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Is it Politically Correct Now to Focus on Healthcare Fraud? Part I

by Don Simborg

At the World Congress Road to Interoperability Leadership Summit in Boston this past July, I brought up the topic of healthcare fraud as an example of one of the health IT related issues being neglected by the current DHHS administration. In the meantime, I have been one of the many volunteers working with the Barack Obama Health Policy Team and, of course, am pleased with the focus on healthcare as a key priority not only in the campaign, but in the upcoming administration. I was disappointed, however, in being unable to raise the fraud issue to any significant level of attention by the campaign. In retrospect, I should not have been surprised as this topic has surprising political sensitivity.

Healthcare fraud is estimated to cost $200B/year – a rate that is 30 times that of credit card fraud. In the past three years, there have been two expert panels commissioned by the Department of Health and Human Services (DHHS) to examine the issue of healthcare fraud as it relates to the emerging use of health information technology. I was the chairman of both of these expert panels. The report issued by our first panel in 2005 concluded that the enormous healthcare fraud problem would become worse in an electronic environment unless proactive anti-fraud measures were built into electronic health record systems and other health information technologies. As a result of that report, the second panel was commissioned to recommend specific anti-fraud measures that should be required of electronic health record systems. A second report was produced in 2007 which recommended 14 such measures. These measures were largely focused on improving the ability to audit the “who, what, when, where, and how” of producing electronic health records and the prevention of medical identity theft.

The recommendations in the second report were strongly opposed by physician groups including the American Medical Association, the American College of Physicians, and the American Academy of Family Practice. As a result, any mention of anti-fraud activities has been omitted in the current DHHS five year plan for health information technology. The physician groups correctly pointed out that implementation of any means to further monitor physicians for fraud would be threatening to all physicians who would fear the possibility of having to defend false accusations of fraud. The reputations of the Office of the Inspector General and the Department of Justice have been tarnished in this regard by highly publicized instances of such false accusations in the current environment leading to costly and traumatic defenses by some physicians. The physician groups argued that if adopting electronic health records meant increased surveillance against fraud, this would further deter the already slow adoption of such technologies. As one physician compliance officer told me, “physicians are not going to buy the gun that shoots them.” Since increasing adoption of technology has been the highest priority in the Bush DHHS administration regarding technology, the adoption goal has trumped any focus on fraud.

The question is what the Obama administration will do regarding this problem. The last thing it wants to do is alienate physicians or undermine the adoption of health IT – one of the cornerstones of its plans to reduce healthcare costs. In part II, an approach to this issue will be discussed.

Donald W. Simborg, MD


1 Comment »

  rdgelzer wrote @ November 24th, 2008 at 10:41 am

Dr. Simborg,

Thank you for your continuing labors to raise the visibility of health care fraud. The diversion of billions of dollars from patient care into overtly criminal enterprises, with so little enforcement, may be historically unprecedented in the US. I recently listened to a Lexis/Nexis webcast on health care fraud which included a presentation from Florida Senator Martinez’ office, including evidence that the actual fraud burden may approach percentages in the high teens generally and, in specific areas like South Florida, Southern California, Texas, and Georgia, even higher.

The fact that your first study highlighted that EHRs would likely make this worse, combined with the lack of apparent action on the second report’s recommendations is especially bewildering. Neither HHS generally nor its leadership in the Office of the National Coordinator are highlighting this huge drain on national resources. The fact that the health care industry is in the top five of voters’ concerns at this makes one wonder, who is benefiting from the inaction on, annually, hundreds of billions of theft?

RDGelzer, MD, MPH, CHCC
Advocates for Documentation Integrity and Compliance

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