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French doctors unite in protest at government reform
THE LANCET
POLICY AND PEOPLE
FBI investigates US hospital chain for potential fraud merica’s largest for-profit hospital chain, Columbia/HCA Healthcare, has finally taken the tumble that many enemies—and some friends—expected. According to almost daily reports in the nation’s largest newspapers, Columbia is being investigated for different reasons by the Federal Bureau of Investigation and the Inspector General of the Department of Health and Human Services. The firm has also been found in violation of labour laws. The biggest threat to Columbia’s future, besides having its reputation dragged through the mud—that it may have defrauded the Medicare programme. If the investigations prove fraud, the hospital chain could face multimillion-dollar fines and its executives may be subject to criminal prosecu-
A
tion. Columbia denies any wrongdoing. With 350 hospitals and annual revenues of close to US$20 billion, the chain has grown ever-larger by aggressively acquiring facilities (often closing ones that are unprofitable), and offering local physicians partnership positions in the hospitals. These arrangements are part of the federal authorities’ scrutiny, since they may violate Medicare laws prohibiting physicians from profiting from making referrals to facilities in which they have an ownership stake. Many Columbia physicians are also being brought in as part-owners of other Columbia facilities, such as home-care agencies, rehabilitation, and cancer-care centres, where the firm is focusing its expansion. According to the New York Times, which has spent more than a year
investigating the hospital giant and is now publishing its results, Medicare is also looking into whether Columbia padded bills it sent to the government, using “upcoding”— claiming that patients were sicker than they were. When the first Times story hit on March 28, Columbia’s stock took a $7-per-share nosedive. Many “short sellers” on Wall Street had anticipated the stock would fall. One financial analyst says he thinks that the publicity may hurt Columbia’s ability to keep expanding. But analyst, Jeff Villwock, of Robinson Humphrey in Atlanta, says, “clearly this does not help Columbia do any transactions, but it’s too early to say it’s going to hurt them”. Alicia Ault
US Congress examines new approach to HIV
T
wo conservative Republican members of the US Congress, one a physician, have introduced legislation that would require states to track more closely cases of HIV and inform sexual contacts. The measure would also encourage HIV-positive physicians who do invasive procedures to disclose their status to patients. “Put simply, the federal government and the public health community have been AWOL in the battle against HIV”, said Representative Thomas Coburn (Republican, Oklahoma), a family physician and sponsor of the HIV Prevention Act in the US House of Representatives. The bill has been introduced in the Senate by another Oklahoma
Republican, Don Nickles. In addition to adding HIV to the list of communicable diseases that must be reported by states to the federal Centers for Disease Control and Prevention and requiring states to institute partner-notification programmes, the measure would also require testing of those accused of sexual assault, would require insurers who require HIV tests for coverage to disclose results, and would permit physicians to require patients scheduled to undergo “any risk-prone invasive procedure” be tested. Among those backing the bill is the American Medical Association. “This legislation would refocus public health efforts on HIV pre-
vention by using proven public health techniques designed for communicable diseases”, wrote AMA executive vice president P John Seward. But AIDS activists strongly oppose the measure. “This bill does nothing to address prevention at all”, said Aimee Berenson, director of government affairs for the AIDS Action Council. “Instead, Representative Coburn is promoting a hodge-podge of coercive testing-related policies, under the pretence that identifying people who are HIV positive, in and of itself, will somehow prevent others from being infected”. Julie Rovner
French doctors unite in protest at government reform espite spectacular protest actions by striking junior doctors in the past few days, the French government is holding firm to its controversial regulation on fines to doctors surpassing fee and prescription limits. The strike began more than 3 weeks ago and in many cities the doctors have caused disruption by sitting on railway lines and occupying motorway toll booths. The doctors have also demonstrated in healthinsurance buildings and offices—but without results. Senior hospital doc-
D
1078
tors are covering the work, but an increasing number of non-urgent treatments and operations have had to be postponed. No resolution is expected in the next few days and a nationwide demonstration will be held on April 13, when junior doctors and doctors in private practice protest once more. Junior hospital doctors, who set up their own practices after hospital training, requested special regulations about fines for their first 7 years in practice. Although the government agreed not to impose fines for these
years—in order not to hinder the establishment of new practices— junior hospital doctors decided to strike for complete withdrawal of the system. For this reason, doctors in private practice support the juniors and the two groups have held several joint demonstrations and strikes. However, many doctors feel that the juniors’ action has come too late to dissuade the government from implementing the controversial reform. Denis Durand de Bousingen
