Poor health outcomes associated with Medicare fraud and abuse

In addition to saving costs, removing Medicare fraud and abuse perpetrators from practice may improve patient health outcomes, a recent study found.

In the retrospective cross-sectional study published in JAMA Internal Medicine, researchers found that exposure to known Medicare fraud and abuse practitioners (FAPs) may have generated 6,700 additional premature deaths among Medicare beneficiaries in 2013.

In dollar terms, the study estimates the related loss of 98,500 life-years attributable to those deaths at roughly $5 billion to $15 billion on top of the estimated $30 billion to $140 billion fraudulent or abusive activities cost Medicare directly.

RELATED: CMS unveils 5 'pillars' to curbing fraud, waste in Medicare

Due to the study’s limitations, these results cannot definitively identify the mechanism by which treatment by FAPs results in worse outcomes, but it still makes a strong case, study author Lauren Nicholas, Ph.D., an assistant professor in the Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, told FierceHealthcare.

“While we could not ethically randomize patients to treatment by fraud and abuse perpetrators, we were able to rule out a number of alternative explanations, making it extremely likely that the increased hospitalization and death rates were driven by FAP contact,” she said.

For one thing, researchers found that, prior to their exposure to the FAPs in the study, patients had similar levels of physician visits and hospitalizations as the comparison group. “We reviewed the crimes committed by FAPs to verify that many of the crimes committed, such as dispensing fake chemotherapy or medically unnecessary prescription drugs and using untrained staff to read medical images and diagnose, could lead to patient death,” Nicholas said.

Previous research has indicated FAPs treat disproportionately more vulnerable Medicare patients than other providers. Since these patient populations frequently experience poorer outcomes than other populations, the authors suggest treatment by FAPs contributes further to health issues among non-white, dually-eligible and disabled Medicare beneficiaries.

RELATED: CMS gets new powers to go after Medicare, Medicaid fraudsters

Based on the team’s work, Nicholas recommends additional studies to narrow down the specific types of fraud and abuse most likely to produce poor health outcomes so that policymakers can target them as investigative priorities.

Further research on the link between patient outcomes and FAPs could also tease out patterns in claims data that could make it easier for investigators to identify fraud and abuse.

In the meantime, Nicholas believes quantifying the additional harm associated with fraudulent Medicare practitioners should provide a greater incentive for CMS to find and remove those responsible.

“We recommend identifying and removing FAPs more rapidly to protect the health of Medicare and Medicaid beneficiaries. The health and mortality consequences should be taken into account when decisions about how to pursue fraud and which providers to target are made,” she said.