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Company gives back $44.7 million after profiting too much on Nebraska Medicaid contract

LINCOLN — WellCare, a Tampa, Florida-based company, raked in more than five times the allowable profit in its first year of managing the care of Nebraska Medicaid patients.

WellCare of Nebraska is one of three private companies that contract with the state to administer physical health, behavioral health and pharmacy services for the majority of Medicaid patients.

Under the contract, the company — which pulled in 15% profits in its first year — had to turn back profits exceeding 3% of revenues. According to the Nebraska Department of Health and Human Services, the excess amounted to $44.7 million for 2017.

Molly McCleery of Nebraska Appleseed called the profit figures “striking,” especially coming out at a time when the advocacy organization is hearing from growing numbers of providers and patients about difficulty getting needed care approved.

The figures surprised Laura Redoutey, president of the Nebraska Hospital Association, which had expressed concerns about unpaid claims, delayed payments, increased bureaucracy and other problems during the first year of the managed care contracts.

“On the face of it, these numbers certainly look shocking,” she said. “However, at this time, we do not know the full story on what this data represents.”

In a statement, Nebraska Medicaid officials attributed WellCare’s profit margin and another plan’s losses in excess of 3% to the uncertainty about which patients would end up in which plan during the first year of the new managed care system, called Heritage Health.

The state pays contractors a flat amount per person per month. Those rates have since been adjusted to account for differing health status of patients.

“Results of risk adjustment in the more recent contract periods clearly indicate that the WellCare health plan had a membership that was relatively healthier than their counterparts in the market and therefore has experienced relatively lower medical costs,” the officials said. “These factors are the primary drivers” for Wellcare’s profits in 2017.

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The statement rejected any suggestion that WellCare had kept costs down by reducing care for members or constricting payment for providers.

Medicaid “has many reporting requirements and controls in place to ensure that eligible services are being authorized and paid for by (the managed care organizations) in accordance with our regulations,” the officials said.

WellCare officials also defended the quality of care delivered by their Nebraska Medicaid plan, noting that the company had been accredited by the National Committee for Quality Assurance this year.

“WellCare of Nebraska has a responsibility to our members and government partners to provide access to quality, affordable healthcare,” officials said in a statement. “We work closely with our provider partners — from clinicians to community health workers to pharmacists — using an integrated approach to care to address members’ needs holistically while improving health outcomes and reducing costs.”

In 2017, the three Heritage Health contractors administered more than $1.2 billion worth of services for about 228,000 people.

Neither of the other two companies — Nebraska Total Care and United Healthcare Community Plan — had profits above the 3% cap. In fact, Nebraska Total Care reported losses of more than 3% for the year.

Under its contract, nearly $25 million of WellCare’s excess profit went back to the federal government, which pays more than half the cost of the state Medicaid program.

The $20 million share that came from state tax dollars is being reinvested in health care, as required by a 2016 state law. The law calls for such funds to be used according to a plan that “shall address the health needs of adults and children, including filling services gaps and providing system improvements.”

Nebraska Medicaid Director Matthew Van Patton said HHS is using the money for six initiatives aimed at strengthening the health care system by making better use of health data across the state. The plan is to be administered by WellCare, subject to HHS approval.

“This is truly a monumental development for Nebraska,” he said. “The developing infrastructure will set us apart in the nation as we begin to make better, data-driven decisions as a health care community.”

The plan puts $5 million into establishing the Nebraska Healthcare Collaborative, a nonprofit group focused on building up the expertise and tools needed to strengthen health data science in the state. Collaborative board members include representatives from hospitals, insurance companies and academia.

An additional $5 million will go into an endowment supporting academic positions at the University of Nebraska and Creighton University, and $5 million will pay for information technology projects at HHS. The rest will support work-study positions, health care provider education and competitive grants for provider-driven proposals.

Van Patton said the initiatives grew out of informal conversations with various health care providers.

The plan began to take shape once the Nebraska Health Information Initiative, or NEHII, got on board. NEHII is a statewide health information exchange that has worked for about a decade to link patient records from a variety of health care entities.

Neither State Sen. John Stinner of Gering, the Appropriations Committee chairman, nor Sen. John Arch of Papillion, the Health and Human Services Committee vice chairman, offered comments about the initiatives.

But both questioned the process used to decide how to spend $20 million of taxpayer funds, as did Annette Dubas, executive director of the Nebraska Association of Behavioral Health Providers.

While the plan was presented at a quarterly Medicaid provider meeting for feedback, there was no opportunity for legislative oversight or input from consumers and taxpayers during its development. Dubas said state law had required involvement by consumers and family members before it was amended in 2016.

