Expanding physician education in health care fraud and program integrity.

Program integrity (PI) spans the entire spectrum of improper payments from fraud to abuse, errors, and waste in the health care system. Few physicians will perpetrate fraud or abuse during their careers, but nearly all will contribute to the remaining spectrum of improper payments, making preventive education in this area vital. Despite the enormous impact that PI issues have on government-sponsored and private insurance programs, physicians receive little formal education in this area. Physicians' lack of awareness of PI issues not only makes them more likely to submit inappropriate claims, generate orders that other providers and suppliers will use to submit inappropriate claims, and document improperly in the medical record but also more likely to become victims of fraud schemes themselves.In this article, the authors provide an overview of the current state of PI issues in general, and fraud in particular, as well as a description of the state of formal education for practicing physicians, residents, and fellows. Building on the lessons from pilot programs conducted by the Centers for Medicare and Medicaid Services and partner organizations, the authors then propose a model PI education curriculum to be implemented nationwide for physicians at all levels. They recommend that various stakeholder organizations take part in the development and implementation process to ensure that all perspectives are included. Educating physicians is an essential step in establishing a broader culture of compliance and improved integrity in the health care system, extending beyond Medicare and Medicaid.

Analysis & commentary: A new quality compass: hospital boards' increased role under the Affordable Care Act.

The Affordable Care Act of 2010 promotes a clinically integrated, systems-based approach to health care. This means coordinating a patient's care over time and across all conditions, diseases, providers, and care settings. The aim is to achieve optimal results in terms of the overall quality of care as well as its efficiency, cost, safety, and timeliness. Hospital boards, which are legally accountable for the quality of the care their institutions provide, need to develop and implement effective quality oversight processes to achieve these objectives. Boards will have to focus less on the competence of individual providers and more on the functioning of the entire system of inpatient and outpatient care. We discuss the increased role of the boards in a systems-based approach to quality, and what steps they can take to meet the quality mandates of the Affordable Care Act.