In the mid 1960s, the American government came under pressure to ensure that all its citizens got access to affordable, high quality and standard medical services throughout the country. According to Centers for Medicare and Medicaid Services (2002), it was during this time that the Medicare alongside the Medicaid health care programs came to being as titles of the social security act. It is projected that in 1965, a whooping five billion dollars was spent on Medicare and Medicaid services. Jacobs and Skocpol (2012) note that the expenditure grew significantly and by 1986, an estimated 94.6 billion dollars had been pumped into the project. The magnitude and exponential growth of these programs have since converted them into bits and pieces of widespread fraud, deception and abuse (Baumann, et al., 1999). A lot of statutes have been adopted and enacted by the congress in an effort to curb if not completely eradicate what can be termed as a waste of taxpayers’ money. These statutes include the Medicare-Medicaid kickback statute or rather the fraud and abuse statute that seek to curb solicitation and receiving of kickbacks, backhanders or rebates. Since then, those who have been implicated in the violation of these statutes have been prosecuted in courts of law. Dennis McClatchy is one of the many individuals who have appeared before a jury on accounts of dishonoring the Medicare Anti-Kickback Act.
United States v. Greber
Case Facts
In this case, Greber who was the defendant is a board certified osteopathic physician in cardiology (Prenetta, 1987). Through his company named Cardio-Med, Greber engaged in the provision of diagnostic services. The company had the capacity to bill Medicare for some of the services it provided to its clients. Greber was later charged of committing fraud against Medicare with the charges stemming from his company’s habit of paying Kickbacks to referring physicians using funds obtained from Medicare in order to secure future referrals. The defendant on the other hand argued that the money paid was intended to compensate the physicians for the work performed. The defendant held that the court lacked evidence to show that the fee paid was solely intended to induce future referrals and nothing else. Prenetta (1987) observes that to him, securing future referrals was a minor intention of the payments although it was among the reasons. The United States court convicted Greber and he later appealed for the decision to be reconsidered. The court insisted that the referring doctors plucked incentives to send more clients to Mr. Greber which is an insult to the law.
United States v. McClathey
Case Facts
During the time of questioning, Mr. McClathey was holding the powerful position of the chief operating officer of Baptist Medical Center. The hospital was approached by Robert and Ronald LaHue who were the directors of the Blue Valley Medical Group (BVMG) which shoulder the responsibility providing health care to patients in nursing homes (Baumann, et al., 1999). The two physicians requested the hospital to hire their practice and in return, they would transfer all their patients to the facility. McClathey rejected the proposal and instead struck a deal with the physicians to offer their services at a fee which was 75000 dollars for a year although the specific services that they were to offer were not categorically stated (Baumann, et al., 1999). This agreement prompted the physicians to start admitting their patients in Baptist medical center which was against Anti-kickbacks statutes. The hospital chief executive officer, chief operating officer who was McClathey and the two physicians were charged in court for violating the AKS. Through an appeal, the court granted McClathey the motion of acquittal owing to the fact that there was no hard evidence to support the fact that he deliberately had intentions to violate the law.
Mr. Greber’s act of paying physicians to induce more referrals to his company differs from other instances of payment for professional services in that, Greber is self-centered and profit oriented. For professional service institutions that include consulting firms, accounting, legal, connectivity, and photography, offering of consumer acceptable, and secure billing alongside invoicing and provision of various payment options is key in building trust and a professional interactive platform for economic engagements (Baumann, et al., 1999). Professional services ought to be client oriented and geared towards ensuring customer satisfaction rather than self-gains.
Cardio-med billing of Medicare can be termed as unethical and unprofessional because the company received payments from Medicare after performing monitoring services to patients who had been referred to the facility and a portion of the money was advanced to the referring physician (Prenetta, 1987). Also, Cardio-Med billed Medicare for services that were rather of less importance to patients courtesy of mail fraud. Greber was accused of using fraud mails to bill Medicare for hospital visits that never occurred. Payment for professional services is made through honest means and for services that were rendered unlike in the case of Cardio-Med.
