Health Department in announcing these announcements of violations in eating establishments. This was but one of a number of similar preemptions that continued to occur. We assumed, therefore, that if Medicaid were to obey the HSA directive about public releases, we could expect that eventually HSA would start releasing under the HSA imprimatur weekly lists of names of aberrant Medicaid practitioners and institutions.

Accordingly we did not zealously discourage the initiative of newspaper reporters who continued to insist on talking with us directly despite the HSA directive. Stories about Medicaid continued to emerge without previous processing by the HSA office of public relations. There was a detailed article of our identification of a major abuse in Medicaid optometry by one of the most important commercial vendors in New York City. There were stories and favorable editorial comment about how we had terminated the "epidemic" of flat feet in New York City by cracking down on the promiscuous prescribing of so called orthopedic shoes by podiatists who would write bogus diagnoses to justify Medicaid reimbursement to shoe stores. There were articles on our discovery of millions of dollars worth of fraud perpetrated by commercial ambulance companies who sought Medicaid payments.

THE CADRE

Every program needs a critical mass of energetic talent. The cadre needs an extraordinary degree of commitment, almost fanaticism about the social non-expendable nature of the program. On a day to day basis the implementers of a controversial program such as Medicaid are very much alone. They need each other's support and trust in a program that they often come to view as the moral equivalent of war.

Other considerations become secondary. This is not to say that the cadre performs its tasks with no hope of reward. Salary increases and promotions are necessary. But mutual professional esteem, particularly recognition rendered by one's real professional superiors, are equally indispensable.

The evidence of the normative high morale of the cadre are many: the excitment, the pervasive fun, the camaraderie, the long hours of work, the profusion of professional papers, the identification of staff with programs, the swagger, even the resentment sometimes manifested by people of competitive agency programs not so endowed.

These were the characteristics of the Health Department Medicaid staff. But, for there to be reasonable prognosis for survival of even the most dedicated cadre, there needs to be the benign nurture of the health commissioner. During my 1967-1972 service with the New York City Health Department. Medicaid was blessed with the tenure of 2 supportive health commissionersinitially Edward O'Rourke, M.D., M.P.H., and thereafter Mary C. McLaughlin, M.D., M.P.H., both of whom played the indispensable roles of patron and protector.

FAILURE AND REGRETS

These brief memoirs properly should include representative failure and regrets. Had we been prescient, or more experienced, we would have done certain things differently. Regretably we could not tap the experience of other programs whether in New York City or elsewhere because ours was the first program of its type and magnitude. This is not to claim that the New York City Department of Health in its role as regulatory agency was doing something totally de novo. Health departments or their historical antecedents have been in the business of regulating since their Biblical forebears identified and quarantined lepers. The regulatory activities of New York City Medicaid represented a quantum leap beyond the important regulatory beach-heads originally established by the Children's Bureau in the Crippled Children's Program. The programmatic originality of New York City Medicaid derived from the fact that we took quite seriously the quality control implications of the Title 19 legislation.

What were our failures? and consequently our regrets? A partial annotative inventory hints at a rich lode of detailed future case studies.

(1) Failure to manipulate Medicaid fees to achieve optimal health goals.Had the New York City Department of Health possessed complete control over the Medicaid fee schedule of reimbursement to professioinal and institutional providers of services, we could have tapped the forces of the market place to

encourage the provision of certain desirable services and discourage the provision of others.

In physician care, for example, we could have encouraged more cervical Pap smears. The State rejected our request for a specific supplementary fee for Pap smears over and above what was incorporated within the fee per visit. We felt that such a fee would act as an effective fiscal incentive because too few physicians were performing such smears as part of the physical examination. In contradistinction the State feared that paying a separate fee for cervical Pap smears would act as a precedent for further separate fees for the now fragmentized portion of the physical examination.

On the other hand, we did have the authority to apply a separate fee for tonometry performed by optometrists. As a result of the fee that we authorized, there was a renaissance of tonometric examinations in New York City. This success in optometry made particularly bitter our legal incapability to use the same technique elsewhere. We wanted to manipulate fees particularly in dentistry, since the denial fee schedule seemed almost designed to promote the provision of extractions and dentures rather than preventive dentistry.

