Gingrich and Frogue: Congress Must Eliminate Fraud
June 08, 2009
By Newt Gingrich and Jim Frogue
Special to Roll Call
Congress is kicking off the most
significant health care debate in a generation. Everything must be on
the table. Our current system is an expensive, frustrating mess where
patients and doctors feel increasingly powerless. Doing more of the
same but with bigger subsidies will be as effective as the General
Motors bailouts.
While there are major
partisan divides over how to permanently restructure our health care
system, there is one key area where Democrats and Republicans should be
working together: fighting health care fraud. Everyone agrees that
fraud should be stopped, and most agree that tackling fraud effectively
would yield savings well into the tens of billions of dollars annually.
Instead of punishing doctors with lower payments and penalizing
patients with reduced access, let’s cut off the crooks.
Last month,
Harvard professor Malcolm Sparrow, author of the seminal “License to
Steal,” testified to the Senate Judiciary Committee that health care
fraud and abuse could amount to as much as $500 billion annually. Sen.
Tom Coburn (R-Okla.), a physician, believes that a full third of all
health spending is wasted on defensive medicine, paperwork and outright
fraud. Considering that $2.5 trillion will be spent on health care this
year, he is talking about a figure in excess of $800 billion per year.
FedEx and UPS
allow customers to track in real time 23 million moving packages every
day at no extra charge. That is the modern world. But when it comes to
health care, no state can even tell you how many people its Medicaid
program supported in 2008. Miami-Dade County has more licensed home
health care agencies than the entire state of California. New York
Medicaid recently paid for maternity benefits for 55 men, according to
Inspector General Jim Sheehan. There are endless other examples of
equal absurdity.
To make serious strides in the fight against fraud, lawmakers can start with the following three steps:
First, immediately
make public all Medicare and Medicaid claims data, but only in a manner
that vigorously protects patient privacy. Claims data contain all the
answers on how health care dollars are spent. This data show in details
where the dollars go, what hospitals and facilities perform which
procedures in what volume and with what success rate. It also shows
infection rates and every other metric imaginable. It would be the
single best tool to identify and root out fraud.
Furthermore,
an ancillary benefit of releasing claims data is that it reveals which
hospital is most likely to kill you. Medicare claims data in the hands
of university researchers, for example, has led to superb academic work
over the years. The Dartmouth Atlas of Health Care team led by Dr. Jack
Wennberg has found that per capita Medicare spending is inversely
correlated with the likelihood of receiving recommended care. As good
as these studies like this are, we should not confine the data and
therefore all research to a handful of universities. The more broadly
we make available the raw data, the more likely we will get new and
innovative ways of thinking.
This is safe
political common ground. According to a 2008 poll, 98 percent of
Americans believe they have the “right to know” cost and quality data
about their health care provider. It must be absolutely clear that
public release of claims data should only occur after patient
identities are safe beyond any doubt. Fortunately, there is long
precedent for that as the CMS has released Medicare claims data to
university researchers for decades with patient identities safely
scrambled by multiple algorithms.
Second,
Congress should ensure that Medicare patients with the most extreme
outlier claims have access to the newest and best disease management
plans. This is to target the less than 1 percent of beneficiaries who
are spending up to 20 percent of Medicare’s budget. All too often,
these individuals receive uncoordinated, haphazard care from standard
Medicare fee-for-service, and it results in their having to endure
harmful, unnecessarily expensive interventions that happen too late.
Plus, many of these high billing patters are the result of stolen
Medicare ID numbers being used fraudulently. Modern, sophisticated,
risk-based disease management plans would do a much better job
combating that fraud.
Third,
Congress can further crack down on criminals by dramatically expanding
the scope, use and distribution of the HHS OIG exclusion list — a list
that publicizes those individuals convicted of health care fraud. Law
enforcement, particularly in areas like child abuse, is much better at
tracking convicts across state lines. Medicare and Medicaid would
benefit tremendously from that same level of sensitivity to those with
checkered pasts.
Fraud is a
destructive tax on Americans in need of health care services.
Fortunately, Congress can move decisively with bipartisan backing to
eliminate much of that fraud. Done right, savings would be in the 12
figures annually.
Former
Speaker Newt Gingrich (R-Ga.) is founder of the Center for Health
Transformation. Jim Frogue is state project director at the center.
Their book on health care fraud will be released this summer.
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