Greber was also accused by the government of charging a referral fee that exceeded the set limit. He charged forty percent of the Medicare payment as referral fee violating the law that requires that the fee should not exceed 65 dollars per patient (Prenetta, 1987). Even if Greber paid the referring physicians an amount that did not exceed Medicare guidelines, as long as the payment was intended to encouraged future referrals, this would qualify the payment as an offense. Rendering of remuneration and kickbacks to other medical practitioners to entice and secure future referrals is against the law.
Hospital Perks to Physicians
In the current competitive world, each and every player wants to get hold of its human resource while recruiting more talent, skills, and abilities in order to improve production. Hospitals in the same way have not been left out and to most of them, retaining physicians and other important members of the health care team is inevitable. Through the provision of perks to physicians, hospitals can ensure that their relevance and contribution towards the realization of a healthy society is recognized (Burda, 1992). This is because physicians are the key players when it comes to provision of medical services. Such perks include preferred parking, free meals, malpractice insurance, education forgiveness, relocation allowance and discounted healthcare for themselves and their families.
The step by hospitals to motivate physicians has met numerous setbacks and obstacles with their legality being questioned. Most hospitals strive to ensure that their efforts to motivate its physicians are in accordance with the key federal laws that govern physician compensation. The three main statutes that dictate employment pacts between hospitals and their physicians include the stark law, the national fraud and abuse statute and the internal revenue code (Jacobs & Skocpol, 2012). Both the stark and the anti-kickback statutes define and contemplate the terms of service between the hospital and physicians allowing for some of the perks and privileges from the employer to employees. They hold that incentives are justified provided they are given to physicians for identifiable services offered; they are in line with the fair market value for the services rendered and they are not reached at taking into consideration the volume or quantity of referrals done. When incentives are offered to physicians against these regulations, their legality becomes questionable and as such, they can be challenged in a court of law. When such regulations are violated, the perks can then be considered too much.
Hospitals give their physicians preferential treatment in terms of perks with different intentions and goals to achieve. For many years, many people believed that working in the private sector as a physician was more rewarding compared to working as a hospital employee (Burda, 1992). However, this notion is not always true, a fact that has seen many physicians take up employment positions in public hospitals up from 5% in 2000 to 40% in 2013 (Burda, 1992). With the hope of attracting and retaining more physicians, hospitals continue to compete in terms of providing an enabling environment for its physicians in order to attract more patients.
Through provision of elusive perks and privileges, public hospitals seek to attract specialist physicians who are utterly few into their systems. These specialists include noninvasive cardiology, orthopedic surgery, ophthalmology not forgetting the rare neonatal medicine pediatrics and neurosurgery. Through the perks, hospital seeks to inculcate the spirit of equality and importance amongst the health care team members and most importantly physicians. Responsibility and commitment is thus enhanced. Perks have been shown to enhance the relationship between various administrators in the hospital and physicians. A collaborative relationship created as a result is important in the realization of the hospitals goals and objectives. Furthermore, Burda (1992) suggests that administrators have used perks to encourage physicians to embrace diversity in the health sector in that they are motivated to learn how to carry out several tasks in other fields of medicine and also develop managerial skills.
United States v. Patel
Case facts
Dr. Patel who was the defendant in the case was an internist who dealt with a heavy Medicare population. In his practice, he ordered home care for a significant number of his patients and his staff provided the patients with almost 20 brochures of different home health companies and left them to select the company of their choice. The staff would then contact the selected company and give them the patient’s details alongside a prescription made by Dr. Patel for home care (United States of America v. Kamal Patel, 2015). One of the home care company called Grand Home Health Care convinced Patel into an agreement after experiencing serious economic challenges following difficulties in its marketing strategy. The Company presented a cash-for-certification plan to Patel which would see it earn more money from patients who selected it.
