Houston Hospital Leaders Sentenced to 45 Years in Prison for Alarming Psychiatric Fraud Scheme

Details of the fraud allegations against Riverside General Hospital executives

The bulk of the Medicare and Medicaid fraud allegations against Gibson, et al. center around Riverside’s psychiatric facilities, which are classified by the government as a “partial hospitalization program” (PHP) A PHP is technically an outpatient treatment facility, but is geared toward the round-the-clock care required for patients enduring a severe mental illness. Under government guidelines, mental health patients receiving care at a PHP must be routinely seen by a psychiatrist, guided through a care plan, and carefully monitored throughout the course of treatment.

According to the allegations, Riverside collected more than $158 million in funds from Medicare and Medicaid on behalf of PHP patients who rarely, if ever, saw a psychiatrist for their illnesses. Moreover, Riverside regularly billed the government for psychiatric services that were never rendered, mostly because the patients were in the advanced stages of dementia and unable to participate in the treatment.

Patient care aside, Riverside is also accused of offering kickbacks and financial incentives to executives group homes, as well as recruiters tasked with increasing referrals of mental health patients to Riverside’s facilities.

In addition to the three main participants listed above, six other individuals recently pled guilty to conspiring with Gibson to bring in the maximum number of Medicare and Medicaid clientele.

According to a statement by the U.S. Attorney General’s Office, “The former President of Houston’s Riverside hospital, his son, and their co-conspirators saw mentally ill, elderly, and disabled Medicare beneficiaries as commodities to be turned into profit centers – not as vulnerable individuals in need of health care….Rather than providing needed medical care to a historically underserved community, the defendants ran a longstanding hospital into the ground through their greed and fraud. According to the evidence presented at trial, the defendants had patients sit around the facility watching movies while they received no treatment. Meanwhile, the defendants billed Medicare more than $158 million for care that was never provided. This brazen fraud cannot and will not be tolerated.”

See Also

Department of Justice Press Release, “Former President of Riverside General Hospital Sentenced to 45 Years in Prison in $158 Million Medicare Fraud.” June 9, 2015.

GAO Finds Major Overuse of Antipsychotic Drugs by the Elderly

From the Illinois Nursing Home Abuse Blog

In late 2014 we blogged about the accusations levied against Dr. Michael J. Reinstein about his improper use of antipsychotic drugs prescribed to patients in abundance, as well as taking kickbacks from the drug maker to prescribe it, and making 140,000 or more false billing claims submitted to Medicare and Medicaid for those treatments. This activity landed him in both civil and criminal hot water, and in more recent news he pled guilty to criminal charges as well as settled civil claims with the Illinois and federal governments.

The companies accused of providing those kickbacks and receiving Medicare and Medicaid dollars from the business Reinstein generated by prescribing their antipsychotic drugs. Reinstein exemplifies a holdover of a slowly diminishing practice of using antipsychotic medications, which now is viewed more as the easy way out and a method of chemical restraint when there are other methods that could more humanely calm and care for a patient, particularly dementia and Alzheimer’s patients who have historically been the recipients of antipsychotic medications. Nursing homes historically used these especially when they kept low staffing levels and did not have the manpower to aid patients. Yet antipsychotic drugs can create a cycle of drug dependency, and can even lead to death.

Changing Tides?

While the movement to eliminate the use of antipsychotic medications has gained steam in recent years, the federal government reports that elderly Americans have been overusing psychiatric drugs such as clozapine (Dr. Reinstein’s apparent drug of choice), Abilify, and others. Such drugs are meant to calm down and sedate patients that are prone to violence or outbursts, which those suffering from dementia or psychosis may be particularly prone to exhibiting. The Government Accountability Office (GAO) has released a report stating that elderly adults who live outside of nursing homes and long-term care facilities overuse antipsychotic drugs which are prescribed to them by doctors, though residents in nursing homes also fell into such dependency and overuse, and efforts to curb over-prescription and overuse must continue there as well.

Notably, according to the report, about 86% of Medicare enrollees who suffer from dementia and live outside of nursing homes are prescribed antipsychotic medications, which is a staggering statistic. It is even more remarkable when considering that only approximately 6% of total Medicare enrollees living outside of nursing homes suffer from dementia. Thus the choice of treatment has predominantly been geared toward chemical intervention. For those in nursing homes, of the elderly dementia patients living in nursing homes for over 100 days in the year 2012, approximately a third of those patients were prescribed antipsychotic drugs (and 14% of those outside of nursing homes during 2012).

