Bad Apples and Sour Grapes

Healthcare fraud is a consistent problem that is ever evolving and adapting to the regulations and restrictions put in place to hinder it. Once one avenue is stopped, those individuals that were cashing in are likely to move to another area and begin anew. So the question I wanted to address here is how Value-Based Healthcare will impact an industry that is rampant with fraud.

In a VBH model the focus on collaboration of providers and coordinated care means one very important thing that is missing from a volume based model, communication. Currently a large portion of fraudulent claims to healthcare payers are made by solo providers that are only one part in the chain of treatment. In a VBH world the chain becomes a web and lots of people suddenly see what procedures have been done, what drugs are prescribed, what tests have been performed and treatments administered. Even my 4 year old will tell you that when someone is watching… you shouldn’t do something you know is wrong.

This is even more important when a group of providers can all benefit from the administration of high quality and cost-effective care to their patients. It is as simple as peer pressure. “My friends made me do it” is a pretty weak excuse except when what they made you do is not commit a crime.

Now I don’t want to make it seem that all avenues of fraud are closed by a VBH system. In fact existing schemes can still flourish it just might be a little more difficult to pass some things by your colleagues. That is unless your colleagues all want to cash in too. So now what you have is a web of providers all collaborating to coordinate care and defraud the payers. If a large portion of the group is “in” on it then there is really not much that can stop them from cashing in… except that quality is being measured by external reference frames. What I mean is that the metrics that have to be reported in order for the assessment of quality to be made are also being reported by lots and lots of other provider collaborations and groups. That assessment of quality and the subsequent payment are therefore being evaluated rather guaranteed and a group of coordinated fraudsters could in fact lose money if their quality and cost measures fall below acceptable levels.

So the system of quality review and measurement is self-correcting right? Sure, in many cases it would be. That is of course (see I told you they always find a way) unless the quality measures are being fabricated as well. What you have now is a group of providers, institutions and patients all working together to get money out of the system. The trouble is that this would be terribly complicated and probably difficult to organize. Unfortunately I am constantly surprised as how innovative and devious people that have been convicted of healthcare fraud can be. Is it out of the realm of possibility? No, certainly not. Is it likely? I would put it at a low or medium-low risk. The ways a scheme like that could fall apart are too numerous to count so in my opinion it just wouldn’t be worth the effort to make a few extra percent on an episode of care.

So this brings me to my closing. Right now what healthcare fraud really looks like is a number of bad apples all hanging out in the barrel making it all look bad.

VBH would do a great deal to pick those out and throw them away. The only trouble then would be the groups of sour grapes that spoil the system. Fruit metaphors aside

I think I have made my point. The trouble today with fighting healthcare fraud is that it’s often very difficult to weed out the bad from the good, like I said they are really good at hiding. VBH can go a long way to shining light into the dark places but I certainly don’t think it will go as far as painting red arrows that say “Fraud This Way”.

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about the author

Kevin McCash

Kevin McCash, PhD is a data analytics manager, an avid reader and trivia buff. Kevin enjoys friendly arguments, deep discussions and above all learning new things. See all posts from Kevin McCash.