To Save America

by Newt Gingrich

  As good as the Dartmouth team is, it is not as comprehensive as the collective wisdom of the general public looking at the data and developing new studies, patterns, and solutions.

  This data should only be released, however, after being vigorously patient de-identified, as is done in the academic world. Patient privacy must remain paramount.

  2. The federally administered Medicare program and the mostly state-administered Medicaid program must improve their sharing of patient data. Their failure to do so results in significant lost opportunities to coordinate care and catch fraud. A 2009 report by the Kaiser Commission found insufficient controls and duplicate claims processing agents that invite fraud and abuse.More than 8.8 million of Medicaid’s 58 million beneficiaries are low-income senior citizens who are eligible for both Medicaid and Medicare.21 That is close to 15 percent of Medicaid enrollment, but 40 percent of outlays. They comprise 18 percent of Medicare’s enrollment, but Medicare spent even more on their care than Medicaid did. These so-called “dual eligibles” account for roughly $300 billion in annual spending, yet the care they receive is often haphazard, uncoordinated, and reactive because Medicare and Medicaid don’t communicate with each other. The result is sub-optimization of patient health outcomes to accompany the waste and fraud.22

  3. Outsource the authentication of new Medicare and Medicaid suppliers to Visa, Mastercard, or American Express. After forty years of failure, it is clear the status quo in Washington, D.C., is incapable of managing these programs, so let’s turn to experts with a track record of success.The American credit card industry processes over $2 trillion in transactions every year, and there are 800 million credit cards accepted by millions of vendors to buy countless products. Yet fraud constitutes just one-tenth of one percent of the credit card industry. Conservatively speaking, fraud in Medicare and Medicaid is 10 percent, making it 100 times worse.

  4. The CMS-855S form that prospective durable medical equipment providers must fill out lacks even a simple, “under penalty of perjury” line by the signature. That little tweak alone would help prosecutors and perhaps even have some deterrent effect. Likewise, we should make the submission of bogus claims a reason for immediately revoking a supplier’s billing number.

  5. Allow seniors on Medicare the option of traveling to another city to receive major non-emergency surgeries. If a particular set of procedures costs thousands of dollars less in the next state over and the quality outcomes are as good or better, we should allow people the choice of facilities, especially if the individual receiving care can split the savings with taxpayers.The commercial insurer Wellpoint launched a demonstration project that allows customers to travel to India for non-emergency elective procedures like plastic surgery. Surely it’s not too radical to take advantage of arbitrage opportunities here in America within the Medicare system.

  6. Enhance discovery of third party liability in Medicaid. Simply maximizing self-reported third party coverage by patients could save state Medicaid programs 1-2 percent per year. That is $4-7 billion a year the insurers would legitimately be paying that the taxpayers currently cover due to bureaucratic incompetence. A GAO report shows up to 13 percent of people on Medicaid with other coverage.23

  7. Medicare and Medicaid should use private-sector standards for establishing the number of suppliers for a product or service in a defined area. California’s Medicaid program has been doing this for nearly a decade in durable medical equipment. While there was some pushback from frustrated potential providers, there were no reports of access to care issues from beneficiaries.In a related experiment last year, the South Carolina Medicaid program told its forty-eight Medicaid beneficiaries with the most number of prescriptions they could thenceforth only get prescriptions from one pharmacy, which they could choose themselves. After eight months those individuals had 40 percent fewer prescriptions, saving Medicaid $320,000.

  8. Reduce the administrative red tape and lengthy appeals that cancelled suppliers often exploit. Currently, suppliers can drag out the process for months and usually get reinstated. In 2007 and 2008 the OIG conducted 1,581 unannounced site visits to durable medical equipment providers in South Florida and found 491 either didn’t have an actual facility or were not properly staffed. All 491 billing privileges were revoked, 243 of those appealed, and 222 (91 percent) were reinstated. Of the 222 reinstated, 111 later had their billing privileges revoked again.24 The Florida Medicaid program requires suppliers to sign contracts agreeing the state has the right to terminate them at any time “without cause.” This has been effective without harming access to care. Any public or private buyer of a service should retain the right to stop buying that service whenever she sees fit.

  9. Move to a system of 100 percent electronic remittances. Paper bills and the postage required to mail them cost billions unnecessarily. Furthermore, paper records guarantee the bureaucrats are always many steps and many months behind the crooks. We currently have paper clerks chasing crooks who use iPhones and Blackberries. It is a hopeless mismatch of technologies favoring the crooks over the cops.

  10. Use unique ID numbers for Medicare beneficiaries instead of their social security numbers. A stolen Social Security number leaves a person much more vulnerable to theft and fraud.

