Sol Price School of Public Policy, University of Southern California, Los Angeles.
Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles.
JAMA Netw Open. 2018 Dec 7;1(8):e185805. doi: 10.1001/jamanetworkopen.2018.5805.
Each year, billions of dollars are wasted owing to health care fraud, waste, and abuse. Efforts to detect fraud have been increasing, yet we have little information about physicians who have been excluded from Medicare and state public insurance programs for fraud, health crimes, or the unlawful prescribing of controlled substances.
To examine the characteristics of physicians excluded from Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study considered all physicians excluded from Medicare and state public insurance programs between 2007 and 2017. The study matched exclusion data to a comprehensive, cross-sectional database of US physicians assembled by Doximity, an online networking service for US physicians. The share of physicians excluded in each state was examined and linear trends of exclusions over time were estimated. Using physician-level multivariable logistic regression models, exclusions (binary variable) were assessed as a function of physician characteristics.
Exclusions for fraud, health crimes (defined legally as criminal penalties for acts involving federal health care programs), and substance abuse; and physician characteristics, including age, sex, allopathic vs osteopathic degree, medical school attended, ranking of that medical school, medical school faculty affiliation, practice state, practice location, and specialty.
Between 2007 and 2017, 2222 physicians (0.29%) were temporarily or permanently excluded from Medicare and state public insurance programs. Fraud, health crimes, and substance abuse exclusions increased, on average, 20% per year (equivalent to 48 [95% CI, 40.4-56.0] convictions/year from a base of 236 convictions in 2007 to 670 convictions in 2017 [an increase of approximately 200% from 2007 to 2017]). Exclusion rates were highest in the West and Southeast. West Virginia had the highest exclusion rate, with 5.77 exclusions per 1000 physicians (32 exclusions among 5720 physicians), while Montana had 0 exclusions during this period. Male physicians, physicians with osteopathic training, older physicians, and physicians in specific specialties (eg, family medicine, psychiatry, internal medicine, anesthesiology, surgery, and obstetrics/gynecology) were more likely to be excluded.
The number of physicians excluded from participation in Medicare and state public insurance reimbursement owing to fraud, waste, and abuse increased between 2007 and 2017. Several physician characteristics, including being a male, older age, and osteopathic training, were significantly and positively associated with exclusion. Our results highlight the potential value of using physician characteristics in conjunction with information on medical claims filed by physicians to help identify adverse physician behavior.
由于医疗保健欺诈、浪费和滥用，每年浪费数十亿美元。尽管我们一直在努力加强对欺诈行为的检测，但对于因欺诈、医疗犯罪或非法开具受控物质而被排除在联邦医疗保险和州公共保险计划之外的医生，我们知之甚少。
研究因欺诈、医疗犯罪或非法开具受控物质而被排除在联邦医疗保险和州公共保险计划之外的医生的特征。
设计、地点和参与者：本横断面研究考虑了 2007 年至 2017 年间所有被排除在联邦医疗保险和州公共保险计划之外的医生。该研究将排除数据与 Doximity 汇编的美国医生综合、横断面数据库进行了匹配，Doximity 是一个面向美国医生的在线网络服务。研究人员检查了每个州的医生被排除的比例，并估计了随时间推移的排除趋势。使用医生层面的多变量逻辑回归模型，将排除（二进制变量）作为医生特征的函数进行评估。
欺诈、医疗犯罪（定义为涉及联邦医疗保健计划的行为的刑事处罚）和药物滥用的排除；以及医生特征，包括年龄、性别、整骨疗法与非整骨疗法学位、就读的医学院、该医学院的排名、医学院教师隶属关系、执业州、执业地点和专业。
2007 年至 2017 年间，有 2222 名（0.29%）医生被暂时或永久排除在联邦医疗保险和州公共保险计划之外。欺诈、医疗犯罪和药物滥用的排除率平均每年增加 20%（相当于 2007 年 236 例定罪基础上每年增加 48 例[95%CI，40.4-56.0]定罪），2017 年达到 670 例定罪[2007 年至 2017 年增加约 200%]）。西部和东南部的排除率最高。西弗吉尼亚州的排除率最高，每 1000 名医生中有 5.77 名被排除（在 5720 名医生中有 32 名被排除），而蒙大拿州在此期间没有被排除。男性医生、接受整骨疗法培训的医生、年龄较大的医生以及特定专业（如家庭医学、精神病学、内科、麻醉学、外科和妇产科）的医生更有可能被排除。
由于欺诈、浪费和滥用，2007 年至 2017 年间被排除参与联邦医疗保险和州公共保险报销的医生人数有所增加。一些医生特征，包括男性、年龄较大和接受整骨疗法培训，与排除有显著正相关。我们的研究结果突出表明，在使用医生特征的同时结合医生提交的医疗索赔信息，有助于识别不良医生行为。