Vol 349 • April 12, 1997
POLICY AND PEOPLE
FBI investigates US hospital chain for potential fraud merica’s largest for-profit hospital chain, Columbia/HCA Healthcare, has finally taken the tumble that many enemies—and some friends—expected. According to almost daily reports in the nation’s largest newspapers, Columbia is being investigated for different reasons by the Federal Bureau of Investigation and the Inspector General of the Department of Health and Human Services. The firm has also been found in violation of labour laws. The biggest threat to Columbia’s future, besides having its reputation dragged through the mud—that it may have defrauded the Medicare programme. If the investigations prove fraud, the hospital chain could face multimillion-dollar fines and its executives may be subject to criminal prosecu-
A
tion. Columbia denies any wrongdoing. With 350 hospitals and annual revenues of close to US$20 billion, the chain has grown ever-larger by aggressively acquiring facilities (often closing ones that are unprofitable), and offering local physicians partnership positions in the hospitals. These arrangements are part of the federal authorities’ scrutiny, since they may violate Medicare laws prohibiting physicians from profiting from making referrals to facilities in which they have an ownership stake. Many Columbia physicians are also being brought in as part-owners of other Columbia facilities, such as home-care agencies, rehabilitation, and cancer-care centres, where the firm is focusing its expansion. According to the New York Times, which has spent more than a year
investigating the hospital giant and is now publishing its results, Medicare is also looking into whether Columbia padded bills it sent to the government, using “upcoding”— claiming that patients were sicker than they were. When the first Times story hit on March 28, Columbia’s stock took a $7-per-share nosedive. Many “short sellers” on Wall Street had anticipated the stock would fall. One financial analyst says he thinks that the publicity may hurt Columbia’s ability to keep expanding. But analyst, Jeff Villwock, of Robinson Humphrey in Atlanta, says, “clearly this does not help Columbia do any transactions, but it’s too early to say it’s going to hurt them”. Alicia Ault
US Congress examines new approach to HIV
T
wo conservative Republican members of the US Congress, one a physician, have introduced legislation that would require states to track more closely cases of HIV and inform sexual contacts. The measure would also encourage HIV-positive physicians who do invasive procedures to disclose their status to patients. “Put simply, the federal government and the public health community have been AWOL in the battle against HIV”, said Representative Thomas Coburn (Republican, Oklahoma), a family physician and sponsor of the HIV Prevention Act in the US House of Representatives. The bill has been introduced in the Senate by another Oklahoma
Republican, Don Nickles. In addition to adding HIV to the list of communicable diseases that must be reported by states to the federal Centers for Disease Control and Prevention and requiring states to institute partner-notification programmes, the measure would also require testing of those accused of sexual assault, would require insurers who require HIV tests for coverage to disclose results, and would permit physicians to require patients scheduled to undergo “any risk-prone invasive procedure” be tested. Among those backing the bill is the American Medical Association. “This legislation would refocus public health efforts on HIV pre-
vention by using proven public health techniques designed for communicable diseases”, wrote AMA executive vice president P John Seward. But AIDS activists strongly oppose the measure. “This bill does nothing to address prevention at all”, said Aimee Berenson, director of government affairs for the AIDS Action Council. “Instead, Representative Coburn is promoting a hodge-podge of coercive testing-related policies, under the pretence that identifying people who are HIV positive, in and of itself, will somehow prevent others from being infected”. Julie Rovner
French doctors unite in protest at government reform espite spectacular protest actions by striking junior doctors in the past few days, the French government is holding firm to its controversial regulation on fines to doctors surpassing fee and prescription limits. The strike began more than 3 weeks ago and in many cities the doctors have caused disruption by sitting on railway lines and occupying motorway toll booths. The doctors have also demonstrated in healthinsurance buildings and offices—but without results. Senior hospital doc-
D
1078
tors are covering the work, but an increasing number of non-urgent treatments and operations have had to be postponed. No resolution is expected in the next few days and a nationwide demonstration will be held on April 13, when junior doctors and doctors in private practice protest once more. Junior hospital doctors, who set up their own practices after hospital training, requested special regulations about fines for their first 7 years in practice. Although the government agreed not to impose fines for these
years—in order not to hinder the establishment of new practices— junior hospital doctors decided to strike for complete withdrawal of the system. For this reason, doctors in private practice support the juniors and the two groups have held several joint demonstrations and strikes. However, many doctors feel that the juniors’ action has come too late to dissuade the government from implementing the controversial reform. Denis Durand de Bousingen
Vol 349 • April 12, 1997