The company would come up with a comprehensive treatment plan for a patient who selected it and then fill the Medicare certification requirement utilizing Patel’s signature. This form 485 claimed reimbursement from Medicare for services rendered to patients by the company; some of which were never actually given. The company met severally with Dr. Patel to pay him 400 dollars for every certification he made and 300 dollars for every recertification. The payments were made face to face in cash with no traceable records or contracts that could be used to prove payment (United States of America v. Kamal Patel, 2015). The government launched investigations into allegations of health fraud and Grand accepted to cooperate with it. Dr Patel was found guilty of violating the provisions of the Medicare statutes and he was prosecuted in court. He was charged a fine amounting to 31900 dollars, and a period of eight months behind bars.
Comparison with Greber and McClathey
Unlike Greber and McClathey, Patel’s case did not involve the direct referral of patients to Grand Health Care Company. The case was complicated by the fact that the Anti-Kickbacks Statute does not define the term referral wholesomely. Patel defended himself in court arguing that he did not refer patients to Grand Company because patients choose the company themselves after being provided with a list of many other companies. This is contrary to Greber who made the referrals directly at and made payments to the referring physicians. On the other hand, McClathey was convicted for directly violating the AKS as he accepted to pay physicians money in order to receive referrals from their hospitals without a clear contract of their mode of operation. Although there were no direct referrals done by Dr. Patel, the court found him guilty of indirectly referring the patients to Grand by agreeing to sing the certification and recertification forms. According to United States of America v. Kamal Patel (2015), the court found him guilty of acting as a channel or gatekeeper between Grand and Patients who sought medical services.
The bottom line in all the three cases is that there was Medicare and Medicaid fraud as money was illegally paid to Cardio-Med, Grand Health Care Company and Baptist Medical Center thus raising the cost of health provision. It is notably clear that in both instances, money paid to the particular physicians and the intern was meant to influence future referrals as the amount more than the set limit. At one point, the investigations found out that Patel had refused to consent onto the certification forms because the company did have money to give him (United States of America v. Kamal Patel, 2015). Over and beyond these obvious violations of the Health statutes, Dr Patel was found to have received payment from Grand company in spite of the fact that he did not provide any other important service apart from the signing of the certifications and recertification forms.
The Health Care Reforms Law of 2010
The Health Care Reform Laws of 2010 also popularly known as the ObamaCare is a US health care system reform law that seeks to expand and improve access medical services while at the same time curbing expenditure through regulations and taxes. The reforms were signed by the office of the president of the United States on the 23rd of March 2010 and later upheld by the Supreme Court in 2012 (Huntington, et al., 2011). The coverage of the reforms was over 32 million citizens who are insured but in need of medical services. Since the act became law, many questions have been raised by different healthcare providers and legal firms on the applicability of the federal anti-kickback statute on clients who procure subsidized wellbeing insurance product (Jacobs & Skocpol, 2012).
On the 30th of October 2013, the Human and Health Services secretary clarified through a letter to McDermott that the HHS department does not consider or recognize programs that are under Title I of the Heath reforms of 2010 as federal healthcare programs (Huntington, et al., 2011). This meant that subsidized insurance products on health under the affordable care act are not part of federal health programs and thus federal anti-kickback statutes could not be applied onto payments that health providers receive from such products.
However, Huntington et al. (2011) write that the HHS has made it clear that carving out patients who are beneficiaries of the federal healthcare programs does not guarantee the provider immunity from the federal anti-kickback statute. To a greater extend, harmonizing the new health reforms and the existing statutes that govern health practices has proved complicated with many gaps yet to be filled. It is, however, worth noting that depending on the operations in question, federal laws alongside other state laws could be recruited and applied. The reforms have not significantly affected health laws especially those that involve referrals of patients who benefit from federal programs.
