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Original Investigation
Health Care Policy and Law
October 28, 2019

Association Between Treatment by Fraud and Abuse Perpetrators and Health Outcomes Among Medicare Beneficiaries

Author Affiliations
  • 1Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  • 2Johns Hopkins University School of Medicine, Baltimore, Maryland
JAMA Intern Med. Published online October 28, 2019. doi:https://doi.org/10.1001/jamainternmed.2019.4771
Key Points

Question  Is receiving treatment from fraud and abuse perpetrators (FAPs) associated with adverse health events among Medicare beneficiaries?

Findings  In this cross-sectional study of 8204 Medicare beneficiaries who received health care services from FAPs in 2013 and 296 298 who received care from non-FAPS, the 3-year, risk-adjusted mortality was 3.3 to 4.6 percentage points (13% to 23%) higher, and rates of emergency hospitalization in 2013 were 3.2 to 9.3 percentage points (11% to 30%) higher for FAP-treated patients compared with patients treated by nonperpetrators.

Meaning  This study’s findings suggest that avoidance of Medicare FAPs may be associated with improvements in beneficiary health and longevity.

Abstract

Importance  Fraud and abuse contribute to unnecessary spending in the Medicare program, and federal agencies have prioritized fund recovery and the exclusion of health care practitioners who violate policy. However, the human costs of fraud and abuse in terms of patient health are unknown.

Objective  To assess whether Medicare beneficiaries’ receipt of health care services from fraud and abuse perpetrators (FAPs) is associated with worse health outcomes.

Design, Setting, and Participants  Retrospective cross-sectional study comparing mortality and emergency hospitalization rates of 8204 patients treated by an FAP with those among patients treated by a randomly selected non-FAP in 2013. Known FAPs were identified from the December 2018 List of Excluded Individuals/Entities (LEIE) published by the Office of the Inspector General in the Department of Health and Human Services. Patients were identified in a 5% sample of Medicare claims data and were enrolled in the Fee-for-Service program.

Exposures  Treatment by a health care professional subsequently excluded from Medicare for fraud, patient harm, or a revoked license.

Main Outcomes and Measures  All-cause mortality between 2013 and 2015 and 2013 emergency hospitalizations.

Results  A total of 8204 Medicare beneficiaries in the study sample (mean [SD] age, 69.2 [14.2] years; 58.2% female, and 23.0% nonwhite) saw an FAP for the first time in 2013. Of these, 5054 (61.6%) were treated by fraud perpetrators, 1157 (14.1%) by patient harm perpetrators, and 1193 (24.3%) by revoked license perpetrators. Compared with 296 298 beneficiaries treated by non-FAPs (mean [SD] age, 71.1 [12.4] years; 58.6% female, and 16.5% nonwhite), beneficiaries exposed to an FAP were more likely to be eligible for both Medicare and Medicaid (34.7% [2845 of 8204] vs 21.9% [64 989 of 296 298]; P < .001) and more likely to be disabled at an age younger than 65 years (27.2% [2231 of 8204] vs 18.6% [55 168 of 296 298]; P < .001). All FAP exposures were associated with higher mortality and emergency hospitalization rates after risk adjustment and propensity score weighting: for mortality, exposures to fraud FAPs were associated with an increase of 4.58 percentage points (95% CI, 2.02-7.13; P < .001); to patient harm FAPs, with an increase of 3.34 percentage points (95% CI, 1.40-5.27; P = .001); and to revoked license FAPs, with an increase of 3.33 percentage points (95% CI, 1.58-5.09; P < .001). Increases were similar for emergency hospitalization rates: for fraud FAP exposures, 3.24 percentage points (95% CI, 0.01-6.46; P = .049); for patient harm FAP exposures, 9.34 percentage points (95% CI, 6.02-12.65; P < .001); and for revoked license FAP exposures, 9.28 percentage points (95% CI, 6.43-12.13; P < .001).

Conclusions and Relevance  This study’s findings suggest that receiving medical care from FAPs may be associated with significantly higher rates of all-cause mortality and emergency hospitalization after risk adjustment. Identifying and permanently removing FAPs from the Medicare program may be associated with improved beneficiary health in addition to financial savings.

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