Governors' Budgets for FY 2013 - What Is Proposed for Medicaid?

Examines trends in governors' Medicaid budget proposals, including expected shortfalls, fiscal priorities, additional spending cuts, policy actions to control Medicaid costs, and targeted investments, as well as tax cuts and fiscal reform proposals

State Implementation of National Health Reform: Harnessing Federal Resources to Meet State Policy Goals

Discusses state options for maximizing coverage and access to care; reforming the health insurance market; holding insurers accountable for high-quality, affordable coverage; restructuring healthcare delivery and financing; and cutting budget deficits

Low Medicaid Spending Growth Amid Rebounding State Revenues: Results From a 50-State Medicaid Budget Survey State Fiscal Years 2006 and 2007

Examines the implementation of the new Medicare prescription drug benefit and the rate of Medicaid spending growth and enrollment in 2006. Identifies possible state level changes in eligibility requirements, program expansion, and enrollment processes

Data Analytics (Ab)Use in Healthcare Fraud Audits

This study explores how government-adopted audit data analytic tools promote the abuse of power by auditors enabling politically sensitive processes that encourage industry-wide normalization of behavior. In an audit setting, we investigate how a governmental organization enables algorithmic decision-making to alter power relationships to effect organizational and industry-wide change. While prior research has identified discriminatory threats emanating from the deployment of algorithmic decision-making, the effects of algorithmic decision-making on inherently imbalanced power relationships have received scant attention. Our results provide empirical evidence of how systemic and episodic power relationships strengthen each other, thereby enabling the governmental organization to effect social change that might be too politically prohibitive to enact directly. Overall, the results suggest that there are potentially negative effects caused by the use of algorithmic decision-making and the resulting power shifts, and these effects create a different view of the level of purported success attained through auditor use of data analytics

Data-Driven Models, Techniques, and Design Principles for Combatting Healthcare Fraud

In the U.S., approximately $700 billion of the$2.7 trillion spent on healthcare is linked to fraud, waste, and abuse. This presents a significant challenge for healthcare payers as they navigate fraudulent activities from dishonest practitioners, sophisticated criminal networks, and even well-intentioned providers who inadvertently submit incorrect billing for legitimate services. This thesis adopts Hevner’s research methodology to guide the creation, assessment, and refinement of a healthcare fraud detection framework and recommended design principles for fraud detection. The thesis provides the following significant contributions to the field:1. A formal literature review of the field of fraud detection in Medicaid. Chapters 3 and 4 provide formal reviews of the available literature on healthcare fraud. Chapter 3 focuses on defining the types of fraud found in healthcare. Chapter 4 reviews fraud detection techniques in literature across healthcare and other industries. Chapter 5 focuses on literature covering fraud detection methodologies utilized explicitly in healthcare.2. A multidimensional data model and analysis techniques for fraud detection in healthcare. Chapter 5 applies Hevner et al. to help develop a framework for fraud detection in Medicaid that provides specific data models and techniques to identify the most prevalent fraud schemes. A multidimensional schema based on Medicaid data and a set of multidimensional models and techniques to detect fraud are presented. These artifacts are evaluated through functional testing against known fraud schemes. This chapter contributes a set of multidimensional data models and analysis techniques that can be used to detect the most prevalent known fraud types.3. A framework for deploying outlier-based fraud detection methods in healthcare. Chapter 6 proposes and evaluates methods for applying outlier detection to healthcare fraud based on literature review, comparative research, direct application on healthcare claims data, and known fraudulent cases. A method for outlier-based fraud detection is presented and evaluated using Medicaid dental claims, providers, and patients.4. Design principles for fraud detection in complex systems. Based on literature and applied research in Medicaid healthcare fraud detection, Chapter 7 offers generalized design principles for fraud detection in similar complex, multi-stakeholder systems.<br/