“There are many good things that could be done with those dollars,” Arch said. “There’s so many priorities, there’s so many things that need to be done.”

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Following the Huskers to Ireland in 2021? Here are five things Nebraska fans must do in Dublin

World-Herald staff writer Paul Hammel compiled five things Husker fans must do while in Dublin for the 2021 Nebraska-Illinois game.

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1. Visit a local pub: There’s “Nebraska Nice” and there’s definitely “Ireland Nice,” particularly when it comes to the local pub. Plenty of local characters there, and they're a colorful, usually talkative bunch. The Irish, as a rule, are very curious about America, since so many of their kin emigrated here. Buying a pint for your new friends is recommended. And the favor will mostly likely be returned.

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2. Take in a local sporting event: There's rugby and soccer, but the Irish particularly love their Gaelic football. It's a sport unique to the Emerald Isle that is sort of like soccer, except you can tackle the person with the ball. It's basically mayhem on grass. It's played by amateurs and each county has a team, so there's lots of local loyalty and fierce rivalries — just like college football in the U.S. Horse racing is huge in Ireland, too.

3. Soak in the culture: Take a stroll along the River Liffey, which runs through the center of Dublin. Walk down O'Connell Street, the main street of the city. Visit Dublin Castle and walk through the 27-acre city park, St. Stephen's Green. The Irish love their music and their verse, so check out The Temple Bar area. It is especially packed with pubs that feature traditional Irish music, but there's music in less touristy areas, too. There's even an Irish Rock 'N' Roll Museum in the city for fans of U2 and other Irish bands.

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4. Tour the Guinness Brewery: Yes, the dark Irish stout that is Ireland's trademark brew does taste better at the brewery and you can prove it by touring the Guinness Storehouse. Best to make reservations in advance, but the tour ends with a visit to a rooftop bar/restaurant that offers great views of the city. 

5. Explore your ancestry: The Irish have comprised a major portion of the population of Omaha and Nebraska since their founding. The Potato Famine forced 1.5 million Irish to leave the island for the U.S. between 1845 and 1855. Some of those who made it to the U.S. found railroad jobs in Omaha or set out for farms near Irish towns like Greeley, O'Neill and Spalding. In Dublin, check out a museum devoted to the great migration, the EPIC The Irish Emigration Museum.

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One mile at a time, Omaha woman raises awareness about male breast cancer after husband's death

When a state trooper pulled her over in South Carolina this summer, Patricia Washburn was prepared for him to ask how fast she’d been going.

But when she rolled down her window, the 33-year-old patrolman leaned down and asked her a question that had nothing to do with how she’d been driving and everything to do with what she was driving.

“What are the symptoms of male breast cancer?” he asked.

After Washburn’s husband, Marlyn, died in May 2017 of breast cancer, the Omaha woman wrapped his last car — a Dodge Dart — in breast cancer awareness logos and slogans to let men know it can happen to them, too.

At the car wrap company’s suggestion, she also put his photograph on the hood. Taken at Christmas 2016, around the time he was diagnosed, the 66-year-old retired school administrator appears healthy. He’d just made dinner for about 25 family members. But the cancer already had spread from his left breast to his liver, lymph nodes, lungs, bones and brain.

Ever since, Washburn has taken her message — printed on the car as well as on the T-shirts she often wears — all over the country, speaking to groups large and small about the disease and visiting sufferers and survivors. She’s often accompanied by a grandchild or a friend.

Washburn said getting the word out is important because most men aren’t aware that they can get breast cancer. Most aren’t taught to check for it.

Male breast cancer is relatively rare compared to the female version. A woman’s risk of getting breast cancer in her lifetime is about one in eight; for men, the risk is roughly one in 833. An estimated 2,670 men will be diagnosed with breast cancer in 2019, according to the American Cancer Society. For women, the estimate is 268,600.

Like the trooper, people notice Washburn’s car and her black T-shirts with their entwined blue and pink ribbons. Recently, Washburn stopped at her neighborhood Walmart. A woman who was putting groceries in her Jeep noticed her T-shirt and mentioned that her uncle has breast cancer. Washburn has since been in touch with the uncle and his daughter.

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If people don’t notice, Washburn doesn’t hesitate to bring it to their attention. Peggy Miller, director of the Male Breast Cancer Coalition, first met Washburn at a cancer conference in Chicago. When the two women got on a hotel elevator to go to their rooms, Miller said, Washburn turned to a fellow passenger and asked whether he knew that men could get breast cancer.

“She never gave up after it all happened,” said Miller, who lives in a Kansas City, Kansas, suburb. “She wanted to make a difference, just like we all do.”