  11. Require more timely updates from states on Medicaid enrollment data. Even senior congressmen, as of April 2010, can only get state-by-state Medicaid enrollment data up to 2007. The latest data available for Maine is 2004.25 Compare that to FedEx and UPS, which track 23 million packages a day in real time, or to McDonald’s, which collects data or sales from 37,000 stores worldwide every night. As shown above, the existing data collection system urgently needs to be fixed.

  12. Experiment with moving to biometric ID for Medicare and Medicaid beneficiaries. Cards are easily lost, stolen, copied, and forged, which contributes to uncoordinated care and fraud.

  13. Recognize the shortcomings of isolated fee-for-service arrangements and follow two of MedPAC’s key recommendations: expand the use of risk-adjusted plans in Medicare, and expand the medical home model particularly for people with one or more chronic conditions. Enhanced use of medical homes would be particularly helpful in a Medicare system where specialists are overpaid relative to primary care. The standard fee-for-service model rewards volume first and foremost, with coordination of care, improvement of patient health, and fraud as secondary considerations at best. The same recommendations are appropriate for Medicaid.26

  14. Encouraging better data analytics across programs and jurisdictions is a must. The entire healthcare system could benefit tremendously from the same level of inter-agency data sharing that is common in law enforcement, particularly in the tracking of sex offenders. When sex offenders move between states they are required to register immediately with local law enforcement. If they miss their deadline, they are flagged instantly by sophisticated systems pulling information from public sources. Doctors who have been sanctioned for fraud, hospital administrators who have engaged in fraud, DME salesmen with fraudulent convictions, criminal beneficiaries, and others are much freer to set up shop in a new state—or to send a new, unknown member of a fraud ring into the system—without being reported from their prior jurisdiction.

  15. Require Medicare and Medicaid to pay closer attention to Medicare ID numbers that show outlier behavior. Individuals who are excessively billing at, say, emergency rooms are likely getting poor, uncoordinated, inefficient care, or their Medicare/Medicaid cards are being billed by fraudulent providers with or without the patient’s knowledge. In either case, both the individual’s health and the taxpayer’s pocketbook would be better served by being instantly identified.

  16. Data sharing across departmental jurisdictions and with state and local governments should be done with the same seriousness as in national security. Prior to September 11, the CIA and the FBI rarely communicated. Now they compare intelligence frequently. There are multiple databases of Medicare and Medicaid providers and suppliers along with th
eir disciplinary records.27 But these databases are not as universally comprehensive or as accessible as, say, the National Instant Criminal Background Check System (NICS) used to keep guns out of the hands of criminals. The National Crime Information Center is another law enforcement tool that allows a local officer to have instant, nationwide access to a suspect’s criminal background. These systems are not perfect, but they are good examples showing how individuals with criminal records and/or disciplinary actions in the healthcare field can at least be flagged early. This concept was part of President Obama’s revised health proposal unveiled on February 22, 2010, based on legislation introduced by Congressman Mark Kirk with bipartisan support. We should utilize data from the Social Security Administration and IRS for these efforts as well.

  17. Require cost reports for Ambulatory Surgical Centers (ASC) similar to what is currently required for hospitals by the Centers for Medicare and Medicaid Services (CMS). It is understood there are specific differences between an ASC and a hospital, and the report requirements should be modified to accommodate this.

  18. Migrate Medicare and Medicaid beneficiaries into arrangements with personal health accounts in which individuals have direct and immediate financial incentives to engage in behaviors that improve their health. The current system includes nothing to deter patients with Medicare, Medicaid, and most private plans from scheduling as many physician visits as they can. Indeed, a classic 2003 New York Times article, entitled “Patients Line Up for All That Medicare Covers,” accurately captures a culture where seniors on Medicare can get as many healthcare services as they can fit on their calendar, regardless of cost to taxpayers or the lack of medical benefit.28 There are myriad ways to structure personal accounts, the least controversial being zero-balance accounts where beneficiaries are paid small amounts of money for achieving improved health status. The vast majority of healthcare spending in the coming decades will be on people with chronic conditions. This means personal choices around care regimens will have a major, long-term impact on quality outcomes and cost. We must continue developing and deploying models of healthcare financing that maximize patient behavior change toward patterns of good health. Ultimately, that is the only way to save American healthcare. Account-based plans are the most effective way to create incentives to accomplish this goal.

  The topic of healthcare fraud, waste, and abuse is too vast for one chapter, one book, or even a ten-volume series. But it is crucial for the American people to grasp just how large a problem this is, how much money is involved, and that there are solutions that would drastically reduce the problem without limiting access to medical care.

  CHAPTER SEVENTEEN

  Green Conservatism Versus Left-wing Environmentalism

  With Terry L. Maple, President and CEO of the Palm Beach Zoo

  More and more people around the world are discovering “green conservatism,” a new pathway to environmental stewardship and a compelling conservative alternative to the high-tax, big-bureaucracy, job-killing, and government-centralizing environmentalism of the Left. Green conservatives understand people can vigorously protect biodiversity and deliver cleaner forms of energy in a fiscally responsible way without the heavy-handed intervention and expansion of government. People with green core values who feel abandoned by extreme, big-government environmental positions are vastly more comfortable with the market-based, entrepreneurial approach of green conservatives.

