HLM: You mentioned that a big surprise for you at CMS was the amount of Medicare and Medicaid fraud. Can you elaborate, especially on Medicaid fraud which we haven't heard much about?
DB: It's a small minority, but they are professional in their criminal behavior, even so that when you shut them down, they come back. I began to see that one of the serious costs of fraud is that we have to screen everybody. It's like if there's a terrorist, we have to do body scans on everybody, and everybody ends up in security lines. That was an eye opener for me.
HLM: Can you give an example?
DB: There was one case where a dentist was charging for root canals in little kids. Kids don't need root canals. He said he was doing a lot but he actually wasn't doing any. Well, when the fraud unit got to him, he started doing root canals on children.
And I remember the case of one child who had, as I recall, something like 14 root canals. For real. When I arrived at CMS there had been set up some very effective mechanisms...and we were beginning to work on predictive analytics using hard data to spot patterns where something was amiss. I thought that was terrific, and assume it's still very much underway.
HLM: How is the improvement movement changing today?
DB: It's maturing. In the early days, the improvement movement was focused on individual processes, and the theory of how you can take a process, redesign it, and end up with a better result. That's the basics, and they're now largely well in hand. We've been doing that now for 20-25 years.
Now we're seeing the improvement movement get more directly involved with the economics of healthcare, such as with the introduction of LEAN production and thinking, and the Toyota production process. These are, in effect, the methods of quality improvement brought to bear directly on the costs of care, so that we reduce waste while we help people more.
The next step, I think, is the connection of improvement to policy. In general, in Washington I'd say that a substantial majority of policy makers do not understand improvement. They have not seen what I have had a chance to see, which is what it's like when doctors and nurses, pharmacists, and managers get together to learn and apply improvement methods.
They haven't realized how much good can be done when we set about to save money by improving the processes and outcomes of care.
They don't see that—the savings potential. The CBO (Congressional Budget Office), the OMB (Office of Management and Budget), the political operatives, their staffs and senators and representatives are generally not familiar with the financial benefits of health care improvement.