Center for Health Transformation Transformation Copyright © 2005 The Center for Health...

Center for HealthCenter for Health TransformationTransformation

Copyright © 2005 The Center for Health Transformation

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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




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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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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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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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.




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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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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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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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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“One cannot solve a problem with the same thinking that created it.”

- Albert Einstein

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