ESSAYS ON THE ROLE OF GOVERNMENT REGULATION AND POLICY IN HEALTH CARE MARKETS

Understanding how health care markets function is important not only because competition has a direct influence on the price and utilization of health care services, but also because the proper functioning, or lack thereof, of health care markets has a very real impact on patients who depend on health care markets and providers for their personal well-being. In this dissertation, I examine the role of government policies and regulation in health care markets, with a focus on the response of health care providers. In Chapter 1, I analyze the impact of Medicare payment rules on hospital ownership of physician practices. Since the mid-2000’s, there has been a rapid increase in hospital ownership of physician practices, however, there is little empirical research which addresses the causes of this recent wave of integration. Medicare’s “provider-based” billing policy allows hospital-owned physician practices to charge higher reimbursement rates for services provided compared to a freestanding, independent physician practice, without altering how or where services are provided. This “site-based” differential creates a premium for physicians to integrate with hospitals, and the size of this differential varies with the types of health care services provided. I find that Medicare payment rules have contributed to hospital ownership of physician practices and that the response varies across physician specialties. A 10 percent increase in the relative reimbursement rate paid to integrated physicians leads to a 1.9 percentage point increase in the probability of hospital ownership for Medical Care specialties, including cardiology, neurology, and dermatology, which explains about one-third of observed integration of these specialties from 2005 through 2015. Magnitudes for Surgical Care specialties are similar, but more sensitive across specifications. There is no significant response for Primary Care physicians. In combination with other empirical literature which finds that integration between physicians and hospitals typically results in higher prices with no impact on costs or quality of care, I cautiously interpret this responsiveness as evidence that Medicare’s provider-based billing policy overcompensates integrated physician practices and leads to an inefficiently high level of vertical integration between physician and hospitals. In Chapter 2, I analyze the effect of anti-fraud enforcement activity on Medicaid spending, with a particular focus on the False Claims Act. The False Claims Act (FCA) is a federal statute which protects the government from making undeserved payments to contractors and suppliers. Individual states have chosen to enact their own versions of the federal FCA, and these statutes have increasingly been used to target health care fraud. FCA statutes commonly include substantial monetary penalties such as “per-violation” monetary fines and tripled damages, as well as a “whistleblower” provision which allows private plaintiffs to initiate a lawsuit and collect a portion of recoveries as a reward. Using variation in statelevel FCA legislation, I find state FCAs reduce Medicaid prescription drug spending by 21 percent, while other spending categories - which are less lucrative for FCA lawsuits - are unresponsive. Within the prescription drug category, drugs prone to off-label use show larger declines in response to the whistleblower laws, consistent with FCA lawsuits being used to prosecute pharmaceutical manufacturers for off-label marketing and promotion. Spending and prescription volume for drugs prone to off-label use fall by up to 14 percent. This effect could be driven by pharmaceutical manufacturers’ changes in physician detailing for drugs prone to off-label use and/or physicians’ changes in prescribing behavior

Medicaid Fraud, Abuse and Waste

The following information has been collected and reviewed over a four-month period surrounding the efforts to better control insurance fraud, particularly involving federally funded programs such as Medicaid, Medicare and TRICARE. The information allows for a better understanding of how healthcare programs came to be, teaches the history and effects of the Affordable Care Act and reflects on Medicaid eligibility and reimbursement factors. In this document, several cases of medical insurance fraud will be examined. Forms of prosecutions as well as the analyzing of white-collar crime will be discussed. The education of fraudulent activity across health care is to be stressed by the information presented in this document. The conclusion consists of two models of suggested solutions in hopes that the government will continue all efforts to minimize Medicaid fraud, abuse and waste in America

