There was speculation that the Health Care Summit hosted by President Obama would be a Kabuki Dance or a highly staged photo opportunity. Instead, the seven- hour event ended up being a good forum for debate. There was no “Minnesota Nice” as both sides openly expressed their views on health reform. While there were some long-winded anecdotes, many of the attendees focused on having a data-driven discussion. Most importantly, the cameras offered some clues on how nonsensical and expensive provisions get incorporated into legislation.
Republican Senator Tom Coburn, a physician, started off strong when he boldly stated that the nation needs to address the escalating costs of health care before expanding access to 30 million additional Americans. He raised the issue of rampant fraud in the system, estimated to cost the $60 billion a year in Medicare alone.
But, his comments took a bad turn when he said, “In your new bill, you have good fraud programs, but you lack the biggest thing to do. The biggest thing on fraud is to have undercover patients so that people know we’re checking on whether or not this is a legitimate bill.”
Obama scribbled some notes, and subsequent news reports highlighted Coburn’s idea as one of the few common areas of agreement. In the President’s follow up letter to Congressional leaders on March 2, he included undercover patients as one of four good ideas that he is willing to integrate into his plan.
Deploying "mystery shoppers" may be useful in highly targeted situations when a thief must be caught red-handed for a quick prosecution. Otherwise, this is an archaic and expensive approach for identifying fraud. Unless there is blatant illegal activity, such as billing for a deceased patient or billing for tests and visits never performed, it requires multiple visits to prove that unnecessary or inappropriate services are repeatedly and systematically rendered.
This approach is neither scalable nor efficient. Organizing a field force of hundreds of secret shoppers would certainly result in yet another department within HHS with its own separate budget. The operational infrastructure would require extensive training, databases, and processes to “review the reviewers” so that inter-rater reliability is minimized and the conclusions are credible. Many of us reading this blog have lived through the expense and inefficiency of conducting onsite HEDIS chart reviews where individuals trained in chart abstraction visited doctors' offices to manually document that preventive services were delivered to patients. Designing and implementing an onsite federal program to detect fraud would be exponentially more complex.
One could also argue that a system that deploys secret shoppers is unethical since these visits consume valuable doctor-patient capacity that would otherwise be used for real patients with real illness. And, consider the intrusiveness and anxiety among the innocent high quality doctors that are randomly selected to be reviewed. Will these doctors be reimbursed the lost income resulting from one of these visits?
Obama is unquestionably tech-savvy. A few days before the Summit, he released his proposal for health reform that outlined some new and aggressive proposals to fight waste and abuse such as a “Comprehensive Sanctions Database” and “Use of Technology for Real-Time Data Review.” These investments would result in continuous national surveillance of claims activity looking for patterns of utilization and billing that suggest fraud. The banking industry has been doing this for years.
So, why did he support a 1980’s solution that is unlikely to drive a meaningful difference in reducing fraud but creates more bureaucracy and costs more money?
To finish reading this blog, go to
http://archelleonhealth.blogspot.com/2010/03/light-camerafight-fraud-in-health-care.html