Map of life expectancy at birth from Global Education Project.

Monday, November 16, 2009

Waste, fraud and abuse

Ronald Reagan used to blame government spending on poor people, who were supposedly ripping off Medicare, Medicaid and welfare programs. There is indeed a lot of ripping off of the government going on, but it's not the beneficiaries, it's doctors and nursing homes and medical device manufacturers.

The Obama administration is trying to make a more effective effort to detect and deter Medicare fraud, but I'll tell you right now it's going to be very difficult unless we have a major reform in how we reimburse for medical services. The kinds of frauds they can detect are only the tip of the iceberg. Once people go into nursing homes, the operators can bill for all sorts of unnecessary services, which they don't even have to actually provide, and all they need is a crooked physician to sign off on it and split the loot. I know this from personal experience. And the boundary between outright fraud and just questionable judgment is sufficiently difficult to establish that even if they got caught it would be hard to hang charges on some of these sleaze dogs.

As a matter of fact, private insurance is subject to a certain amount of similar gaming. This is anecdotal, but I'm sure it's pretty common. I had friends who took their child to a hospital for a procedure, and they found his pediatrician hanging out in the waiting room. The pediatrician chatted with them for a minute, and the next time they got an insurance statement, he'd billed $350 for a consultation. And no, he had nothing to do with the procedure, he was just vulturing on the opportunity.

This sort of thing will continue as long as we pay doctors to do stuff instead of paying them to take care of people. It's sad but true that physicians are human. They're just about all subject to unconscious pecuniary influences, and a certain percentage of them -- probably about the same percentage as people in other occupations -- are thieves. The problem is, we give them absolute authority to decide what is appropriate for particular patients. If they want to make money off of us first and heal us second, they can do that. In Canada and the UK, however, they can't, certainly not to nearly the same extent. (In the UK, they are on salary; in Canada, the single payer has access to 100% of the claims of all practicing physicians, and can detect strange patterns.)

Just one more reason why we need universal, comprehensive, single payer national health care.


roger said...

ethically challenged doctors, just another group of "stakeholders."

keep that stake away from me doc.

Anonymous said...

I probably shouldn’t say this. But in Switz. (all private health insurance, stiffly regulated by the Gvmt.) the most common insurance frauds are, not in any order, and no estimate of the dollar amounts exist:

1) docs /others charging poor patients for procedures they did not carry out. Many patients, their families, etc. will never contest a bill, as that will make them visible, a problem, etc. and their bill is paid anyway, etc.

The perverse effect, if I may go on, is that they count on the insurance step in.

2) Patients - Swapping identities. Very common.