(2) Failure to restructure the practice of optometry.-We saw Medicaid as our opportunity to eliminate a historical conflict of interest that has plagued optometry since its inception. Optometrists simultaneously have prescribed lenses and have sold glasses. This state of affairs is similar to the situation that would exist were physicians to write prescripitons and simultaneously sell pharmaceuticals as well. We tried to promulgate a regulation in New York City Medicaid that every optometrist who wished to be reimbursed for any Medicaid services would first have to decide if he were to be exclusively (1) a Medicaid refracting optometrist or (2) a Medicaid dispensing optometrist. The predictable protests occurred. The State Health Department subsequently declined to support our petition on the grounds that we had no legal right to limit the scope of professional practice permitted by State optometric licensure.

(3) Failure to make compulsory continuing education a requisite for participation of practitioners in Medicaid.-(10). This is described elsewhere in detail. Here the New York Health Department and the New York State Department of Education failed to support the pertinent administrative regulation of New York City Medicaid. Actually here the failure was not total. The dental, optometric, and podiatric societies ultimately went on record favoring such compulsory continuing professional education as a requisite for continuing licensure.

(4) Failure to restructure publicly funded health services.-Here Medicaid represented a chance missed-not only in New York City, but throughout the country. Surely there had to be a more intelligent way to pay for and deliver publicly funded health services to the 2.5 million New York City Medicaid enrollees in a program costing $750,000,000 annually! Although the mix of administrative constraints compelled certain absurdities, we discerned enough theoretical flexibility within the program to permit overdue changes provided there was exercise of opportunistic ingenuity. In part, what prevented the inception of these changes was the total immersion of key Medicaid people on the local, state, and federal level in the overwhelming start up problems of an enormous program that had begun abruptly rather than incrementally. The division of responsibility between departments of social services and health at each of three governmental levels almost guaranteed no intelligent overall social planning. Within health and welfare departments in the nation-with notable and honorable exceptions-there was a paucity of ingenuity and courage with respect to the administration of Medicaid. Although Medicaid fiscal leverage to enforce standards was available everywhere, there seemed to be almost a difference in state after state, and in city after city-again with notable and honorable exceptions-about applying it.

Well meaning Medicaid administrators from outside New York City would visit us and depart now armed with reprints, memoranda, policy papers, procedures from our files. They customarily vowed to replicate at least portions of the New York City program when they returned to their own communities. We rarely heard from them or about their replications again. Once after a presentation of our material at an APHA meeting, one State Medicaid director called me aside and privately recounted an inventory of reasons why it was manifestly impossible for him to institute anything but ceremonial enforcement of Medicaid health care standards because of certain local political peculiarities. He was right.

GENERAL COMMENT

Quality control programs of health care services are always controversial. If seriously applied, they must provoke the hostility and often the countermeasures of the professionals and institutions being monitored.

Certain attributes of administration are called for: absolute staff integrity in deed and image, superb technical proficiency, a secure political base, a cadre of associates equipped with political cunning and zealotry, altertness and readiness to repel encroachments upon the program's legitimate turf.

None of these attributes is uniquely desirable for quality control. They are all desirable for effective management of any program. But for any future programs, that, like New York City Medicaid, tries to enforce standards of health care services, these attributes will be found to be utterly indispensable.

BIBLIOGRAPHY

(1) Alexander, R. S., "Medicaid in New York: Utopianish and Bare Knuckles in Public Health-11." "Administrative Dynamics in Megalopolitan Health Care," American Journal of Public Health, 59:5, p. 815-820, May 1969.

(2) Alexander, R. S., Bellin, L. E., Kavaler, F., Najac, H., Rosenthal, J., "The Participation of Optometrists in New York's Medicaid Program," Public Health Reports, 84:11, p. 1008-1012, November 1969.

(3) Alexander, R. S., "The Participation of Chiropractors in the New York City Medicaid Program," a case history written under contract with The Public Health Service for the Medical Administration Case History Series (Public Health Service).

(4) Bellin, L. E., "Medicaid in New York: Utopianism and Bare Knuckles in Public Health-III." "Realpolitik in the Health Care Arena: Standard Setting of Professional Services," American Journal of Public Health, 59:5, p. 820-825, May 1969.

(5) Bellin, L. E., Kavaler, F., "Policing Publicly Funded Health Care for Poor Quality, Overutilization, and Fraud-The New York City Medicaid Experience," A.J.P.H., 60:5, p. 811-820, May 1970.

(6) Bellin, L. E., Kavaler, F., “An Inventory of Medicaid Practitioner Abuses and Excuses vs. The Counter Strategy of The New York City Health Department," AJPH, 61: 11, pp. 2201-2210, November 1971.

