On the clinical side of healthcare, patient safety and quality care proponents often speak about the importance of establishing a "culture of safety." Although checklists, best practices and training are imperative to avoiding medical errors, quality efforts will be stonewalled unless healthcare organizations prioritize a company-wide attitude that allows clinicians to openly share safety information and promotes change.
This can be difficult to grasp. Aside from the importance of leadership buy-in, there is no blueprint for culture change. It's a shifting attitude that happens organically. Sometimes it takes years before any measurable change becomes apparent.
Just as an empowering culture can be influential, a poor culture can be a destructive force in any organization. Much like culture impacts clinical concerns, fraud prevention and reporting relies heavily on leadership within healthcare organizations and government regulators tasked with identifying fraud.
Which bring us to the Texas Health and Human Services Commission's (HHSC) Office of Inspector General (OIG), an agency embroiled in controversy surrounding its Medicaid fraud prevention efforts. The final straw came last week when Doug Wilson, inspector general of HHSC, was asked to resign. Wilson's resignation came just a week after that of Jack Stick, general counsel at HHSC, who unfairly brokered a contract with 21CT, an Austin-based software company that was hired to detect fraud.
What's particularly illuminating about the reports that have surfaced from the Texas HHSC OIG is the pervasive and seemingly willful incompetence demonstrated by the agency's leaders. This became clear as far back as October, when an audit report revealed startling ineffectiveness regarding fraud prevention within the Texas OIG, including "a lack of priorities, criteria, processes, transparency, or accountability."
The courts haven't been any kinder to the agency. On Nov. 25, the Third District Texas Court of Appeals handed down a decision that the OIG unlawfully withheld millions of dollars to dentists and orthodontists over minor billing errors. The decision painted the OIG as "overzealous" and "politically motivated," according to the Houston Chronicle. Even when the agency appeared to be uncovering fraud, it was doing so illegally.
It seems the $110 million no-bid contract with 21CT was the last straw. An investigation by the Austin American-Statesman showed how Stick steered money towards the company, but it also revealed rampant dysfunction within the OIG. When Reflective Medical Information Systems analyzed three years of Medicaid data, as part of an audition for the contract 21CT received, the company found egregious mismanagement of fraud detection.
"We recommended that they get out of the police business and turn over protection of Medicaid to the attorney general's office," Dr. David Gibson, owner of Reflective Medical, told The Statesman.
Gibson recounted particularly egregious instances of fraud: Nine-year-olds getting tubal ligations and births, 198-year-old women getting testicular biopsies, even men who were giving birth. According to Gibson, when the company showed the OIG its findings, instead of absorbing a sobering moment of eye-opening self-reflection, Wilson threatened to sue if he made the report public.
Piece everything together--the audit, the lawsuit, the 21CT contract disaster--and it becomes clear that the agency tasked with preserving taxpayer dollars for Medicaid funding had deep-rooted cultural issues that began with the agency's top brass. Healthcare organizations are often tasked with creating a culture of compliance in order to root out fraud. In Texas, even the very agency tasked with overseeing statewide fraud prevention wasn't equipped to ensure any measure of compliance. Creating a culture conducive to effectively uncovering healthcare fraud can be a difficult endeavor, but it's one made infinitely harder when the leaders tasked with operating the program are inept, deceitful or both.
On the bright side, as the New Year coincides with new resolutions, now may be the best time for Texas to start over. Removing Wilson and Stick was the first step toward a complete overhaul for the agency. By replacing them with leaders that will make Medicare and Medicaid fraud a top priority, the state can take its first steps in completely rewiring the culture of the OIG and targeting fraud schemes that have plagued the state for years.
Although it's not always easy, culture of change is possible. It just requires the right people to institute it. - Evan (@HealthPayer)