Crackdown on Medicaid Fraud

Medicaid is a federal government program designed to provide health care coverage for low income families and their children, and the disabled. But like any other program, Medicaid is susceptible to fraud and  abuse by others. Each year Medicaid and Medicare are estimated to have $60 billion in fraud a year (Wayne, 2012). This staggering amount is the result of an ongoing issue with the quality and security of the utilization of Medicare/Medicaid. Fortunately, the government has created the Office of Inspector General (OIG) at the Health and Human Services Commission, an organization that is focused on helping to end fraud and recover billions of dollars that Medicaid/Medicare has lost. Although their intentions are necessary, their strategies have brought much opposition from providers and health care organization who provide care for Medicaid patients.

The OIG's strategy consists of an increased reliance on a rule that allows investigators to freeze financing for any health care provider accused of over-billing, more focus on investigations with the biggest potential monetary returns (Ramshaw, 2012). Much of these strategies have been implemented under the new management and leadership of the new inspector general, Douglas Wilson. Along with his deputy, Jack Stick, they have taken a new approach to addressing the problem. According to Wilson, the division had operated like law enforcement, performing lengthy investigations, and instead he wanted to approach the situation as an accountant and freeze the flow of finances to questionable providers (Ramshaw, 2012). Although it is difficult to measure how successful their strategies have been, records show that they have been able to reduce case work from 3 or 4 years to eight weeks.

Where much of the opposition exists is from providers and organizations who treat large numbers of Medicaid patients. Freezing the finances of a health care provider accused of over-billing without a hearing creates huge risks for the organization. Providers who are waiting to get hearings are struggling to to continue providing care, which is resulting in cutting wages, labor hours, and declining Medicaid patients who can not receive care from these places while under investigation.Wilson's response to the frustration of providers is that the O.I.G. gives them the chance to come in for an informal review at any time. If the allegations are unfounded, the unpaid money is reimbursed and their financial flow is restored (Ramshaw, 2012).

Medicare/Medicaid fraud has been going on for too long and it is good to see that someone is willing to be more aggressive and stern in there strategy to resolve this issue. Hopefully, providers who see that it is for the best, that this is not a personal attack on medical practices but to improve the process of providing care for both providers and patients. The success of Wilson and Stick's strategy relies on the cooperation and continuous support of both parties. The billions of dollars that can be saved will benefit everyone and will bring this country closer to having an efficient health care system.  



Ramshaw, E. (2012). The big push on medicaid fraud. The New York Times. Retrieved from:       http://www.nytimes.com/2012/07/20/us/medicaid-fraud-push-gets-results-but-angers-doctors.html?pagewanted=1&ref=health

Wayne, A. (2012). Medicaid fraud audits cost five times amount u.s. found. Bloomberg. Retrieved from: http://www.bloomberg.com/news/2012-06-14/medicaid-fraud-audits-cost-five-times-amount-u-s-found.html

Patient Safety & Adverse Events

The purpose of Health care is improve and manage an individuals personal health. Throughout the years numerous studies, experiments and treatments have taken place in order to fulfill the role that health care plays in life. But there are incidences when things don't go right, known as an adverse event, whether it is during treatment. No matter the case, it is important that these incidences are reported and reviewed. People are at the center of these events, and getting their perspective will help determine the severity of an adverse event.
It is important because a patient or a participant may not suffer from physical side effects of experimental drugs or treatments, so providers will need to talk to patients to get an idea of how they are feeling psychologically. Their perspective may provide important feedback that could improve the treatment process. The importance of a patient's perspective is because the ultimate consequence, death, outweighs any potential gain that can be made from the completion of treatment. Also, gaining a patient's perspective helps build better communication between patient and provider. Once again, it reinforces any physical or mental issues the patient might be experiencing that a physician would be unable to detect. Measuring the severity of an adverse event can only be done with effective communication between the two parties.

Creating E"Quality" in Healthcare

Many people would think that the US health care system is the best in the world. For what it is worth and how much is invested into the system, one would think that the quality of care would be great for everyone who has access to it. But the reality of it all is that, our health care system is not the best, nor is the quality the best that it could be regardless of who or what is measuring it, it needs to be improved across the entire industry. A person's experience with health care is going to be different based on the individual, but if broken down into racial/ethnic groups, majority of whites would most likely state that the health care they receive is sufficient, while the black and Hispanic communities would claim that they receive little to no health care and that the care they do receive is not of good quality. Many questions arise to how and why these two groups are at the bottom of the "totem pole" in terms of receiving quality care.