Part of the problem, according to the GAO report, is the lack of oversight by the government. Medicare and Medicaid specifically take responsibility for such oversight on behalf of the federal government, and states typically have Medicaid fraud units that look into not only financial fraud related to health care, but also investigate when issues include abuse or misuse of medications (which can result in unnecessary and excessive, and thus fraudulent, payments to providers and pharmaceuticals with federal dollars). Those agencies and offices, as well as the U.S. Department of Health and Human Services as the report notes, should be vital in promoting awareness of the dangers of antipsychotic drugs and reducing that use far more than the government has in the past.

Drugging our kids: RX alliance rewards doctors as drug companies get richer

An Investigative report by the Los Angeles Daily News

The following is from a much larger article well worth reading:

An investigation by this news organization has found that drugmakers, anxious to expand the market for some of their most profitable products, spent more than $14 million from 2010 to 2013 to woo the California doctors who treat this captive and fragile audience of patients at taxpayers’ expense.

Drugmakers distribute their cash to all manner of doctors, but the investigation found that they paid the state’s foster care prescribers on average more than double what they gave to the typical California physician.

The connection raises concerns that Hernandez and many other unsuspecting youth have been caught in the middle of a big-money alliance that could be helping to drive the rampant use of psychiatric medications in the state’s foster care system.

“It sucks that the people marketed it that way, but that’s not that shocking. I’m more mad at the doctors for just going along with it,” said Hernandez, 22, who was prescribed as many as four of the drugs at a time as a foster youth in Southern California.

Overall, drugmakers reported payments to 908 doctors — well over half of those who prescribed psych medications to the state’s foster children, according to this news organization’s analysis of prescribing data and four years of pharmaceutical company payments compiled by the public interest journalism nonprofit ProPublica. And those who prescribed the most typically received the most, the analysis found.

The results provide the most comprehensive look to date at the pharmaceutical industry’s influence on the doctors who treat the 60,000 kids in the country’s largest foster care system — a lucrative target because Medi-Cal pays the bill with little scrutiny.

One Sacramento doctor raked in more than $310,000 in four years to give promotional speeches and an extra $8,500 in meals, records show. Another 224 doctors each got more than $500 in meals, and two of them each received more than $20,000 for travel. The biggest payments went for research, with two Southern California doctors each receiving more than $2 million to conduct drug company-sponsored trials.

Doctors who accept the drug companies’ offerings say they aren’t influenced, and the pharmaceutical industry defends its partnerships as a necessity for developing the lifesaving drugs of tomorrow.

“The kind of medical innovation that we have in this country wouldn’t happen without a robust dialogue between industry and physicians,” said John Murphy, assistant general counsel for the Pharmaceutical Research and Manufacturers of America.

But critics say the drug companies are disguising investments in the name of science to reward doctors who in turn boost the industry’s bottom line.

“These figures suggest these doctors are not looking out primarily for the kids’ interests,” said UCLA social welfare professor David Cohen, who has studied medication use in the foster care system and drug company influence. “They suggest many doctors are looking out for their financial interests, and we should all be wary.”

The findings are especially disturbing because of the growing evidence that psychiatric drugs are being overprescribed to California’s foster children despite their significant side effects, the subject of this news organization’s yearlong investigation “Drugging Our Kids.” The news organization previously reported that almost 1 in every 4 adolescents in California foster care has been prescribed psychotropic medications, often to manage troublesome behavior rather than treat the severe mental illnesses for which they are approved.

While the federal government has cracked down in recent years on how drug companies market powerful antipsychotic drugs to the elderly and children, the industry’s investment in courting doctors appears to still be paying off: California taxpayers spend more on psychotropic drugs than on any other kind of medication prescribed to foster children, according to a decade of Medi-Cal spending data revealed by this news organization in August.

This is only the tip of the iceberg

Antipsychotic Drugs Abused as Chemical Restraints for Elderly

The WSJ Health Blog is carrying this item pointing to this expose in The Wall Street Journal

Nursing homes are loading up patients on antipsychotic drugs and regulators have started to take notice, the WSJ reports.