(7) Bellin, L. E., "Testimony Before Subcommittee on Medicaire-Medicaid of the Committee of Finance, United States Senate, Ninety-First Congress, Second Sssion:" Part 2 of 2 Parts, U.S. Government Printing Office, Washington, 1970, p. 511-538, 558-561, Tuesday, June 2, 1970.

(8) Bellin, L. E., "Podiatry's Future Through the Medicaid Crystal Ball," Journal of American Podiatry Assoc., 59:11, p. 437-441, November 1969.

(9) Bellin, L. E., "Should a Paper on the Administration of Chiropractic Have Been Published in Medical Care-With Comments on Derivative Questions," Medical Care (in press).

(10) Bellin, L. E., "Compulsory Continuing Education for Licensed Health Care Professionals," a case history written under contract with the Public Health Service for the Medical Administration Case History Series (Public Health Service).

(11) Bellin, L. E., "Ever Subtler Refinement vs. State Implementation of 'Crude' Quality Control of Health Services-The PSRO as Implementation or Gimmickry?" (in press).

(12) Dintenfass, J., "Chiropractic in the New York City Medicaid Program," Journal of Clinical Chiropractic, 2:4, p. 26-34, January 26, 1969.

(13) Dintenfass, J., "The Administration of Chiropractic in The New York City Medicaid Program," Medical Care 11: 1, p. 40, 1973.

(14) Fisher, M., "The Costs of Delivering Dental Services," Journal of Public Health Dentistry, 30:2, p. 76-79, Spring 1970 issue.

(15) Fisher, A., "New Directors For Dentistry," American Journal of Public Health, 60:5, p. 848-853, May 1970.

(16) Kavaler, F., "Medicaid in New York: Utopianism and Bare Knuckles in Public Health-IV." "People, Providers and Payment-Telling It How It Is,” American Journal of Health, 59:5, p. 825-829, May 1969.

(17) Kavaler, F., Bellin, L. E., Green, A., Gorelik, E. A., and Alexander, R. S. "A Publicly Funded Pharmacy Program Under Medicaid in New York City," Medical Care, VII, 5, p. 361-371, September-October 1969.

(18) Kavaler, F., Bellin, L. E., Watkins, B. W., Schumann, N., and Herbst, E., "Publicly Funded Podiatry-First Data From Office Audits of New York City Medicaid Practice," Journal of American Podiatry Assoc., 59:11, p. 442-445, November 1969.

(19) Kavaler, F., Folsom, W. C., Jr., Rosenthal, J., Bellin, L. E. and Herbst, E., "A Preview of On-Site Visits in Optometry Under the New York City Medicaid Program," American Journal of Optometry and Archives of American Academy of Optometry, Vol. 47, No. 9, p. 728–735, September 1970.

(20) Rosenthal, J., and Segal, C., "Frontiers of Careers in Optometry: Opportunity for Members of Minority Groups," Journal of the American Optometric Assoc., 41:6, p. 540–542, June 1970.

(21) Schumann, N. S., Kavaler, F., Bellin, L. E., Lieberman, D. J., Watkins, B. W., and Haber, Z. G., "Publicly Funded Podiatry: The New York City Medicaid Experience," Medical Care, 9:2, p. 117–126, March-April 1971.

Reprint File: Bellin, Lowell E.; M.D.

[From American Journal of Public Health, November 1971]

MEDICAID PRACTITIONER ABUSES AND EXCUSES VS. COUNTERSTRATEGY OF THE NEW YORK CITY HEALTH DEPARTMENT

(Lowell Eliezer Bellin, M.D., M.P.H., F.A.P.H.A., and Florence Kavaler, M.D., M.P.H., F.A.P.H.A.)

Based in three years experience in the New York City Health Department, abuses in the provision of Medicaid are analyzed and methods for dealing with those involved are described.

INTRODUCTION

Neither to pander to administrative voyeurism nor to muckrake Medicaid practitioner abusers is the objective of this paper, but rather to pass along "savvy" in frustrating the behavioral excesses of certain participants in monumentally funded health care programs. During three years of formulating, monitoring, and enforcing Medicaid health care standards, the New York City Health Department has gained insight into (1) the methodology of abuses by a small percentage of practitioners (at least 5% by our estimate); (2) the normative defenses of these practitioners against the department's allegations of such abuses; and (3) the requisite governmental counterstrategy of gathering germane evidence to anticipate these defenses.