Caring Too Much: Misapplying the False Claims Act to Target Overtreatment

As the costs of health care administration and delivery continue to grow, health care fraud enforcement actions have increased in number and severity, and, with the recently upheld Patient Protection and Affordable Care Act adding more than $350 million over the next ten years to fight health care fraud, they will likely continue to do so. Continuing a strategy it has used for decades, the federal government is relying mainly on the False Claims Act (FCA), an age-old statute with blunt penalties, to levy remarkable fines against providers in an ever-expanding net of enforcement. But recent examples indicate that the government is applying the FCA to scenarios in which its application seems unwarranted. Namely, the government is now increasingly wielding the FCA against “overtreatment” — defined as cases in which a provider has allegedly provided “too much” care in an inefficient, overly expensive, or unnecessary way — presumably to address the looming fiscal crisis. Exemplified by the Department of Justice’s ongoing implantable cardioverter defibrillator investigation, the federal government is seeking to regulate overtreatment through application of its powerful anti-fraud statute. Even though health care waste and abuse undeniably plague American health care, this Article argues that the government’s solution of applying the FCA against providers who engage in overtreatment is doctrinally unsatisfying and practically destructive. The overreliance on “data mining,” a desire to freeze vague and developing practice standards, and the FCA’s overwhelming penalties that precipitate immediate settlement make up the key components of this overtreatment enforcement model. This results in cascading settlements, allowing the government to unilaterally change developing medical practice standards with little clinical input or judicial review in what can be called “backdoor rationing.” Further, these anti-fraud initiatives often impact the wrong providers and can stifle innovation. This analysis provides an in-depth critique of this new development in health care fraud enforcement in an effort to decouple conventional health care fraud cases from overtreatment investigations. Ideally, this piece will start the conversation toward an improved and more legitimate enforcement framework. At bottom, it illustrates the doctrinal and practical problems that will likely continue to exist at the complex intersection of medical necessity, health care financing, and fraud — even as the administration of America’s health care undergoes radical change

Manipulating the Prescription Drug Market: Spiking Prices, Inducing Demand, and Costs to the Public

In 2016, Mylan made headlines when it spiked the price of its EpiPen AutoInjector by 400%, raising the price from an average of $57 to$500. Critics called the price hike “outrageous, “brutal” and “corrupt.” Public outcries fueled a demand for a Congressional investigation, and Mylan negotiated a settlement with the United States Department of Justice over alleged violations of the False Claims Act. Although competition self-corrected and similar products entered the marketplace, this case – and other similar cases involving generic drugs and insulin – highlighted the skyrocketing costs of prescription drugs in the United States. In 2019, United States outpatient spending on prescription drugs totaled $369.7 billion. Despite massive expenditures, the United States ranks below comparable countries on health outcomes. This article traces the reasons for high medication prices; describes two key lawsuits alleging patterns of anticompetitive pricing, collusion, and fraud; and analyzes how corporate practices contribute to unnecessary and harmful healthcare costs through the pharmacological imperative. Industry practices described in this article reflect a pattern of organizational business ethics that contravenes market guardrails through both alleged and admitted dishonesty and illegal conduct. This article proposes solutions that will improve patient health, reduce healthcare costs, and uphold market fairness by reforming the expectations of corporate conduct

Health Care Fraud Across Time and Delivery Systems: Assessing the Legal Impact of the Affordable Care Act

Health care fraud is a crime that costs the United States billions of dollars each year. Health insurance fraud against government programs such as Medicaid and Medicare make up the majority of false claims. Government health care programs are particularly susceptible to fraud for three reasons: (a) high volume of claims; (b) recipient characteristics; and (c) a favorable ratio of reward to risk. Modes of fraud commission change depending on the health care delivery and payment model in use. In part, the Patient Protection and Affordable Care Act of 2010 sought to dramatically reduce health care fraud. The Affordable Care Act and related documents were analyzed using a qualitative, inductive approach that involved aspects of legal impact study and grounded theory methodology. The principles of Cressey’s Fraud Triangle Theory were applied with the goal of generating new hypothetical understanding about how the law influences pressure, opportunity, and rationalization in terms of the way the legislation was intended as well as its real world application. The Act decreases pressure by awarding grants and providing funding and incentives to institutions and individuals, thus improving their financial stability. In a small number of cases, the Act may increase pressure on specific entities by imposing financial penalties, although the purpose of these sanctions is to coerce compliance with requirements of the law. The Act has the strongest effect on opportunity through increased regulation and oversight, linking payment with quality and outcomes, reporting requirements, use of alternative payment methods, and innovative demonstration projects. The Act addresses rationalization by consistently endorsing a consensus-based, multi-stakeholder approach when it comes to the creation of operating rules and standards. Emphasis is also placed on public reporting of performance data and information related to safety and quality standards. This was found to have a culture changing effect in ways that discourage favorable definitions of trust violation. The study concludes that linking provider payment with performance and outcomes is the optimal way to control costs while safeguarding patient health and deterring fraud, waste, and abuse. Future studies should explore the impact of the Act after it has been fully implemented