Almost a third of patients in nursing homes are receiving powerful antipsychotic drugs, the feds say. And patients can be given the medicines, whether they are psychotic or not. The drugs are often used to calm demented patients, some with Alzheimer’s disease, and to help maintain order in nursing homes, which are often understaffed and reluctant to use physical restraints. But the FDA hasn’t approved the drugs for these uses, compounding the ethical questions.

Nearly 21% of the nursing-home patients who receive the drugs don’t have a psychosis diagnosis and some think that’s too much. “You walk into facilities where you see residents slumped over in their wheelchairs, their heads are hanging, and they’re out of it, and that is unacceptable,” says Christie Teigland, director of informatics research for the New York Association of Homes and Services for the Aging, a not-for-profit industry group.

Commenting on the WSJ article, the blog Furious Seasons notes that the “numbers are alarming, especially since there is no scientific proof that these drugs work well in dementia patients and are, in fact, outperformed by placebo,” according to a federally funded study known as CATIE.

[...]

Goverment Nightmare Sentences Man to Hell in a Psych Ward

As seen in this editorial

Charles Haroutunian’s ordeal is a classic illustration of the road to hell being paved with good intentions, and how much worse that hell can be once too many well-intentioned government and legal agencies enter the fray.

After a 2002 suicide attempt, the Sun Lakes resident found himself at the mercy of no less than four government agencies or contractors, each of whom had a role to play once the suicidal 76-year-old man had been transferred from another hospital to Maricopa Medical Center, and his family had decided to have him committed to a mental institution.

This became possible when one of two court-appointed psychiatrists testified he met the criteria, and the other failed to show up. Once the process was set in motion, nobody seemed to want to be at the steering wheel. Value Options, which handles the county’s mental health care services, claimed it was responsible for outpatient treatment only, ceding the job to the county hospital, which in turn deferred to the Veterans Administration, who would be footing the bill.

The VA would only pay for him to be sent to a Tucson nursing home for the severely mentally ill; Haroutunian, now 80, wasn’t in any shape to protest.

“I just thought I had my 180 days of punishment for breaking man’s law and God’s law for trying to take my life,” he told the Tribune’s Gary Grado, in a story that ran Tuesday.

In reality, he faced a potential life sentence, after his case was never transferred into the Pima County supervision it needed, but instead was mistakenly closed out by a Value Options employee. It was only the arrival of a sympathetic psychologist at the nursing home and having the means to hire a lawyer to track his case down that saved Haroutunian. Even then, it took four years for him to receive any compensation for having spent months in a locked ward with about 30 other patients who were not capable of communicating with him in any way other than spitting in his food.

The $310,250 court award, reached in October, divvied up the blame among two agencies — as much an indictment of an overgrown state that cannot keep track of which paperwork went down which rabbit hole, as anything else.

The process of this and so many other tasks, jury-rigged like a computer with a spaghetti nest of wires underneath it, must be streamlined. There is an agency, the Maricopa County Public Fiduciary, responsible for protecting the rights of vulernable adults, and it was found by the trial jury to be relatively less liable for Haroutunian’s treatment.

The map needs be redrawn so the agency that has the ultimate responsibility can’t credibly pass the buck to another entity, particularly a government contractor. This isn’t about paperwork, it is about people, and they should be treated better if for no other reason than they need someone to look out for their best interests, not create more problems for them.

Mental Health Abuse and Neglect in Missouri

A St. Louis Post-Dispatch investigation has found abuse and neglect of mentally retarded and mentally ill residents in state centers and in private facilities the state supervises. Since 2000, there have been more than 2,000 confirmed cases of abuse and neglect with 665 injuries and 21 deaths. This investigation was published over a 4 day period, with many graphics, interviews, and additional information documenting the horror story. And it is all available online here

Filth and shame in an NHS hospital

In Briatain, it's not just the Psychs, although I too easily suspect they are leading the pack. As seen in this editorial on mixed sex hospital wards in Britain.

Twenty-four hours to save the NHS! I wonder how often that promise comes back to haunt Tony Blair 10 years later. Week after week reliable reports and the government’s own figures tell a disgraceful story of incompetence, debt, misery and filth in the National Health Service. That story is supported, week after week, by heart-rending personal accounts of horrors on the wards.

The broken new Labour promise that caught most public attention last week was the failure to abolish mixed-sex wards. Janet Street-Porter, the ferocious media personality, wrote about the misery of her sister when dying of cancer in a mixed-sex NHS ward. Plenty of other people have tried to draw attention to this disgrace and Baroness Knight, the Conservative peer, has been campaigning about it for years but — such is the spirit of the times — it takes a loud-mouth celebrity to get public attention.

