The Los Angeles County Public Health Department falsified the dates it received complaints about nursing homes as pressure rose to meet state deadlines for launching investigations, according to two employees.

In a letter last month to county, state and federal officials,  inspector Kimberly Nguyen cited 11 cases in which she said the dates typed into the computer system were later than the dates the complaints were actually received. The cases mentioned in the letter involve alleged abuse, falls and pressure sores, she said.

“In my belief, falsification is a serious matter and unlawful and our department should know better to not manipulate paperwork to mislead others and the public,” Nguyen wrote in the Oct. 7 letter.

In an Aug. 6 email, Sharon Geraneo, an assistant supervisor in the department, also wrote administrators to protest alleged falsification of complaint dates. She wrote that the department cites nursing homes for fraudulent record-keeping and yet, “here we are falsifying the records.”

Under state law, investigations must be started within 10 days of receipt of a complaint— or 24 hours if the allegation involves the imminent threat of death or serious harm.  California Department of Public Health policy requires inspectors to enter the dates based on when the complaint was first received by telephone, fax, email or letter.

In Los Angeles County, the dates of some complaints were entered much later than when they were received — by as much as 79 days, Nguyen said.

Officials with the state public health department said they are investigating the allegations.

The Los Angeles County Department of Public Health issued a statement saying it has “zero tolerance for intentional document falsification” and is not aware of any deliberate falsification of records.

Department officials said they did identify a data entry error by one person that affected 35 cases. The error “prompted swift and appropriate corrective actions,” including re-training that staff member, according to the statement.

The health facilities inspection division “recognizes the importance of handling records in a timely manner,” the statement read.

Los Angeles County is under contract with the state to investigate potential problems at nursing homes, which typically are made by residents or family members, or are reported by the facilities themselves.

Both the county and the state have faced mounting criticism over the past several months for lax oversight of nursing homes. Legislative hearings, audits and reports have faulted public health officials for allowing thousands of open cases to languish,  often for a year or more.

The most recent allegations focus on problems at the other end — in starting the investigations. A state audit released last week said that in addition to the delays in finishing cases,  officials had not begun investigations within the required time frames.  In August, the Los Angeles County Auditor-Controller also faulted the county public health department for problems with entering complaints in the system days after receipt, rather than on the same day as required.

Nguyen said she believes the practice in some cases was deliberate, in part because it continued even after the August audit. She said she decided to speak publicly about her concerns because she believes the department is “putting patients in harm’s way” and should be held accountable.  She has made repeated attempts to get her superiors to address problems but said she has received little or no response.

“I’ve exhausted the proper channels,” she said. “It was time for me to come forward … This is a safety issue.”

In an interview, Nguyen said several cases concerned her, one of them involving Imperial Crest Health Care Center in Hawthorne. Documents showed the center submitted a report to the county public health department on Aug. 5, 2013 about a resident suffering a broken finger.  The receipt date, however, was listed as Aug. 16 — 11 days later. The investigation was begun within 10 working days after that.

The injury, which required stitches and a splint, resulted from an altercation in which a nursing aide snatched a mobile phone away from the patient, documents show. In fining the facility $10,000, the county said the facility had failed to intervene when the resident earlier accused the aide of being rough and asked for a different aide.

According to an Oct. 3 email, Nguyen raised concerns about falsified dates in other cases to her supervisor, Adewole Adegoke. In a response that day, Adegoke wrote that so much “behind-the-scene” work needs to be done before an investigation can be assigned and that the start dates are “not so black and white.” Also, the supervisor blamed a fax machine, saying it “had not really functioned as designed.”

Meanwhile, the state, which directly oversees nursing homes in every district except Los Angeles County, has had its own history of problems with timely investigations. A lawsuit by California Advocates for Nursing Home Reform, or CANHR, resulted in a 2006 order by a Superior Court judge instructing public health officials to follow the law regarding investigation timelines.

Geraneo noted that order in her e-mail to administrators, referring to a case involving a non-working generator in which the complaint year had allegedly been changed from 2013 to 2014. “We cannot change the initiation dates of these complaints because of the CANHR lawsuit!”

Geraneo declined to be interviewed.

Since Kaiser Health News began writing about the department’s health facilities inspection division in March, administrators have sent e-mails to staff telling them not to speak to the media and to forward all requests. Reached by phone, several inspectors have declined to talk, saying they feared retaliation.