Paul Tillich’s Theology
Paul Tillich, a renowned existential theologian who lived and was born in Germany in 1886. As a Lutheran minister and lecturer, Tillich recorder most of his though in books with the famous entitle the Systemic Theology. In his book love, power and justice, the ambiguity of the words in all spheres of the mind brews a whole new problem that leaves a lot to be desired. He approaches the terms from a whole new dimension; the principles of being, ultimately prompting an ontological exploration into their meaning. Tillich (1954) examines love in the schism of drifting apart and reunion. He insists that love is the sole driver of unity of the alienated since human beings are always under a state of existence. He presents power as the potentiality that only comes to reality when people encounter each other.
Power to Tillich is what becomes apparent when lives confront each other and as such compulsion and force become an important manifestation of power. Tillich (1954) goes further to present justice as a form in which authority or supremacy of being actualizes itself. The most striking thing in his arguments in this book is how he relates the three key themes. He asserts that justice is what keeps what love reunited together and knit. Justice is the best and only form in which love operates and the compulsive and influential power of love is directed.
Tillich’s theology exploration of being applies and is relevant to corporate compliance and maintenance of ethical relationships in business. The fact that when love manifests, justice is realized should be a platform to cultivate justice and fairness in business operations just by simply loving each other (Tillich, 1954). Federal statutes on anti-kickbacks and other malpractices in the healthcare systems would be rendered useless if love formed the bond between providers and clients. This is because justice would not be something that must be found in courts of law and enforcement bodies but rather it would be intrinsic and self-inflicted. A system that is characterized with compulsion and forceful implementation of laws in order to realize a smooth flow of business lacks love that translates to lack of justice. Tillich’s mind harbors the belief that lack of determinate ethical stands leads to a random and anarchic world because being is not viewed through the frame that intertwines love, power and justice (Tillich, 1954). All spheres of life, including the business and corporate world yearn for a magical touch that will restore the real meaning of being.
Christian Worldview
The Bible extols the belief that God is the healer, “‘Nevertheless, I will bring health and healing to it; I will heal my people and will let them enjoy abundant peace and security” (Jeremiah 33: 6 New International Version). Therefore, doctors and administrators in the health sectors should ensure that while working to improve the lives of patients, they should do so with love and made decisions that are aimed at saving lives and not focus on their personal gains.
Conclusion
Healthcare provision continues to be perfected day in day out not only in the United States but across all nations of the world. Many policies were formulated, many more are being developed, and so many more will be adopted and implemented in an effort to ensure medical services are affordable, quality and standard. However, it rests upon the key players in the sector to bring the much desired change that continue to claim billions of dollars from different relevant bodies. Healthcare professionals are guided by a standard prescribed code of conduct that is deeply entrenched in obligation, confidentiality and passion to serve. All players in the sector right from clients, employees, employers, physicians, regulatory bodies, state governments and federal governments have a role to make the healthcare system better. Reforms that touch the system will only be successful and bare the intended fruits if all players commit to ensure that the objectives are met through ethically acceptable means.
References
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Burda, D. (1992). Physician pay, perks vary by employer. Modern healthcare, 22(11), 58.
Centers for Medicare and Medicaid Services. (2002). History of Medicare and Medicaid. Updated March, 6, 2002.
Huntington, W. V., Covington, L. A., Center, P. P., Covington, L. A., & Manchikanti, L. (2011). Patient Protection and Affordable Care Act of 2010: reforming the health care reform for the new decade. Pain Physician, 14(1), E35-E67.
Jacobs, L. R., & Skocpol, T. (2012). Health care reform and American politics: What everyone needs to know. New York: Oxford University Press.
Prenetta Jr, J. P. (1987). United States v. Greber: A New Era in Medicare Fraud Enforcement. J. Contemp. Health L. & Pol’y, 3, 309.
The Holy Bible, New International Version. (1984). Grand Rapids: Zondervan Publishing House
Tillich, P. (1954). Love, power, and justice: Ontological analyses and ethical applications (Vol. 38). Oxford University Press, USA.
United States of America v. Kamal Patel. 14-2607 United States Court of Appeals for the Seventh Circuit (2015) Appeal from The United States District Court for the Northern District of Illinois, Eastern Division.
