Healthcare: Still Not Like Any Other Business
- Reid Pearlman, JD, CCEP
- May 29, 2024
- 3 min read
I recently returned from my professional association’s big national annual conference, the Healthcare Compliance Association’s Compliance Institute. This year, held in Nashville, the global healthcare mecca. Hosting compliance professionals, regulators, lawyers and consultants from across the US.
I always enjoy hearing directly from our industry’s top regulators about the latest enforcement priorities. This year was no exception. Our keynote speaker, Rob DeConti, HHS OIG Deputy Inspector General, was quite clear. The government’s ongoing priorities are PPP (taking on Covid relief fund fraud), protecting seniors (again, from fraud schemes), and winding down the opioid epidemic (ie, shutting down remaining pill mills, etc). A new (or newish) arrival to the list, are the Medicare Advantage plans, in the crosshairs for allegedly using bogus diagnostic conditions in their population health compensation formulas. And, now a recurrent priority over the last few years, is the private equity industry. For allegedly putting profits over patients.
Rob DeConti‘s comments immediately reminded me of how unique the healthcare industry has long been. And how it becomes even more so with each passing day. It’s still the second most regulated industry of any, only behind financial services. How compelling, considering that sector’s storied history of mercenary financial schemes, wild market crashes, hyped stock speculation, and the like.
Healthcare, at least from the government’s perspective, is almost as bad. What other industry has such a great focus on fraud, waste and abuse? Not manufacturing, energy, or even environmental protection. No, only healthcare saw the near overnight revival of a 150+ year-old law, the False Claims Act, become the industry’s primary enforcement vehicle. As President Obama launched the blitz on healthcare fraud waste and abuse some 15 years ago.
Maybe that’s appropriate, given the $4.5 trillion a year US healthcare spend, nearly a fifth of GDP. Vastly larger than the entire economies of most countries. Approximately $1.7 trillion of that, nearly 40%, through federal healthcare programs. 11% of which, $187 billion, is, in the government’s opinion, lost to fraud waste and abuse.
Like any business with a consistent resource drain, the government has tried various approaches, and stuck with what has worked. It claims a 10-to-1 return on investment. Practically all False Claims recoveries come from healthcare. HHS OIG is the largest enforcement arm of any federal agency, with 1,700 staff. Dwarfing all other agencies’ enforcement arms.
Of course, healthcare is not unique solely because it is so highly regulated. Our healthcare system is unique because it is so vast and pervasive, touching upon the lives of practically every single person in the country. Regardless of ethnicity, politics, personal beliefs, or even affluence.
I consider it a great honor to be a part of the healthcare industry. I believe that I make life a little less complicated and threatening for my clients, including so many providers, as they navigate what can sometimes be an unpredictable, unforgiving system.
At the end of the day, thriving in the healthcare ecosystem means accepting that what is routine in most industries is not in ours. Whistleblower enrichment, narrow self-referral exceptions, and harsh anti-kickback enforcement, are clear examples why.
And so, if it ever was (and it probably never was), healthcare, since at least 2010, when the current fraud, waste and abuse enforcement regime was born, is unique unto itself.
Is there light at the end of the tunnel? Of course there is. Compliance. The mechanism to find, fix and prevent legal and regulatory hiccups. A perspective and approach that the government believes strongly in. A message clearly delivered to us, yet again, by healthcare’s top enforcement officials. And a sensible thing to do.
It’s springtime, folks. Time to take some stock, clear out some clutter, focus, and maybe even to try something new. Meet my friend, strategic compliance!
Reid Pearlman is an independent healthcare compliance consultant at True Compliance Consulting in Atlanta, Georgia. He may be reached at Reid@MyComplianceOfficer.net.
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