Nguyen said  she has been she has been targeted for retaliation as a result of raising questions since July 2013 about the quality of nursing home oversight.

In May 2014, Nguyen was suspended for five days without pay because she allegedly failed to renew her nursing license. A department letter said her license expired on November 30, 2013 and that she worked for six days without a valid license.

But as the Board of Nursing later confirmed in writing, her license actually had been renewed promptly. The Board simply hadn’t entered the renewal on its website. Nguyen called the board on Dec. 11, as soon as she found out about the problem, and it was fixed within an hour.

The suspension occurred five months later — and just days after Nguyen said she provided evidence of allegedly improper case closures to the Los Angeles County Auditor-Controller.

Nguyen said she believes she was being punished by her bosses for exposing the department’s “unethical practices.”

“They were being vindictive,” she said.

A spokesman said the county public health department could not comment on personnel matters.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Supreme Court on Friday agreed to hear a case on a subject that’s important to millions of people who receive subsidies to help purchase coverage under the health-care law. Friday’s decision follows earlier action in July when two U.S. appeals courts issued conflicting rulings on the issue.  KHN’s Mary Agnes Carey answers some frequently asked questions about those court decisions and how they impact consumers.

Q: What did the Supreme Court do?

The justices decided to hear a case that challenges the federal government’s ability to provide subsidies to individuals in nearly three dozen states where the federal government operates the online marketplaces, or exchanges. There are several legal challenges on this issue that are working their way through the courts. The high court’s decision to accept the case surprised many analysts who thought the Supreme Court might wait until they had a ruling from the full District of Columbia Court of Appeals, one of the other courts considering the issue.

Q:  How did the lower courts rule on the subsidy issue?

A three-judge panel from the U.S. Court of Appeals for the District of Columbia Circuit ruled in July that the health law’s subsidies are available only to individuals in states now operating their own health insurance exchanges. In 2014, only 14 states and the District of Columbia ran their own exchanges, while 36 relied on the federal government. Judge Thomas Griffith, writing the majority opinion in the 2-1 decision, said they concluded “that the ACA unambiguously restricts” the subsidies to “exchanges ‘established by the state.’” That ruling was later vacated when the full District of Columbia Court of Appeals agreed to rehear the case, which is scheduled for December next month.

In a separate ruling, a three-judge panel for the Fourth Circuit Court of Appeals in Richmond, Va., ruled unanimously for the Obama administration, allowing subsidies to be available to residents in all states.  Judge Roger Gregory, writing the opinion, said while the health law is “ambiguous and subject to multiple interpretations,” the court decided to uphold the IRS’s interpretation of the law that residents of states using the federal exchange are entitled to subsidies. That Virginia case, King v. Burwell, is the case the Supreme Court said would hear this term.

Q: What was the issue the lower courts decided on?
The case centers on a brief description in the health law that says subsidies will be available “through an exchange established by the state.”

In implementing the law, the Internal Revenue Service (IRS) interpreted the law to allow eligible consumers to receive subsidies to help purchase coverage, regardless of whether they are in an exchange run by their state or by the federal government.

Opponents of the law questioned that interpretation, saying that the law as written clearly directs subsidies to state-based exchanges only.  But proponents – including several lawmakers who helped write it – said lawmakers fully intended that subsidies be offered on all exchanges no matter if they were administered by the feds or state officials.

Q: I live in a state with a federally run exchange, and I get a subsidy to help me buy coverage. Am I going to lose it?

Current subsidies will likely remain in place until there is a final legal decision on the matter.

White House spokesman Josh Earnest said the administration was confident it would prevail. “The ACA is working. These lawsuits won’t stand in the way of the Affordable Care Act and the millions of Americans who can now afford health insurance because of it,” Earnest said in a statement Friday. “We are confident that the financial help afforded millions of Americans was the intent of the law and it is working as Congress designed.” Open enrollment begins again Nov. 15.

Supporters of the court challenge to the IRS interpretation on subsidies also maintain their case is strong. “The Supreme Court’s decision is a rebuke to the Obama administration and its defenders, who dismissed as frivolous the plaintiffs’ efforts to defend their right not to be taxed without congressional authorization,” Michael Cannon, director of health policy studies at the libertarian Cato Institute who championed the subsidy appeals, said in a statement Friday. “It is essential that these cases receive expedited resolution, if only to eliminate the uncertainty currently facing states, employers, insurers, and taxpayers.”

