Uwe Reinhardt and "Evidence Based Administration"

Princeton economist Uwe Reinhardt has a thought-provoking piece in the New York Times (How Much Fraud and Abuse Is There in U.S. Health Care?) in which he argues that there is inordinate attention paid to ferreting out fraud and abuse in US hospitals. The column is a response to one of the ideas Republicans raised at last week's health care summit: the use of undercover agents posing as patients to find fraud and abuse.Reinhardt makes a few interesting observations:

• Hospital try extremely hard to avoid defrauding the US government. The penalties are just too great
• The effort that hospitals put in is onerous and costly
• We could learn from foreign governments, who practice scrutiny by exception --only focusing on outliers rather than everyone
• Wide variations in costs and practice patterns are driven by affiliated physicians --not the hospitals' own employees-- and hospitals have little control over them
• I especially like his suggestion of evidence--based administration (EBA): "just as the use of clinical procedures should be based on solid empirical evidence that they work and are worth their cost, the ever-new administrative burdens that government imposes on health-care providers should meet the same evidence-based test."

Maybe because it's the Times, the reader comments are pretty good, and they add some important dimensions to the argument:

• Much of the fraud in health care lies outside major hospitals in small operations such as home health care and ambulatory clinics
• A lot of high spending and unneeded testing is wasteful --but isn't fraud. The public tends to get these things confused

I'm generally with Reinhardt. There's so much focus on compliance with billing rules --not to mention other regs like HIPAA-- that costs go up and service levels fall. It really is smoother in some socialized systems, a fact it's hard for Americans (including me) to accept.And I really don't like the idea of fake patients. It reminds me a bit of the health care "mystery shoppers," which I also don't care for. I don't want my doctor wondering if I'm a real patient. It will introduce a whole new form of defensive medicine if it happens and may also cause physicians to  be wary of new patients in general.