  Green conservatives are politically active in Australia, Canada, and the United Kingdom among other nations, and the label is increasingly claimed by an emerging center-right coalition in the United States. When we first applied the term in U.S. politics, we defined green conservatism as: “an optimistic, positive, science and technology-based, entrepreneurial, market-oriented, incentive-led, conservative environmentalism that creates more solutions faster and that will result in more biodiversity with less pollution and a safer planet.”

  More simply, green conservatism describes conservatives who incorporate green concerns into their ideology.

  From the business side, entrepreneurial environmentalists are the new agents of change on the frontlines of a creative environmental movement. Government’s role, rather than to dictate, is to incentivize. In homes throughout America, energy efficiency has been facilitated by government rebates and matching funds to encourage investment in efficient appliances, insulation, and technology.

  Green conservatives worldwide are broadening their political platforms by including environmental initiatives. In the UK, conservative leader David Cameron has proposed a “smart power grid,” incentives for small-scale renewables, sustainable public transit, and technological innovation to cut carbon emissions. In France, a conservative president presides over a nation whose investment in nuclear energy is a model for other European countries.

  And in Canada, Preston Manning, founder of the Canadian Reform Party, insists Western Canadian conservatism, with its rural and populist origins, must reconcile its support for strong growth with the necessity of environmental protection.

  As documented in our book A Contract with the Earth, many U.S. businesses and industries have already adopted sustainable practices for their employees and their facilities. Deploying fleets of electric, hybrid, natural gas, or hydrogen-powered cars and trucks, they are also building new plants that comply with green building practices such as LEED (Leadership in Energy and Environmental Design) guidelines. Combining innovation with LEED-type guidelines is an inspiring public platform for our new movement.

  A COMMITMENT TO ENVIRONMENTAL LEADERSHIP

  We believe unwavering political and citizen leadership is the key to effective environmental policies. Quality of life and environmental sustainability with continued economic growth in jobs and incomes must become national priorities. In the 2008 paperback edition of A Contract with the Earth, we proposed that green conservatives could provide leadership for a polarized and stalemated environmental movement:The fact that green conservatism is attracting converts from every political faction renders the movement mainstream. Breaking out from the current stalemate means we must find a way to get things done. An inclusive, bipartisan movement can be built on green conservative principles.1

  In contrast, a global, left-wing environmental movement organized around a doomsday theory of climate change is pushing for a massive wealth transfer from the West to developing nations, and an enormous increase in bureaucratic control by governments. Meanwhile, UN-designated experts and an alliance of global bureaucrats are lobbying for treaties to enforce international climate change regulations within a system of global taxation. This entire “solution” is a kind of class warfare applied to nation states.

  With our historical emphasis on free enterprise and national sovereignty, Americans have resisted these extreme measures. But we believe genuine environmental problems, many of them ignored due to the global warming obsession, cannot be resolved without U.S. leadership. Therefore, green conservatives must offer rational alternatives to the extremist positions now dominating the discussion. Pursuing affordable programs of worldwide reforestation, for example, could help capture carbon dioxide while protecting biodiversity—the ultimate win/win conservation strategy.

  To lead on this issue, conservatives must determine how a healthy environment is compatible with key conservative political ideas. We can begin by advocating sustainability. Defined as “meeting the needs of the present without compromising the ability of future generations to meet their own needs,” this concept is consistent with a conservative political philosophy. “Conservative,” after all, comes from the same root as “conservation.” Adherence to this fundamental principle will conserve future opportunity for optimal quality of life, economic stability, and human happiness. Ronald Reagan campaigned on these kinds of universal human aspirations.

  For the sake of our children and grandchildren, we must act cooperatively to ensure a sustainable world. However, green conservatives are uniquely committed to empowering people r
ather than government.

  The government can play a modest role setting the general direction. An example is the 1969 U.S. National Environmental Policy Act, which aimed to “create and maintain conditions under which man and nature can exist in productive harmony, and fulfill the social, economic and other requirements of present and future generations of Americans.” The key connection is the need to achieve and sustain environmental and economic harmony.

  Green conservatives must do more than simply say no to the big-government, environmental Left; we need to provide a clear and robust political alternative for local and global environmental stewardship. We must articulate this vision in party platforms, newspaper op-ed columns, community and national blogs, and other electronic media in order to generate a menu of green conservative ideas in the environmental marketplace.h Affiliating with the tea party movement is also a good opportunity to spread green conservatism, since many tea party activists strongly favor a healthy environment but oppose using socialist policies to achieve it.