Fraud, Waste, and Abuse

Fraud and Abuse continues to be discovered on a massive scale; and that Pay-for-Performance (intended to improve the quality of care) still doesn’t work.  Why? Because both of these are far more complex, intractable problems than the public policy discussions have admitted.

A widely publicized US crackdown:

http://news.yahoo.com/s/nm/20110217/ts_nm/us_usa_healthcare_fraud

 As is often the case, it is difficult to judge the substance of the charges from the news item, which is sourced from the government agencies making the allegations. Nevertheless, if the allegations are as reported, then most of this is outright fraud, and on a massive scale. The involvement of organized crime is disconcerting, as it suggests that defrauding the US government has been either more lucrative or safer than any other crime they could commit.

and an admission of the scope of the problem:

http://news.yahoo.com/s/ap/20110205/ap_on_re_us/us_health_care_fraud_most_wanted

Years ago, I could not have imagined that health care fraud would have become such a problem that it would require its own Most-Wanted list, and that the list would be crowded.  Ineresting times indeed.

This is a news item about How Pay-For-Performance (P4P) doesn’t:

http://www.reuters.com/article/2011/01/26/us-incentives-idUSTRE70P6GY20110126

This last article is interesting, as it makes apparent that in spite of an exhaustive analysis of the data, they could not find even a hint of benefit from P4P.  This matters, as a lot of ‘health care reform’ in the US is to be built on this, which at present appears to be a house of cards.  If there is any benefit from P4P, it has been elusive, and cannot be easily or consistently demonstrated. 

Why did I put these items side-by-side? They’re both about fraud. One is fraud perpetrated against the government, the other perpetrated by the government against health care providers. It is within the power of the government to extinguish one of these completely.

 

 

Comments

[mkeamy]

I have heard discussions amongst primary care physicians on how to "game" the P4P system; people feel justified because they feel victimized by the extraordinarily low reimbursement for Federal programs relative to their practice operating costs; there are no margins, and no prospect of any improvement. I am loath to criticize the system, since I don't really have a good alternative, although I have always liked the German ability to form ad-hoc purchasing coalitions. The reform bill is disappointing to me, since a primary goal was to preserve a for-profit insurance market, in addition to all else. I'm conflicted about that, as well; after all, what's ideologically wrong with a profit based insurance system operating beside a not-for-profit and government? In trying to do too much, it risks not doing anything meaningful, I'm afraid.

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[Daniele]

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