THE DIRTY LITTLE SECRET

The accessible health care literature is sanitarily devoid of such mundane information. Has the subject been deemed too charged or repugnant to be discussed save as gossip or savory anecdote? Consider where we would ordinarily inquire— the third party payers.

But the private health insurance companies have traditionally viewed themselves as indemnifying conduits of payment, not as monitors of health care standards. Historically the commercial carriers have kept hands off the professionals, relying on professional licensure for surety of their technical competence and professional worthiness. In short, the companies would have little to publish about administrative enforcement of standards even in the unlikely event that they chose to publish. And what about the nonprofit carriers who allege they maintain quality and cost controls? Blue Cross, Blue Shield and the prepaid plans understandably prefer discreet privacy regarding their negotiations with abusers.

Somehow administrators of public and privately supported health service programs are expected to leave about abuses and their controls—presumably through the grapevine, or through individual enterprise.

NEW YORK CITY MEDICAID

Between late 1966 and 1968, New York City Medicaid burgeoned to encompass its zenith enrollment of 2.5 million citizens and pay out annually about 750 million dollars. By 1970, the subsequently more stringent qualifications for enrollment in Medicaid diminished the number of recipients to about 1.9 million.

Each year about 600 million dollars pass to 18 municipal, 101 voluntary and 27 proprietary hospitals. About 150 million dollars are distributed to the private offices of participating practitioners: physicians, dentists, optometrists, podiatrists, pharmacists, and chiropractors. The swift growth of the program coupled with the bicephalic administration of two separate city agencies posed nettlesome problems. (6) The political interplay in standard setting (7, 18) and the department's unprecedented governmental venture into on-site auditing of the offices of practitioners submitting huge bills (8, 13, 14, 15, 18) provoked consternation on the part of some professionals. But the statistics on abuses that the New York City Health Department subsequently released to the press and to the literature blunted overt opposition.

There are 134 professionals, 60 para-professionals and 113 clerks engaged collaboratively in identifying potential abuse. The allegedly errant practitioner comes before an informal hearing to account for professional behavior seemingly at variance with appropriate standards. The Health Department then takes action on the basis of these hearings. (18) Previous papers have detailed the Medicaid activities of the New York City Health Department. (1-22)

THE VOCABULARY OF ABUSES

There are 3 major abuses: (1) fraud, (2) unsatisfactory quality, (3) overutilization.

Fraud refers to the practitioner's charging for a service that in fact he never performed.

Unsatisfactory quality refers to the practitioner's performing a health service that fails to meet Medicaid standards.

Overutilization refers to the practitioner's performing a superfluous service, lacking therapeutic or preventive justification.

In dollar value, fraud has been the least important of the three abuses. It is the easiest to identify. The Medicaid abuser who engages in fraud is deemed by the cognoscenti to be stupid, for fraud is easiest to detect and easiest to prosecute. Unsatisfactory quality is de-emphasized in this paper, not because it is rare and unimportant, but because this abuse deserves detailed analysis of its own. We shall concentrate on fraud and overultilization. The inventory in this paper is representative, but by no means inclusive, of every variety of abuse that we have encountered. To avoid repetition we select typical examples. A specific abuse by one type of health professional has its counterpart within the practices of other species of health professionals as well.

FRAUD

In all the professions there may be billing for a mythical office visit; in dentistry, billing for phantom dentures, extractions, or filling: in optometry, billing for glasses never provided; in podiatry, billing for surgery never performed. Two excuses are common:

1. The clerk erred. (Employees are routine scapegoats).

2. The event under investigation occurred because the practitioner misunderstood the contents or policies of the program.

To counteract fraud, direct inspection is indispensable. The New York City Health Department samples invoices, and calls back, and actually examines Medicaid services provided for patients. Health Department staff dentists assess the quality of dentistry. The Optometric Center of New York and the M. J. Lewi College of Podiatry assess the quality of service of their respective professions in accordance with the Health Department's contractual protocol of evaluation. The very existence of a program of direct reexamination represents a deterrent.

FRAUD IN PHARMACY

The major fradulent abuses in pharmacy are "kiting" and "shorting" (11) Kiting refers to forging upward the quantity of medication originally prescribed by the practitioner. In New York State the physician, the dentist, and the podiatrist may each write prescriptions. The pharmacist may "kite" the quantity of the original prescription, for example, by inserting two more X's to increase a total number of prescribed tetracycline capsules from xx to xxxx. The pharmacist then provides the patient with the originally prescribed quantity, but bills Medicaid for the new and larger quantity. The patient receives the proper amount