Q: If there are legal disputes ongoing about who qualifies to receive a subsidy, do I still have to buy health insurance?

Yes.  The law’s “individual mandate,” which requires most people to purchase health insurance or pay a fine, is still in place and has been upheld by the Supreme Court.

Q. What if I get my insurance through work?
This decision applies only to policies sold on the online marketplaces. It does not affect work-based insurance, Medicare or Medicaid, regardless of where you live.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Once again, the Supreme Court will decide whether the Affordable Care Act lives or dies.

Defying expectations, the court announced Friday it has agreed to hear – during this term –  a case that challenges the heart of the law: subsidies to help people pay their insurance premiums. In about three dozen states, the federal government runs the online marketplaces where individuals can find health plans.

At issue is a phrase in the law stipulating that subsidies to help those with incomes under 400 percent of poverty are available only in “exchanges established by a state.” The authors of the law argue that the rest of the statute makes it clear that subsidies are available not only in state-run exchanges, but in those where the federal government is doing the work of the state.

When the law was written, most people expected that states would want to run their own exchanges. It was a surprise when most opted to let the federal government do it instead.

A decision to strike down the subsidies in federally-run exchange states could end up making insurance unaffordable for millions of people and threaten the viability of the law’s entire health insurance program.

In a rare Friday afternoon notice following their closed-door conference, the justices noted with no further comment that they have agreed to hear King v. Burwell. That is the case in which a three-judge Appeals Court panel in Richmond ruled unanimously that Congress did intend to allow subsidies to be available nationwide.

That same day, a panel  in the District of Columbia Court of Appeals ruled 2-1 the opposite way. But that case, Halbig v. Burwell, was vacated when the full court agreed to rehear the case. That is scheduled for December.  Because there are not yet contradictory decisions by appeals courts, most observers thought the Supreme Court would at least wait until the lower courts were finished considering the case before weighing in.

“We are disappointed that at least four Justices decided to hear this case despite the lack of a circuit split and while this issue is still being actively litigated in the lower courts,” said Doug Kendall of the Constitutional Accountability Center, which is representing the members of Congress who wrote the law. “But we remain very confident that the Court will ultimately find that both the text of the ACA and the intentions of Congress mandate a ruling for the federal government.”

Those who argue that the federal subsidies are illegal, however, say time is of the essence.

“In King there is a serious argument that it would be better to resolve the underlying question of statutory interpretation sooner rather than later,” wrote Jonathan Adler, a law professor at Case Western University, in The Washington Post last week. “The resolution of this litigation will alter the calculus for many political and private actors considering how to respond to the PPACA, and the statute contains various deadlines and timeframes that may become harder to navigate the longer this litigation drags on.”

The White House said in a statement that the lawsuits challenging the language would not stand in the way of the law’s implementation. “This lawsuit reflects just another partisan attempt to undermine the Affordable Care Act and to strip millions of American families of tax credits that Congress intended for them to have,” the White House statement said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

After strong pushback from ALS patients and lawmakers, the government has reversed a decision that could have blocked Medicare reimbursement for certain speech generation devices beginning Dec. 1.

The decision announced Thursday by the Centers for Medicare & Medicaid Services means Medicare will continue a longstanding policy to cover most of the cost of devices that can be upgraded by patients at their own expense.

Speech generation equipment is critically important to patients with ALS and similar neurodegenerative disorders – conditions that limit their capacity for movement and speech. Patients, since 2001, have had the option of paying themselves for upgrades, including those that enable them to connect to the Internet and open doors or adjust room temperatures. But in February, Medicare announced a policy interpretation that would have precluded coverage of the cost of upgradable devices.

Patients with ALS, amyotrophic lateral sclerosis, and their advocates strongly objected. On Thursday, the government backed off.

In reversing course, CMS “emphasized the importance of technology and how critical it really is, at this point, I think, to not make a new policy immediately,” said Kathleen Holt, associate director at the Center for Medicare Advocacy, which advocates for Medicare beneficiaries.

Advocates are still worried about the future. Medicare intends to update its National Coverage Determination – the federal rule that determines what Medicare can cover – so as to incorporate technological advances that weren’t around in 2001. Public comment will be solicited, and a revised rule is likely by July 2015, said Patrick Wildman, director of public policy at the ALS Association.