The same thing happened when Lord Winston made a fuss about the dreadful treatment that his elderly mother received in hospital. Only then did the government stop denying that there was anything wrong.

Street-Porter published extracts last week of the diary of Patricia Balsom, her dying sister. They were horrifying. Among the miseries she endured was lying neglected in a mixed ward, where she was woken more than once to see a naked male patient masturbating opposite her bed. Her shocking stories prompted a flood of others.

The late Eileen Fahey, for instance, dying of cancer, was put onto a mixed geriatric ward where confused people wandered about without supervision. One man with dementia regularly masturbated at the nurses’ station and tried to get into women patients’ beds; he was a threat to them all but staff took no notice, according to her daughter Maureen. Other patients have to give answers to intimate questions in the hearing of other patients. One deaf old man was repeatedly asked when he last had an erection, until tears ran down his cheeks.

A former midwife described eloquently on Radio 4 the indignities of being in a 24-bed mixed-sex ward, stripped of all dignity and intimidated. Bedlam was the word she used, and it applies even more accurately to the secure psychiatric mixed ward in London endured by Susan Craig last year, after a breakdown. She suffered regular sexual harassment, with mentally ill men groping her and exposing themselves. The nurses disbelieved her and told her husband she was “flaunting herself”.

If so (I don’t believe them), their job was to protect a patient from her own folly. Instead they chose, in modern cant, to blame the victim.

Sexual harassment is only a small part of the problem. Many people, both men and women, feel their modesty is violated by such closeness to random members of the opposite sex, even when they are not threatened.

Patients lie naked, half washed and forgotten, their sick and ageing flesh exposed to everyone, while nurses rush elsewhere. It is commonplace to have to walk to filthy mixed lavatories with gowns wide open at the back. At a time of sickness and anxiety many people are profoundly embarrassed to be surrounded by a clutter of bed pans, colostomy bags, nakedness, cries of pain and sweat, blood and tears — their own and other people’s.

All this is much worse, for many, when they are surrounded by members of the opposite sex; shame and anxiety are not the best bedfellows of hope and healing.

Much has been written about the rape of modesty and the death of shame. However, it is still true in this weary country that most men and women prefer to perform private bodily functions alone if possible, and among their own sex only, if not. That’s why we have separate public lavatories and separate changing rooms in shops and clubs and pubs. That’s why people put up towels on the beach. That’s why women give birth in female wards, not in mixed wards or not — I hope — so far.

Admittedly there are some who believe that mixed wards are not a problem, but our prime minister is not one. “Is it really beyond the collective wits of the government and health administrators to deal with the problem?” he demanded in 1996, flying high on vectors of dizzying youthful indignation as leader of the opposition. “It’s not just a question of money,” he went on. “It’s a question of political will.” Well, he said it and he promised to end mixed-sex wards by 2002

What we have come to expect of new Labour promises, following failure, changing the goalposts, more failure and exposure, is denial. Sure enough Patricia Hewitt, the health secretary, was sent onto the Today programme in denial mode last week.

Although the Healthcare Commission watchdog found that on average 22% of patients have to stay in mixed-sex wards, rising to 60% in some hospitals, Hewitt’s officials at the Department of Health say the government has achieved its target of abolishing mixed-sex wards, with 99% of trusts providing single-sex accommodation.

It is not difficult to spot the problem with that claim. It is not the same as saying 99% of patients get single-sex accommodation; it may be “provided” for very few. There has been the usual goalpost shifting: hospitals can claim they are providing single-sex accommodation by putting screens between beds in mixed-sex wards. Brilliant.

Hewitt admits there was a problem of perception; she even admitted that there was a “clear gap” between patients’ experiences and figures provided by hospital trusts to the Department of Health. One does tend to have a problem of perception, I find, if one is being misled.

My feeling is that mixed-sex wards are not the worst of NHS hospitals’ problems, although they demonstrate them. They demonstrate the incompetence and deviousness of hospital management in general, and they also show something worse. In all the stories I’ve come across what stands out is the ignorance, incompetence, laziness and heartlessness of all too many nurses, who are allowed to neglect and insult their patients without supervision and without sanction — in single-sex wards just as much as mixed.

Blair did not just promise to abolish mixed-sex wards, he also promised to save the entire NHS. He believes in divine judgment; I wonder how he will answer.

