Abusing the Patient: Medicare Fraud and Abuse and Hospital-Physician Incentive Plans

Part I provides a background discussion of the PPS, DRGs, and incentive plans. Part II focuses on the fraud and abuse provisions of the Medicare statute and argues that incentive plans violate the plain language · of the statute, which prohibits any knowing and willful remuneration for the inducement of referrals. Part III concentrates on the fraudulent and abusive practices that incentive plans encourage. The plans frustrate legislative intent because they encourage practices that subvert the cost-containment purposes of the PPS and have an adverse effect on patient care

The Medicare Rx: Prospective Pricing to Effect Cost Containment

This Note analyzes the impact of changing hospital reimbursement while maintaining charge-based reimbursement for physicians on hospital-physician relationships and on cost and quality of care. This Note contends that if the stated goals of redirecting incentives and containing costs are to be realized, physicians must be drawn into the revised reimbursement scheme. An indirect, aggregate approach is advocated to maintain the integrity of the physician-patient relationship and to avoid a direct financial impact upon the physician regarding patient care decisions. Part I will briefly examine the reasons for changing hospital reimbursement from retrospective cost-based reimbursement to prospective fixed rates. Part II of this Note will demonstrate that to realize the stated goals of hospital prospective payment, physicians must be drawn into the incentive structure. The necessity of incorporating physicians into this structure, however, is moderated by the desirability, indeed, necessity, of insulating the physician-patient relationship from any direct financial impact. Thus, Part III of this Note will conclude by advocating a mandatory Medicare incentive plan, administered jointly by the hospital and medical staff, that encourages physicians to share jointly in reduced cost care while forcing them to absorb any losses

Physician Incentive Programs: Is it Possible to Develop Incentive Programs that Provide Financial Incentives for Primary Care Physicians while Balancing Quailty Medicine and Utilization Controls?

Managed care organizations have focused on utilization controls through the use of managed care techniques as a manner of containing costs. Managed care techniques such as selective contracting, risk sharing and risk adjustment, gatekeepers, medical management and utilization review have presented a more measurable means o f financially incentivizing the primary care physician. However, has the focus on utilization controls been at the expense of practicing quality care medicine? Compensation that rewards physicians for withholding care can interfere with physicians’ loyalty to patients and ultimately their candor and trust. Structural incentives to reduce cost can be effective if they are not so direct and substantial to influen ce medical decisions. Thoughtful incentive structures can use measures o f quality and patient satisfaction instead o f rewarding less costly treatment decisions. How do we develop and balance these incentive structures and what other issues need to be taken into consideration? Thus, in order to find a solution for such a complex issue, the complexity needs to be analyzed and defined. My research will utilize information already available on utilization controls and quality incentives to help better understand the existing relationships and structure. Additionally, my research will include gathering and analyzing data on two existing quality incentive programs to determine the effectiveness o f using financial incentives for practicing quality medicine. The findings o f this research will provide health care administrators with a cost / benefit analysis of the development of similar and more extensive models.Master'sCollege of Arts and Sciences: Public AdministrationUniversity of Michiganhttp://deepblue.lib.umich.edu/bitstream/2027.42/117813/1/JonesC.pd