Hispanics are fastest and the largest growing population in our country, yet their experience with health care has been the worse. According to the Sick in America Poll, Hispanics are more likely to wait for test results, receive poorly managed care, and less likely to get access to the latest technology in comparison to whites (Knox, 2012). This could possibly be due to the fact that many of these Hispanics live in areas where access to existing health care facilities with the latest technology do not exist or are too far away. Also the number of them who may not be legal citizen eliminates their chances of receiving any form of health insurance or quality of care because they can not afford the services. 31 percent of Hispanics are uninsured, compared to 21 percent of non-Hispanic blacks and 12 percent of non-Hispanic whites (Knox, 2012), and a majority of them are enrolled in the Medicaid or are eligible for Medicaid but are not enrolled. The black community is facing similar issues and like Hispanics are not receiving good quality of care. But with more of a focus on where the majority of black communities exist and their proximity to health care facilities that offer what many would consider good quality of care. Cultural competency is greatly discussed and understood by some providers, and is being addressed in an ongoing battle to lessen the gap between race, culture and health care outcomes. 

It would be too easy to quickly point to the obvious factors that stand as barricades between them and access to quality health care. Other factors such as the difference in physiological and biological traits between minorities and whites may also play a role into the type of care they are receiving. Maybe the lifestyles of cultures of these groups are creating a challenge for health facilities in terms of how they can treat these patients. It may be necessary for health care providers to adjust their 'plan of action' for care if certain minority groups are more prone to or respond differently to certain health issues than whites, who are the majority that receive health care in this country.

No matter the living situation, cultural background or the color of one's skin, we all deserve proper access to the health care. Our health care system can not continue to ignore and close their doors to the groups who are unable to poor or reach out to health care facilities, because what is one community's problem can and will eventually become our nation's problem. The health care reform that has been created is a step in the right direction in terms of expanding coverage, but the next move and most difficult will be improving the quality of care to the millions of new health care beneficiaries. There is still hope as long as we look to close the gap and resolve the issues affecting the minority groups.

Knox, R. (2012, May 31). Sick in america: hispanics grapple with cost and quality of care. Retrieved from http://www.npr.org/blogs/health/2012/05/31/154063427/sick-in-america-hispanics-grapple-with-cost-and-quality-of-care

The Immeasurability of Quality

Quality is a universal word used in every industry and almost every facet of life, as a means to define and is also attributed to affecting the desired outcome from customers/consumers. The challenging factor of quality is that it is perceived differently by different people. What may be considered a product or service of high quality for one person may not be the same for another. Each industry has their own way of effectively handling and providing different levels of quality for their customers. For example, in the auto industry, quality can be measured by the types of materials and resources used to build the exterior and interior features of an automobile. A care doesn't have to be fitted with the finest leathers and cloths or come equipped with the latest technology to be considered high or good quality. It all comes down to the individual customer and how the vehicle will satisfy their needs and wants. But within the healthcare industry, it would seem that quality is much more difficult to measure and effectively implement. According to Berwick and Joshi (2008), "the quality of care provided should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organizational management elements of health care".

In the U.S. there are close to 50 million people uninsured, 25 million under-insured (Commonwealth Fund, 2008), and unfortunately many of those who have insurance do not possess an adequate amount of health care literacy. So how can we expect our society to benefit from high quality health care service, and for our health care organizations to provide quality care, if most of us do not know how to properly measure it. Many health care facilities have looked at other industries such as hospitality to improve their quality. For example, many hospitals have improved the look of inpatient rooms, installed fancy decorations, flat-screen televisions, and five-star gourmet food. With this strategy, I think health care facilities look to provide better quality in the nonclinical aspect in hopes of having their patient be overwhelmed with luxurious items while still providing the same mediocre or poor quality they've been providing. In actuality, they are possibly masking the real problem at hand of not knowing how to effectively and efficiently improve the quality of care that the patient receives. Also, how much of an impact does this have on outpatients and other customers who don't get the "five-star" treatment? They are left to measure the quality of they care they receive solely on the interactions made with clinical staff members and the results from procedures and health care services they were provided.

For me, quality, especially in health care requires understanding and cooperation from both parties. Quality is in the eye of the beholder, and even the beholder may not know what they want in terms of quality. So it is health organizations who are looking to provide a particular type of  quality through the products/services they offer should look to do so by knowing what their customers desire. On the other side of the spectrum, customers need to be informed as much as they can about the industry, having customers who are knowledgeable about their health will result in better relationships and outcomes in terms of care received.



Berwick, D., & Joshi, Maulik (2008). Healthcare Quality and the Patient. The Healthcare Quality Book.

C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, "How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007," Health Affairs Web Exclusive, June 10, 2008, w298–w309.