The message appears to be getting out.

A handful of coalition members were in the audience of the Dr. Oz Show recently for the host’s interview with Mathew Knowles, Beyoncé’s father. Knowles, 67, revealed this month that he’d been treated for breast cancer this summer, undergoing a mastectomy. The coalition members also weighed in on questions during the episode, which aired Friday.

In September, Washburn showed her car in Denver as part of the Hot Wheels Legends Tour and told about 200 people about male breast cancer. She was invited after sending photos of the car and explaining her mission.

Miller’s son, Bret, the coalition’s co-founder, last year appeared in a public service announcement on breaking male stereotypes created by the makers of the ABC drama “A Million Little Things.” The show features a male character who’s been treated for breast cancer. Bret Miller, now 33, found a lump near his nipple at age 17. A doctor told him it was a calcium deposit associated with puberty. He was diagnosed with breast cancer seven years later at age 24.

“Because of our big mouths and squeaky wheels, we’re getting notoriety,” Peggy Miller said.

Breast cancer certainly wasn’t on Marlyn Washburn’s radar.

Patricia Washburn said her husband, who served as high school principal in Red Cloud, Nebraska, before retiring in 2014, went to the doctor in early December 2016 for a regular blood test for his diabetes. He also mentioned that his right arm and shoulder hurt, which the couple assumed was from golfing.

The blood test pointed to a problem with his liver or gallbladder. He went back the next day for an ultrasound, which showed six lesions on his liver. The couple later learned the cancer had spread well beyond his liver.

“We had no idea anything was wrong,” Washburn said. “He had pain in his arm, that was it.”

As it turned out, he did have a lump in his breast, right under the nipple. Washburn said her husband told her that he didn’t remember whether he’d ever felt it. If he had, he told her, he probably would have thought it was a lipoma, a kind of fatty, usually benign lump under the skin that can show up in middle age.

Doctors, she said, biopsied both the breast tumor and a liver lesion and determined that both were breast cancer. But people often assumed that because he also had cancer in his lungs and brain that he had lung or brain cancer. The couple would explain that he had breast cancer that had spread to those organs.

“We find a lot of people do not understand the difference,” she said.

Five months later, he died.

Washburn first made brochures explaining that men, too, can get breast cancer. She’s handed out about 15,000 of them. Then she outfitted the car.

Her husband, she said, devoted 41 years to education. “I guess I just felt like it was my turn to step up to the plate and start educating people,” she said.

She later became involved in the coalition, which has become family. Peggy Miller, the group’s director, said the coalition is all about bringing men together so they can open up and feel like they’re not alone. The condition still carries stigma, although the two women believe Knowles’ openness will help shift that.

So when the South Carolina trooper leaned in this summer, Washburn had answers.

After explaining the possible signs and symptoms of breast cancer in men, she asked whether he was worried about himself. He said yes. She gave him some brochures and encouraged him to see a doctor.

She said she hasn’t been able to find out whether he’s done so. But she’s glad she got the chance to help.

“Even if I don’t touch anybody else,” Washburn said, “I touched him. And everything I paid for that car was worth it because he had a chance to ask somebody about breast cancer.”

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Trump orders Turkey sanctions; U.S. scrambles for Syria exit

WASHINGTON (AP) — Targeting Turkey's economy, President Donald Trump announced sanctions Monday aimed at restraining the Turks' assault against Kurdish fighters and civilians in Syria — an assault Turkey began after Trump announced he was moving U.S. troops out of the way.

Meanwhile, the Americans were scrambling for Syria's exits, a move criticized at home and abroad as opening the door to a resurgence of the Islamic State fighters who were the reason U.S. forces came in the first place.

The Turks began attacks in Syria last week against Syrian Kurdish fighters, longtime U.S. battlefield allies against the IS group. On Monday, Syrian government troops moved north toward the border region, setting up a potential clash with Turkish-led forces.

Kurdish forces previously allied with the U.S. said they had reached a deal with President Bashar Assad's government to help them fend off Turkey's invasion.

In Washington, Trump said in a statement that he was halting trade negotiations with Turkey and raising steel tariffs. He said he would soon sign an order permitting sanctions to be imposed on current and former Turkish officials.

American troops consolidated their positions in northern Syria on Monday and prepared to evacuate equipment in advance of a full withdrawal, a U.S. defense official said.

The hurried preparations, triggered by Trump's decision Saturday to expand a limited troop pullout into a complete withdrawal, came as Trump's national security team considered imposing what he called "big sanctions" on NATO ally Turkey.

