As a healthcare ethics keynote speaker, healthcare ethics consultant and book author, I was fascinated by an opinion piece by healthcare expert Merrill Matthews, the resident scholar with the Institute for Policy Innovation (March 21, 2023). He makes an interesting case that I find difficult to refute: If the government cuts Medicare fraud, it wouldn’t have to cut Medicare.
Isn’t it inevitable?
The cutting of Medicare is fraught with politics, on that point, both Matthews and I agree. What is needed, in my opinion, is a lot less politicking and a lot more honesty. Medicare fraud has endured from one administration to the next.
In a recent CNBC article (March 9, 2023), it was stated that: “Taxpayers are losing more than $100 billion a year to Medicare and Medicaid fraud, according to estimates from the National Health Care Anti-Fraud Association.”
The lead government fraud investigator, Pérez Aybar, believes $100 billion is a highly conservative amount, “When we think about all lines of business in Medicare and Medicaid, that’s probably a drop in the bucket.”
According to the Matthews article, Medicare spending for last year alone “was $982 billion, with $755 billion of that total coming from the federal government and $227 billion in premiums paid by Medicare beneficiaries to the government.”
Of that amount, it has been estimated that 7.5-percent of Medicare payments were due to fraud and for Medicaid, the estimates run close to 16-percent. The numbers are staggering. The article went on to explain the huge frauds in “durable medical equipment.” Fraud is allegedly running rampant in New York, Florida and California.
The biggest take-aways from the article, of course, were the most obvious: Medicare and Medicaid frauds are relatively easy to perpetrate, tens of billions are lost each year to fraud, the government – while priding itself on fraud reduction – still does not have a handle on how much is actually stolen.
The inevitability of fraud seems to be built into the program. It is both frustrating and sad. Why sad? Because those who truly need the assistance, may not be able to get it and long-term, the reductions will be bound to increase. It is not a bottomless pit. In short, fraudsters may be killing people and no one seems to get a handle on it,
The application of technology and ethics
Fraud exists in the realm of little to no oversight. Whether a surgical practice, dentist, radiology or pain management clinic, “bad players” generating billions in false billings, get away with what they do because no one is looking over their shoulder. Monitoring these players are like fixing faulty sieves; it is near impossible. Adding to that truth is the government, much like any other organization that is employing people, does not seem to have enough “inspectors.” Fraudsters know and understand that fact.
It is a numbers game and they are winning. The fraudster need for cash is ever-present and ironically, they rationalize their behavior by believing the well of funds they can steal from is never-ending. I say “ironically,” because they are a chief cause for the well running dry.
The world is atwitter with the potential uses of AI. It seems a not-so-far reach for AI to be applied to problems of Medicare fraud. Are there not expected payouts and outcomes? Are there not guardrails for determining if certain costs are out of control?
However, aside from the technical, Medicare abuse is clearly a call for greater healthcare ethics and the application of ethics to the problem along with much stiffer penalties for abuse.
To this point, the Medicare fraud business has largely been a legal and financial cat-and-mouse game. Suppose healthcare ethics took the lead? Suppose any institution requiring funds was required to attend a “college” where ethical expectations were measured and reviewed?
Considering the billions currently being lost it is worth exploration. The truth behind Medicare cuts may come down to this: good ethics and expectations placed above all other measurements.
Is it an impossible task? I think not. The alternative is to allow Medicare to slip away with catastrophic result.
Who is prepared to let that happen?
LEAVE YOUR COMMENTS!
