Elimination of Fraud and Abuse in Health Care - Part 3

Waste, fraud and abuse in healthcare stops customers to have economical health facilities and it ultimately results in decline of quality as well. The United States of America's one of the biggest challenge is to come up with the strategy and ideas which help people having health facilities with quality, coverage and most importantly economical. It is explained in "Elimination of fraud and abuse in health care "part 2 that the customers dealing with healthcare is out of their reach each year and their pockets do not allow them to have quality and economical health. President Obama is appreciating and welcoming "ideas which can cut the cost, bring quality, reduce waste, fraud and abuse, last but not the least gives customer choice in healthcare.

One of the focal points is to bring innovation in healthcare and develop a system which can bring the mentioned constraints in healthcare. For that matter there is a need to take a look in what the Obama's healthcare reform plan is?

Barack Obama's Health Care Reform Plan

President Obama envisions the healthcare system so perfect that not even a single American suffers from healthcare. He puts emphasis on the reforms and his plan estimated cost is around $50 to $65 billion. The key factors of Obama's interest are:

1. Quality, Affordable & Portable Health Coverage for All.

2. Modernizing The U.S. Health Care System To Lower Costs & Improve Quality

3. Promoting Prevention & Strengthening Public Health.

One of the core aspect of this plan is the claim that every family will save approximately $2,500 each year. The plan caters a Health information technology investment aimed at dropping needless expenses that result from avoidable errors and ineffective paper billing systems. It will also help preventing and organizing of persistent circumstances. The preparation is required to raise insurance industry competition and reduce underwriting costs and profits in order to decrease insurance overhead. The health insurance should be universal which will diminish spending on uncompensated care.

The critics say that there is cost shift rather than cost reduction in this plan. Obama's stresses over creating another program just like Medicare or under- 65 age is itself a costly thinking. He also wants to empower government programs Medicaid and SCHIP. Obama makes investments in health information technology a significant element of his cost control strategy. This is the point of discussion. The only way to cope up with all these issues is to significantly use the technology. In order to improve quality Obama has planned to take steps which can produce results. It includes disease management programs, coordinated care, transparency about cost and quality of care, improved patient safety, aligning incentives for excellence, comparative effectiveness reviews, and reducing disparities in health care treatments for the same illness.

The three essential points to reduce inefficiency and abuse and improve healthcare quality are:

o Adopting state-of-the-art health information technology system.

o Ensuring that patients receive and providers deliver the best possible care, including prevention and chronic disease management services.

o Reforming the market structure to increase competition; and offering federal reinsurance to employers to help ensure that unexpected or catastrophic illnesses do not make health insurance unaffordable or out of reach for businesses and their employees.

The 3rd point of the Obama's plan is to Promote Prevention & Strengthening Public Health. For that matter he thinks, employers, school systems the medical and public health workforce, and federal and state and local governments have to play their role. The employers have o offer onsite clinical preventive services such as flu vaccinations, hygienic food in cafeterias etc. the workshops,seminars and training programs should be held in schools in order to educate children. Finally the government has to effectively use the electronic and print media and other ways to create awareness among people.

Problem Area

The healthcare costs are escalating and the health insurance have gone up too in the last few years, almost doubled with mounting 3.7 times faster in comparison to the salaries of employees. About 100,000 Americans die from medical errors in hospitals every year1. The personal bankruptcies are greater than ever due to lack of affordable health. Over 45 million Americans, including over 8 million children not having health insurance. 80% of the working families are uninsured. Intensifying health care costs are making it extremely intricate for employers, particularly small businesses, to endow with health insurance to their workers.

The basic problem is that until or unless a plan is not executed, things will not be changed. They will remain static. The claim that every American family will save $2,500 will be a dream, if there is no proper strategy and its implementation. There has to be a pro active procedure to fight with these issues. The nucleus of the strategy is to eliminate waste, fraud and abuse in healthcare. As it is discussed before that there are a lot of statements and thirst for the enhanced healthcare system but nobody talks about the central point. By just saying "reforming the market structure" or "Adopting state-of-the-art health information technology system" and "Ensuring that patients receive and providers deliver the best possible care" the healthcare system would not improve. One has to come up with the practical approach and a "system" which can actually deal with these problems.

Steps to be taken to avoid fraud and abuse

The "system" has to be flawless in order to achieve what is promised. The Americans are going through a difficult phase of recession. It is the prime responsibility of the state to deliver what is pledged. There are some vital steps to be taken to ensure the paramount quality.

- Any one who is involved in care providers, the flow of information has to be accurate.

- This is absolutely vital to encounter Date Reporting System in place which can accumulate or transfer such information that can reduce the fraud and abuse.

- The existing encounter Data Reporting Systems are creating insufficient information to provide any means for the reduction of potential fraud and abuse.

- There is a strong need of making enhancements or addendum to the existing ERRS.

The very first problem occurs when the measurements taken to avoid fraud and abuse are considered to be satisfactory. The CMS has a lot more potential to recover as they are recovering currently. It is discussed thoroughly that what is fraud and abuse? And how it occurs? A unanimous plan of the strategy builders is to have precautionary measures to avoid fraud and abuse. When the fraud and abuse actually takes place then the need of identification is required. It is considered that the identification of improper payments is reasonable. Here is the problem; the CMS (Centers of Medicare and Medicaid services) came up with RACs (Recovery Audit Contractors) and they were able to identify only 0.3 percent ($ 1.03 billion) of the claims received whereas the total of $317 billion Medicare claim payments available for review. Just because the amount of recovery is high RACs are considered to be satisfactory but the percentage o recovery is extremely near to the ground.

References

1. Linda T. Kohn, Janet M. Corrigan, and Molla S. Donaldson, Editors; Committee on Quality of Health Care in America, Institute of Medicine (2000). To Err is Human. Washington, DC: National Academy Press.