The U.S. pullout raised many questions, including how and whether the Trump administration would continue putting military pressure on the Islamic State in Syria without a troop presence on the ground. U.S. forces have been there since 2015, arming and advising a Kurdish-led Syrian group of fighters who largely eliminated IS control of Syrian territory but were still working to prevent an IS resurgence.

The defense official, who was not authorized to be quoted by name, said U.S. officials were weighing options for the future of a counter-IS campaign, including the possibility of waging it with a combination of air power and special operations forces based outside of Syria, perhaps in Iraq.

Defense Secretary Mark Esper said Sunday that Trump had directed U.S. troops in northern Syria to begin pulling out "as safely and quickly as possible." He did not say Trump ordered troops to leave Syria, but that seemed like the next step in a combat zone growing more unstable by the hour. The only exception, it appeared, is a group of perhaps 200 U.S. troops who will remain at a base in southern Syria near the Jordanian border, working with opposition forces unrelated to the Kurdish-led fighters in northern Syria.

The controversy over Trump's plan to pull US troops out of Syria, explained

Esper said the U.S. withdrawal would be done carefully to protect the troops and to ensure that no U.S. equipment was left behind. He declined to say how long that might take.

In a series of tweets Monday, Trump defended his gamble that pulling U.S. forces out of Syria would not weaken U.S. security and credibility. He wrote that the IS prisoners who escaped amid the pandemonium in Syria can be "easily recaptured" by Turkey or European nations, even as France said it was pulling its remaining troops out of Syria.

Trump took sarcastic swipes at critics who say his Syria withdrawal amounts to a betrayal of the Kurds and plays into the hands of Russia.

"Anyone who wants to assist Syria in protecting the Kurds is good with me, whether it is Russia, China, or Napoleon Bonaparte," he wrote. "I hope they all do great, we are 7,000 miles away!"

Trump has dug in on his decision to pull out the troops, believing it fulfills a key campaign promise and will be a winning issue in the 2020 election, according to White House officials.

It's not a new issue for the president. He rallied around it in 2016 and, during his term, has repeatedly urged bringing the troops home only to be talked out of it by moderating forces including former Defense Secretary James Mattis and chief of staff John Kelly. Mattis resigned last December when Trump announced — and later partly rescinded — a decision to pull all troops out of Syria.

In his remarks Sunday, Esper said the administration had little choice but to order a pullout.

"We have American forces likely caught between two opposing advancing armies and it's a very untenable situation," Esper said.

This seemed likely to herald the end of a five-year effort to partner with Syrian Kurdish and Arab fighters to ensure a lasting defeat of the Islamic State group. Hundreds of IS supporters escaped a holding camp amid clashes between invading Turkish-led forces and Kurdish fighters, and analysts said an IS resurgence seemed more likely, just months after Trump declared the extremists defeated.

Republican Senate leader Mitch McConnell, normally a staunch Trump supporter, said he was "gravely concerned" by events in Syria and Trump's response so far.

Withdrawing U.S. forces from Syria "would re-create the very conditions that we have worked hard to destroy and invite the resurgence of ISIS," he said in a statement. "And such a withdrawal would also create a broader power vacuum in Syria that will be exploited by Iran and Russia, a catastrophic outcome for the United States' strategic interests."

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However, Trump got quick support from Republican Sen. Lindsey Graham of South Carolina, who had lambasted his withdrawal decision last week as "shortsighted," ''irresponsible" and "unnerving to its core." On Monday, echoing Trump, Graham said on the Fox News Channel that the current situation was Turkish leader Recep Tayyip Erdogan's fault and Turkey would face "crippling sanctions" from the U.S. on its economy.

The U.S. has had about 1,000 troops in northeastern Syria allied with the Kurdish-led Syrian Democratic Forces to combat IS. The Pentagon previously had pulled about 30 of these troops from the Turkish attack zone along the border. With an escalation of violence, a widening of the Turkish incursion and the prospect of a deepening conflict, all U.S. forces along the border will now follow that move. It was unclear where they would go.

The Kurds have turned to the Syrian government and Russia for military assistance, further complicating the battlefield.

The prospect of enhancing the Syrian government's position on the battlefield and inviting Russia to get more directly involved is seen by Trump's critics as a major mistake. But he tweeted that it shouldn't matter.

"Others may want to come in and fight for one side or the other," he wrote. "Let them!"

New Jersey Sen. Bob Menendez, the top Democrat on the Senate Foreign Relations Committee, said Trump is weakening America. 'To be clear, this administration's chaotic and haphazard approach to policy by tweet is endangering the lives of U.S. troops and civilians," Menendez said in a statement. "The only beneficiaries of this action are ISIS, Iran and Russia."


AP writer Jonathan Lemire contributed to this story.