farbj@gao.gov.
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