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Does Medicare Have The Claims Data To Get The “Crooks”?

Stanley Feld M.D., FACP,MACE

I have opposed Medicare’s use of claims data to evaluate the quality of medical care. Quality medical care is the goal that must be achieved. However, no one has described the measurement of quality medical care adequately.

Physicians recognize when other physicians are not performing quality medical care. Physicians recognize when another physician is just testing and performing procedures to increase revenue.

These over testing physicians are a small minority of physicians in practice.

Quality medical care is not about doing quarterly HBA1c’s on patients with Diabetes Mellitus. Quality medical care is about helping patients control their blood sugars so their HbA1c becomes normalized. It is about the clinical and financial results of treatment.

The clinical and financial results depend on both patients and physicians. Patients must be responsible for managing their intake of food, exercise and medication. Physicians are responsible for choosing the right medication at the most cost effective prices and teaching patients how to control their intake and their exercise. This can be accomplished by a team approach with the physicians Diabetes Management team. The patient must be at the center of the team.

Medicare’s medical claims data does not provide this connection of the clinical information with the financial information.

I am not opposed to the use of claims data in identifying physicians, hospital systems and hospice or home healthcare organizations potential fraud. Potential fraud can be spotted by medical claims data by recognizing outliers.

The Wall Street Journal, in conjunction with the nonprofit Center for Public Integrity, attempted for nearly a year to obtain a Medicare database, the Carrier Standard Analytic File. The database contains 5% of all beneficiaries, and includes all doctor claims that Medicare paid directly in association with their care.

 It focuses on doctors and others paid on a fee-for-service basis.

The Journal and CPI wanted the data at no cost under the freedom of information act. The government wanted $100,000 for eight years of data. The Wall Street Journal and the Center for Public Integrity sued the government for the data.

The Journal and CPI obtained the requested data at a substantially reduced price and agreed not to name individual physicians or patients.  

The government lost a lawsuit to the AMA in 1979 and had been required to keep secret monies paid to individual physicians by Medicare. The AMA has continued try to defend this ruling, 

The government is not barred from revealing the monies paid to hospitals, hospices or home healthcare agencies. This information about hospital, hospices and home healthcare agencies is difficult to come by.

Former House Speaker Newt Gingrich has been screaming for years that the database should be public as long as patients’ and physicians’ identity is kept confidential. "Our estimate is that the federal government, in Medicare and Medicaid alone, loses between $70 billion and $120 billion a year to crooks. You ought to be able to identify those."

 "It's very hard to defend ignorance and willful hiding of data in the 21st Century,"   

Newt Gingrich estimates that physicians are the biggest crooks in the system. If we lived in a price transparent ecosystem, we would be able to tell if he is correct. It would be important to know which stakeholder (physicians, hospitals, hospices, and home healthcare organizations) abuses the system the most.

The Wall Street Journal and the Center for Public Integrity in studying the database made available to them found government records suggesting one family practitioner in New York City collected more than $2 million in 2008 from Medicare.

According to experts who have examined her records, her pattern of billing strongly suggests abuse or even outright fraud, She consistently performed wide array of expensive tests that suggests she has been overcharging and over testing.

 The procedures included polysomnography sleep analyses, nerve conduction probes and needle electromyography procedures. She is a doctor of osteopathy certified in family practice as well as hands on treatment called “manipulative therapy."

Eighty-nine percent of her patients received 29 tests. Fifty-six per cent of her billing came from these 29 tests. 13.1 procedures cost $2,048 each.  The antifraud authorities have flagged her for special scrutiny.

I found something strange about these numbers. Medicare only allows a certain number of dollars for certain tests. Medicare does not reimburse the tests that are not approved for certain diseases. I do not know anything about “manipulative therapy” except that it is an alternative therapy that is based upon manipulation and/or movement of one or more parts of the human body

I assume that Medicare approved this therapy and approved the charges for these tests since Medicare paid for them. Procedures and laboratory tests must be correlated with approved diagnoses. This physician might have a large manipulative therapy practice doing approved testing. She has figured out a system to generate a good return within the rules of the system.

The real issue should is not discussed. Did Medicare make a mistake in approving payment for this treatment and these tests? If so, the tests and treatment should not be approved nor paid for by the government.

The physician administrators at Medicare who approve these tests, procedures and treatments are sharp people. They use evidence-based medicine to make reimbursement decisions.

There are reasons to suggest there is more to this story than meets the eye.

 Never the less it is an example of how the Medicare outcomes medical database can be used to discover outliers. After the outliers are discovered, appropriate investigation must be done to discover why the physician is an outlier.

The real problems to be solved are ending the added cost of defensive medicine through tort reform and ending the additional costs of retesting by physicians and hospitals. .

President Obama has done nothing to decrease these billions of dollars in additional cost that add little value to patient care.


The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 





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