Medicare – A Prescription to Cure Its Built-In Cancer

To Whom It May Concern: [Dept. Health & Human Service (HHS), Congress, Public]

Medicare is one of the nation’s approaches to providing healthcare, mostly to the elderly. The system was set up to deal with insuring there was a way that provided for medical insurance coverage to the elderly. It is funded through payroll taxes, premium payments, and a few other sources. Medicare spends over $600B annually. Since it uses relatively little on administrative costs, most of that money goes into the economy particularly the healthcare industry segment. So, it makes a significant contribution to the US’s economy on a first-order basis and as it purchases services and item from market providers Medicare has an expanded impact as those funds cycle throughout other facets of the country’s economy.

This doesn’t mean there are no problems or issues with the Medicare program or system. That scant amount of money (after all what’s $600B) does draw the predators and scavengers out from the less savory segments of society. We have and will continue to hear that there’s a lot of waste and fraud in the Medicare system. Periodically some news report comes out about a sting-operation or court case where a doctor, healthcare provider, or medical equipment/service company is prosecuted for defrauding or abusing the system. An estimate of “improper payments” (fraud) is $65B, so quite a lot for someone like you or me. Now this has been a persistent problem for decades, and there’s nothing on the horizon that would indicate it going to stop. HHS, Congress, nor other government agencies would seem to have much interest in the abuse let alone a handle on how to bring this abuse under control. Now given the value that such an undertaking would have, this is a classic case of ineptitude, incompetence and abuse by the government and our leaders. If you looked at the value during a single Presidential term of office, addressing this problem would be over $260B; or almost enough to do something worthwhile for the nation and its citizens. Why almost enough money to make a difference.

If you think the problem is just too difficult to solve or that if you find a way to stop one form of abuse that those profiting from the abuse will simply turn to other methods, then you are accepting that your money can be wasted. If you approve of wasting your and others money, I am very willing to accept some from you also, so please send me some of the money you are happy to have used but not benefit you. Otherwise, you ought to be demanding that your elected federal officials act responsibly and deal with the abuse. This is not an unreasonable demand nor is the problem a particularly difficult one to solve. So, it’s not like you are asking for much in return for your money and if you didn’t care it’s more than you deserve.

Now if creating a $65B annual source of funding or funding relief isn’t worth even a minimal effort by Congress, maybe HHS could undertake a process improvement to extend the projected Medicare funding exhaustion date. The current lose-lose situation can be converted into a win-win. And not that anyone would care, but the tax-payers would directly benefit even if that’s not something Congress pays any attention to.

How then to solve the abuse? Well, nothing could be simpler. Medicare settles claims submitted by service providers or clients. Medicare determines what is covered and by what amount and settles the claim. This means that Medicare is looped into every claim and thus into every instance of fraud and abuse. This connection provides the leverage that HHS/Medicare can use to gain control over fraud and abuse.

Developing the system that implements fraud management is a straight-forward problem-solving task. It only requires a spark of insight into understanding the problem. Consider one instance of fraud/abuse, where a company acquires a list of Medicare clients with a particular malady or symptom. The company contacts the Medicare clients to provide ‘free’ service/product covered by Medicare, and the scam begins. This is a link that’s controllable and useful. The issue isn’t can you control fraud and abuse, but can you see how easy it is to do.

Now there is a big barrier to solving Medicare’s abuse problem. Even if Congress or HHS attempted to address the problem, they are just not skilled or competent in accomplishing efforts of this type. This task requires an innovative perspective, an unconstrained examination of options, a commitment to providing assured results, and an evolutionary approach that preserves delivery of the objectives and maintaining goal states. Think more NASA and less HHS. The answers aren’t found in legislating what you want, which Congress doesn’t know anyway; nor is it in implementing Congress’s solution as it doesn’t work anyway. The answer is admitting that you need to turn to problem-solvers. Even here there’s a need to have problem-solvers who know what they are trying to do which means someone with an idea. Again, not in Congress’s or HHS’s wheelhouse.

If all else fails, the government (Congress or the Administration) just needs to ask.