Characteristics of Physicians Excluded from Medicare Reimbursement Programs Examined
Older male physicians who practice family medicine, internal medicine, psychiatry, or surgery were more likely to have been excluded from insurance reimbursement participation.
During the 10-year period between 2007 and 2017, a noticeable increase in the number of physicians excluded from Medicare and state public insurance reimbursement participation due to fraud, waste, or abuse was observed, according to results of an analysis published in JAMA Network Open.
Older male physicians who practiced family medicine, internal medicine, psychiatry, or surgery were more likely to have been excluded during this study period.
Physicians who were excluded from Medicare and state public insurance programs between the years 2007 and 2017 were matched to a cross-sectional database provided by Doximity. Study researchers evaluated the share of physicians who were excluded in each US state and also examined linear trends of exclusions during the 10-year period. Physician variables, including legal factors (eg, fraud, health crimes, and substance abuse) and characteristics (eg, age, sex, allopathic vs osteopathic degree, medical school attended, ranking of that medical school, medical school faculty affiliation, practice state, practice location, and specialty) were also examined to identify factors associated with exclusion.
In total, 2222 physicians (0.29%) in the United States were either temporarily or permanently excluded from Medicare and state public insurance programs between 2007 and 2017. Investigators observed an approximately 20% per-year increase in exclusions due to fraud, health crimes, and substance abuse. This increase was found to be equivalent to 48 (95% CI, 40.4-56.0) convictions per year, from 236 convictions in 2007 to 670 convictions in 2017, representing an increase of 200% during the 10-year study period.
The adjusted odds ratios [aOR] for fraud, but not for health crimes or substance abuse, were higher in surgery (aOR, 1.75; 95% CI, 1.09-2.81), anesthesiology (aOR, 1.69; 95% CI, 1.06-2.68), and obstetrics/gynecology (aOR, 1.76; 95% CI, 1.10-2.80) physicians. The aOR for health crimes were higher in internal medicine physicians (aOR, 2.24; 95% CI, 1.21-4.14).
The West and the Southeast had the highest exclusion rates, with West Virginia representing the state with the highest exclusion rate per 1000 physicians (5.77 exclusions). Conversely, Montana had 0 exclusions between 2007 and 2017. Physician characteristics associated with a higher likelihood of exclusions during this period include male sex, having osteopathic training, being older, and having specific specialties (eg, family medicine, psychiatry, internal medicine, anesthesiology, surgery, and obstetrics/gynecology).
Higher adjusted ORs of exclusion for fraud and health crimes were correlated with physicians specialized and practicing family medicine (fraud: aOR, 1.70; 95% CI, 1.09-2.65 and health crimes: aOR, 2.20; 95% CI, 1.18-4.08) and psychiatry (fraud: aOR, 2.38; 95% CI, 1.52-3.73 and health crimes: aOR, 2.08; 95% CI, 1.09-3.95). In addition, adjusted ORs for fraud were higher in surgery (aOR, 1.75; 95% CI, 1.09-2.81), anesthesiology (aOR, 1.69; 95% CI, 1.06-2.68), and obstetrics/gynecology (aOR, 1.76; 95% CI, 1.10-2.80) specialties.
The cross-sectional design of the study, as well as the inclusion of only physicians who had been identified as fraudulent represent likely limitations of the study.
Identifying the associations found in this study “lays the foundation for further studies to illuminate the mechanisms underlying these associations and their potential for improving predictive models.”
Chen A, Blumenthal DM, Jena AB. Characteristics of physicians excluded from US Medicare and state public insurance programs for fraud, health crimes, or unlawful prescribing of controlled substances. JAMA Netw Open. 2018;1(8):e185805.