Study says antipsychotic drugs don't ease dementia (psychotic behavior)

As reported in the NY Times, seen via The Austin American-Statesman.

The drugs most commonly used to soothe agitation and aggression in people with Alzheimer's disease are no more effective than placebos for most patients and put them at risk of serious side effects, researchers are reporting today.

The side effects include confusion, sleepiness and Parkinson's disease-like symptoms.

The report, based on a large government comparison of the drugs' effectiveness, challenges current practice so sharply that it could quickly alter prescribing habits, some experts said. About 4.5 million Americans suffer from the progressive dementia of Alzheimer's disease, and most patients with the advanced disease exhibit agitation or delusions at some point.

The drugs tested in the study — Zyprexa from Eli Lilly, Seroquel from AstraZeneca and Risperdal from Janssen Pharmaceutical — belong to a class of medications known as atypical antipsychotics. The drugs are used to treat schizophrenia and other psychoses and are commonly prescribed for elderly patients in long-term care facilities.

About a third of the estimated 2.5 million Medicare beneficiaries in nursing homes in the United States have taken the medications, researchers found. And the use of atypical antipsychotics in the elderly accounts for an estimated $2 billion in annual sales of the drugs, with much of the cost paid by Medicare and Medicaid.

Representitives from Lilly, AstraZeneca and Johnson & Johnson, which owns Janssen, noted that the drugs are not approved by the Food and Drug Administration for treating people who have Alzheimer's and that the companies do not market them for that purpose.

The results of the study, published today in The New England Journal of Medicine, the company spokespeople said, simply reflected the need for more research into the treatment of behavioral issues in Alzheimer's patients.

Prescribing information for the drugs warns that patients with Alzheimer's-related psychosis "are at increased risk of death compared to placebo."

But the medications are commonly prescribed for Alzheimer's patients "off label" by doctors because families are desperate, because these drugs sometimes seem to help and because company-sponsored doctors promoted them.

"The question is whether these drugs have a place in the treatment of Alzheimer's patients at all," said Dr. Jason Karlawish, an associate professor of medicine at the University of Pennsylvania who wrote an editorial accompanying the study.

"I think the answer is yes, but only for a subgroup of patients who can tolerate them."

In the study, researchers followed 421 Alzheimer's patients with disabling agitation, delusions or hallucinations who were randomly assigned to receive either dummy pills or one of the three antipsychotic drugs. Doctors adjusted the doses as needed, tracked how long patients stayed on the drugs and noted their improvement, if any.

Experts say that the amount of time a patient spends on a medication is an important measure of its usefulness, because patients often stop taking a drug if it is not doing any good or if the side effects are intolerable.

After 12 weeks, "there were no significant differences between the groups with regard to improvement" on a scale that measured symptom relief, said Dr. Lon Schneider, the lead author of the study and a professor of psychiatry, neurology and gerontology at the University of Southern California School of Medicine.

The researchers also found no significant difference in the amount of time the patients stayed on the drugs or the placebos; about 80 percent stopped taking the drugs and the placebos alike before the end of the study.

But those taking the drugs were far more likely to quit because of side effects.

The side effects included sedation in 15 percent to 24 percent of the patients and confusion in 6 percent to 18 percent; both symptoms can increase the risk of falls. And 12 percent of the patients on either Zyprexa or Risperdal experienced Parkinson's disease-like symptoms, including tremors.

"What the study does indicate is that this is a very sensitive population and that any treatment needs to be done with a lot of forethought and constant re-evaluation" said Dr. Bruce Kinon, a psychiatrist at Lilly.

The report is the third large study in the past year to conclude that atypical antipsychotics are not as effective or as safe as initially portrayed.

Last year, government researchers found that three of four drugs tested were no more effective than an older, far less expensive drug in treating schizophrenia, the disorder for which the medications were originally approved.

And last week, English researchers published a study that found that schizophrenia patients did as well — or better — on older medications than on newer, atypical drugs.

State Fines New York Psych Clinic $16.5 Million in Medicaid Inquiry

From the NY Times, another psychiatrist gets caught handing out inappropriate drugs and treatments for the sake of profits. This is also another example of psychiatric abuse of the elderly.

Some patients at a Queens substance abuse clinic who had only minor alcohol problems were given intensive treatments, four or five days a week, for up to two years, with Medicaid picking up the bill, investigators said. Other patients needed more serious psychiatric care but were instead kept in unnecessary treatments for chemical dependency, again at taxpayer expense.

