The Justice Department calls it the largest criminal health care fraud case ever brought against individual suspects: Three people are accused of orchestrating a massive fraud involving a number of Miami-based health care providers.

The three facing charges are all from Florida’s Miami-Dade County; they include Philip Esformes, 47, owner of more than 30 Miami-area nursing and assisted living facilities; hospital administrator Odette Barcha, 49; and physician assistant Arnaldo Carmouze, 56, the Justice Department says.

“Medicare fraud has infected every facet of our health care system,” U.S. Attorney Wifredo Ferrer said as indictments against the three were announced Friday.

The indictments accuse Esformes of leading “a complex and profitable health care fraud scheme that resulted in staggering losses — in excess of $1 billion,” said Special Agent in Charge George L. Piro of the FBI’s Miami field office.

Investigators say Esformes used his access to thousands of Medicare and Medicaid beneficiaries to perpetrate a fraud:

“Many of these beneficiaries did not qualify for skilled nursing home care or for placement in an assisted living facility; however, Esformes and his co-conspirators nevertheless admitted them to Esformes Network facilities where the beneficiaries received medically unnecessary services that were billed to Medicare and Medicaid.”

More money was in play, investigators say, in the form of kickbacks Esformes and his co-conspirators received in return for “steering beneficiaries to other health care providers — including community mental health centers and home health care providers — who also performed medically unnecessary treatments that were billed to Medicare and Medicaid.”

In addition to charges of conspiracy, money laundering and health care fraud, Esformes and Barcha were also charged with obstructing justice.

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Patients may go to rehabilitation hospitals to recover from a stroke, injury or recent surgery. But sometimes the care makes things worse.

In a government report published Thursday, 29 percent of patients in rehab facilities suffered a medication error, bedsore, infection or some other type of harm as a result of the care they received.

Doctors who reviewed cases from a broad sampling of rehab facilities say that almost half of the 158 incidents they spotted among 417 patients were clearly or likely preventable.

“This is the latest study over a long time period now that says we still have high rates of harm,” says Dr. David Classen, an infectious disease specialist at the University of Utah School of Medicine who developed the analytic tool used in the report to identify the harm to patients.

“We’re fooling ourselves if we say we have made improvement,” Classen says. “If the first rule of health care is ‘Do no harm,’ then we’re failing.”

The oversight study, from the office of the inspector general of the U.S. Department of Health and Human Services, focused on rehabilitation facilities that were not associated with hospitals. Rehab facilities generally require that patients be able to undergo at least three hours of physical and occupational therapy per day, five days a week. Patients at these facilities are presumed to be healthier than patients in a more typical hospital or a nursing home.

Still, the findings echoed those of previous studies that found that more than a quarter of patients in hospitals and a third in skilled nursing facilities suffered harm related to their care.

“It’s important to acknowledge that harm can occur in any type of inpatient setting,” says Amy Ashcraft, a team leader for the rehabilitation hospital study. “This is one of the settings that’s most likely to be underestimated in terms of what type of harm can occur.”

For the purposes of the study, doctors and nurses identified harm by reviewing the medical records of 417 randomly selected Medicare patients who stayed in U.S. rehabilitation facilities in March 2012. The events they identified varied in severity, ranging from a temporary injury to something that required a longer stay at the facility or that led to permanent disability or death.

Almost a quarter of the harmed patients had to be admitted to an acute care hospital, at a cost of about $7.7 million for the month analyzed, the study shows.

The physicians who reviewed the cases for the OIG say substandard treatment, inadequate monitoring, and failure to provide needed care caused most of the harm. Almost half the cases, 46 percent, were related to medication errors and included bleeding from gastric ulcers due to blood thinners and a loss of consciousness linked to narcotic painkillers.

That high number indicates there’s lots of room for improvement, says Dr. Eric Thomas, director of the UT Houston-Memorial Hermann Center for Healthcare Quality and Safety.

“We know a lot about preventing medication errors,” Thomas says.

An additional 40 percent of the cases in which patients were harmed were traced to lapses in routine monitoring that led to bedsores, constipation or falls. These problems almost never contributed to a patient’s death but could mean extra days or weeks of recovery, a loss of independence or permanent disability, says Lisa McGiffert, director of the Consumers Union Safe Patient Project.

“It is a domino effect for any person who has had an adverse event,” says McGiffert, who was not involved in the study.

The inspector general is recommending that Medicare and the Agency for Healthcare Research and Quality work together to reduce harm to patients by creating a list of adverse events that occur in rehab hospitals. In their responses to the report, the agencies have pledged to follow that suggestion.

Officials from the American Medical Rehabilitation Providers Association, the trade group that represents rehab facilities, say they have not yet seen the report and decline to comment for now.

ProPublica is interested in hearing from patients who have been harmed while undergoing medical care, through its Patient Harm Questionnaire and Patient Safety Facebook Group.

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Maryland Medicaid officials have made what appears to be a small change to the list of preferred medications to treat opioid addictions. The agency used to pay for the drug in a dissolvable film form. Now it’s steering patients to tablets, which some doctors say are not as effective for their patients.

Those doctors say the change is having a profound effect on some people struggling to stay clean.

Starting on July 1, Maryland’s Medicaid program removed Suboxone film — a drug that can be used by people addicted to opioids to keep their cravings at bay — from the state’s list of preferred drugs and replaced it with a tablet form of the medication called Zubsolv.

State officials say the change was made to stop the illicit flow of the drug into jails and prisons.

