Met with Dr Shantanu Agarwal, Deputy Administrator and Director, Center for Program Integrity
Excellent discussion comparing notes on system integrity in Australia and US.
CMS overall pays $1 trillion in program payments annually.
Point estimate is that 12% are improper payments – $48-52B per year.
The observation was made that FFS schedules like MBS were more than administrative tools, but effectively were clinical guidelines given the powerful incentives that they provide for particular treatments.
Analytic methods have been set and maturing for the last 5 years.
Most challenging element is how to close loop on anomalous behaviour:
- Start with on-boarding/educating newly enrolled clinicians (prevention) using videos, literature, data, feedback.
- Engagement with providers needs to be longitudinal, long term, personal, especially around low value care.
- You need a credible (peer matched) messenger and data needs to be properly presented and matched.
This Health Affairs article describes a typical journey for a system Shantanu used to work for – ChenMed in Miami.
Discussed:
- Fraud > Abuse > Waste > Error continuum
- The agile human adversary
- Chasing value slide
- Gamma scoring methodologies
- Choosing wisely > disinvestment
- Surgeon dashboard
- Surgeon selector
Shantanu mentioned that http://www.healthcostinstitute.org/ were seeking to build out similar statistical presentations to our own, but had so far only developed cost-oriented metrix with no dimension for quality/experience etc.
Other references for the meeting:
Reducing Medicare and Medicaid Fraud and Abuse – interview
Powerpoint: 764496_slide_CMS_DrShantanuAgrawal