The clinic, Community Related Services Inc., which investigators said specialized in treating elderly patients from the former Soviet bloc, was fined $16.5 million for overbilling the Medicaid system, Gov. George E. Pataki’s office said yesterday.

It was the largest fine levied by the state’s new Medicaid inspector general’s office, created last year to combat rampant abuse in the joint federal-state health care program for the poor.

The state also froze $30 million in payments to the clinic, on Queens Boulevard in Rego Park, and began proceedings to revoke its license.

The inspector general and the state’s Office of Alcoholism and Substance Abuse Services cited the clinic for what they said were 45 regulatory violations, like improper patient assessments and poor record-keeping, and issued 25 findings of “serious Medicaid fraud, waste and abuse.”

The clinic can request an administrative review or challenge the fine in court, said Henry Zwack, executive deputy commissioner of the alcoholism and substance abuse office.

State records say the clinic, a profit-making entity, is owned and operated by Dr. Yelena Mamedova-Braz, a psychiatrist, and Maya Gurevich. Phone calls were placed to both owners yesterday, but they could not be reached for comment.

The clinic was founded in 1998 in an area of Queens that has a large number of immigrants from the former Soviet Union. According to Mr. Zwack, the clinic treated about 600 people a day, most of them elderly women from Uzbekistan.

Investigators found that patients had visited the clinic an average of 152 times a year, compared with an average of 34 visits a year for other chemical-dependency centers regulated by the state. The state also determined that patients at the Queens clinic tended to stay in treatment an average of 20 months, compared with 3.7 months at other clinics.

The agency also cited the clinic for paying its counselors based on the number of sessions they had with patients, creating an incentive for counselors to overbill. This system contributed to the high volume of services for patients who seemingly had minor or negligible histories of alcohol and drug abuse, investigators wrote.

Mr. Zwack said that investigators had found some people who needed mental health services but were getting alcohol treatment instead, or no services at all. For some patients, he said, the clinic acted more as a “senior day care center, a place for people to come together, speak the same language and interact.” He also said that English courses offered by the clinic had been billed as treatment.

The clinic billed Medicaid an average of $11 million a year.

“What this company was sucking out of Medicaid could have provided care for 2,400 more patients who really needed it,” Mr. Zwack said.

According to the report by the substance abuse agency, the clinic made an interest-free loan of $3.52 million in 2004 to another company that Dr. Mamedova-Braz and Ms. Gurevich owned, Advanced Community Services Inc., after the owners became aware of an investigation by the office of the state’s attorney general, Eliot Spitzer. When asked about the loan, Ms. Gurevich told investigators that it was made to ensure that they had money in case the clinic’s money was seized, the report said.

Mr. Zwack said that Dr. Mamedova-Braz was in the process of trying to get licensing for another mental health clinic. But if the Queens Boulevard clinic loses its license, Mr. Zwack said, she and Ms. Gurevich could be permanently barred from the Medicaid system.

Investigators found other problems as well, including what they said was poor record-keeping and what they described as the unethical treatment of patients. According to an agency report, Russian-born counselors referred to themselves as “real Russians” and made disparaging comments about the ethnic backgrounds of their patients.

In justifying extensive treatment programs, the clinic’s director-owner, Dr. Mamedova-Braz, told investigators that her patients had limitations due to intermarriage. “These marriages, according to Dr. Braz, produce generation after generation of mentally disabled individuals who lack the capacity to function successfully and independently,” investigators wrote.

Mr. Zwack said, “It’s just not the kind of description any of us would expect a doctor to have.”

Billing irregularities were initially discovered by the state attorney general’s Medicaid Fraud Control Unit, Mr. Zwack said. A spokesman for the attorney general, Darren Dopp, declined to comment on whether the clinic was still under investigation.

The governor created the inspector general’s position and appointed Kimberly O’Connor, a former prosecutor in Schenectady County, to fill it last year after articles in The New York Times detailed widespread abuse and poor oversight in the state’s $45-billion-a-year Medicaid program.

This year, at the governor’s urging, the Legislature set aside money for 81 positions to monitor Medicaid fraud. But in a report in June, auditors with the federal Department of Health and Human Services said that Mr. Pataki’s changes, while laudable, were not sufficient to make up for years of staff cuts and lax enforcement.