The Ether Way

More on Fraud and misconduct

Florida seems to be the epicenter of criminal medicare fraud AND problematic prescription of opiate painkillers, at least according to these two news items:

http://news.yahoo.com/s/nm/20110413/ts_nm/us_usa_healthcare_fraud

http://news.yahoo.com/s/ap/20110419/ap_on_he_me/us_pill_mills_us_response

The first elaborates on a theme that has been clear from previous news items and posts on real medicare fraud: Florida seems to be an epicenter. It may be a consequence of better surveillance, more aggressive investigation, or it just may be that there is more medicare fraud in Florida than in much of the rest of the US.  This is an enforcement effort that is welcomed by everyone else in the health care system, including physicians and patients, as fraud on this scale sucks resources from the system sufficient to make providing real care to real patients more difficult. The first news item does make it clear that, historically, it has been fairly easy to defraud medicare. 

The second news item deals with one of the dark underbellies of medicine: the rampant abuse of prescription opiates(interestingly, benzodiazepines are not presently on anyone's radar).  As with medicare fraud, it seems that this is also an activity for which Florida is an epicenter. While Florida has a disproportionate number of elderly residents, I doubt that this alone explains the fact that 85% of all oxycodone in the US is prescribed there. Unlike outright medicare fraud, it is easy for a private practice doc, especially a pain doc, to fall into the trap of running  a pill mill. Why? There is no objective evidence of pain: you have to accept what your patient self-reports. Pain treatment is often not covered by insurance, hence many pain patients pay cash on the barrel for monthly visits, which is very attractive in a world awash in insurance paperwork and payment denials. Patient satisfaction drives prescription as well: patients, including drug-seekers, give very low marks to physicians who undertreat or don't treat their pain.  Being liberal with opiates can only help your satisfaction scores, being stingy can only hurt them.  Sadly, all of this has produced a situation where physicians, especially those who specialize in pain, legally prescribe to drug-seeking individuals opiates that they previously obtained illegally.  If what my colleagues tell me is true, then there are physicians out there who run pill-mills, knowing full well that a large percentage of their 'patients' are full of BS, and that much of what they prescribe is being diverted. It only takes a few such pill-mills to generate huge problems. These bad actors are likely to make life ever more difficult for the honest pain docs in the next few years, especially as enforcement efforts like this ramp up.

  It is difficult, and usually impossible, for the prescribing physician to tell which of their patients is diverting, and which among them simply has terrible pain.  In an era where pain is the 5th (or 6th) vital sign, being liberal with opiates to treat it (as all authorities have exhorted all physicians to do) can put practitioners in regulatory and legal peril.  And yet, in our midst are physicians whose business and ethics are indistinguishable from a street-corner drug dealer. 

What do the numbers mean?

This is a very cogent and thought provoking news item about the NHS from the BBC:

http://www.bbc.co.uk/news/health-13130678

Wait times are at a 3 year high. Wait times, which correlate with patients seeking care, must of course vary over time, over days, weeks, months, and years.  Everyone inside and outside the NHS is aware that its wait-times have been a patient-care issue and political football for a long time.  So why is this news?

First, as demand increases and budgets are cut, extra funds that were once used to surge in times of increased demand are no longer available.  The strategy of setting aside funds to respond to fluctuations in operational tempo was a very smart strategy for the NHS; it mimics supply-demand in a system that would otherwise be completely unresponsive to cycles in activity. As the budget problems in the NHS worsen, wait times, especially during upswings in demand, are certain to become worse than they are now.  In short: less overtime = longer wait times.

As you would expect, there is a large gap between what independent (but not necessarily politically non-partisan) experts represent as the wait time and what they government reports.  In this instance,the outsiders say that 15% of patients wait more than 18 weeks for specialty care, while the government claims that only around 10% do.  This is a huge gap. Spin? Propaganda? Everyone knows that government agencies have an enormous incentive to represent their performance in the most favorable possible light. Over time, they can adopt methods for reporting data that are consistent, reproducable, precise, and completely divorced from reality.  There are plenty of instances of this from the various levels of government in the US. Orwell could not have imagined someone like Baghdad Bob, or how statistics that translate into misery, suffering, and death can be transformed and reported by political agendas.

The other interesting part of the news item is that various trusts have very smartly decided to utilize clinical criteria to change the position of individual patients on a list.  This is wise in that it accounts for details that no master-list schedule of criteria possibly could; it is hazardous in that it invites corruption and shennanigans en-masse. Absent a policy of random or comprehensive review, the pockets of the list-keepers will soon be lined with gold.

Within the NHS, there is intense interest in making the best of the substantial changes that are occurring. If I had the time and the money, I would attend this meeting:

http://www.hsj-patientexperience.com/

The lessons I might learn there could be helpful in years to come in the USA.