How badly do we want to reduce the cost of Medicare? For me, one of the most important steps will be to provide public access to the Medicare claims database and use it to root out fraud. This is the goal of two senators who have introduced some new legislation (see: Senators Push to Open Database on Medicare). Below is an excerpt from the Wall Street Journal article about this topic:
Two senators have introduced legislation to overturn a 1979 court injunction that bars the government from revealing what individual physicians earn from Medicare. That information is stored in the Medicare-claims database, widely considered one of the best tools for finding fraud and abuse in the $500 billion federal health-insurance program for the elderly and disabled. Soaring Medicare costs threaten to overwhelm the federal budget, yet American taxpayers are blocked from seeing exactly where their money goes. Under a three-decade-old court order, Medicare can't publish the billings of individual physicians who participate in the program....The judge who issued the 1979 injunction shielding the data ruled that physicians' privacy trumped the public's interest in knowing how tax dollars are spent. He relied on a privacy provision in the Freedom of Information Act, or FOIA. The new bill explicitly exempts physician Medicare billing data from that FOIA provision. The legislation would also order the Department of Health and Human Services to make the data available at no cost. Patient identities would remain confidential....Last month, the [Wall Street] Journal used the data to detect potentially negligent or harmful care. It identified an Oregon neurosurgeon, Vishal James Makker, who had an unusual propensity for performing multiple spine surgeries—as many as seven—on the same patients. Dr. Makker denied wrongdoing and said he acted in the best interests of his patients. The American Medical Association, which opposes releasing physician-specific Medicare billing records, has argued that such data could be misused to erroneously assess quality of care.
I've go another idea prompted, in part, by a previous blog note here about how governmental access to the hidden web is spurring entrepreneurial activity (see: Entrepreneurs Repurpose Useful Governmental Data from the Hidden Web). Not only should we rapidly provide public access to the Medicare claims database, but we should also offer graduated rewards for citizens who discover fraudulent behavior when mining it. This is analogous to the SEC reward for whistleblowers (see: Does SEC Whistleblower Reward of $1 Million Signal A New Attitude Toward Wall Street Whistleblowing?). The idea differs from the SEC example in that the Medicare "whistleblowers" do not need to be in the employment of those submitting fraudulent claims. They only need to be adroit in analyzing huge databases after being shown examples of suspicious claims in the past that have lead to convictions.
I will take exception to the assertion of the AMA that providing open access to the Medicare claims data "could be misused to erroneously assess quality of care." In fact, I think that rooting out fraud in Medicare will have the opposite effect. Knowing that the high school computer whiz who lives next door may be a threat to one's livelihood and reputation may make more physicians aware of their responsibility for delivering quality care to Medicare patients.
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