“Those Suboxone strips were diverted and smuggled into jails and later were sold or traded in criminal activity that was happening in jails,” says Shannon McMahon, deputy secretary of Maryland’s Department of Health and Mental Hygiene. “The numbers were frankly staggering, the amount of diversion that was happening in the jails.”

So far this year more than 2,300 hits of Suboxone have been seized in Maryland jails and prisons, according to Gerald Shields of the state’s Department of Public Safety and Correctional Services. That’s about 40 percent more than at this time last year, Shields says.

The drug helps people control their opioid habit. But it is also an opioid itself. It doesn’t produce a high as strong as many opioid painkillers that have turned into popular street drugs, but it does stave off cravings and can create a mild sense of euphoria.

It comes as a tiny, dissolvable film — about the size of a Listerine breath mint strip — that’s transparent and easy to hide.

“They have been cut up into multiple different pieces,” McMahon tells Shots. A single strip can be worth as much as $50 on the street and they are often divided into several “hits” that are sold individually, she says.

“They were coming into prisons through letters — backs of stamps, corners of folks’ eyeglasses,” she says. McMahon says the strips were causing problems in prisons because of illegal sales and trade.

So at the recommendation of the Department of Corrections, along with a panel that advises the state’s Medicaid program on medications, officials decided to replace the Suboxone strip with Zubsolv, made by a Swedish company called Orexo AB.

The choice is raising eyebrows because Maryland’s health secretary Van Mitchell used to work for Manis Canning & Associates, the lobbying firm that represents Orexo. Mitchell’s spokeswoman says he left the firm before Orexo became a client.

Mitchell and Steven T. Moyer, Maryland’s secretary of Public Safety and Correctional Services, argued in an article in the Baltimore Sun that the change would save lives. They said Maryland’s correctional system, since 2010, “has seen 13 fatal overdoses.” However, a spokeswoman for the state’s health department acknowledged that those were overdoses on opioids in general, and not specifically overdoses on Suboxone film.

Doctors say Suboxone film, as well as the Zubsolv pill that replaces it, actually protect against overdoses because they contain both the opioid Buprenorphine and a drug called naloxone that reverses the effects of an overdose. Naloxone is used by emergency responders to revive people who overdose.

The change has drawn broad opposition from doctors who treat people with substance abuse problems and from advocates for people who are recovering from addictions. Those include the Behavioral Health System of Baltimore, a nonprofit that oversees the city’s behavioral health system, and the Maryland Association for the Treatment of Opioid Dependence.

The change has wreaked havoc on some people with substance abuse problems who, until a few days ago used Suboxone film, says Adrienne Breidenstine, vice president for policy and communications at the Behavioral Health System of Baltimore.

One of them is Nicole, a mother of two who has been in recovery for about eight years. Nicole became addicted to painkillers after she was injured in a car accident. She was stable on Suboxone strips but switched to Zubsolv 10 days ago. She asked NPR not to use her full name because her history of addiction is not common knowledge.

“When I got on Suboxone I didn’t even have custody of my son,” she says. “After I got clean, I got put on Suboxone. I’ve got both my kids now, we have our own house, I’m working, they’re doing good in school, I finished school, and that’s why it’s so scary to me that they completely switched me over.”

Since the change, she says, she’s been feeling sick, having trouble sleeping, having cravings and symptoms of withdrawal.

“It hasn’t been working for me,” she says. “I don’t know what I’m going to do if they don’t cover it again. I just don’t want to go back to that life and I don’t want my kids to go there.”

Nicole’s doctor, Michael Fingerhood, has a primary care practice at Johns Hopkins Bayview Medical Center in Baltimore. His practice, which overlooks downtown Baltimore from across the water, welcomes people with substance abuse problems. The group treats about 450 patients who, until this month, were using Suboxone strips.

He says just two weeks into the change many of his patients, like Nicole, are struggling.

“This is taking patients who are stable, who are doing really well, and saying we’re going to do something to disturb how well you’re doing,” he tells Shots.

Fingerhood says Zubsolv is supposed to be the equivalent of Suboxone. But not all patients react the same to different medications. Many, like Nicole, have been clean for years and for the first time, they’re feeling sick again and some, he says, are in real danger.

Feeling even the slightest bit of withdrawal symptoms can be awful for someone in recovery, he says.

“In the midst of addiction people are searching for a high, they’re having withdrawal, they’re running the streets. Their lives were horrible,” Fingerhood says. “Having withdrawal brings back all those memories of how terrible life had been and it’s a terrible feeling to be in withdrawal.”

Shaking up all the Suboxone patients across the state to keep a relatively safe drug away from a handful of inmates doesn’t make sense, Fingerhood says. And the numbers are indeed pretty small.

If those 2,300 Suboxone hits seized in prison were whole strips — and prison officials say they weren’t — that’s still only the equivalent of about 10 prescriptions from January through last week.

Instead, Fingerhood says, “We should be providing treatment in the prison system.”

He says if someone who was on Suboxone gets arrested, it makes sense that family members or friends would try to get them the drugs in prison.

The only place in Maryland that inmates can legally get any medication to help get or keep them off opioids is in the Baltimore City Jail, according to Shields, the Department of Corrections spokesman. He says the system provides methadone to some inmates to help wean them off opioids before moving them to another prison.

State officials say Medicaid patients can still get Suboxone if they really need it. Doctors just fill out a form requesting a waiver, known as a prior authorization, and get an answer the next day.

Fingerhood made that request for Nicole. Five days later, he still had no response.

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