That means “there’s still the uncertainty of what is the coverage policy going to look like, come July 2015,” Wildman said. “Will it be something different?”

“One of the things I would say to beneficiaries is, we’ve got a temporary reprieve on this, but don’t stop fighting,” Holt said.

CMS did not immediately respond to requests for comment.

ALS patients had aggressive support from Congress on the question of speech generating devices. Some  200 members signed a bipartisan “Dear Colleague” letter in September, asking CMS to respond to patients’ concerns. On Tuesday, Rep. Tim Murphy, R-Pa., sent the agency another letter.

The letters also expressed concern about a recent pattern of Medicare denials of coverage of eye-tracking technology, which uses eye movements to generate commands for the speech devices. Those claim denials are routinely reversed on appeal, but the appeals process can take months.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The percentage of babies born prematurely fell to 11.4 percent in 2013, its lowest level in 17 years, according to an annual March of Dimes report released this week. While many factors contributed to the decline, officials say the health law’s expansion of Medicaid to adults with incomes up to 138 percent of the federal poverty level has played a role.

Going forward, other health law provisions will likely contribute to further reductions in preterm births, defined as live births at less than 37 full weeks, women’s health advocates suggest.

“This decline can’t be attributed to the marketplaces, which haven’t even had a full year of enrollment yet,” says Cynthia Pellegrini, senior vice president for public policy and government affairs at the March of Dimes. “But there were places that did the Medicaid expansion earlier,” after the law passed in 2010.

So far, 27 states and the District of Columbia have decided to expand their state Medicaid programs to adults as permitted under the health law.

The report card measures states’ preterm birth rates against the March of Dimes’ 9.6 percent goal and assigns letter grades. This year, grades for 27 states improved from the previous year. The United States’ 11.4 percent rate earned it a “C” grade.

Preterm birth is the number one cause of death in newborns. In 2013, more than 450,000 babies were born prematurely.

The report card tracks states’ progress in implementing strategies that reduce the risk of preterm birth. In 2013, 30 states and the District of Columbia reduced the percentage of women of childbearing age who were uninsured. The percentage of younger women who smoke fell in 34 states and the District, and the late preterm birth rate, meaning babies born between 34 and 36 weeks gestation, came down in 30 states.

The health law’s expansion of public and private health insurance coverage to millions of women will likely have the largest impact on reducing preterm births, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive health research and education organization. Pregnant women who meet their state’s income eligibility standards (typically at or near 200 percent of the federal poverty level, or $23,340), can receive Medicaid services until 60 days after they give birth, but more consistent coverage helps ensure that women are healthy before they become pregnant and that they receive early prenatal care.

Other health law provisions will make inroads as well, according to Sonfield, who authored a Guttmacher brief on pregnancy-related services shortly after the law passed in 2010. Maternity and newborn care is now required coverage in plans sold on the individual and small group markets. A range of preventive services must be provided free of charge to pregnant women, including folic acid supplements, smoking cessation counseling, screening for gestational diabetes and prenatal care.

“Better access to insurance helps you plan and space your pregnancies, and better access to preventive care helps make sure you’re healthy” before and between pregnancies, says Sonfield.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The health law’s open enrollment season is just around the corner. Are you ready?

Here’s a quick checklist for people who don’t get their health insurance at work and plan to shop for coverage on the health law’s online exchanges, or marketplaces, starting Nov. 15. You can compare plans and prices at healthcare.gov or, if your state has its own exchange, shop there to find out which coverage is best for you. And you may be eligible for subsidies to help pay your premium.

Keep these five things in mind as the three-month open enrollment period begins.

– Shop Around: Just because you’re enrolled in a policy now doesn’t means it’s the best deal for you next year. If you’re currently in the federal marketplace and don’t take any action, you’ll be re-enrolled in the same plan you’re in now. Federal officials, as well as many analysts, are urging consumers to go back to the exchanges to compare plans and prices. You might discover that you have more –or different – choices than you had a year ago.

– Don’t Get Billed Twice: Insurers have expressed concerns that if a consumer changes plans, problems with the federal website might keep insurers from learning of the change and consumers could get billed for both plans. “It’s an issue we’re aware of and we’re working with exchange officials to make sure there’s a solution for consumers,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, an industry trade group. Aaron Albright, a spokesman for the Centers for Medicare & Medicaid Services, said insurers will get lists of individuals who have been automatically enrolled into their current plan as well as those who chose to re-enroll. He also said that the agency is “examining options” on how to provide insurers the names of people who picked another plan during open enrollment.

