The Ether Way

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.

 

 

The Good and Bad of the NHS

 

The Bad

Many advocates of government administration of health care point to the potential efficiencies that can arise from centralizing some functions.  The sad truth is that centralizing some functions simply allows for failure to occur on an even larger scale.

This is a story from the BBC from last summer:

http://www.bbc.co.uk/news/health-10740225

It’s important to note that the sums involved are somewhere between substantial and massive.  The NHS is leaving very large sums of money on the table, money that it could use to provide higher quality or more timely service to the populace.  How can this happen? Because those tasked with collecting this money likely have no incentive to do this well.  If they got even 2% of the money involved as a bonus, they would very likely be relentless in collecting every last penny.  The more energetic among them could become richer than the queen.  This is likely what happens when government bureaucrats see this as a paperwork problem instead of a way to create resources for their organization.  Instead, the NHS is a reliable source of windfall revenues to the pharmaceutical companies that supply these drugs. Ironically, these companies almost certainly invest a majority of their windfall into future product development, which will ultimately benefit the NHS and its patients.

The Good

There are few benefits to centrally administered or regulated health care.  One of them (theoretically at least) is that the regulators can study the performance of the system, and make changes that will predictably improve outcomes.  This is talked about much, much more than it happens. Why? Political considerations shape the options available to regulators. The universe of the politically possible is far smaller than the universe of the theoretically possible. Why so? Because governmental and regulatory power ultimately derives from political power and politics. Nevertheless, every once-in-a-while, a regulating body will study and analyze what it is doing, and come to a very smart decision about how to proceed. This story, also from the BBC, is a narrative of a very wise decision by the NHS to concentrate very complex pediatric cardiac surgery to a few centers of excellence.  The US system has many strengths, but among its weaknesses are that it is presently completely incapable of doing something similar.

http://www.bbc.co.uk/news/health-12462913

There is a back-story to this decision. The events that compelled it that are outlined in the associated BBC stories.  It is enough to say that doing pediatric cardiac surgery well is a very, very difficult undertaking.

This is an outstanding decision, and deserves to be recognized as such. I am flummoxed at the lack of interest in and coverage of this, in both the lay press and medical media.

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This is an interesting item about a problem of our times:

http://www.nhsonline.net/news/article.asp?CategoryId=2&ArticleId=5080

The decision to only selective deploy the ability to transport the morbidly obese is an interesting one, as it seems that one ambulance crew will end up having to summon another.  My guess is that, over time, every ambulance in the UK and the US will have this capability.