Thursday, September 8, 2011

NHS Reform: Great Opportunity or Fraud

Phew! What a few days!

7 September 2011

Lord Howe: To be honest I don't think it should matter one jot whether a patient is looked after by a hospital or a medical professional from the public, private or charitable sector”

"The NHS isn't a place to earn a fast buck. There are some outstanding performers in the NHS and they will not give up their patients easily."

He said that the changes being made presented "huge opportunities" to private groups who could provide high quality care.

And he added: "In the coming months and years, the NHS is going to evolve and grow into a very different animal."

What can I say?

Winter’s Tale/Tristram Kenton Guardian

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

In the current push for applying market principles, the NHS is in serious danger of paying dearly for unnecessary treatment and worse, fraudulent claims by the new “suppliers” in the market place.

I have highlighted the problems in the US before. Fraud is seen as more profitable than drug dealing.

The US Medicare and Medicaid systems are in a way very similar to what the new market style NHS will be like. Tax-payers pay for them! The much hyped saving, if there is going to be any, will be swallowed up by paying for unnecessary treatment and fraud.

Medicare did not detect that more than one-third of spending for wheelchairs, oxygen supplies and other medical equipment in its 2006 fiscal year was improper, according to the report. Based on data in other Medicare reports, that would be about $2.8 billion in improper spending.

Arrests in three separate cases in Brooklyn, Detroit and Miami included a Florida doctor accused of running a $40 million home health care scheme that falsely listed patients as blind diabetics so he could bill for twice-daily nurse visits.       Also>>>

But hospitals too:

>>>How about My bill from ….. for a $540 tongue depressor. Or one for a $270 2oz. cup of liquid Motrin?

>>>While she was in the hospital a few days old, we were charged for 11 pacifiers at a cost of $121.00 each.

>>>My 70 year old father was hospitalized with Legionnaires Disease. His hospital bill included a bill for a pap smear! His first name was Faye – the hospital must have assumed he was a woman and could scam the insurance company for the charge.

By how much? In the US:

26 OCT 2009

The U.S. healthcare system wastes between $600 billion and $850 billion annually, according to a white paper published by Thomson Reuters.

The report identifies the most significant drivers of wasteful spending - including administrative inefficiency, unnecessary treatment, medical errors, and fraud - and quantifies their cost. It is based on a review of published research and analyses of proprietary healthcare data.

"The bad news is that an estimated $700 billion is wasted annually. That's one-third of the nation's healthcare bill," said Robert Kelley, vice president of healthcare analytics at Thomson Reuters and author of the white paper. "The good news is that by attacking waste, healthcare costs can be reduced without adversely affecting the quality of care or access to care.

UNNECESSARY CARE (40% of healthcare waste): Unwarranted treatment, such as the over-use of antibiotics and the use of diagnostic lab tests to protect against malpractice exposure, accounts for $250 billion to $325 billion in annual healthcare spending.
FRAUD (19% of healthcare waste): Healthcare fraud costs $125 billion to $175 billion each year, manifesting itself in everything from fraudulent Medicare claims to kickbacks for referrals for unnecessary services.

“The Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public
and private healthcare programs are 3-10 percent of total health spending, or $75–$250
billion in fiscal year 2009.”

“Fraud and abuse” occupies the extreme end of the continuum of appropriateness of use and potential waste. While arguments can be made about the appropriateness of some of the care described in the previous section, and, therefore, its classification as waste, no reasonable argument can be made for the contribution of fraud and abuse to quality of care or outcomes. They are cases of intentional misrepresentation resulting in excess payment, including billing for services never rendered and the knowing provision of unnecessary care. Most fraudulent and abusive practices simply add cost with no value, but others actually expose patients to the risk associated with unnecessary procedures.

Practices leading to waste include:
• The intentional provision of unnecessary or inappropriate services
• Billing for services never provided, often with patients’ participation in the fraud, often for
deceased patients
• Misrepresentation of the cost of care by insurers to group plan sponsors
• Kickbacks for referrals for unnecessary services
• Misbranding of a drug by a pharmaceutical company
• Abuse of the healthcare system by patients to receive harmful services, such as Medicaid  recipients with drug addictions enrolling in multiple states.

ADMINISTRATIVE INEFFICIENCY (17% of healthcare waste): The large volume of redundant paperwork in the U.S healthcare system accounts for $100 billion to $150 billion in spending annually.
HEALTHCARE PROVIDER ERRORS (12% of healthcare waste): Medical mistakes account for $75 billion to $100 billion in unnecessary spending each year.
PREVENTABLE CONDITIONS (6% of healthcare waste): Approximately $25 billion to $50 billion is spent annually on hospitalizations to address conditions such as uncontrolled diabetes, which are much less costly to treat when individuals receive timely access to outpatient care.
LACK OF CARE COORDINATION (6% of healthcare waste): Inefficient communication between providers, including lack of access to medical records when specialists intervene, leads to duplication of tests and inappropriate treatments that cost $25 billion to $50 billion annually.

Not just the US though:

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