Just in case, keep proof of payment to answer any billing questions and once you’ve cancelled the old policy watch your credit card statements or, if the payment was deducted directly from a bank account, watch those charges to make sure you aren’t paying for two policies. And don’t cancel your current insurance until you have confirmation from your new carrier that you’re covered.

– Find Out If You Qualify For Financial Help: Enter your most up-to-date income information on healthcare.gov or with your state exchange to see if you are entitled to receive a tax credit toward the cost of your health insurance. Even if you are like the majority of those enrolling in marketplace plans who receive a subsidy, update your income to make sure you get the correct amount next year. This is important because if you get too much of a subsidy, you’ll have to repay it when you file your taxes the following year.

– Know All Costs: It’s not just the monthly premium that will cost you. Understand a policy’s out-of-pocket costs, things like co-pays, co-insurance and deductibles, before you enroll. The health law allows out-of-pocket maximum caps of $6,600 for an individual policy and $13,200 for a family policy in 2015 but some of your health care expenses – including out-of-network care – might not be included in that cap.

– Get Help If You Need It: Confused? There are several ways to get help. Work with a local insurance agent or broker. Find one of the law’s trained navigators or assistors. Or call the federal consumer assistance center at 800-318-2596 for extra help or to find out if you eligible for a subsidy. Folks there can also help you enroll in a health plan or if you qualify, Medicaid, the federal-state program for low-income people.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The kids are asleep, and I’ve settled into a comfy armchair in the corner of my New England living room, one of my favorite spots for shopping online. I’ve got my laptop open and I’m ready to search for a bone density test.

Hmmm … looks like the price that my insurer pays for that test varies from $190 at Harvard Vanguard to $445 at Brigham and Women’s Hospital.

Really? I’m calm, but this is a seismic moment. In most of the country, it is still nearly impossible to compare the price and quality of anything in health care. Ten years ago, I tried filing Freedom of Information Act requests to get this information and got nothing. Occasionally, sources would leak me spread sheets from one hospital or another.

Websites that mine such data are springing up to fill the void, revealing price tags on everything from an office visit to a cesarean section. But thanks to a law enacted in October, Massachusetts health insurers now have to make all their prices public – in advance.

“This is a very big deal,” says Barbara Anthony, undersecretary for consumer affairs in Massachusetts. “We’re letting the light shine in.”

The online tools also calculate your cost, based on your plan. Anthony’s office has launched an ad campaign, urging patients to shop around. She says doctors and hospitals are becoming frequent users of the online cost tools, too.

“They’re already saying, ‘I don’t want to be the highest priced provider on your website — I thought I was lower than my competitors.’ That’s exactly the kind of reaction we want to see,” she says.

It’s key to getting at why one hospital charges three, four or five times more than its competitors, she says, and to seeing if exposing these differences will drive down prices.

“I’m just talking about sensible, rational pricing,” Anthony says, “and right now, health prices are anything but that.”

Take, for example, the cost in Boston of an MRI of the upper back, which, the numbers show can range from $614 to $1,800.

“That to me is a very big range,” says Sue Amsel, who oversees the shopping tool at the insurer, Harvard Pilgrim Health Care.

In this case, the most expensive MRI is at Boston Children’s Hospital — and the option of lowest cost is at New England Baptist, a hospital that specializes in orthopedics. The total cost of most surgeries is not yet available, but Amsel says you can now search for hundreds of tests, procedures and office visits.

“It’s eye opening,” she says. “I’m always surprised at the difference between providers.”

Now, most of us don’t have a strong incentive to shop. We pay the same $25 or $30 co-pay, no matter where we get an MRI. But more and more people have high-deductible plans, says Amsel, where patients pay the full cost of an office visit or test, up to the amount of their deductible.

The benefit’s not just in getting to choose, Amsel says. “It’s primarily for getting you the information about whatever you’re having done, so you can plan for it.”

After spending a lot of time window shopping for common tests, I have some tips: There are no uniform prices; they vary from one insurer to the next. And you have to read the fine print on these sites to know what is and is not included in the dollar figure you’ll see online.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.