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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
Medicaid Spending and Medicaid Spending and the Open Source the Open Source
SolutionSolution
Alliance for Health ReformAlliance for Health ReformRussell Senate Office BuildingRussell Senate Office Building
Feb 15, 2008Feb 15, 2008Jim Frogue
State Project DirectorThe Center for Health Transformation
www.healthtransformation.net202-375-2001
Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
Health TransformationHealth Transformation
To avoid change, most bureaucracies prefer the comfortable routine of explaining failure.
Current Healthcare
System
Reforms within the current framework
21st Century Intelligent
Health System
Where we should be going
Where we are currently going
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
The Trend toward The Trend toward TransparencyTransparency
Our government is more transparent every day
Coburn-Obama legislation on earmarks Campaign finance laws that require disclosure Even your salaries on Legistorm FloridaHealthFinder.gov 93 percent of people believe they have the
“right to know” cost and quality information about their health care providers
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
The Medicaid Federal The Medicaid Federal MatchMatch Federal government provides an open-ended match
for state Medicaid programs between 50-76 percent Incentives for states:
$1 of extra Medicaid spending = $1-$3 of “free” federal money
To save $1 in a state budget means leaving $1-$3 federal dollars on the table
States’ spending on Medicaid as a proportion of their budgets has climbed steadily for 40 years. Will continue. In most states, now greater than K-12 education spending. Medicaid spending is crowding out education, law
enforcement, highways, environmental protection, etc
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
Medicaid Fraud in New Medicaid Fraud in New YorkYork New York has by far the highest absolute and per capita
Medicaid spend of any state. 13 percent of federal funds for 6 percent of US population
New York Times series in July, 2005 Brooklyn dentist billed for 991 procedures in one day (Sept, 2003) James Mehmet, former Inspector General, “40 percent of all claims are
questionable”
2006 private study was buried in New York’s Health Department. It found: “One quarter of that program cannot be explained.”
Medicaid Commission 2005-2006 tasked with finding $10 billion in federal savings over 5 years They could have found all of that in New York in 2 years in fraud
alone. Instead they recommended various broad cuts to honest providers.
Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
The Open Source The Open Source SolutionSolution
As a condition of accepting bailout As a condition of accepting bailout money, states must post provider money, states must post provider
bills on-line for public accessbills on-line for public access
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
How to do Open Source?How to do Open Source? Work with states and provider groups to
create low-cost, administratively simple way for provider billing records to go on-line in real-time for viewing by the general public To get started, could limit to 10 or 20 high-volume
services or procedures that are susceptible to fraud. Could limit to fee-for-service Medicaid.
Could guarantee providers real-time reimbursement in exchange for real-time public disclosure of bills.
Maintain/Reiterate rigorous patient privacy safeguards.
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
Why Would This Work?Why Would This Work? More sunlight is always better In-state, in-house fraud monitoring can
never be as good as the collective wisdom of interested academics, researchers, other clinicians and providers from all over the country
Taxpayers have a right-to-know how their dollars are being spent
Google “Goldcorp Challenge”
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
Who Should Support This Who Should Support This Concept?Concept?
Every honest provider of Medicaid services
Every Medicaid patient advocacy group
Every taxpayer
Every elected official who has an interest in eliminating waste, fraud, and abuse
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Center for HealthCenter for Health TransformationTransformation
Copyright © 2005 The Center for Health Transformation
www.healthtransformation.net
“One cannot solve a problem with the same thinking that created it.”
- Albert Einstein