Association between Treatment by Fraud and Abuse Perpetrators and Health Outcomes among Medicare Beneficiaries

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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 296298 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% [64989 of 296298]; P <.001) and more likely to be disabled at an age younger than 65 years (27.2% [2231 of 8204] vs 18.6% [55168 of 296298]; 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.

Original languageEnglish (US)
Pages (from-to)62-69
Number of pages8
JournalJAMA internal medicine
Issue number1
StatePublished - Jan 2020

ASJC Scopus subject areas

  • Internal Medicine


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